Improving plan quality and consistency by standardization of dose constraints in prostate cancer patients treated with CyberKnife.

Treatment plans for prostate cancer patients undergoing stereotactic body radiation therapy (SBRT) are often challenging due to the proximity of organs at risk. Today, there are no objective criteria to determine whether an optimal treatment plan has been achieved, and physicians rely on their personal experience to evaluate the plan's quality. In this study, we propose a method for determining rectal and bladder dose constraints achievable for a given patient's anatomy. We expect that this method will improve the overall plan quality and consistency, and facilitate comparison of clinical outcomes across different institutions. The 3D proximity of the organs at risk to the target is quantified by means of the expansion-intersection volume (EIV), which is defined as the intersection volume between the target and the organ at risk expanded by 5 mm. We determine a relationship between EIV and relevant dosimetric parameters, such as the volume of bladder and rectum receiving 75% of the prescription dose (V75%). This relationship can be used to establish institution-specific criteria to guide the treatment planning and evaluation process. A database of 25 prostate patients treated with CyberKnife SBRT is used to validate this approach. There is a linear correlation between EIV and V75% of bladder and rectum, confirming that the dose delivered to rectum and bladder increases with increasing extension and proximity of these organs to the target. This information can be used during the planning stage to facilitate the plan optimization process, and to standardize plan quality and consistency. We have developed a method for determining customized dose constraints for prostate patients treated with robotic SBRT. Although the results are technology specific and based on the experience of a single institution, we expect that the application of this method by other institutions will result in improved standardization of clinical practice

Effects of the pre-irradiation storage procedure on the dose response of a Fricke xylenol orange gel dosimeter

Abstract The Fricke xylenol orange (FX) gel system is a chemical dosimeter characterized by good sensitivity, linear dose response, tissue equivalence, no toxicity, easy preparation, reproducibility and low cost. Thanks to the presence of the gelatinous matrix, the system is particularly suitable to perform reliable 3D mapping of the absorbed dose spatial distribution via magnetic resonance imaging (MRI) or optical techniques. The aim of this work is to study in a systematic way the influence of the pre-irradiation storage procedure upon sensitivity, dose response stability and lifetime of use of a FX gel system made with gelatin from porcine skin subjected to homogeneous irradiation. For this purpose, different pre-irradiation storage procedures, in terms of temperature and duration of each storage step, were investigated. In order to evaluate the dose response stability, the optical analyses of the samples were performed up to 6 hours after irradiation. Moreover, the samples were irradiated at time intervals of 24 hours for up to 7 days after preparation in order to evaluate the system lifetime of use. Regardless of their thermal and temporal life, the samples show linear dose responses in the investigated dose range (3-24 Gy) and an increase of sensitivity with the time elapsed between preparation and irradiation. Among the three pre-irradiation storage procedures considered here, a procedure that provides the best dose response stability and lifetime of use was identified and recommended for further use. The analyzed dosimetric system possesses good properties that make it promising for medical application, particularly concerning the evaluation of pre-treatment plan quality assurance within the conformational external beam radiotherapy</jats:p

A microRNA prognostic signature in patients with diffuse intrinsic pontine gliomas through non-Invasive liquid biopsy

SIMPLE SUMMARY: Diffuse intrinsic pontine glioma (DIPG) is a neuro-radiologically defined tumor of the brainstem, primarily affecting children, with most diagnoses occurring between 5 and 7 years of age. Surgical removal in DIPGs is not feasible. Subsequent tumor progression is almost universal and no biomarker for predicting the course of the disease has entered into clinical practice so far. Under these premises, it is essential to develop reliable biomarkers that are able to improve outcomes and stratify patients using non-invasive methods to determine tumor profiles. We designed a study assessing circulating miRNA expression by a high-throughput platform and divided patients into training and validation phases in order to disclose a potential signature with clinical impact. Our results for the first time have proved the usefulness of blood-circulating nucleic acids as powerful, easy-to-assay molecular markers of disease status in DIPG. ABSTRACT: Diffuse midline gliomas (DMGs) originate in the thalamus, brainstem, cerebellum and spine. This entity includes tumors that infiltrate the pons, called diffuse intrinsic pontine gliomas (DIPGs), with a rapid onset and devastating neurological symptoms. Since surgical removal in DIPGs is not feasible, the purpose of this study was to profile circulating miRNA expression in DIPG patients in an effort to identify a non-invasive prognostic signature with clinical impact. Using a high-throughput platform, miRNA expression was profiled in serum samples collected at the time of MRI diagnosis and prior to radiation and/or systemic therapy from 47 patients enrolled in clinical studies, combining nimotuzumab and vinorelbine with concomitant radiation. With progression-free survival as the primary endpoint, a semi-supervised learning approach was used to identify a signature that was also tested taking overall survival as the clinical endpoint. A signature comprising 13 circulating miRNAs was identified in the training set (n = 23) as being able to stratify patients by risk of disease progression (log-rank p = 0.00014; HR = 7.99, 95% CI 2.38–26.87). When challenged in a separate validation set (n = 24), it confirmed its ability to predict progression (log-rank p = 0.00026; HR = 5.51, 95% CI 2.03–14.9). The value of our signature was also confirmed when overall survival was considered (log-rank p = 0.0021, HR = 4.12, 95% CI 1.57–10.8). We have identified and validated a prognostic marker based on the expression of 13 circulating miRNAs that can shed light on a patient’s risk of progression. This is the first demonstration of the usefulness of nucleic acids circulating in the blood as powerful, easy-to-assay molecular markers of disease status in DIPG. This study provides Class II evidence that a signature based on 13 circulating miRNAs is associated with the risk of disease progression

