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This study investigated the cosmetic degradation and toxicity for an accelerated partial breast irradiation (APBI) prescription delivered in 5 fractions over 1 week and compared the outcomes with those of whole breast irradiation (WBI). The trial was a multicenter, single-arm, phase 2 prospective cohort study. Eligible women 50 years of age or older with estrogen receptor–positive and human epidermal growth factor receptor 2–negative invasive ductal carcinoma or ductal carcinoma in situ after breast-conserving surgery received 27 Gy in 5 daily fractions of APBI. The primary endpoint was noninferiority of 2-year cosmesis using the RAPID trial's WBI arm as the control arm. A global consensus cosmetic score using a European Organisation for Research and Treatment of Cancer rating scale score of excellent, good, fair, or poor for each patient at baseline and 2 years was generated by a panel of 5 radiation oncologists using photographs of treated and untreated breasts. From 2016 to 2019, 298 eligible women were enrolled. By the 2-year follow-up, 76 patients had been lost or withdrawn and 3 had died, resulting in 219 patients available for complete, 2-year photographic cosmetic evaluation. The median follow-up for all participants was 4.7 years (IQR, 3.8-5.5 years). No patient had a fair or poor cosmetic score at the 2-year evaluation. Cosmesis was better or unchanged for 97% of patients and worse for 3% (excellent to good), and no cosmetic failures occurred. The confidence intervals were 0.88 (0.86-0.90) and 1.00 (0.99-1.00) for the RAPID and ACCEL trials, respectively. Cosmetic degradation with 5 daily treatments of the ACCEL trial's APBI intervention is noninferior to the WBI arm of the RAPID trial. [ABSTRACT FROM AUTHOR]

To develop a technology-enhanced education methodology with competency-based evaluation for radiation therapy treatment planning. The education program is designed for integration in the existing framework of Commission on Accreditation of Medical Physics Education Programs (CAMPEP) accredited medical physics residency programs. This education program pairs an accessible, multi-institutional infrastructure with established medical education evaluation tools to modernize treatment planning education. This program includes 3 evaluation components: (1) competency-based evaluation, (2) inter- and intramodality comparison, and (3) learner feedback. For this study, synchronous bilateral breast cancer was selected to demonstrate a complex treatment site and nonstandardized technique. Additionally, an online study was made available to a public cohort of worldwide participants of certified Medical Dosimetrists and Medical Physicists to benchmark performance. Before evaluation, learners were given a disease site-specific education session on potential clinical treatment strategies. During the assessment, learners generated treatment plans in their institutional planning system under the direct observation of an expert evaluator. Qualitative proficiency was evaluated for all learners on a 5-point scale of graduated task independence. Quantitative dosimetry was compared between the learner cohort and public cohort. A feedback session provided learners context of multi-institutional experience through multimodality and technique comparison. After study completion, learners were provided a survey that was used to gauge their perception of the education program. In the public study, 34 participants submitted treatment plans. Across 3 CAMPEP-accredited residency programs, 6 learners participated in the education and evaluation program. All learners successfully completed treatment plans that met the dosimetric constraints described in the case study. All learners favorably reviewed the study either comprehensively or in specified domains. The competency-based education and evaluation program developed in this work has been incorporated in CAMPEP-accredited residency programs and is adaptable to other residency programs with minimal resource commitment. [ABSTRACT FROM AUTHOR]

Development of a novel auto-delineation methodology for observed hypointensity from focal liver reaction in hepatobiliary-specific contrast (Primovist) enhanced MRI acquired post Stereotactic Body Radiation Therapy (SBRT). Additionally, the methodology for the quantification of the threshold dose associated with the observed focal liver reaction was also established. An auto-delineation algorithm was created based on the correlation between intensity and radiation dose information. The error associated with the auto-delineation was quantified using virtual FLRs, as well as clinical patient scans. Patients underwent liver SBRT with a total dose prescription of 50 Gy in 5 fractions. An inherent correlation was established between the contrast-to-noise ratio (CNR) on MRI scans and expected performance of the algorithm using centre-of-mass (COM). Threshold dose associated with focal liver reaction was quantified for all ten patients and verified with associated most conformal isodose line. Based on the CNR vs COM error relationship, the expected median (range) auto-delineation COM error for ten patients was 0.5 (0 to 3.2) mm. The median threshold dose for ten clinical cases was 21.3 Gy based on the auto-delineation framework. This threshold dose was compared to the most conformal isodose line with the hypointensity; there was no significant difference observed (p = 0.6). We developed a framework for post-SBRT Primovist observed focal liver reaction localization. Furthermore, this study established an automated approach for the determination of the threshold dose associated with the hypointense region. [ABSTRACT FROM AUTHOR]

