Patterns of CT lung injury and toxicity after stereotactic radiotherapy delivered with helical tomotherapy in early stage medically inoperable NSCLC.

OBJECTIVE: To evaluate toxicity and patterns of radiologic lung injury on CT images after hypofractionated image-guided stereotactic body radiotherapy (SBRT) delivered with helical tomotherapy (HT) in medically early stage inoperable non-small-cell lung cancer (NSCLC). METHODS: 28 elderly patients (31 lesions) with compromised pulmonary reserve were deemed inoperable and enrolled to undergo SBRT. Patterns of lung injury based on CT appearance were assessed at baseline and during follow up. Acute (6 months or less) and late (more than 6 months) events were classified as radiation pneumonitis and radiation fibrosis (RF), respectively. RESULTS: After a median follow-up of 12 months (range, 4-20 months), 31 and 25 lesions were examined for acute and late injuries, respectively. Among the former group, 25 (80.6%) patients showed no radiological changes. The CT appearance of RF revealed modified conventional, mass-like and scar-like patterns in three, four and three lesions, respectively. No evidence of late lung injury was demonstrated in 15 lesions. Five patients developed clinical pneumonitis (four patients, grade 2 and one patient, grade 3, respectively), and none of whom had CT findings at 3 months post-treatment. No instance of symptomatic RF was detected. The tumour response rate was 84% (complete response + partial response). Local control was 83% at 1 year. CONCLUSION: Our findings show that HT-SBRT can be considered an effective treatment with a mild toxicity profile in medically inoperable patients with early stage NSCLC. No specific pattern of lung injury was demonstrated. ADVANCES IN KNOWLEDGE: Our study is among the few showing that HT-SBRT represents a safe and effective option in patients with early stage medically inoperable NSCLC, and that it is not associated with a specific pattern of lung injury.

Comparison of IMRT planning with two-step and one-step optimization: a strategy for improving therapeutic gain and reducing the integral dose.

The aim of this study was to evaluate the effectiveness and efficiency in inverse IMRT planning of one-step optimization with the step-and-shoot (SS) technique as compared to traditional two-step optimization using the sliding windows (SW) technique. The Pinnacle IMRT TPS allows both one-step and two-step approaches. The same beam setup for five head-and-neck tumor patients and dose-volume constraints were applied for all optimization methods. Two-step plans were produced converting the ideal fluence with or without a smoothing filter into the SW sequence. One-step plans, based on direct machine parameter optimization (DMPO), had the maximum number of segments per beam set at 8, 10, 12, producing a directly deliverable sequence. Moreover, the plans were generated whether a split-beam was used or not. Total monitor units (MUs), overall treatment time, cost function and dose-volume histograms (DVHs) were estimated for each plan. PTV conformality and homogeneity indexes and normal tissue complication probability (NTCP) that are the basis for improving therapeutic gain, as well as non-tumor integral dose (NTID), were evaluated. A two-sided t-test was used to compare quantitative variables. All plans showed similar target coverage. Compared to two-step SW optimization, the DMPO-SS plans resulted in lower MUs (20%), NTID (4%) as well as NTCP values. Differences of about 15-20% in the treatment delivery time were registered. DMPO generates less complex plans with identical PTV coverage, providing lower NTCP and NTID, which is expected to reduce the risk of secondary cancer. It is an effective and efficient method and, if available, it should be favored over the two-step IMRT planning.

Role of the parameters involved in the plan optimization based on the generalized equivalent uniform dose and radiobiological implications.

We investigated the role and the weight of the parameters involved in the intensity modulated radiation therapy (IMRT) optimization based on the generalized equivalent uniform dose (gEUD) method, for prostate and head-and-neck plans. We systematically varied the parameters (gEUDmax and weight) involved in the gEUD-based optimization of rectal wall and parotid glands. We found that the proper value of weight factor, still guaranteeing planning treatment volumes coverage, produced similar organs at risks dose-volume (DV) histograms for different gEUDmax with fixed a=1. Most of all, we formulated a simple relation that links the reference gEUDmax and the associated weight factor. As secondary objective, we evaluated plans obtained with the gEUD-based optimization and ones based on DV criteria, using the normal tissue complication probability (NTCP) models. gEUD criteria seemed to improve sparing of rectum and parotid glands with respect to DV-based optimization: the mean dose, the V40 and V50 values to the rectal wall were decreased of about 10%, the mean dose to parotids decreased of about 20-30%. But more than the OARs sparing, we underlined the halving of the OARs optimization time with the implementation of the gEUD-based cost function. Using NTCP models we enhanced differences between the two optimization criteria for parotid glands, but no for rectum wall.

