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Definitive, nonsurgical management of gynecologic malignancies involves external beam radiation therapy (EBRT) and/or brachytherapy (BT). Summation of the cumulative dose is critical to assess the total biologic effective dose to targets and organs at risk. Cumulative dose calculation from EBRT and BT can be performed with or without image registration (IR) and biologic dose summation. Among these dose summation strategies, linear addition of dose-volume histogram (DVH) parameters without IR is the global standard for composite dose reporting. This approach stems from an era without image guidance and simple external beam and brachytherapy treatment approaches. With technological advances, EBRT and high-dose-rate BT have evolved to allow for volume-based treatment planning and delivery. Modern conformal therapeutic radiation involves volumetric or intensity modulated EBRT, capable of simultaneously treating multiple targets at different specified dose levels. Therefore, given the complexity of modern radiation treatment, the linear addition of DVH parameters from EBRT and high-dose-rate BT is challenging to represent the combined dose distribution. Deformable image registration (DIR) between EBRT and image guided brachytherapy (IGBT) data sets may provide a more nuanced calculation of multimodal dose accumulation. However, DIR is still nascent in this regard, and needs further development for accuracy and efficiency for clinical use. Biologic dose summation can combine physical dose maps from EBRT and each IGBT fraction, thereby generating a composite DVH from the biologic effective dose. However, accurate radiobiologic parameters are tissue-dependent and not well characterized. A combination of voxel-based DIR and biologic weighted dose maps may be the best approximation of dose accumulation but remains invalidated. The purpose of this report is to review dose summation strategies for EBRT and BT, including conventional equivalent dose in 2-Gy fractions dose summation without image registration, physical dose summation using 3-dimensional rigid IR and DIR, and biologic dose summation. We also provide general clinical workflows for IGBT with a focus on cervical cancer.

Purpose/Objective (s): Due to manual OAR contouring challenges, various automatic contouring solutions have been introduced. Historically, common clinical auto-segmentation algorithms used were atlas-based, which required maintaining a library of self-made contours. Searching the collection was computationally intensive and could take several minutes to complete. Deep learning approaches have shown significant benefits compared to atlas-based methods in improving segmentation accuracy and efficiency in auto-segmentation algorithms. This work represents the first multi-institutional study to describe and evaluate an AI algorithm for the auto-segmentation of organs at risk (OARs) based on a deep image-to-image network (DI2IN). Materials/Methods: The AI-Rad Companion Organs RT (AIRC) algorithm(Siemens Healthineers, Erlangen, Germany) uses a two-step approach for segmentation. In the first step, the target organ region in the optimal input image is extracted using a trained deep reinforcement learning network (DRL), which is then used as input to create the contours in the second step based on DI2IN. The study was initially designed as a prospective single-center evaluation. The automated contours generated by AIRC were evaluated by three experienced board-certified radiation oncologists using a four-point scale where 4 is clinically usable and 1 requires re-contouring. After seeing favorable results in a single-center pilot study, we decided to expand the study to six additional institutions, encompassing eight additional evaluators for a total of 11 physician evaluators across seven institutions. Results: One hundred and fifty-six patients and 1366 contours were prospectively evaluated. The five most commonly contoured organs were the lung (136 contours, average rating = 4.0), spinal cord (106 contours, average rating = 3.1), eye globe (80 contours, average rating = 3.9), lens (77 contours, average rating = 3.9), and optic nerve (75 contours, average rating = 4.0). The average rating per evaluator per contour was 3.6. On average, 124 contours were evaluated by each evaluator. 65% of the contours were rated as 4, and 31% were rated as 3. Only 4% of contours were rated as 1 or 2. Thirty-three organs were evaluated in the study, with 19 structures having a 3.5 or above average rating (ribs, abdominopelvic cavity, skeleton, larynx, lung, aorta, brachial plexus, lens, eye globe, glottis, heart, parotid glands, bladder, kidneys, supraglottic larynx, submandibular glands, esophagus, optic nerve, oral cavity) and the remaining organs having a rating of 3.0 or greater (female breast, proximal femur, seminal vesicles, rectum, sternum, brainstem, prostate, brain, lips, mandible, liver, optic chiasm, spinal cord, spleen). No organ had an average rating below 3. Conclusion: AIRC performed well with greater than 95% of contours accepted by treating physicians with no or minor edits. It supported a fully automated workflow with the potential for time savings and increased standardization with the use of AI-powered algorithms for high-quality OAR contouring. [ABSTRACT FROM AUTHOR]

