Scripting a planning avoidance structure to perform simultaneous integrated boost breast on Halcyon linear accelerators.

When planning a simultaneous integrated boost in breast treatment with sliding window intensity-modulated radiotherapy, the use of an oblique anterior field can be advantageous. To limit the irradiation to the tumor bed on the oblique anterior field, we use the "fixed jaw" option during optimization in Eclipse (v15.6, Varian Medical System). However, this option is not available for Halcyon (Varian Medical System) linear accelerators because the beam-defining collimator is only composed of a dual-layer multileaf collimator (MLC) without any jaw collimator. Hence, the optimizer opens the leaves on all target volumes, and leaves facing the heart or medullary canal may be opened on the oblique anterior field. To avoid this unacceptable behavior, we created an avoidance structure using the Eclipse Scripting Application Programming Interface (ESAPI) to force the optimizer to close the leaves when facing critical organs at risk. The avoidance structure was the whole body of the patient subtracted from every beam path used: the tangential fields collimated to the breast planning target volume (PTV) and the oblique anterior field collimated to the tumor bed PTV. The ESAPI has a built-in method that returns a table of points, drawing the outline of a structure at the isocenter plane of a beam. We used this method to build the avoidance structure. We planned 6 breast cancer patients using this structure, and we were able to meet all dosimetric constraints. All MLC leaves were fully closed outside the tumor bed PTV for the oblique anterior field.

Assessment of a conventional volumetric-modulated arc therapy knowledge-based planning model applied to the new Halcyon© O-ring linac in locoregional breast cancer radiotherapy.

INTRODUCTION: The aim of this study was to evaluate the performance of a knowledge-based planning (KBP) model for breast cancer trained on plans performed on a conventional linac with 6 MV FF (flattening filter) beams and volumetric-modulated arc therapy (VMAT) for plans performed on the new jawless Halcyon© system with 6 MV FFF (flattening filter-free) beams. MATERIALS AND METHODS: Based on the RapidPlan© (RP) KBP optimization engine, a DVH Estimation Model was first trained using 56 VMAT left-sided breast cancer treatment plans performed on a conventional linac, and validated on another 20 similar cases (without manual intervention). To determine the capacity of the model for Halcyon©, an additional cohort of 20 left-sided breast cancer plans was generated with RP and analyzed for both TrueBeam© and Halcyon© machines. Plan qualities between manual vs RP (followed by manual intervention) Halcyon© plans set were compared qualitatively by blinded review by radiation oncologists for 10 new independent plans. RESULTS: Halcyon© plans generated with the VMAT model trained with conventional linac plans showed comparable target dose distribution compared to TrueBeam© plans. Organ sparingwas comparable between the 2 devices with a slight decrease in heart dose for Halcyon© plans. Nine out of ten automatically generated Halcyon© plans were preferentially chosen by the radiation oncologists over the manually generated Halcyon© plans. CONCLUSION: A VMAT KBP model driven by plans performed on a conventional linac with 6 MV FF beams provides high quality plans performed with 6 MV FFF beams on the new Halcyon© linac.

Cuidados paliativos ao paciente com esclerose lateral amiotrófica: vivência de fisioterapeutas no âmbito hospitalar / Palliative care to patients with amyotrophic lateral sclerosis: experiences of physiotherapists in a hospital setting / Cuidados paliativos al paciente con esclerosis lateral amiotrófica: vivencia de fisioterapeutas en el ámbito hospitalario

Objetivo: Investigar a vivência de fisioterapeutas na atenção a pacientes com esclerose lateral amiotrófica (ELA) sob cuidados paliativos no âmbito hospitalar. Métodos: Estudo descritivo, exploratório, com abordagem qualitativa, realizado com fisioterapeutas das enfermarias clínica médica e cirúrgica de um hospital público do município de João Pessoa-Paraíba-Brasil, mediante entrevista semiestruturada e material empírico submetido à técnica de análise de conteúdo. Resultados: Foram entrevistados oito fisioterapeutas e, da análise dos dados, emergiram quatro categorias temáticas: I- Compreensão dos cuidados paliativos; II- Estratégias dos fisioterapeutas na promoção dos cuidados paliativos a esses pacientes; III- Interação dos fisioterapeutas com a equipe multiprofissional promovendo os cuidados paliativos na ELA; IV- Vivência dos fisioterapeutas ao assistir esses pacientes. Conclusão: Os fisioterapeutas discorreram seus argumentos com base em sua vivência profissional, destacando-se a necessidade de maiores discussões e aprofundamentos sobre a temática entre esses profissionais para articular a teoria e a prática