Management of the vertebrae as an organ at risk in paediatric radiotherapy clinical trials: Initial QUARTET experience

Irradiation of the vertebrae in prepubertal patients, if non-homogenous, can result in future growth deformities including kyphoscoliosis. Vertebral delineation and dosimetry were assessed for 101 paediatric cases reviewed within QUARTET-affiliated trials. Despite the availability of published consensus guidelines, a high variability in vertebral delineation was observed, with impact on dosimetry

Effects of the pre-irradiation storage procedure on the dose response of a Fricke xylenol orange gel dosimeter

The Fricke xylenol orange (FX) gel system is a chemical dosimeter characterized by good sensitivity, linear dose response, tissue equivalence, no toxicity, easy preparation, reproducibility and low cost. Thanks to the presence of the gelatinous matrix, the system is particularly suitable to perform reliable 3D mapping of the absorbed dose spatial distribution via magnetic resonance imaging (MRI) or optical techniques. The aim of this work is to study in a systematic way the influence of the pre-irradiation storage procedure upon sensitivity, dose response stability and lifetime of use of a FX gel system made with gelatin from porcine skin subjected to homogeneous irradiation. For this purpose, different pre-irradiation storage procedures, in terms of temperature and duration of each storage step, were investigated. In order to evaluate the dose response stability, the optical analyses of the samples were performed up to 6 hours after irradiation. Moreover, the samples were irradiated at time intervals of 24 hours for up to 7 days after preparation in order to evaluate the system lifetime of use. Regardless of their thermal and temporal life, the samples show linear dose responses in the investigated dose range (3-24 Gy) and an increase of sensitivity with the time elapsed between preparation and irradiation. Among the three pre-irradiation storage procedures considered here, a procedure that provides the best dose response stability and lifetime of use was identified and recommended for further use. The analyzed dosimetric system possesses good properties that make it promising for medical application, particularly concerning the evaluation of pre-treatment plan quality assurance within the conformational external beam radiotherap

Preliminary epi-diode characterization for HDR brachytherapy quality assurance

High Dose Rate vaginal brachytherapy for endometrial cancer has evolved from simple single-channel (i.e. cylindrical applicator) deliveries to treatments involving several channels (i.e. multichannel applicator) for the radiotherapy source to dwell, increasing the complexity of the dose distribution, and allowing more space for potential errors. For this reason real-time treatment verification has gained a greater importance than ever before, and more methods need to be developed in order to provide assurance that the dose delivery has been carried out as intended by the hospital staff. P-type silicon epi diodes have been designed at the Centre for Medical Radiation Physics (CMRP) in Australia to suit the specific needs of HDR BT, and characterized in the clinical BT facility of the Fondazione IRCCS (INT) in Italy. They have shown great potential for BT treatment verification in real time due to their radiation hardness, dose rate independence, flexibility in physical design, and ability to monitor the treatment at a 1-kHz readout frequency. Their dynamic range has been determined as ± 17 to ± 20 mm and dwell time calculation accuracy of \u3e 0.1 s has been shown. If placed on the same longitudinal plane of a treatment accessory, these detectors would enable coverage of about 40 mm for source position and dwell time tracking. Respective detector positioning at (0, +3, -3 mm) would extend this range to 45-50 mm, depending on the catheter location, proving to be sufficient for the majority of treatment cases. Further studies are encouraged to develop diodes with a wider dynamic range

How Xylenol Orange and Ferrous Ammonium Sulphate Influence the Dosimetric Properties of PVA–GTA Fricke Gel Dosimeters: A Spectrophotometric Study

The development of Fricke gel (FG) dosimeters based on poly(vinyl alcohol) (PVA) as the gelling agent and glutaraldehyde (GTA) as the cross-linker has enabled significant improvements in the dose response and the stability over time of spatial radiation dose distributions. However, a standard procedure for preparing FG in terms of reagent concentrations is still missing in the literature. This study aims to investigate, by means of spectrophotometric analyses, how the sensitivity to the radiation dose and the range of linearity of the dose–response curve of PVA-GTA-FG dosimeters loaded with xylenol orange sodium salt (XO) are influenced by ferrous ammonium sulphate (FAS) and XO concentrations. Moreover, the effect of different concentrations of such compounds on self-oxidation phenomena in the dosimeters was evaluated. PVA-GTA-FG dosimeters were prepared using XO concentrations in the range 0.04–0.80 mM and FAS in the range 0.05–5.00 mM. The optical absorbance properties and the dose response of FG were investigated in the interval 0.0–42.0 Gy. The results demonstrate that the amount of FAS and XO determines both the sensitivity to the absorbed dose and the interval of linearity of the dose–response curve. The study suggests that the best performances of FG dosimeters for spectrophotometric analyses can be obtained using 1.00–0.40 mM and 0.200–0.166 mM concentrations of FAS and XO, respectively

