Radiation treatment planning study to investigate feasibility of delivering Immunotherapy in Combination with Ablative Radiosurgery to Ultra-High DoSes (ICARUS).

PURPOSE: Immune checkpoint inhibitors improve survival in metastatic diseases for some cancers. Multisite SBRT with pembrolizumab (SBRT + Pembro) was shown to be safe with promising local control using biologically effective doses (BEDs) = 95-120 Gy. Increased BED may improve response rate; however, SBRT doses are limited by surrounding organs at risk (OARs). The purpose of this work was to develop and validate methods for safe delivery of ultra-high doses of radiation (BED10  > 300) to be used in future clinical trials. METHODS AND MATERIALS: The radiation plans from 15 patients enrolled on a phase I trial of SBRT + pembro were reanalyzed. Metastatic disease sites included liver (8/15), inguinal region (1/15), pelvis (2/15), lung (1/15), abdomen (1/15), spleen (1/15), and groin (1/15). Gross tumor volumes (GTVs) ranged from 80 to 708 cc. Following the same methodology used in the Phase I trial on which these patients were treated, GTVs > 65 cc were contracted to a 65 cc subvolume (SubGTV) resulting in only a portion of the GTV receiving prescription dose. Volumetric modulated arc therapy (VMAT) was used to plan treatments BED10  = 360 Gy. Plans utilizing both 6FFF and 10FFF beams were compared to clinical plans delivering BED10  = 112.50 Gy. The target primary goal was V100% > 95% with a secondary goal of V70% > 99% and OAR objectives per the trial. To demonstrate feasibility, plans were delivered to a diode array phantom and evaluated for fidelity using gamma analysis. RESULTS: All 30 plans met the secondary coverage goal and satisfied all OAR constraints. The primary goal was achieved in 12/15 of the 6FFF plans and 13/15 of the 10FFF plans. Average gamma analysis passing rate using criteria of 3% dose difference and 3, 2, and 1 mm were 99.1  ±  1.0%, 98.5  ±  1.6%, and 95.1  ±  3.8%, respectively. CONCLUSION: Novel VMAT planning approaches with clinical treatment planning software and linear accelerators prove capable of delivering radiation doses in excess of 360 Gy BED10 to tumor subvolumes, while maintaining safe OAR doses.

Utilizing the TrueBeam Advanced Imaging Package to monitor intrafraction motion with periodic kV imaging and automatic marker detection during VMAT prostate treatments.

BACKGROUND: Fiducial markers are frequently used before treatment for image-guided patient setup in radiation therapy (RT), but can also be used during treatment for image-guided intrafraction motion detection. This report describes our implementation of automatic marker detection with periodic kV imaging (TrueBeam v2.5) to monitor and correct intrafraction motion during prostate RT. METHODS: We evaluated the reproducibility and accuracy of software fiducial detection using a phantom with 3 implanted fiducial markers. Clinical implementation for patients with intraprostatic fiducials receiving volumetric modulated arc therapy (VMAT) utilized periodic on-board kV imaging with 10 s intervals during treatment delivery. For each image, the software automatically identified fiducial locations and determined whether their distance relative to planned locations were within a 3 mm tolerance. Motion was corrected if either ≥2 fiducials in a single image or ≥1 fiducial in sequential images were out of tolerance. RESULTS: Phantom studies demonstrated poorer performance of linear fiducials compared to collapsible fiducials, and wide variability to accurately detect fiducials across eight software settings. For any given setting, results were relatively reproducible and precise to ~0.5 mm. Across 17 patients treated with a median of 20 fractions, the software recommended a shift in 44% of fractions, and a shift was actually implemented after visual confirmation of movement greater than the 3 mm threshold in 20% of fractions. Adjustment of our approach led to improved accuracy for the latter (n = 7) patient subset. On average, table repositioning added 3.0 ± 0.3 min to patient time on table. Periodic kV imaging increased skin dose by an estimated 1 cGy per treatment arc. CONCLUSIONS: Periodic kV imaging with automatic detection of motion during VMAT prostate treatments is commercially available, and can be successfully implemented to mitigate effects of intrafraction motion with careful attention to software settings.

Axial vibrations of brass wind instrument bells and their acoustical influence: Experiments.

It has recently been proposed that the effects of structural vibrations on the radiated sound of brass wind instruments may be attributable to axial modes of vibration with mode shapes that contain no radial nodes [Kausel, Chatziioannou, Moore, Gorman, and Rokni, J. Acoust. Soc. Am. 137, 3149-3162 (2015)]. Results of experiments are reported that support this theory. Mechanical measurements of a trumpet bell demonstrate that these axial modes do exist in brass wind instruments. The quality factor of the mechanical resonances can be on the order of 10 or less, making them broad enough to encompass the frequency range of previously reported effects attributed to bell vibrations. Measurements of the input impedance show that damping bell vibrations can result in impedance changes of up to 5%, in agreement with theory. Measurements of the acoustic transfer function demonstrate that the axial vibrations couple to the internal sound field as proposed, resulting in changes in the transfer function of approximately 1 dB. In agreement with theory, a change in the sign of the effect is observed at the frequency of the structural resonance.

Axial vibrations of brass wind instrument bells and their acoustical influence: Theory and simulations.

Previous work has demonstrated that structural vibrations of brass wind instruments can audibly affect the radiated sound. Furthermore, these broadband effects are not explainable by assuming perfect coincidence of the frequency of elliptical structural modes with air column resonances. In this work a mechanism is proposed that has the potential to explain the broadband influences of structural vibrations on acoustical characteristics such as input impedance, transfer function, and radiated sound. The proposed mechanism involves the coupling of axial bell vibrations to the internal air column. The acoustical effects of such axial bell vibrations have been studied by extending an existing transmission line model to include the effects of a parasitic flow into vibrating walls, as well as distributed sound pressure sources due to periodic volume fluctuations in a duct with oscillating boundaries. The magnitude of these influences in typical trumpet bells, as well as in a complete instrument with an unbraced loop, has been studied theoretically. The model results in predictions of input impedance and acoustical transfer function differences that are approximately 1 dB for straight instruments and significantly higher when coiled tubes are involved or when very thin brass is used.