Randomized self-controlled study comparing open-face vs. closed immobilization masks in fractionated cranial radiotherapy.

PURPOSE: To compare patient discomfort and immobilisation performance of open-face and closed immobilization masks in cranial radiotherapy. MATERIAL AND METHODS: This was a single-center randomized self-controlled clinical trial. At CT simulation, an open-face and closed mask was made for each patient and treatment plans with identical dose prescription were generated for each mask. Patients were randomised to start treatment with an open-face or closed mask. Masks were switched halfway through the treatment course; every patient was their own control. Patients self-reported discomfort, anxiety and pain using the visual analogue scale (VAS). Inter- and intrafraction set-up variability was measured with planar kV imaging and a surface guided radiotherapy (SGRT) system for the open-face masks. RESULTS: 30 patients with primary or metastatic brain tumors were randomized - 29 completed radiotherapy to a median total dose of 54 Gy (range 30-60 Gy). Mean discomfort VAS score was significantly lower with open-face masks (0.5, standard deviation 1.0) vs. closed masks (3.3, standard deviation 2.9), P < 0.0001. Anxiety and pain VAS scores were significantly lower with open-face masks (P < 0.0001). Closed masks caused more discomfort in infraorbital (P < 0.001) and maxillary (P = 0.02) areas. Two patients and 27 patients preferred closed or open-face masks, respectively. Interfraction longitudinal shifts and roll and yaw rotations were significantly smaller and lateral shifts were significantly larger with closed masks in combination with the laser system (P < 0.05) compared to open masks in combination with a SGRT system. Intrafraction variability did not differ between the masks. CONCLUSIONS: Open-face masks are associated with decreased patient discomfort without compromising patient positioning and immobilisation accuracy.

Distance to isocenter is not associated with an increased risk for local failure in LINAC-based single-isocenter SRS or SRT for multiple brain metastases.

PURPOSE: To evaluate the impact of the distance between treatment isocenter and brain metastases on local failure in patients treated with a frameless linear-accelerator-based single-isocenter volumetric modulated arc (VMAT) SRS/SRT for multiple brain metastases. METHODS AND MATERIALS: Patients treated with SRT for brain metastases (BM) between April 2014 and May 2019 were included in this retrospective study. BM treated with a single-isocenter multiple-target (SIMT) SRT were evaluated for local recurrence-free intervals in dependency to their distance to the treatment isocenter. A Cox-regression model was used to investigate different predictor variables for local failure. Results were compared to patients treated with a single-isocenter-single-target (SIST) approach. RESULTS: In total 315 patients with a cumulative number of 1087 BM were analyzed in this study of which 140 patients and 708 BM were treated with SIMT SRS/SRT. Median follow-up after treatment was 13.9 months for SIMT approach and 11.9 months for SIST approach. One-year freedom from local recurrence was 87% and 94% in the SIST and SIMT group, respectively. Median distance to isocenter (DTI) was 4.7 cm (range 0.2-10.5) in the SIMT group. Local recurrence-free interval was not associated with the distance to the isocenter in univariable or multivariable Cox-regression analysis. Multivariable analysis revealed only volume as an independent significant predictor for local failure (p-value <0.05). CONCLUSION: SRS/SRT using single-isocenter VMAT for multiple targets achieved high local metastases control rates irrespective of distance to the isocenter, supporting efficacy of single-isocenter stereotactic radiation therapy for multiple brain metastases.

Comparison of beam segment versus full plan re-optimization in daily magnetic resonance imaging-guided online-adaptive radiotherapy.

The optimal approach for magnetic resonance imaging-guided online adaptive radiotherapy is currently unknown and needs to consider patient on-couch time constraints. The aim of this study was to compare two different plan optimization approaches. The comparison was performed in 238 clinically applied online-adapted treatment plans from 55 patients, in which the approach of re-optimization was selected based on the physician's choice. For 33 patients where both optimization approaches were used at least once, the median treatment planning dose metrics of both target and organ at risk differed less than 1%. Therefore, we concluded that beam segment weight optimization was chosen adequately for most patients without compromising plan quality.

Treatment plan quality during online adaptive re-planning.

BACKGROUND: Online adaptive radiotherapy is intended to prevent plan degradation caused by inter-fractional tumor volume and shape changes, but time limitations make online re-planning challenging. The aim of this study was to compare the quality of online-adapted plans to their respective reference treatment plans. METHODS: Fifty-two patients treated on a ViewRay MRIdian Linac were included in this retrospective study. In total 238 online-adapted plans were analyzed, which were optimized with either changing of the segment weights (n = 85) or full re-optimization (n = 153). Five different treatment sites were evaluated: prostate, abdomen, liver, lung and pelvis. Dosimetric parameters of gross tumor volume (GTV), planning target volume (PTV), 2 cm ring around the PTV and organs at risk (OARs) were considered. The Wilcoxon signed-rank test was used to assess differences between online-adapted and reference treatment plans, p < 0.05 was considered significant. RESULTS: The average duration of the online adaptation, consisting of contour editing, plan optimization and quality assurance (QA), was 24 ± 6 min. The GTV was slightly larger (average ± SD: 1.9% ± 9.0%) in the adapted plans than in the reference plans (p < 0.001). GTV-D95% exhibited no significant changes when considering all plans, but GTV-D2% increased by 0.40% ± 1.5% on average (p < 0.001). There was a very small yet significant decrease in GTV-coverage for the abdomen plans. The ring Dmean increased on average by 1.0% ± 3.6% considering all plans (p < 0.001). There was a significant reduction of the dose to the rectum of 4.7% ± 16% on average (p < 0.001) for prostate plans. CONCLUSIONS: Dosimetric quality of online-adapted plans was comparable to reference treatment plans and OAR dose was either comparable or decreased, depending on treatment site. However, dose spillage was slightly increased.

