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Purpose: To compare the pencil beam (PB) and collapsed cone (CC)-based three-dimensional dose calculation used for stereotactic irradiation of pulmonary targets.Methods and materials: Three-dimensional conformal dose distributions (using 6-MV and 18-MV photon beams) were generated for 33 pulmonary targets using the PB algorithm implemented in the Helax-TMS treatment planning system and then recalculated with the CC algorithm of TMS using an identical beam setup and parameters. The differences were analyzed by evaluating the dose–volume histograms for the planning target volume (PTV) and clinical target volume (CTV) and evaluating the computed absolute monitor units (MUs). The influence of the photon energy was also studied. For three cases, the results were compared with Monte-Carlo calculations.Results: Use of the CC model typically showed increased dose inhomogeneity. Owing to a more accurate modeling of secondary charged particle disequilibrium at the tumor–lung interface, the beam penumbra is broadened. The median and mean target dose decreased by 13.9% and 11.2% for the PTV and 9.2% and 9.4% for the CTV, respectively, using the CC algorithm. Consequently, the average PTV dose coverage decreased by 7.1% (SD, 6.5%). On average, the MUs calculated to achieve the prescribed dose were 5.4% (SD, 5.8%) greater for the CC algorithm. The difference in MUs between the PB and CC increased with decreasing PTV size and high photon energy (18 MV; r = -0.68), reaching 26% at the maximum.Conclusion: The absorbed dose at the lung–tumor interface calculated by the PB algorithm was considerably greater than the dose calculated using the CC algorithm. In small targets (PTV ≤100 cm3) and for 18-MV photons, the MUs calculated with PB may lead to an insufficient dose to the target volume. [Copyright &y& Elsevier]

Purpose: To investigate the influence of tumor motion on the calculation of four-dimensional (4D) dose distributions of the gross tumor volume (GTV) in pulmonary stereotactic body radiotherapy. Methods and Materials: For 7 patients with eight pulmonary tumors, a respiratory-correlated 4D-computed tomography study was acquired. The internal target volume was the sum of all tumor positions in the planning 4D-computed tomography study, and a 5-mm margin was used for generation of the planning target volume. Three-dimensional (3D) treatment plans were generated with a dose prescription of 3 x 12.5 Gy to the planning target volume enclosing the 65% and 80% isodose. After model-based nonrigid image registration, the 4D dose distributions were calculated. Results: No significant difference was found in the dose to the GTV with the tumor in the end-exhalation, end-inhalation, or mid-ventilation phase of the breathing cycle. The high-dose region was confined to the solid tumor, and lower doses were delivered to the surrounding pulmonary tissue of lower density. This nonstatic, variant dose distribution increased the 4D dose to the GTV by 6.2%, on average, compared with calculations using on a static dose distribution during the breathing cycle. The 4D accumulation resulted in a biologic effective dose (BED) of 143 +/- 8 Gy and 106 +/- 4 Gy to the GTV in the plan-65% and plan-80%, respectively. The dose to the ipsilateral lung was not different between the 3D and 4D dose calculations or between plan-65% and plan-80%. Conclusions: In this study, the dose to the GTV was not decreased or blurred in the 4D plan compared with the 3D plan. The 3D doses to the GTV, internal target volume, and dose at the isocenter were good approximations of the 4D dose calculations. The 3D dose at the planning target volume margin underestimated the 4D dose significantly. [ABSTRACT FROM AUTHOR]