Objective: The study's main purpose has been to investigate the experiences of physiotherapists caring for patients with Amyotrophic Lateral Sclerosis (ALS) undergoing palliative care in a hospital setting. Methods: It is a descriptive-exploratory study with a qualitative approach, which was performed with physiotherapy professionals from the internal medicine and surgical wards of a public hospital in João Pessoa city, Paraíba State, Brazil, using a semi-structured interview and empirical material subjected to the content analysis technique. Results: After interviewing eight physiotherapists and based on data analysis, the following four thematic categories were elaborated: I- Physical therapists' understanding in regard to palliative care; II- Strategies used by physical therapists to promote palliative care for ALS patients; III- Interaction of physical therapists with the patient care team promoting palliative care for ALS patients; IV- Experience of physical therapists when assisting the patient with ALS undergoing PC. Conclusion: The physiotherapists based their arguments on their professional experience, underlining the need for further discussions and a better understanding of the subject amongst these professionals aiming to align theory with practice

Objetivo: Investigar la vivencia de fisioterapeutas en atención a los pacientes con esclerosis lateral amiotrófica (ELA) en cuidados paliativos en ámbito hospitalario. Métodos: Estudio descriptivo, exploratorio, con abordaje cualitativo, realizado con fisioterapeutas de las enfermerías clínica médica y quirúrgica de un hospital público de la ciudad de João Pessoa-Paraíba-Brasil, por medio de entrevista semiestructurada y material empírico sometido a la técnica de análisis de contenido. Resultados: Fueron entrevistados ocho fisioterapeutas y, del análisis de los datos, emergieron cuatro categorías temáticas: I- Comprensión de cuidados paliativos; II- Estrategias de fisioterapeutas en la promoción de cuidados paliativos para eses pacientes; IIIInteracción de los fisioterapeutas con el equipo multiprofesional promoviendo los cuidados paliativos en ELA; IV- Vivencia de los fisioterapeutas al asistir eses pacientes. Conclusión: los fisioterapeutas hablaron sus argumentos con base en su vivencia profesional, se destacando la necesidad de mayores discusiones y profundizaciones sobre la temática entre eses profesionales para articular teoría y práctica

Whole breast radiotherapy in the lateral isocentric lateral decubitus position: Long-term efficacy and toxicity results.

PURPOSE: To evaluate previously published whole breast radiotherapy (WBRT) using ILD (isocentring lateral decubitus) technique in terms of toxicity and efficacy. MATERIALS AND METHODS: From 2006 to 2010, 832 female patients with early-stage breast cancer (BC) treated by conservative surgery underwent 3D-conformal WBRT-ILD at Institut Curie. The acute toxicity of treatment was evaluated weekly and the late toxicity (6months and later after the treatment) was evaluated every 6months till the 5th year after the end of the radiotherapy using NCI CTC v3.0 scale. Dosimetric study was performed to analyse the mean cardiac dose and the mean homolateral and contralateral lung doses. RESULTS: The median follow up was 6.4years. The median age was 61.5years (range, 29-90), and median body mass index (BMI) was 26.3. Fifty one percent of the patients presented left sided BC and 49% right sided. Different type of fractions were used: 46.5% of pts.: 50 (breast)+16Gy (boost) in 33fractions (fr), in 17.9%-50Gy/25fr, in 26.1%-40/15fr or 41.6Gy/13fr and in 9.5%: 30Gy/5fr. Acute dermatitis was present in 93% with a median of apparition of 4weeks, and only 2,8% grade 3. In multivariate analysis, the cup size had significant influence (p=0.0004) and the fractionation had a significative influence (p=0.0001). In the all patients' population, 94.1% of cases had no skin toxicity at 1year. No cardiac or pulmonary toxicity was reported. The median overall survival had not been reached at the end of follow-up. We observed 36 (3.6%) recurrences, as following: 30 local (breast) recurrences, 4 lymph node (LN), and 2pts experiencing both. CONCLUSION: Whole breast radiotherapy in the lateral decubitus position provides excellent results in terms of local control and survival. ILD is well tolerated with very good acute toxicity profile. No cardiac or pulmonary toxicity were observed in this study. Longer follow-up is needed to confirm these results.

Long-Term Results of a Highly Performing Conformal Electron Therapy Technique for Chest Wall Irradiation After Mastectomy.