The objective of this work was to outline and demonstrate a standardized framework for evaluating automatically propagated contour quality against expert contours. A 2-pronged approach is used to evaluate contour quality: a geometric evaluation to identify geometric and spatial discrepancies between propagated and expert contours, and a comprehensive dosimetric comparison to provide clinical context for the results. The standardized framework requires a primary image, with reference contours and a radiation therapy treatment plan, and a secondary image. Reference contours are automatically propagated onto the secondary image anatomy and compared with expert contours obtained in an interobserver study. The standardized framework outlines geometric and dosimetric evaluation methodologies for determining indistinguishability between propagated and expert contours in a cohort analysis. Propagated contours are geometrically compared with expert contours in terms of the Dice similarity coefficient and the mean distance to agreement. Statistical analysis is performed on the central tendency and variability of Dice similarity coefficient and mean distance to agreement values over the patient cohort. Dosimetric evaluation involves computing the mean and 95% confidence intervals for the differences in cumulative dose-volume histograms for propagated and expert contours. A case study in accelerated partial breast irradiation was shown to demonstrate the framework. The standardized framework was applied to a case study of 24 patient data sets with 3 radiation oncologists providing the expert contours. Cohort analysis indicated that propagated contours were geometrically indistinguishable and dosimetrically distinguishable from expert contours. The recommended framework standardizes the comparison of geometric and dosimetric parameters to demonstrate indistinguishability of propagated contours from expert contours. Adoption of this framework is vital for consistent and comprehensive validation of automatic contour propagation for use in large-scale cohort analyses. [ABSTRACT FROM AUTHOR]

To report 1-year cosmesis and toxicity outcomes of a prospective, phase II trial of accelerated partial breast irradiation using intensity-modulated radiation therapy (RT) to deliver 27 Gy in 5 daily fractions. Node-negative breast cancer patients after breast conserving surgery with clear excision margins, with physician-assessed excellent or good baseline cosmesis were invited to participate in a prospective clinical trial to receive 27 Gy in 5 daily fractions to the expanded primary site. Clinical photographs and European Organisation for Research and Treatment of Cancer cosmetic score were collected at baseline prior to RT and 1-year after radiation therapy. A protocol-specified, interim analysis was scheduled when 50 patients had completed 1-year follow-up. A panel of 6 physicians provided a consensus global cosmetic score (termed panel-assessed score) based on clinical photographs at baseline and 1-year. Fibrosis and telangiectasia were prospectively assessed by clinical research staff at clinic visits. At the interim analysis, 55 patients had baseline and 1-year post-RT images available. Most patients had either an improvement (53%) or no change (40%) in cosmesis from baseline to 1-year. Among 49 patients with excellent or good panel-assessed score at baseline, only 2 (4%) patients had a fair score at 1-year post-RT, indicating cosmetic deterioration. No patients had evidence of telangiectasia or grade 2 or higher fibrosis. There were no recurrences. APBI using 27 Gy in 5 daily fractions achieved acceptable 1-year cosmesis and no grade 2 fibrosis. A preplanned stopping rule of 5% grade 2+ fibrosis was not observed. The trial will continue to the planned target accrual of 274 patients. [ABSTRACT FROM AUTHOR]

Objective: This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.Method: The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.Results: 488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.Conclusion: Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.Practice Implications: Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids. [ABSTRACT FROM AUTHOR]

Background Hilar cholangiocarcinoma is a rare but highly lethal type of cancer. A minority of patients present with resectable disease. Surgery remains the only treatment modality offering a chance of long-term survival. Unresectable patients are typically offered palliative treatment. The aim of this systematic review was to summarize the evidence for neoadjuvant therapy followed by surgical resection in patients presenting with hilar cholangiocarcinoma. Methods Cochrane databases, Medline, PubMed and EMBASE were systematically searched to identify articles describing neoadjuvant therapy and surgical resection or re-assessment of resectability in patients with hilar cholangiocarcinoma. Included were all articles with original research. Study selection and data extraction were performed separately by two reviewers using a standardized protocol. Results From 732 articles 8 full text articles and 2 abstracts met the inclusion criteria. The 2 abstracts and 1 full text article were case reports, 3 articles were retrospective and 4 were prospective studies (2 phase I and 2 phase II studies). Photodynamic therapy, chemotherapy and radiation therapy were used in various indications in populations that included patients with hilar cholangiocarcinoma, some of which were primarily unresectable. Overall quality of articles was limited. Conclusion Current evidence suggests that neoadjuvant therapy in patients with unresectable hilar cholangiocarcinoma can be performed safely and in a selected group of patients can lead to subsequent surgical R0 resection. Surgical resection of downstaged patients should be assessed in properly designed phase II studies. [ABSTRACT FROM AUTHOR]

Purpose A comprehensive set of planning guidelines was developed to aid in achieving reproducible dosimetric results for external beam accelerated partial breast irradiation (APBI). The methodology for the development of class solutions for dosimetric planning of the APBI technique, including dose constraint recommendations, is presented for target coverage and conformity as well as normal tissues. Methods and materials A conservative patient setup was simulated on a linear accelerator, and a comprehensive arrangement of gantry and couch angles was measured for clearance. This provided the foundation for available beam arrangements to develop reproducible and conformal 5-field intensity modulated radiation therapy partial breast plans. Forty patients were planned. Patient plans were assessed according to anatomy specific features, such as laterality and seroma location within the breast. Results Clearance tables are presented to give permissible gantry and couch orientations according to measurements facilitated by patient simulation. Beam arrangement class solutions are presented for left- and right-sided APBI patients. Dosimetric recommendations are made based on the results of 40 patient plans. The median and range, describing target coverage and target conformity, are reported, as are normal tissue constraints for ipsilateral lung, ipsilateral breast, heart, liver, and contralateral breast. In all cases, the dose recommendations were at least as strict as multi-institutional APBI trials. In the case of ipsilateral lung and ipsilateral breast, the planning recommendations are more stringent. Conclusions APBI using a 5-field intensity modulated radiation therapy technique was comprehensively developed and evaluated to provide recommendations yielding highly conformal and reproducible treatment plans. This provides a clear method to implement external beam APBI planning and delivery. [ABSTRACT FROM AUTHOR]