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Purposes: To provide abdominal contrast-enhanced MR image synthesis, we developed an gradient regularized multi-modal multi-discrimination sparse attention fusion generative adversarial network (GRMM-GAN) to avoid repeated contrast injections to patients and facilitate adaptive monitoring. Methods: With IRB approval, 165 abdominal MR studies from 61 liver cancer patients were retrospectively solicited from our institutional database. Each study included T2, T1 pre-contrast (T1pre), and T1 contrast-enhanced (T1ce) images. The GRMM-GAN synthesis pipeline consists of a sparse attention fusion network, an image gradient regularizer (GR), and a generative adversarial network with multi-discrimination. The studies were randomly divided into 115 for training, 20 for validation, and 30 for testing. The two pre-contrast MR modalities, T2 and T1pre images, were adopted as inputs in the training phase. The T1ce image at the portal venous phase was used as an output. The synthesized T1ce images were compared with the ground truth T1ce images. The evaluation metrics include peak signal-to-noise ratio (PSNR), structural similarity index (SSIM), and mean squared error (MSE). A Turing test and experts’ contours evaluated the image synthesis quality. Results: The proposed GRMM-GAN model achieved a PSNR of 28.56, an SSIM of 0.869, and an MSE of 83.27. The proposed model showed statistically significant improvements in all metrics tested with p-values < 0.05 over the state-of-the-art model comparisons. The average Turing test score was 52.33%, which is close to random guessing, supporting the model’s effectiveness for clinical application. In the tumor-specific region analysis, the average tumor contrast-to-noise ratio (CNR) of the synthesized MR images was not statistically significant from the real MR images. The average DICE from real vs. synthetic images was 0.90 compared to the inter-operator DICE of 0.91. Conclusion: We demonstrated the function of a novel multi-modal MR image synthesis neural network GRMM-GAN for T1ce MR synthesis based on pre-contrast T1 and T2 MR images. GRMM-GAN shows promise for avoiding repeated contrast injections during radiation therapy treatment.

Purposes: To provide abdominal contrast-enhanced MR image synthesis, we developed an image gradient regularized multi-modal multi-discrimination sparse-attention fusion generative adversarial network (GRMM-GAN) to avoid repeated contrast injections to patients and facilitate adaptive monitoring. Methods: With IRB approval, 165 abdominal MR studies from 61 liver cancer patients were retrospectively solicited from our institutional database. Each study included T2, T1 pre-contrast (T1pre), and T1 contrast-enhanced (T1ce) images. The GRMM-GAN synthesis pipeline consists of a sparse attention fusion network, an image gradient regularizer (GR), and a generative adversarial network with multi-discrimination. The studies were randomly divided into 115 for training, 20 for validation, and 30 for testing. The two pre-contrast MR modalities, T2 and T1pre images, were adopted as inputs in the training phase. The T1ce image at the portal venous phase was used as an output. The synthesized T1ce images were compared with the ground truth T1ce images. The evaluation metrics include peak signal-to-noise ratio (PSNR), structural-similarity-index (SSIM), and mean-squared-error (MSE). A Turing test and experts’ contours evaluated the image synthesis quality. Results: The proposed GRMM-GAN model achieved a PSNR of 28.56, an SSIM of 0.869, and an MSE of 83.27. The proposed model showed statistically significant improvements in all metrics tested with p-values

Uncertainty is ubiquitous in medicine. Studies link intolerance of uncertainty to burnout, ineffective communication, cognitive bias, and inappropriate resource use. Little is known about how uncertainty manifests in the clinical learning environment. We aimed to explore the perceptions and experiences of uncertainty among residents and attendings.We conducted a mixed-methods study including a survey, semi-structured interviews, and ethnographic observations during rounds with residents and attendings at an academic medical center. The survey included three validated instruments: Physicians' Reaction to Uncertainty Scale; Maslach Burnout Inventory 2-item; and Educational Climate Inventory.35/60 (58%) of eligible residents and 14/21 (67%) attendings completed the survey. Residents reported higher anxiety due to uncertainty than attendings, higher concern about bad outcomes, and greater reluctance to disclose uncertainty to patients. Residents reported increased symptoms of burnout (Medical curricula should be developed to promote recognition and acknowledgement of uncertainty. Greater acknowledgement of uncertainty, specifically by attendings and senior residents, may positively impact the clinical learning environment.

