The purpose of this study was to evaluate setup accuracy and quantify random and systematic errors of the BrainLAB stereotactic immobilization mask and localization system using kV on‐board imaging. ...Nine patients were simulated and set up with the BrainLAB stereotactic head immobilization mask and localizer to be treated for brain lesions using single and hypofractions. Orthogonal pairs of projections were acquired using a kV on‐board imager mounted on a Varian Trilogy machine. The kV projections were then registered with digitally‐reconstructed radiographs (DRR) obtained from treatment planning. Shifts between the kV images and reference DRRs were calculated in the different directions: anterior‐posterior (A‐P), medial‐lateral (R‐L) and superior‐inferior (S‐I). If the shifts were larger than 2 mm in any direction, the patient was reset within the immobilization mask until satisfying setup accuracy based on image guidance has been achieved. Shifts as large as 4.5 mm, 5.0 mm, 8.0 mm in the A‐P, R‐L and S‐I directions, respectively, were measured from image registration of kV projections and DRRs. These shifts represent offsets between the treatment and simulation setup using immobilization mask. The mean offsets of 0.1 mm, 0.7 mm, and −1.6 mm represent systematic errors of the BrainLAB localizer in the A‐P, R‐L and S‐I directions, respectively. The mean of the radial shifts is about 1.7 mm. The standard deviations of the shifts were 2.2 mm, 2.0 mm, and 2.6 mm in A‐P, R‐L and S‐I directions, respectively, which represent random patient setup errors with the BrainLAB mask. The BrainLAB mask provides a noninvasive, practical and flexible immobilization system that keeps the patients in place during treatment. Relying on this system for patient setup might be associated with significant setup errors. Image guidance with the kV on‐board imager provides an independent verification technique to ensure accuracy of patient setup. Since the patient may relax or move during treatment, uncontrolled and undetected setup errors may be produced with patients that are not well‐immobilized. Therefore, the combination of stereotactic immobilization and image guidance achieves more controlled and accurate patient setup within 2 mm in A‐P, R‐L and S‐I directions.
PACS numbers: 87.56.‐v, 87.56.Da
In oncology trials, the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) is the standard tool for reporting adverse events (AEs), but it may underreport symptoms ...experienced by patients. This analysis of the NRG Oncology RTOG 1203 compared symptom reporting by patients and clinicians during radiotherapy (RT).
Patients with cervical or endometrial cancer requiring postoperative RT were randomly assigned to standard 4-field RT or intensity-modulated RT (IMRT). Patients completed the 6-item patient-reported outcomes version of the CTCAE (PRO-CTCAE) for GI toxicity assessing abdominal pain, diarrhea, and fecal incontinence at various time points. Patients reported symptoms on a 5-point scale. Clinicians recorded these AEs as CTCAE grades 1 to 5. Clinician- and patient-reported AEs were compared using McNemar's test for rates > 0%.
Of 278 eligible patients, 234 consented and completed the PRO-CTCAE. Patients reported high-grade abdominal pain 19.1% (
< .0001), high-grade diarrhea 38.5% (
< .0001), and fecal incontinence 6.8% more frequently than clinicians. Similar effects were seen between grade ≥ 1 CTCAE toxicity and any-grade patient-reported toxicity. Between-arm comparison of patient-reported high-grade AEs revealed that at 5 weeks of RT, patients who received IMRT experienced fewer GI AEs than patients who received 4-field pelvic RT with regard to frequency of diarrhea (18.2% difference;
= .01), frequency of fecal incontinence (8.2% difference;
= .01), and interference of fecal incontinence (8.5% difference;
= .04).
Patient-reported AEs showed a reduction in symptoms with IMRT compared with standard RT, whereas clinician-reported AEs revealed no difference. Clinicians also underreported symptomatic GI AEs compared with patients. This suggests that patient-reported symptomatic AEs are important to assess in this disease setting.
In this work, a popular additive manufacturing (AM) aluminum alloy - AlSi10Mg and a new AM aluminum alloy - AlF357 are fabricated using Laser-Powder Bed Fusion (L-PBF) approach to evaluate ...quasi-static and dynamic fracture behaviors. Four build orientations - horizontal, vertical, flat, and diagonal - are assessed. A Kolsky pressure bar apparatus along with ultrahigh speed photography is used to carry out the dynamic fracture experiments. In-plane surface displacements near cracks are measured using Digital Image Correlation (DIC) to evaluate the fracture parameters directly. A hybrid experimental-numerical approach that combines DIC measurements and finite element analysis is implemented to extract critical energy release rate and crack growth resistance behaviors. The effect of build orientation is found to be significant on the quasi-static fracture behavior with the horizontal and flat orientations having the best and worst fracture responses, respectively. Under dynamic loading conditions, however, the effects of build orientation are marginal. Both AlF357 and AlSi10Mg show strain-rate sensitivity and change in fracture mechanism under dynamic loading conditions with ~175% and ~200% increase in critical energy release rate. AlF357 consistently outperforms AlSi10Mg in both quasi-static (~30%) and dynamic (~10%) loading conditions.