Dosimetric and geometric end-to-end accuracy of a magnetic resonance guided linear accelerator.

The introduction of real-time imaging by magnetic resonance guided linear accelerators (MR-Linacs) enabled adaptive treatments and gating on the tumor position. Different end-to-end tests monitored the accuracy of our MR-Linac during the first year of clinical operation. We report on the stability of these tests covering a static, adaptive and gating workflow. Film measurements showed gamma passing rates of 96.4% ± 3.4% for the static tests (five measurements) and for the two adaptive tests 98.9% and 99.99%, respectively (criterion 2%/2mm). The gated point dose measurements in the breathing phantom were 2.7% lower than in the static phantom.

Effect of the positron range of 18F, 68Ga and 124I on PET/CT in lung-equivalent materials.

PURPOSE: The aim of this study was to investigate the effect of positron range on visualization and quantification in (18)F, (68)Ga and (124)I positron emission tomography (PET)/CT of lung-like tissue. METHODS: Different sources were measured in air, in lung-equivalent foams and in water, using a clinical PET/CT and a microPET system. Intensity profiles and curves with the cumulative number of annihilations were derived and numerically characterized. RESULTS: (68)Ga and (124)I gave similar results. Their intensity profiles in lung-like foam had a peak similar to that for (18)F, and tails of very low intensity, but extending over distances of centimetres and containing a large fraction of all annihilations. For 90% recovery, volumes of interest with diameters up to 50 mm were required, and recovery within the 10% intensity isocontour was as low as 30%. In contrast, tailing was minor for (18)F. CONCLUSION: Lung lesions containing (18)F, (68)Ga or (124)I will be visualized similarly, and at least as sharp as in soft tissue. Nevertheless, for quantification of (68)Ga and (124)I large volumes of interest are needed for complete activity recovery. For clinical studies containing noise and background, new quantification approaches may have to be developed.

Identification of a shine-through artifact in the trachea with (124)I PET/CT.

UNLABELLED: The presence of (124)I in tissue near the trachea can cause a phenomenon that might be called shine-through. The effect is due to high-energy positrons that cross the air-filled trachea and annihilate at the opposite tracheal wall, incorrectly suggesting uptake at that location. METHODS: We investigated shine-through using (124)I, (68)Ga, and (18)F PET/CT scans of a neck phantom. Additionally, we evaluated (124)I studies of 29 patients with differentiated thyroid cancer who underwent imaging for postsurgical staging. RESULTS: In the phantom studies with a 0.1-mL (124)I source, the relative intensity of shine-through decreased from 7% to nearly zero when the thickness of the positron-stopping layer was increased from 0.3 to 3.85 mm. In patients, shine-through was observed in 5 of the 29 studies, with intensities between 0.7% and 14%. CONCLUSION: Shine-through appears rather common in differentiated thyroid cancer. Recognition is important for identification of real lesions, calculation of uptake, and dosimetry.

Comparison of sentinel gamma probes for 99mTc breast cancer surgery based on NEMA NU3-2004 standard.

PURPOSE: Hand-held gamma-probes are used for the identification of the sentinel node location during intra-operative radio-guided surgeries. Various gamma-probes, which use different detectors, collimation and electronics, are available on the market. Spatial resolution, sensitivity and angular resolution of the probes are believed to be determinant for the success of the identification of the sentinel node during radiosurgery. MATERIALS AND METHODS: We compared the above-mentioned performances of sentinel probes from six manufacturers available in the European market by means of the NEMA NU3-2004 standard, which allows the users to evaluate the probes during a situation which mimics a intra-operative radio-guided surgery. RESULTS AND CONCLUSION: This study presents a summary of characteristics to be expected when using the tested gamma-probes during intra-operative radio-guided surgeries, with particular emphasis on breast cancer sentinel node surgery. The results from this study can be used as the guidance for the selection of a sentinel lymph node probe.

Dopamine release in human ventral striatum and expectation of reward.

Using the ability of [11C]raclopride to compete with dopamine for D(2)/D(3) receptors, we investigated by positron emission tomography the effect of placebo (saline) injection on dopamine release in the ventral striatum of patients with Parkinson's disease. We found evidence for placebo-induced dopamine release of similar magnitude to that reported in healthy volunteers after amphetamine administration. However, in contrast to the dorsal striatum, there were no differences in [11C]raclopride binding potential changes between patients who experienced the reward (those who reported placebo-induced clinical benefit) and those who did not. We conclude that the release of dopamine in the ventral striatum (nucleus accumbens) is related to the expectation of reward and not to the reward itself. These observations have potential implications for the treatment of drug addiction.