PURPOSE: To evaluate locoregional control and survival after mastectomy, as well as toxicity, in patients irradiated by a previously described postmastectomy highly conformal electron beam radiation therapy technique (PMERT). METHODS AND MATERIALS: We included all women irradiated by postmastectomy electron beam radiation therapy for nonmetastatic breast cancer between 2007 and 2011 in our department. Acute and late toxicities were retrospectively assessed using Common Terminology Criteria for Adverse Events version 3.0 criteria. RESULTS: Among the 796 women included, 10.1% were triple-negative, 18.8% HER2-positive, and 24.6% received neoadjuvant chemotherapy (CT). Multifocal lesions were observed in 51.3% of women, and 64.6% had at least 1 involved lymph node (LN). Internal mammary chain, supraclavicular, infraclavicular, and axillary LNs were treated in 85.6%, 88.3%, 77.9%, and 14.9% of cases, respectively. With a median follow-up of 64 months (range, 6-102 months), 5-year locoregional recurrence-free survival and overall survival were 90% (95% confidence interval 88.1%-92.4%) and 90.9% (95% confidence interval 88.9%-93%), respectively. Early skin toxicity was scored as grade 1 in 58.5% of patients, grade 2 in 35.9%, and grade 3 in 4.5%. Concomitant CT was associated with increased grade 3 toxicity (P<.001). At long-term follow-up, 29.8% of patients presented temporary or permanent hyperpigmentation or telangiectasia or fibrosis (grade 1: 23.6%; grade 2: 5.2%; grade 3: 1%), with higher rates among smokers (P=.06); 274 patients (34.4%) underwent breast reconstruction. Only 24 patients (3%) had early esophagitis of grade 1. Only 3 patients developed ischemic heart disease: all had been treated by anthracycline-based CT with or without trastuzumab, all had been irradiated to the left chest wall and LN, and all presented numerous cardiovascular risk factors (2-4 factors). CONCLUSIONS: This study demonstrated the good efficacy of this technique in terms of locoregional control and survival, and good short-term and long-term safety. Longer follow-up is required to analyze chronic cardiac events.

Helical tomotherapy and volumetric modulated arc therapy: New therapeutic arms in the breast cancer radiotherapy.

AIM: To analyse clinical and dosimetric results of helical tomotherapy (HT) and volumetric modulated arc therapy (VMAT) in complex adjuvant breast and nodes irradiation. METHODS: Seventy-three patients were included (31 HT and 42 VMAT). Dose were 63.8 Gy (HT) and 63.2 Gy (VMAT) in the tumour bed, 52.2 Gy in the breast, 50.4 Gy in supraclavicular nodes (SCN) and internal mammary chain (IMC) with HT and 52.2 Gy and 49.3 Gy in IMC and SCN with VMAT in 29 fractions. Margins to particle tracking velocimetry were greater in the VMAT cohort (7 mm vs 5 mm). RESULTS: For the HT cohort, the coverage of clinical target volumes was as follows: Tumour bed: 99.4% ± 2.4%; breast: 98.4% ± 4.3%; SCN: 99.5% ± 1.2%; IMC: 96.5% ± 13.9%. For the VMAT cohort, the coverage was as follows: Tumour bed: 99.7% ± 0.5%, breast: 99.3% ± 0.7%; SCN: 99.6% ± 1.4%; IMC: 99.3% ± 3%. For ipsilateral lung, Dmean and V20 were 13.6 ± 1.2 Gy, 21.1% ± 5% (HT) and 13.6 ± 1.4 Gy, 20.1% ± 3.2% (VMAT). Dmean and V30 of the heart were 7.4 ± 1.4 Gy, 1% ± 1% (HT) and 10.3 ± 4.2 Gy, 2.5% ± 3.9% (VMAT). For controlateral breast Dmean was 3.6 ± 0.2 Gy (HT) and 4.6 ± 0.9 Gy (VMAT). Acute skin toxicity grade 3 was 5% in the two cohorts. CONCLUSION: HT and VMAT in complex adjuvant breast irradiation allow a good coverage of target volumes with an acceptable acute tolerance. A longer follow-up is needed to assess the impact of low doses to healthy tissues.

EPID based in vivo dosimetry system: clinical experience and results.