To assess efficacy and toxicity of cisplatin (C) and gemcitabine (G) with intensity-modulated radiation therapy (IMRT) in patients with locally advanced vulvar cancer not amenable to surgery.
...Patients enrolled in a single-arm phase II study. Pretreatment inguinal-femoral nodal assessment was performed. Sixty-four Gy IMRT was prescribed to the vulva, with 50-64 Gy delivered to the groins/low pelvis. Radiation therapy (RT) plans were quality-reviewed pretreatment. C 40 mg/m
and G 50 mg/m
were administered once per week throughout IMRT. Complete pathologic response (CPR) was the primary end point. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and adverse events were assessed with Common Terminology Criteria for Adverse Events v 4.0.
Fifty-seven patients enrolled, of which 52 were evaluable. The median age was 58 years (range, 25-58), and 94% were White. Forty (77%) had stage II or III disease, and all had squamous histology. A median of six chemotherapy cycles (range, 1-8) were received. Eighty-five percent of RT plans were quality-reviewed with 100% compliance to protocol. Seven patients came off trial because of toxicity or patient withdrawal. Of 52 patients available for pathologic assessment, 38 (73% 90% CI, 61 to 83) achieved CPR. No pelvic exenterations were performed. With a median follow-up of 51 months, the 12-month PFS was 74% (90% CI, 62.2 to 82.7) and the 24-month OS was 70% (90% CI, 57 to 79). The most common grade 3 or 4 adverse events were hematologic toxicity and radiation dermatitis. There was one grade 5 event unlikely related to treatment.
Weekly C and G concurrent with IMRT sufficiently improved CPR in women with locally advanced vulvar squamous cell carcinoma not amenable to surgical resection.
Introduction: To review outcomes of medically inoperable patients treated with stereotactic body radiation therapy (SBRT) for multiple primary lung cancer (MPLC).
Methods: We retrospectively reviewed ...the charts of 10 patients (21 lesions) treated with SBRT for synchronous (seven), metachronous (one) or synchronous/metachronous lung cancers. All patients were male, medically inoperable and had a median age of 66 years. Eight patients had bilateral disease and two had unilateral disease. All patients had a histological diagnosis in at least one of the two lesions and four patients (44.4%) had both lesions biopsied. There were 18 T1 lesions and three T2 lesions. SBRT was in three fractions of 20 Gy or five fractions of 11–12 Gy to each lesion.
Results: Mean and median follow up were 18.8 and 15.5 months, respectively. At analysis, six patients (60.0%) are alive, and five of these living patients (83.3%) have no evidence of disease recurrence or progression. Four patients (44.4%) developed distant metastatic disease. Twenty lesions (95.2%) achieved in‐field local control. No patients experienced acute pulmonary complications and only two patients (22.2%) experienced late grade I lung toxicity as per the Radiation Therapy Oncology Group toxicity criteria.
Conclusion: SBRT for MPLC in medically inoperable patients is a safe, feasible and effective treatment approach.
Background
In the hospital, interprofessional team members must work collaboratively. That creates a gap in medical practice, particularly in a hectic emergency that may lead to medical errors, with ...associated ethical, legal, and financial consequences. Mannequin-based simulation can be a solution to bridge this gap in team training. While mannequin-based simulations are effective as a synchronous method, they are expensive, time and space-bound, use hospital resources, and require the whole team to be present.
Objective
To develop a prototype of a 3D virtual simulation emergency room (ER) environment for interprofessional team training. And to assess the usability of the prototype in a simulation environment for team training using a clinical scenario.
Methods
Tools and technologies used for this prototype included the Unity platform, C# programming language, and Photon Voice 2. With 3DS Max, we modified and created 3d assets in the ER simulation room. Adobe XD was used to create interactive prototype iterations. Clinical cases were developed with simple algorithms to prove the concepts. We used complex algorithms with Artificial Intelligence and Machine Learning capabilities for the final product. We conducted two usability tests (n = 10, n = 9) using a think-aloud method, a semi-structured follow-up interview, and a survey.
