Stereotactic radiotherapy of intracranial tumors : optimizing treatment and improving outcome

This thesis consists of studies on stereotactic radiotherapy (SRT) of intracranial tumors aiming at optimizing the treatment technique and improving the patients__ outcome. We compared two treatment planning techniques (dynamic conformal arc and intensity-modulated radiotherapy) and concluded that for most patients optimal plans were possible with both techniques. We also found that patient fixation during SRT could be improved by adding a vacuum mouthpiece to the standard stereotactic frame. Five chapters deal with treatment results of SRT in patients with brain metastases. From our own results and a literature review we concluded that single fraction SRT produces excellent local control results in patients with small brain metastases, but insufficient local control rates in patients with large metastases. The higher biologically equivalent doses needed for improved local control rates in large brain metastases can be administered with fractionated SRT. Finally, we studied the clinical problem of lesion growth after SRT of brain metastases. The cause can be real tumor progression or pseudo-progression (radiation toxicity). We found that symptomatic pseudo-progression is serious radiation toxicity of the normal brain tissue surrounding the metastasis. Reduction of pseudo-progression rates is possible by limiting the volume of normal brain tissue that receives high radiation doses.UBL - phd migration 201

The influence of a six degrees of freedom couch and an individual head support in patient positioning in radiotherapy of head and neck cancer

Reproducible patient positioning is important in radiotherapy (RT) of head-and-neck cancer. We therefore compared set-up errors in head-and-neck RT resulting from three different patient positioning systems. Patients were either treated with a standard head support (SHS) and conventional treatment couch (SHS-3, n = 10), a SHS and rotational couch (SHS-6, n = 10), or an individual head support (IHS) and rotational couch (IHS-6, n = 10). Interfraction mean translation vector lenghts were significantly lower for IHS-6 compared to SHS-3 (0.8 ± 0.3 mm vs. 1.4 ± 0.7 mm, P = 0.001). Intrafraction displacement was comparable among cohorts. This study showed that the use of a six degrees of freedom couch combined with an IHS in head-and-neck RT resulted in better interfraction reproducibilit

Train design features affecting boarding and alighting of passengers

Accurately predicting train dwell time is critical to running an effective and efficient service. With high-density passenger services, large numbers of passengers must be able to board and alight the train quickly – and within scheduled dwell times. Using a specially constructed train mock-up in a pedestrian movement laboratory, the experiments outlined in this paper examine the impact of train carriage design factors such as door width, seat type, platform edge doors and horizontal gap on the time taken by passengers to board and alight. The findings illustrate that the effectiveness of design features depends on whether there are a majority of passengers boarding or alighting. An optimum door width should be between 1.7 and 1.8 m. The use of a central pole and platform edge doors produced no major effects, but a 200 mm horizontal gap could increase the movement of passengers. There is no clear effect of the type of seats and neither the standbacks between 50, 300 and 500 mm. Further research will look for the relationship between the dwell time and the characteristics of passengers such as personal space

A Fuzzy Logic-Based Approach for Estimation of Dwelling Times of Panama Metro Stations

Passenger flow modeling and station dwelling time estimation are significant elements for railway mass transit planning, but system operators usually have limited information to model the passenger flow. In this paper, an artificial-intelligence technique known as fuzzy logic is applied for the estimation of the elements of the origin-destination matrix and the dwelling time of stations in a railway transport system. The fuzzy inference engine used in the algorithm is based in the principle of maximum entropy. The approach considers passengers’ preferences to assign a level of congestion in each car of the train in function of the properties of the station platforms. This approach is implemented to estimate the passenger flow and dwelling times of the recently opened Line 1 of the Panama Metro. The dwelling times obtained from the simulation are compared to real measurements to validate the approach.The authors of this paper want to express their gratitude to the National Secretary of Science and Technology (SENACYT) of the Government of the Republic of Panama for funding this study through the R & D project (MDEPRB09-001). Additionally, they want to thank the support received from Technological University of Panama (UTP), the University of Granada, the Fundación Carolina and the Secretaría del Metro de Panamá (SMP)

