Stereotactic Body Radiation Therapy for Gynecologic Malignancies: A Case-Based Radiosurgery Society Practice Review.

PURPOSE: The use of stereotactic body radiation therapy (SBRT) for gynecologic malignancies is controversial. We discuss certain circumstances when highly precise SBRT may be a useful tool to consider in the management of selected patients. METHODS AND MATERIALS: Case selection included the following scenarios, the first 2 with palliative intent, para-aortic nodal oligorecurrence of ovarian cancer, pelvic sidewall oligorecurrence of cervical cancer, and inoperable endometrial cancer boost after intensity modulated radiation to the pelvis treated with curative intent. Patient characteristics, fractionation, prescription dose, treatment technique, and dose constraints were discussed. Relevant literature to these cases was summarized to provide a framework for treatment of similar patients. RESULTS: Treatment of gynecologic malignancies with SBRT requires many considerations, including treatment intent, optimal patient selection, fractionation selection, tumor localization, and plan optimization. Although other treatment paradigms including conventionally fractionated radiation therapy and brachytherapy remain the standard-of-care for definitive treatment of gynecologic malignancies, SBRT may have a role in palliative cases or those where high doses are not required due to the unacceptable toxicity that may occur with SBRT. CONCLUSIONS: A case-based practice review was developed by the Radiosurgery Society to provide a practical guide to the common scenarios noted above affecting patients with gynecologic malignancies.

Comparison of Tumor Bed Delineation Using a Novel Radiopaque Filament Marker Versus Surgical Clips for Targeting Breast Cancer Radiotherapy.

BACKGROUND: Accuracy of tumor bed (TB) delineation is essential for targeting boost doses or partial breast irradiation. Multiple studies have shown high interobserver variability with standardly used surgical clip markers (CMs). We hypothesize that a radiopaque filament marker (FM) woven along the TB will improve TB delineation consistency. METHODS: An FDA-approved FM was intraoperatively used to outline the TB of patients undergoing lumpectomy. Between January 2020 and January 2022, consecutive patients with FM placed after either (1) lumpectomy or (2) lumpectomy with oncoplastic reconstruction were identified and compared with those with CM. Six "experts" (radiation oncologists specializing in breast cancer) across 2 institutions independently defined all TBs. Three metrics (volume variance, dice coefficient, and center of mass [COM] deviation). Two-tailed paired samples t tests were performed to compare FM and CM cohorts. RESULTS: Twenty-eight total patients were evaluated (14 FM and 14 CM). In aggregate, differences in volume between expert contours were 29.7% (SD ± 58.8%) with FM and 55.4% (SD ± 105.9%) with CM ( P < 0.001). The average dice coefficient in patients with FM was 0.54 (SD ± 0.15), and with CM was 0.44 (SD ± 0.22) ( P < 0.001). The average COM deviation was 0.63 cm (SD ± 0.53 cm) for FM and 1.05 cm (SD ± 0.93 cm) for CM; ( P < 0.001). In the subset of patients who underwent lumpectomy with oncoplastic reconstruction, the difference in average volume was 21.8% (SD ± 20.4%) with FM and 52.2% (SD ± 64.5%) with CM ( P <0.001). The average dice coefficient was 0.53 (SD ± 0.12) for FM versus 0.39 (SD ± 0.24) for CM ( P < 0.001). The average COM difference was 0.53 cm (SD ± 0.29 cm) with FM versus 1.25 cm (SD ± 1.08 cm) with CM ( P < 0.001). CONCLUSION: FM consistently outperformed CM in the setting of both standard lumpectomy and complex oncoplastic reconstruction. These data suggest the superiority of FM in TB delineation.

Disparities in Radiation Therapy: Practice Patterns Analysis of Deep Inspiratory Breath Hold Use in Non-English Speakers.

PURPOSE: Our purpose was to examine current practice patterns in non-English-speaking patients with breast cancer undergoing deep inspiratory breath hold (DIBH). METHODS AND MATERIALS: An anonymous, voluntary REDCap survey was distributed to 60 residency program coordinators of US radiation oncology departments to survey their faculty and recent graduates. Eligibility was limited to board-certified radiation oncologists who had treated breast cancer within the prior 6 months. RESULTS: There were 69 respondents, 53 of whom were eligible. Forty-two percent (n = 22) of eligible respondents were from the main site at an academic center, with 28% (n = 15) representing a satellite site and 30% (n = 16) from private practice. Fifty-three percent reported at least 10% of their patients were non-English speaking. Ninety percent offered DIBH at their institution; of those, 74% used DIBH for at least one-fourth of their patients with breast cancer. Ninety-eight percent of those who use DIBH performed coaching at simulation, with 32% answering they would be "less likely" to use DIBH for non-English speakers. When used, 94% take into consideration potential language barriers for proper execution of DIBH. However, 51% had an interpreter present 76% to 100% of the time at computed tomography simulation, which decreased to 31% at first fraction and 11% at subsequent treatments. For non-English-speaking patients undergoing DIBH coaching without a certified interpreter, 55% of respondents indicated that they provided verbal coaching in English, 32% indicated "not applicable" because they always use a certified interpreter, 11% used visual aids, and 32% indicated "other." Of those who answered "other," the most commonly cited response was using therapists or staff who spoke the patient's native language. CONCLUSIONS: Disparities in the application of DIBH exist despite its established utility in reducing cardiac dose. This study provides evidence that language barriers may affect physician treatment practices from initial consideration of DIBH to subsequent delivery. These data suggest that breast cancer treatment considerations and subsequent execution are negatively affected in non-English-speaking patients.

