Dosimetric evaluation of VMAT and helical tomotherapy techniques comparing conventional volumes with clinical target volumes based on new ESTRO ACROP post-mastectomy with immediate implant reconstruction contouring guidelines.

BACKGROUND: The ESTRO-ACROP Consensus Guideline (EACG) recommends implant excluded clinical target volume (CTVp) definitions for post-mastectomy radiation therapy after implant-based immediate breast reconstruction (IBR). The purpose of this study is to investigate the effectiveness of Helical Tomotherapy (HTp) and Volumetric Modulated Arc Therapy (VMATp) treatment techniques in terms of CTVp coverage and reduced organ at risk (OAR), normal tissue and implant doses when CTVp was used for treatment planning as the target structure instead of conventional CTV. METHODS: Eight left-sided and eight right-sided breast cancer patients who underwent IBR after mastectomy were included in this study. Planning CT data sets were acquired during free breathing and patients were treated with HT technique targeted to conventional CTV. Retrospectively, CTVp was delineated based on EACG by the same radiation oncologist, and treatment plans with HTp and VMATp techniques were generated based on CTVp. For each patient, relevant dosimetric parameters were obtained from three different treatment plans. RESULTS: There was no statistically significant difference on target coverage in terms of, PTVp-D95, PTVp-Vpres, homogeneity index (p > 0.05) between HTp and VMATp plans. But, the conformity numbers were significantly higher (HTp vs VMATp, 0.69 ± 0.15 vs 0.79 ± 0.12) for VMATp (Z = - 2.17, p = 0.030). While HTp significantly lowered Dmax and Dmean for LAD (LAD-Dmax: χ2 = 12.25, p = 0.002 and LAD-Dmean: χ2 = 12.30, p = 0.002), neither HTp nor VMATp could reduce maximum and mean dose to heart (p > 0.05). Furthermore, heart volume receiving 5 Gy was significantly higher for VMATp when compared to HTp (21.2 ± 9.8 vs 42.7 ± 24.8, p: 0.004). Both techniques succeeded in reducing the mean dose to implant (HTp vs HT, p < 0.001; VMATp vs HT, p < 0.001; VMATp vs HTp, p = 0.005). CONCLUSION: Both HTp and VMATp techniques succeeded to obtain conformal and homogeneous dose distributions within CTVp while reducing the mean implant dose. HTp was found to be superior to VMATp with regards to lowering all OAR doses except for CB.

Limited field adaptive radiotherapy for glioblastoma: changes in target volume and organ at risk doses.

OBJECTIVE: This study aimed to investigate the tumor volume changes occurring during limited-field radiotherapy (RT) for glioblastoma patients and whether a volume-adapted boost planning approach provided any benefit on tumor coverage and normal tissue sparing. MATERIALS AND METHODS: Twenty-four patients underwent simulation with magnetic resonance (MR) and computed tomography (CT) scans prior to RT (MR_initial, CT_initial) and boost treatment (MR_adapt, CT_adapt). For the boost phase, MR_initial and MR_adapt images were used to delineate GTV2 and GTV2_adapt, respectively. An initial boost plan (Plan_initial) created on CT_initial for PTV2 was then reoptimized on CT_adapt by keeping the same optimization and normalization values. Plan_adapt was generated on CT_adapt for PTV2_adapt volume. Dose volume histogram parameters for target volumes and organs-at-risk were compared using these boost plans generated on CT_adapt. Plan_initial and Plan_adaptive boost plans were summed with the first phase plan and the effect on the total dose was investigated. RESULTS: Target volume expansion was noted in 21% of patients while 79% had shrinkage. The average difference for the initial and adaptive gross tumor volume (GTV), clinical target volume (CTV), and planning target volume (PTV) volumes were statistically significant. Maximum dose differences for brainstem and optic chiasm were significant. Healthy brain tissue V10 and ipsilateral optic nerve maximum doses were found to decrease significantly in Plan_adaptive. CONCLUSION: Results of this study confirm occurrence of target volume changes during RT for glioblastoma patients. An adaptive plan can provide better normal tissue sparing for patients with lesion shrinkage and avoid undercoverage of treatment volumes in case of target volume expansion especially when limited-fields are used.

Does radiotherapy planning without breath control compensate intra-fraction heart and its compartments' movement?

This prospective study investigated radiation dose and volume changes during breathing cycle. Ten patients with left breast carcinoma receiving radiotherapy were included. Treatment planning images were obtained as three different sets of series taken: without breath control (F), deep inspiration (I), and end of expiration (E), with 3-mm intervals. As such, whole breath cycle was simulated. CT images taken during I and E were registered to F, according to DICOM coordinates. Each patient's target and organ at risk volumes were contoured by the primary radiation oncologist except heart components which were contoured by radiologist on F, I and E series. Radiotherapy planning was done on F series, then planning and beam data were transferred from F to I and E image series. Target and organs at risk (OAR) dose distributions for E and I image series were obtained. Dose changes between F, E, and I phases for whole heart and components, namely, left ventricle (LV), right ventricle (RV), left auricle (LA), right auricle (RA), and left anterior descendent artery (LAD) were examined. Furthermore, the issue of any compartment representing the maximum heart dose was investigated. Volume and dose variations for heart, LV, RV, LA, RA, and LAD were observed during breath cycle. Exposured dose was more than defined tolerance level for LV, RV, and LAD in some patients. However, dose differences between F-I and F-E were not statistically significant. Radiotherapy planning without breath control is not capable of compensating for whole intra-fraction heart and its components' volumes and dose changes.

The effect of glutamine on radiation-induced organ damage.

Radiation enteritis is a significant clinical problem in patients receiving ionizing radiation directed to the abdomen or pelvis. Although radiation is aimed to be directed against the malignant tissue, adjacent healthy tissues are also affected. The small intestine is the most sensitive organ to radiation. The present study was undertaken to investigate the possible protective effect of glutamine against radiation-induced intestinal, hepatic and pancreatic toxicity. Rats received 1 g/kg/day glutamine for seven days before irradiation and continued for three days after irradiation until sacrifice. Then intestinal, pancreatic and hepatic myeloperoxidase (MPO) activities, malondialdehyde (MDA) levels and caspase-3 activities of the sacrificed rats were measured. Irradiation significantly increased the intestinal and pancreatic MPO and caspase-3 activities and MDA levels in comparison to sham group. Glutamine treatment significantly decreased this elevation. Histopathological examination revealed that the intestinal mucosal structure was preserved and pancreatic inflammation decreased in the glutamine treated group. In irradiation group, NF-kappaB over expression was detected. There was no significant difference in histopathological and biochemical examinations of the liver between the groups. In conclusion, glutamine has beneficial effects on intestinal and pancreatic damage in abdominal irradiation through the inflammatory process and apoptosis.