SMART syndrome: a late reversible complication after radiation therapy for brain tumours

With intensified treatment leading to longer survival, complications of therapy for brain tumours are more frequently observed. Regarding radiation therapy, progressive and irreversible white matter disease with cognitive decline is most feared. We report on four patients with reversible clinical and radiological features occurring years after radiation for brain tumours, suggestive for the so called SMART syndrome (stroke-like migraine attacks after radiation therapy). All four patients (males, age 36–60 years) had been treated with focal brain radiation for a primary brain tumour or with whole-brain radiation therapy for brain metastases. Ranging from 2 to 10 years following radiation therapy patients presented with headache and focal neurological deficits, suggestive for tumour recurrence. Two patients also presented with focal seizures. MRI demonstrated typical cortical swelling and contrast enhancement, primarily in the parieto-occipital region. On follow-up both clinical and MRI features improved spontaneously. Three patients eventually proved to have tumour recurrence. The clinical and radiological picture of these patients is compatible with the SMART syndrome, a rare complication of radiation therapy which is probably under recognized in brain tumour patients. The pathophysiology of the SMART syndrome is poorly understood but bears similarities with the posterior reversible encephalopathy syndrome (PRES). These four cases underline that the SMART syndrome should be considered in patients formerly treated with radiation therapy for brain tumours, who present with new neurologic deficits. Before the diagnosis of SMART syndrome can be established other causes, such as local tumour recurrence, leptomeningeal disease or ischemic disease should be ruled out

3D-conformal-intensity modulated radiotherapy with compensators for head and neck cancer: clinical results of normal tissue sparing

BACKGROUND: To investigate the potential of parotic gland sparing of intensity modulated radiotherapy (3D-c-IMRT) performed with metallic compensators for head and neck cancer in a clinical series by analysis of dose distributions and clinical measures. MATERIALS AND METHODS: 39 patients with squamous cell cancer of the head and neck irradiated using 3D-c-IMRT were evaluable for dose distribution within PTVs and at one parotid gland and 38 patients for toxicity analysis. 10 patients were treated primarily, 29 postoperatively, 19 received concomittant cis-platin based chemotherapy, 20 3D-c-IMRT alone. Initially the dose distribution was calculated with Helax (® )and photon fluence was modulated using metallic compensators made of tin-granulate (n = 22). Later the dose distribution was calculated with KonRad (® )and fluence was modified by MCP 96 alloy compensators (n = 17). Gross tumor/tumor bed (PTV 1) was irradiated up to 60–70 Gy, [5 fractions/week, single fraction dose: 2.0–2.2 (simultaneously integrated boost)], adjuvantly irradiated bilateral cervical lymph nodes (PTV 2) with 48–54 Gy [single dose: 1.5–1.8]). Toxicity was scored according the RTOG scale and patient-reported xerostomia questionnaire (XQ). RESULTS: Mean of the median doses at the parotid glands to be spared was 25.9 (16.3–46.8) Gy, for tin graulate 26 Gy, for MCP alloy 24.2 Gy. Tin-granulate compensators resulted in a median parotid dose above 26 Gy in 10/22, MCP 96 alloy in 0/17 patients. Following acute toxicities were seen (°0–2/3): xerostomia: 87%/13%, dysphagia: 84%/16%, mucositis: 89%/11%, dermatitis: 100%/0%. No grade 4 reaction was encountered. During therapy the XQ forms showed °0–2/3): 88%/12%. 6 months postRT chronic xerostomia °0–2/3 was observed in 85%/15% of patients, none with °4 xerostomia. CONCLUSION: 3D-c-IMRT using metallic compensators along with inverse calculation algorithm achieves sufficient parotid gland sparing in virtually all advanced head and neck cancers. Since the concept of lower single (and total) doses in the adjuvantly treated volumes reduces acute morbidity 3D-c-IMRT nicely meets demands of concurrent chemotherapy protocols