Development of large-scale microalgae production in the Middle East.

Microalgae in the Middle East can theoretically address food security without competing for arable land, but concerns exist around scalability and durability of production systems under the extreme heat. Large-scale Chlorella sorokiniana production was developed in outdoor raceway ponds in Oman and monitored for 2 years to gather data for commercial production. Biological and technical challenges included construction, indoor/outdoor preculturing, upscaling, relating productivity to water temperature and meteorological conditions, harvesting, drying, and quality control. Small cultivation systems required cooling for initial scale-up, but, despite maximum temperatures of 49.7 °C, water temperatures were at acceptable levels by evaporative cooling in larger raceway ponds. Contamination with Vampirovibrio chlorellavorus was identified by 16S rDNA amplicon sequencing and addressed by culture replacement. Productivities ranged from 8 to 30 g-dry weight m-2d-1, with estimated annual productivity of 16 g-dry weight m-2d-1 as functions of solar intensity and water temperature, confirming that the region is suitable for commercial microalgae production.

Reanimating the Body: Comics Creation as an Embodiment of Life with Cancer.

Cancer is regarded as a disease that redefines an individual's life and relationships. The medicalization and reclamation of the individual's sense of body, self, and social life have been long examined by psychiatry and anthropology alike. We argue that creating comics is a form of artistic narrative that affirms and proclaims the existence of a past and future possibilities for individuals diagnosed with cancer. Despite the interconnections among lived experience and meaning making, little attention has been paid to the potential therapeutic effects of comics creation. Individuals diagnosed with cancer were recruited for ten weekly comics making workshops. Data include qualitative interviews and workshop observations. Six women who were diagnosed with cancer consented to participate. Meaning making themes included (1) slowing down to process their experiences, (2) expressing frustration with medical encounters, and (3) reflecting on traumatic relationships. The process of redefining their cancer experience connects the sufferer's individual and social context. We find that the physical act of 'making' comics works to create meaning and an embodied expression of meaning. Creating comics, for our participants, offered multiple entry points and perspectives for redefining their stories that provided new insights and paths to explore their medical traumas and reanimating their bodies.

Eliminating Daily Shifts, Tattoos, and Skin Marks: Streamlining Isocenter Localization With Treatment Plan Embedded Couch Values for External Beam Radiation Therapy.

PURPOSE: The Radiation Oncology Incident Learning System demonstrated that incorrect or omitted patient shifts during treatment are common near-misses or incidents. This single pediatric hospital quality improvement experience evaluated a markless isocenter localization workflow to improve safety and streamline treatment, obviating the need for daily shifts. METHODS AND MATERIALS: Patients undergoing radiation therapy were simulated and treated with indexed immobilization devices. User origins were established at simulation based on a limited set of fixed couch-top references. In treatment planning, shifts from the user origin to the planned isocenter were converted to absolute couch parameters and embedded in the setup field parameters. Thus, the first fraction did not require any shifts. Before kilovoltage imaging, setup verification was often supplemented with surface-guided imaging. After image guidance and final couch adjustments, couch parameters could be reacquired and used for subsequent treatments. No skin marks were used. RESULTS: Over 3 years, approximately 300 patients were treated with over 5000 treatment fractions using this workflow. There were no wrong-site treatment errors. Approximately a dozen near-miss events related to the daily setup process occurred, largely on the first treatment. Root-cause analysis attributed errors to user origin misidentification, couch parameter miscalculation, incorrect immobilization device use, and immobilization device indexed at the wrong indexing position. Skin marks and tattoos were unnecessary. Continuous quality improvement added additional quality assurance checks, resulting in no near-miss incidents or adverse events in the preceding 12 months. CONCLUSION: We minimized near-miss incidents by using limited simulation user origins, converting user origin-to-isocenter shifts to absolute couch parameters, and enforcing restrictive tolerance tables to limit delivery parameter changes, coupled with surface guidance and quality assurance tools. This technique can be applied across institutions, age ranges, and tumor types and with or without surface guidance. This workflow has removed a common treatment setup error and the need for skin marks.

Large Vaginal Varicosities in the Setting of Pregnancy without Known Hepatic or Vascular Risks: A Case Report and Review of the Literature.

Pregnancy may cause the onset of vaginal or vulvar varicosities that may be a concern for hemorrhage risk during childbirth. A 38-year-old female G4P1112 at 34 weeks and 1 day was referred to an outpatient OB/Gyn clinic for evaluation of a large vaginal mass. The referring provider had concern for malignancy. Lesions of the vulva were biopsied and found to be benign. For two months prior to presentation, she was experiencing discomfort with walking, yellow vaginal discharge, and dysuria. Treatment with fluconazole showed no improvement. She denied any personal or family history of malignancies, varicosities, or hepatic issues. Past surgical history was significant for laparoscopic cholecystectomy and two cesarean sections. A large vaginal mass during pregnancy is a concern whether it is malignancy or large vaginal varicosities that may put the patient at risk of severe hemorrhage during childbirth. We concluded that the mass was large vaginal varicosities as there was no discernible etiology. A repeat cesarean section was recommended due to the risk of hemorrhage during childbirth. For long-term management, close observation postpartum was recommended. Spontaneous resolution is a potential outcome and this is what our patient experienced. Without an underlying etiology, supportive measures are the best options.