Mandatory in several countries, in vivo dosimetry has been recognized as one of the next milestones in radiation oncology. Our department has implemented clinically an EPID based in vivo dosimetry system, EPIgray, by DOSISOFT S.A., since 2006. An analysis of the measurements per linac and energy over a two-year period was performed, which included a more detailed examination per technique and treat-ment site over a six-month period. A comparison of the treatment planning system doses and the doses estimated by EPIgray shows a mean of the differences of 1.9% (± 5.2%) for the two-year period. The 3D conformal treatment plans had a mean dose difference of 2.0% (± 4.9%), while for intensity-modulated radiotherapy and volumetric-modulated arc therapy treatments the mean dose difference was -3.0 (± 5.3%) and -2.5 (± 5.2%), respectively. In addition, root cause analyses were conducted on the in vivo dosimetry measurements of two breast cancer treatment techniques, as well as prostate treatments with intensity-modulated radiotherapy and volumetric-modulated arc therapy. During the breast study, the dose differences of breast treatments in supine position were correlated to patient setup and EPID positioning errors. Based on these observations, an automatic image shift correc-tion algorithm is developed by DOSIsoft S.A. The prostate study revealed that beams and arcs with out-of-tolerance in vivo dosimetry results tend to have more complex modulation and a lower exposure of the points of interest. The statistical studies indicate that in vivo dosimetry with EPIgray has been successfully imple-mented for classical and complex techniques in clinical routine at our institution. The additional breast and prostate studies exhibit the prospects of EPIgray as an easy supplementary quality assurance tool. The validation, the automatization, and the reduction of false-positive results represent an important step toward adaptive radiotherapy with EPIgray.

Análise do tempo de internação de crianças com Pneumonia em Hospital Público de João Pessoa-PB / Analysis on the length of hospitalization of children with pneumonia admitted to a public hospital in João Pessoa, PB

Avaliar o tempo de internação de crianças de 0 a 5anos com pneumonia, internadas em um hospital de referênciana cidade de João Pessoa – PB. Material e Métodos: estudodocumental, analítico e retrospectivo, realizado a partir dobanco de dados de um hospital pediátrico público de JoãoPessoa, do período de 2007 a 2009, onde foram coletadasinformações de 683 crianças. Resultados: foi observadoque 59,6% das crianças eram do sexo masculino; 70,6%tinham de 0 a 2 anos;61,9% eram procedentes de JoãoPessoa, o tempo médio de permanência no hospital foi de 9 ±7,52 dias e as crianças provenientes de outros municípiospassavam mais tempo internadas (p < 0,01). Conclusão:houve diferença significativa para o tempo de internaçãopara a variável procedência, onde crianças que moravamfora da cidade de João Pessoa permaneciam mais tempointernadas...

To evaluate the length of hospitalization of childrenaged 0 to 5 years with pneumonia admitted to a referralhospital in the city of João Pessoa, Paraíba, Brazil. MATERIALand Methods: This was a documentary, analytical,retrospective study, from the database of a public pediatrichospital in João Pessoa in the period 2007-2009, whichcontained information on 683 children. Results: We observedthat 59.6% of children were male; 70.6% were 0-2 yearsold; 61.9% were from the city of João Pessoa; the averagelength of hospital stay was 9 to 7.52 days and the childrenfrom other cities stayed longer in the hospital (p< 0.01).Conclusion: There was a significant difference in the lengthof stay with regard to origin, where children who lived outsidethe city of João Pessoa stayed longer in the hospital...

O Idoso e seus direitos em saúde: Umacompreensão sobre o tema na realidade atual / The Elderly and Their Health Rights: A perspective of the Current Reality

Identificar o conhecimento produzido na literaturanacional dos últimos anos acerca dos direitos em saúde dapopulação idosa. Material e Métodos: Trata-se de umarevisão integrativa da literatura, realizada na Biblioteca Virtualem Saúde, durante o mês de julho de 2013, constituída por 7artigos científicos. Resultados: Os artigos originaisprevaleceram sobre as pesquisas bibliográficas e aEnfermagem foi a área que mais contribuiu com tais estudos.Da análise emergiram duas categorias: A garantia e aefetivação dos direitos do idoso em saúde e O cumprimentodos direitos em saúde do idoso: um desafio para osprofissionais da área, nas quais os autores enfatizam odesconhecimento dos profissionais, da família e do próprioidoso sobre seus direitos, e em especial no âmbito da saúde,bem como a falta de divulgação destes perante a sociedade.Conclusão: O desconhecimento e a falta de informação dosdireitos da pessoa idosa contribuem para o não cumprimentodaquilo que lhe é assegurado por lei, dificultando a suareivindicação...

Objective: To identify the knowledge produced in the nationalliterature of recent years about the health rights of the elderlypopulation. Material and Methods: This was an integrativeliterature review carried out in the Virtual Health Library duringthe month of July 2013, consisting of 7 scientific articles.Results: According to the literature searches, there was apredominance of original articles and nursing was the areathat most contributed to such studies. Two categories resultedfrom the analysis: The assurance and implementation of healthrights for the elderly, and the compliance with their healthrights; this is a challenge for professionals working in thisfield, in which, according to the authors, there is ignoranceof professionals, family and the elderly themselves abouttheir rights, as well as failure to disclose these rights tosociety. Conclusion: The lack of knowledge and informationof the elderly’s rights contribute to the non-fulfillment of whatis already assured by law, making it difficult to claim...