How Xylenol Orange and Ferrous Ammonium Sulphate Influence the Dosimetric Properties of PVA&ndash;GTA Fricke Gel Dosimeters: A Spectrophotometric Study

The development of Fricke gel (FG) dosimeters based on poly(vinyl alcohol) (PVA) as the gelling agent and glutaraldehyde (GTA) as the cross-linker has enabled significant improvements in the dose response and the stability over time of spatial radiation dose distributions. However, a standard procedure for preparing FG in terms of reagent concentrations is still missing in the literature. This study aims to investigate, by means of spectrophotometric analyses, how the sensitivity to the radiation dose and the range of linearity of the dose&ndash;response curve of PVA-GTA-FG dosimeters loaded with xylenol orange sodium salt (XO) are influenced by ferrous ammonium sulphate (FAS) and XO concentrations. Moreover, the effect of different concentrations of such compounds on self-oxidation phenomena in the dosimeters was evaluated. PVA-GTA-FG dosimeters were prepared using XO concentrations in the range 0.04&ndash;0.80 mM and FAS in the range 0.05&ndash;5.00 mM. The optical absorbance properties and the dose response of FG were investigated in the interval 0.0&ndash;42.0 Gy. The results demonstrate that the amount of FAS and XO determines both the sensitivity to the absorbed dose and the interval of linearity of the dose&ndash;response curve. The study suggests that the best performances of FG dosimeters for spectrophotometric analyses can be obtained using 1.00&ndash;0.40 mM and 0.200&ndash;0.166 mM concentrations of FAS and XO, respectively

An innovative gynecological HDR brachytherapy applicator system for treatment delivery and real-time verification

The multichannel vaginal cylinder (MVC) applicator employed for gynecological high dose rate (HDR) brachytherapy increases dose delivery complexity, and thus makes the treatment more prone to errors. A quality assurance (QA) procedure tracking the source throughout dose delivery can detect dwell position and time errors in the multiple channels of the applicator. A new MVC system with integrated real time in vivo treatment delivery QA has been developed based on diodes embedded on the outer surface of the MVC. It has been pre-calibrated and verified using a non-clinical treatment plan with consecutive test positions and dwell times within each catheter, followed by the delivery of ten clinical plans of adjuvant vaginal cuff brachytherapy following hysterectomy for endometrial cancer. The non-clinical verification showed overall mean dwell position and time discrepancies between the nominal and measured treatment of −0.2 ± 0.5 mm and −0.1 ± 0.1 s (k = 1), respectively. The clinical plans showed mean positional discrepancies of 0.2 ± 0.4 and 0.0 ± 0.8 mm, for the central and peripheral catheters, respectively, and mean dwell time discrepancies of −0.1 ± 0.2 and −0.0 ± 0.1 s for central and peripheral catheters, respectively. The innovative prototype of the MVC system has shown the ability to track the source with sub-mm and sub-second accuracy, and demonstrated potential for its incorporation into the clinical routine

Repeatability and reproducibility of MRI-radiomic features: A phantom experiment on a 1.5 T scanner

Purpose Aim of this study is to assess the repeatability of radiomic features on magnetic resonance images (MRI) and their stability to variations in time of repetition (TR), time of echo (TE), slice thickness (ST), and pixel spacing (PS) using vegetable phantoms. Methods The organic phantom was realized using two cucumbers placed inside a cylindrical container, and the analysis was performed using T1-weighted (T1w), T2-weighted (T2w), and diffusion-weighted images. One dataset was used to test the repeatability of the radiomic features, whereas other four datasets were used to test the sensitivity of the different MRI sequences to image acquisition parameters (TR, TE, ST, and PS). Four regions of interest (ROIs) were segmented: two for the central part of each cucumber and two for the external parts. Radiomic features were extracted from each ROI using Pyradiomics. To assess the effect of preprocessing on the reduction of variability, features were extracted both before and after the preprocessing. The coefficient of variation (CV) and intra-class correlation coefficient (ICC) were used to evaluate variability. Results The use of intensity standardization increased the stability for the first-order statistics features. Shape and size features were always stable for all the analyses. Textural features were particularly sensitive to changes in ST and PS, although some increase in stability could be obtained by voxel size resampling. When images underwent image preprocessing, the number of stable features (ICC &gt; 0.75 and mean absolute CV &lt; 0.3) was 33 for apparent diffusion coefficient (ADC), 52 for T1w, and 73 for T2w. Conclusions The most critical source of variability is related to changes in voxel size (either caused by changes in ST or PS). Preprocessing increases features stability to both test-retest and variation of the image acquisition parameters for all the types of analyzed MRI (T1w, T2w, and ADC), except for ST