Results
A prototype was built to achieve asynchronous team training with easy user access from anywhere in the world. The prototype, which includes voice communication and control of the avatars by players from a distance, supported the usability of the technology for asynchronous team training in health education.
Conclusions
CyberPatient
ER
can be used as an additional tool to support team training and communication skills in the health education and healthcare environment.
To determine the feasibility of vaginal cuff brachytherapy (VCB) followed by 3 cycles of dose dense paclitaxel and carboplatin chemotherapy (ddTC) in enriched, high-intermediate risk (H-IR) patients ...with early stage endometrial cancer following hysterectomy.
A phase II trial of early stage endometrial cancer patients treated with VCB (2100 cGy) followed by three cycles of carboplatin (AUC 6) and dose dense paclitaxel (80 mg/m2) weekly within 12-weeks of surgery was conducted. The primary endpoint was the proportion of patients completing both VCB and ddTC. Secondary outcomes include short and long-term toxicities, recurrence rate and sites, and progression free survival. Toxicity assessments were patient reported as well as those resulting in delays or dose modifications.
A total of 32 evaluable patients with median age of 64.5 years were included. Most patients were endometrioid histology (18/32, 56.3%) and fully staged (21/32, 65.6%) to stage Ib (18/32, 56.3%). In total, 27/32 (84.4%) patients completed treatment per protocol. Protocol non-completion included renal insufficiency, paclitaxel reaction, and treatment refusal. Median time to VCB completion was 11 days with all patients completing three fractions of VCB. Acute toxicities with VCB included grade 1 and 2 gastrointestinal, genitourinary and fatigue symptoms. Acute toxicities associated with ddTC included infusion reaction and neutropenia. Most reported long-term toxicities were grade 1 or 2 and resolved with time.
Treatment with VCB followed by three cycles of ddTC is well-tolerated with promising utility for treatment in enriched high-intermediate risk endometrial cancer patients. Recurrence-free and overall survival outcomes are not yet mature.
•Early HIR EC remains at high risk for recurrence.•VCB followed by ddTC is well tolerated with few acute and no long-term toxicities.•VCB followed by three cycles of ddTC approached completion rates of 85% in enriched HIR EC patients.
This work evaluated the difference in dosimetry of high dose rate (HDR) brachytherapy treatments between plans using advanced multichannel applicators and simplified base versions. Eighteen HDR ...patients treated using Interstitial Ring CT/MR Applicator Set (Elekta Brachytherapy, Netherlands) (TRN) (21 plans), CapriTM Applicator Set (Varian Medical Systems, Inc., Palo Alto, CA) (CC) (19 plans), Rotte Endometrial Applicator Set (Elekta Brachytherapy, Netherlands) (RDT) (18 plans), and the Advanced Gynecological Applicator Venezia (Vz) (Elekta Brachytherapy, Netherlands) (6 plans) were retrospectively reviewed. For each plan, "advanced" channels including any interstitial channels, the 12 noncentral channels in the CC, and the lateral extending aspects of the RDT were removed and a new plan with the original inverse planning settings was optimized using only the remaining "simplified" applicator and compared to the original. The new plans were renormalized to match the original percent dose to 90% of the high-risk clinical target volume (HR-CTV). Critical structures included bladder, rectum, sigmoid colon, and small bowel. Comparisons were made utilizing dose volume histograms of HR-CTVs, conformation number (CN), and the equivalent total dose in 2 Gy fractions (EQD2) to 2 cm
of the normal structures. Comparing simplified to advanced plans, the average percent differences in EQD2 to 2 cm
for Vz, with 95% confidence interval, were 101.7 ± 85.9%, 147.8 ± 76.7%, 95.3 ± 61.6%, and 44.0 ± 12.4% for Rectum, Bladder, Sigmoid, and Bowel, respectively. For TRN: 36.9 ± 18.5%, 38.2 ± 14.5%, 20.3 ± 8.8%, and 15.3 ± 8.2%. For CC: 18.9 ± 3.7%, 12.3 ± 5.3%, 27.8 ± 7.1%, and 17.1 ± 3.6%. For RDT: 1.5 ± 6.8%, 7.4 ± 6.7%, 11.1 ± 4.4%, and 8.0 ± 8.7%. The CN was better in advanced applications by 0.024 for RDT, 0.104 for TRN, 0.043 for CC, and 0.251 for Vz (all p < 0.05). Advanced multichannel treatments allow better target dose conformation and normal tissue dose manipulation. The biggest factors influencing the brachytherapy dose distributions are the number of available channels and their separation from each other within the target.
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