Purpose: To establish volume imaging using an on-board cone-beam CT (CB-CT) scanner for evaluation of three-dimensional patient setup errors. Methods and Materials: The data from 24 patients were included in this study, and the setup errors using 209 CB-CT studies and 148 electronic portal images were analyzed and compared. The effect of rotational errors alone, translational errors alone, and combined rotational and translational errors on target coverage and sparing of organs at risk was investigated. Results: Translational setup errors using the CB-CT scanner and an electronic portal imaging device differed <1 mm in 70.7% and <2 mm in 93.2% of the measurements. Rotational errors >2° were recorded in 3.7% of pelvic tumors, 26.4% of thoracic tumors, and 12.4% of head-and-neck tumors; the corresponding maximal rotational errors were 5°, 8°, and 6°. No correlation between the magnitude of translational and rotational setup errors was observed. For patients with elongated target volumes and sharp dose gradients to adjacent organs at risk, both translational and rotational errors resulted in considerably decreased target coverage and highly increased doses to the organs at risk compared with the initial treatment plan. Conclusions: The CB-CT scanner has been successfully established for the evaluation of patient setup errors, and its feasibility in day-to-day clinical practice has been demonstrated. Our results have indicated that rotational errors are of clinical significance for selected patients receiving high-precision radiotherapy. [Copyright &y& Elsevier]

Purpose: To analyze the radiation-induced levels of gammaH2AX and its decay kinetics in 10 human cell lines covering a wide range of cellular radiosensitivity (SF2, 0.06-0.63).Methods and Materials: Five tumor cell lines included Colo-800 melanoma, two glioblastoma (MO59J and MO59K), fibrosarcoma HT 1080, and breast carcinoma MCF7. Five primary skin fibroblasts lines included two normal strains, an ataxia telangiectasia strain, and two fibroblast strains from breast cancer patients with an adverse early skin reaction to radiotherapy. Cellular radiosensitivity was assessed by colony-forming test. Deoxyribonucleic acid damage and repair were analyzed according to nuclear gammaH2AX foci intensity, with digital image analysis.Results: The cell lines tested showed a wide degree of variation in the background intensity of immunostained nuclear histone gammaH2AX, which was higher for the tumor cell lines compared with the fibroblast strains. It was not possible to predict clonogenic cell survival (SF2) for the 10 cell lines studied from the radiation-induced gammaH2AX intensity. In addition, the slopes of the dose-response (0-4 Gy) curves, the rates of gammaH2AX disappearance, and its residual expression (Conclusions: The results from 10 cell lines showed that measurements of immunofluorescence intensity by digital image analysis of phosphorylated histone H2AX as a surrogate marker of DNA double-strand breaks did not allow reliable ranking of cell strains according to their clonogenic survival after irradiation. [ABSTRACT FROM AUTHOR]

Purpose: The clinical results of dose escalation using stereotactic radiotherapy to increase local tumor control in medically inoperable patients with Stage I-II non–small-cell lung cancer or pulmonary metastases were evaluated.Methods and materials: Twenty patients with Stage I-II non–small-cell lung cancer and 41 patients with 51 pulmonary metastases not amenable to surgery were treated with stereotactic radiotherapy at 3 × 10 Gy (n = 19), 3 × 12–12.5 Gy to the planning target volume enclosing 100%–isodose, with normalization to 150% at the isocenter; n = 26) or 1 × 26 Gy to the planning target volume enclosing 80%–isodose (n = 26). The median follow-up was 11 months (range, 2–61 months) for primary lung cancer patients and 9 months (range, 2–37 months) for patients with metastases.Results: The actuarial local control rate was 92% for lung cancer patients and 80% for metastasis patients ≥1 year after treatment and was significantly improved by increasing the dose from 3 × 10 Gy to 3 × 12–12.5 Gy or 1 × 26 Gy (p = 0.038). The overall survival rate after 1 and 2 years was 52% and 32%, respectively, for lung cancer patients and 85% and 33%, respectively, for metastasis patients, impaired because of systemic disease progression. After 12 months, 60% of patients with primary lung cancer and 35% of patients with pulmonary metastases were without systemic progression. No severe acute or late toxicity was observed, and only 2 patients (3%) developed symptomatic Grade 2 pneumonitis, which was successfully treated with oral steroids.Conclusion: Stereotactic radiotherapy for lung tumors offers a very effective treatment option locally without significant complications in medically impaired patients who are not amenable to surgery. Patient selection is important, because those with a low risk of systemic progression are more likely to benefit from this approach. [Copyright &y& Elsevier]