PurposeTo summarize the results of American Society for Radiation Oncology (ASTRO)'s analysis of appropriate delivery of postoperative radiation therapy (RT) for endometrial cancer using the RAND/University of California, Los Angeles (UCLA) Appropriateness Method, outline areas of convergence and divergence with the 2014 ASTRO endometrial Guideline, and highlight where this analysis provides new information or perspective.Methods and materialsThe RAND/UCLA Appropriateness Method was used to combine available evidence with expert opinion. A comprehensive literature review was conducted and a multidisciplinary panel rated the appropriateness of RT options for different clinical scenarios. Treatments were categorized by the median rating as Appropriate, Uncertain, or Inappropriate.ResultsThe ASTRO endometrial Guideline and this analysis using the RAND/UCLA Appropriateness Method did not recommend adjuvant RT for early-stage, low-risk endometrioid cancers and largely agree regarding use of vaginal brachytherapy for low-intermediate and high-intermediate risk patients. For more advanced endometrioid cancer, chemotherapy with RT is supported by both documents. The Guideline and the RAND/UCLA analysis diverged regarding use of pelvic radiation. For stages II and III, this analysis rated external beam RT plus vaginal brachytherapy Appropriate, whereas the Guideline preferred external beam alone. In addition, this analysis offers insight on the role of histology, extent of nodal dissection, and para-aortic nodal irradiation; the use of intensity modulated RT; and management of stage IVA.ConclusionsThis analysis based on the RAND/UCLA Method shows significant agreement with the 2014 endometrial Guideline. Areas of divergence, often in scenarios with low-level evidence, included use of external beam RT plus vaginal brachytherapy in stages II and III and external beam RT alone in early-stage patients. Furthermore, the analysis explores other important questions regarding management of this disease site.

Context.--Cervical cancer affects 12 000 women in the United States annually. However, despite its prevalence, there remains no good methodology to detect its recurrence. Objective.--To identify the role of cervicovaginal high-risk human papilloma virus (hr-HPV) testing in predicting cervical cancer recurrence. Design.--This is a retrospective study of patients who underwent hr-HPV testing as part of their routine surveillance for cervical cancer. Standard statistical analyses, including [chi square] test and multivariable logistic regression, were performed with IBM SPSS 19.0. Results.--A total of 133 patients were identified, of whom 107 (80%) had squamous cell carcinoma. Ninety patients (68%) had bulky disease and were treated primarily with chemoradiation and brachytherapy. Of patients whose disease recurred, 5 patients (42%) had tested positive for hr-HPV during their surveillance period, compared to 13 patients (11%) for whom disease did not recur (relative risk: 3.88, P = .002). On multivariate logistic regression, hr-HPV status remained significantly predictive of disease recurrence (odds ratio: 12.3, P = .02, 95% confidence interval: 1.5-99.6). Using 2 X 2 table analysis, we found that while cervicovaginal cytology has limited specificity (5.7%) in predicting recurrence, the combination of cytology with hr-HPV testing increases the specificity of testing to 89.3%. Conclusions.--Persistence of hr-HPV is a risk factor for disease recurrence. High-risk-HPV testing is not routinely used during surveillance for cervical cancer, but this study suggests that large, prospective trials investigating the role of hr-HPV testing in cervical cancer surveillance are needed. (Arch Pathol Lab Med. 2015; 139:1437-1440; doi: 10.5858/arpa.2014-0534-0A), Cervical cancer is associated with persistence of high-risk (hr) human papilloma viral (HPV) infections. (1) As the second most common malignancy worldwide, it is responsible for 275 000 deaths annually. [...]

Abstract Background The purpose of this study was to compare the change in depth of target volume and dosimetric parameters between the supine and lateral decubitus positions for breast boost treatment with electron beam therapy. Methods We analyzed 45 patients who were treated, between 2009–2010, with whole breast radiation (WBRT) followed by a tumor bed boost in the lateral decubitius position. Tumor bed volume, distance from skin to the maximal depth of the tumor bed, D90 (dose covering 90% of the tumor bed volume), maximal dose, electron energy and doses to heart and lungs were compared. Additional variables of body mass index (BMI) and tumor bed location were also analyzed to see if there was a benefit limited to any subgroup. Results Median BMI for the 45 patients treated was 30.6 (20.6-42.4). When comparing the supine scan to the lateral decubitus scan, there was no significant difference in the tumor bed volume (p = 0.116). There was a significant difference between depth to the tumor bed in the supine scan and lateral decubitus scan (p Conclusions Delivering a tumor bed boost in the lateral decubitus position reduces the distance to the tumor bed allowing for a lower energy treatment to be used to treat breast cancer. It improves coverage and decreases maximal dose to the target volume, all of which would help reduce skin morbidities and should be considered for patients with upper outer quadrant disease, irrespective of BMI status.