Prospective Study Delivering Simultaneous Integrated High-dose Tumor Boost (≤70 Gy) With Image Guided Adaptive Radiation Therapy for Radical Treatment of Localized Muscle-Invasive Bladder Cancer

PurposeImage guided adaptive radiation therapy offers individualized solutions to improve target coverage and reduce normal tissue irradiation, allowing the opportunity to increase the radiation tumor dose and spare normal bladder tissue.Methods and MaterialsA library of 3 intensity modulated radiation therapy plans were created (small, medium, and large) from planning computed tomography (CT) scans performed at 30 and 60 minutes; treating the whole bladder to 52 Gy and the tumor to 70 Gy in 32 fractions. A “plan of the day” approach was used for treatment delivery. A post-treatment cone beam CT (CBCT) scan was acquired weekly to assess intrafraction filling and coverage.ResultsA total of 18 patients completed treatment to 70 Gy. The plan and treatment for 1 patient was to 68 Gy. Also, 1 patient's plan was to 70 Gy but the patient was treated to a total dose of 65.6 Gy because dose-limiting toxicity occurred before dose escalation. A total of 734 CBCT scans were evaluated. Small, medium, and large plans were used in 36%, 48%, and 16% of cases, respectively. The mean ± standard deviation rate of intrafraction filling at the start of treatment (ie, week 1) was 4.0 ± 4.8 mL/min (range 0.1-19.4) and at end of radiation therapy (ie, week 5 or 6) was 1.1 ± 1.6 mL/min (range 0.01-7.5; P=.002). The mean D98 (dose received by 98% volume) of the tumor boost and bladder as assessed on the post-treatment CBCT scan was 97.07% ± 2.10% (range 89.0%-104%) and 99.97% ± 2.62% (range 96.4%-112.0%). At a median follow-up period of 19 months (range 4-33), no muscle-invasive recurrences had developed. Two patients experienced late toxicity (both grade 3 cystitis) at 5.3 months (now resolved) and 18 months after radiation therapy.ConclusionsImage guided adaptive radiation therapy using intensity modulated radiation therapy to deliver a simultaneous integrated tumor boost to 70 Gy is feasible, with acceptable toxicity, and will be evaluated in a randomized trial

Quality assuring "Plan of the day" selection in a multicentre adaptive bladder trial: Implementation of a pre-accrual IGRT guidance and assessment module

Background and purpose Hypofractionated bladder RT with or without image guided adaptive planning (HYBRID) is a multicentre clinical trial investigating "Plan of the Day" (PoD) adaptive radiotherapy for bladder cancer. To ensure correct PoD selection a pre-accrual guidance and assessment module was developed as part of an image guided radiotherapy quality assurance (IGRT QA) credentialing programme. This study aimed to evaluate its feasibility and effectiveness across multiple recruiting centres.Materials and methods Individuals from participating centres remotely accessed an image database in order to complete the PoD module. An assessment score of ≥83% was required in order to receive QA approval. A questionnaire was used to gather user feedback on the module. PoD decisions for the first patient at each recruiting centre were retrospectively reviewed for protocol adherence.Results 71 radiation therapists (RTTs) from 10 centres completed the PoD module. The median assessment score was 92% (Range: 58-100%) with 79% of RTTs passing the assessment on first attempt. All questionnaire respondents reported that the PoD module prepared them for plan selection. In 51/60 of on-trial treatments reviewed, the PoD selected by the centre agreed with QA reviewers.Conclusions The PoD QA module was successfully implemented in a multicentre trial and enabled pre-accrual assessment of protocol understanding. This increased operator confidence and resulted in appropriate PoD selection on-trial

A Feminist Stylistic Analysis of The Domestic Crusaders by Wajahat Ali

There is a general perception that a male member of the society projects only male perception of life and generally ignores female perception of life. As a result, women are discriminated and subordinated to men which is projected in the literature as it reflects the true picture of society. In the present study, the researcher has tried to find out the stylistic features that represent the gender discrimination in the play of Wajahat Ali. The present research has been conducted to decode the text of The Domestic Crusader stylistically by applying 'Sara Mills' model of Feminist Stylistics.  The data have been analyzed at the level of words, sentences and discourse. This research has been conducted by qualitative approach. The present research concludes that the writer has used negative words and sentences to represent women and men and used body parts to describe a woman while man is described overall either positive or negative. Furthermore, the writer has used generic noun, woman as marked form, naming and androcentrism, semantic derogation of women at the level of words, readymade phrases, metaphors, jokes and humor and presupposition and inferences at the level of sentences while fragmentation has used at the level of discourse. Moreover, the writer has portrayed male character opposite to female characters for instance when female has defined as sex object, weak and helpless, the writer has used male as pleasure seeker, terrorist and extremist

MR-guided adaptive radiotherapy for bladder cancer

Radiotherapy has an important role in the curative and palliative treatment settings for bladder cancer. As a target for radiotherapy the bladder presents a number of technical challenges. These include poor tumor visualization and the variability in bladder size and position both between and during treatment delivery. Evidence favors the use of magnetic resonance imaging (MRI) as an important means of tumor visualization and local staging. The availability of hybrid systems incorporating both MRI scanning capabilities with the linear accelerator (MR-Linac) offers opportunity for in-room and real-time MRI scanning with ability of plan adaption at each fraction while the patient is on the treatment couch. This has a number of potential advantages for bladder cancer patients. In this article, we examine the technical challenges of bladder radiotherapy and explore how magnetic resonance (MR) guided radiotherapy (MRgRT) could be leveraged with the aim of improving bladder cancer patient outcomes. However, before routine clinical implementation robust evidence base to establish whether MRgRT translates into improved patient outcomes should be ascertained