Monte Carlo dose calculations using MCNP4C and EGSnrc/BEAMnrc codes to study the energy dependence of the radiochromic film response to beta-emitting sources.

The energy dependence of the radiochromic film (RCF) response to beta-emitting sources was studied by dose theoretical calculations, employing the MCNP4C and EGSnrc/BEAMnrc Monte Carlo codes. Irradiations with virtual monochromatic electron sources, electron and photon clinical beams, a (32)P intravascular brachytherapy (IVB) source and other beta-emitting radioisotopes ((188)Re, (90)Y, (90)Sr/(90)Y,(32)P) were simulated. The MD-55-2 and HS radiochromic films (RCFs) were considered, in a planar or cylindrical irradiation geometry, with water or polystyrene as the surrounding medium. For virtual monochromatic sources, a monotonic decrease with energy of the dose absorbed to the film, with respect to that absorbed to the surrounding medium, was evidenced. Considering the IVB (32)P source and the MD-55-2 in a cylindrical geometry, the calibration with a 6 MeV electron beam would yield dose underestimations from 14 to 23%, increasing the source-to-film radial distance from 1 to 6 mm. For the planar beta-emitting sources in water, calibrations with photon or electron clinical beams would yield dose underestimations between 5 and 12%. Calibrating the RCF with (90)Sr/(90)Y, the MD-55-2 would yield dose underestimations between 3 and 5% for (32)P and discrepancies within +/-2% for (188)Re and (90)Y, whereas for the HS the dose underestimation would reach 4% with (188)Re and 6% with (32)P.

Comparison of EPR occupational lifetime external dose assessments for Mayak nuclear workers and film badge dose data.

The Mayak worker cohort is one of the major sources of information on health risks due to protracted exposures to plutonium and external ionizing radiation. Electron paramagnetic resonance (EPR) measurements in tooth enamel in combination with personal dose monitoring can help to improve external dose assessment for this cohort. Here, the occupational lifetime external exposure was evaluated individually for 44 nuclear workers of three plants of the Mayak Production Association by EPR measurements of absorbed doses in collected tooth enamel samples. Analysis included consideration of individual background doses in enamel and dose conversion coefficients specific for photon spectra at selected work areas. As a control, background doses were assessed for various age groups by EPR measurements on teeth from non-occupationally exposed Ozyorsk residents. Differences in occupational lifetime doses estimated from the film badges and from enamel for the Mayak workers were found to depend on the type of film badge and the selected plant. For those who worked at the radiochemical processing plant and who were monitored with IFK film badges, the dose was on average 570 mGy larger than estimated from the EPR measurements. However, the average difference was found to be only -4 and 6 mGy for those who were monitored with IFKU film badges and worked at the reactor and the isotope production plant respectively. The discrepancies observed in the dose estimates are attributed to a bias in film badge evaluation.

Monte Carlo calculation and experimental verification of the photon energy response of tooth enamel in a head-sized plexiglas phantom.

The use of electron paramagnetic resonance (EPR) tooth dosimetry for calculation of organ doses requires conversion of the measured absorbed dose in enamel. Before deriving conversion factors from simulation calculations with a realistic anthropomorphic human phantom, in the current study a simplified phantom was chosen to compare EPR measurement and Monte Carlo calculation. The dose response of tooth enamel of molars at various positions inside a cylindrical Plexiglas phantom of head-size was calculated hy Monte Carlo modelling in parallel photon beams of X rays of 63 keV equivalent energy and 60Co gamma rays (1.25 Mev). For X ray exposure, preliminary results of EPR dosimetry with tooth enamel samples prepared from molars irradiated in the phantom were in agreement with calculation. The mean value of the ratio of the measured to the calculated dose was 0.93 +/- 0.08.