Scientific research has been changing medical practice at an increasing pace. To keep up with this change, physicians of the future will need to be lifelong learners with the skills to engage with emerging science and translate it into clinical care. How medical schools can best prepare students for ongoing scientific change remains unclear. Adding to the challenge is reduced time allocated to basic science in curricula and rapid expansion of relevant scientific fields. A return to science with greater depth after clinical clerkships has been suggested, although few schools have adopted such curricula and implementation can present challenges. The authors describe an innovation at Harvard Medical School, the Advanced Integrated Science Courses (AISCs), which are taken after core clerkships. Students are required to take 2 such courses, which are offered in a variety of topics. Rather than factual content, the learning objectives are a set of generalizable skills to enable students to critically evaluate emerging research and its relationship to medical practice. Making these generalizable skills the defining principle of the courses has several important advantages: it allows standardization of acquired skills to be combined with diverse course topics ranging from basic to translational and population sciences; students can choose courses and projects aligned with their interests, thereby enhancing engagement, curiosity, and career relevance; schools can tailor course offerings to the interests of local faculty; and the generalizable skills delineate a unique purpose of these courses within the overall medical school curriculum. For the 3 years AISCs have been offered, students rated the courses highly and reported learning the intended skill set effectively. The AISC concept addresses the challenge of preparing students for this era of rapidly expanding science and should be readily adaptable to other medical schools.

Purpose Achieving competency as educators is increasingly recognized as a critical part of residents’ training in graduate medical education across specialties. In addition to teaching medical students, radiation oncology residents often play a vital role in peer and interprofessional education. We conducted a survey to identify the needs of radiation oncology residents for developing skills in teaching. Methods and Materials An anonymous, web-based survey was developed and distributed to resident physicians at US radiation oncology programs. Analyses describe respondent demographics, experiences with teaching, and interest in various aspects of a formal “residents-as-teachers” curriculum. Results There were 171 completed survey responses (27.5% response rate). A total of 146 residents (85.4%) reported receiving no formal training in teaching before residency, and 121 (70.8%) reported no formal training during residency. Residents who had formal training in teaching were significantly more likely to be “quite” or “extremely” confident about teaching compared with residents who had no prior formal training (76.0% vs 51.4%; P = .022). Residents most commonly taught other residents and medical students (163 [95.3%] and 160 [93.6%] respondents, respectively). The most common settings for teaching were one-on-one teaching (164 respondents [95.9%]), small-group lectures (135 respondents [78.9%]), and intradepartmental lectures (136 respondents [79.5%]). In response to open-ended questions regarding desired teaching opportunities and domains for teaching development, many residents expressed a lack of confidence in teaching and were interested in improvement across many aspects of teaching. Conclusions Radiation oncology residents are expected and desire to teach in a multitude of settings across a wide variety of audiences. However, a significant proportion of radiation oncology residents lack formal training and rarely receive feedback for their teaching skills. The results of this national survey support the development of a residents-as-teachers curriculum for radiation oncology residents that would address the needs for and significant interest in this area.

Purpose To perform a propensity-score matched analysis comparing stereotactic body radiation therapy (SBRT) boost and high-dose-rate (HDR) boost for localized prostate cancer. Methods and Materials A single-institution retrospective chart review was conducted of men treated with pelvic external beam radiation therapy (EBRT) and SBRT boost (21 Gy and 19 Gy in 2 fractions) to the prostate for prostate cancer. A cohort treated at the same institution with HDR brachytherapy boost (19 Gy in 2 fractions) was compared. Propensity-score (PS) matching and multivariable Cox regression were used for analysis. Outcomes were biochemical recurrence freedom (BCRF) and metastasis freedom (MF). Results One hundred thirty-one men were treated with SBRT boost and 101 with HDR boost with median follow-up of 73.4 and 186.0 months, respectively. In addition, 68.8% of men had high-risk and 26.0% had unfavorable-intermediate disease, and 94.3% received androgen deprivation therapy. Five- and 10-year unadjusted BCRF was 88.8% and 85.3% for SBRT and 91.8% and 74.6% for HDR boost (log-rank P = .3), and 5- and 10-year unadjusted MF was 91.7% and 84.3% for SBRT and 95.8% and 82.0% for HDR (log-rank P = .8). After adjusting for covariates, there was no statistically significant difference in BCRF (hazard ratio [HR] 0.81; 95% confidence interval [CI], 0.37-1.79; P = .6) or MF (HR 1.07; 95% CI, 0.44-2.57; P = .9) between SBRT and HDR boost. Similarly, after PS matching, there was no statistically significant difference between SBRT and HDR (BCRF: HR 0.66, 0.27-1.62, P = .4; MF: HR 0.84, 0.31-2.26, P = .7). Grade 3+ genitourinary and gastrointestinal toxicity in the SBRT cohort were 4.6% and 1.5%, and 3.0% and 0.0% in the HDR cohorts (P = .4, Fisher exact test). Conclusions SBRT boost plus pelvic EBRT for prostate cancer resulted in similar BCRF and MF to HDR boost in this single institution, PS matched retrospective analysis. Toxicity was modest. Prospective evaluation of SBRT boost for the treatment of unfavorable-intermediate and high-risk prostate cancer is warranted.

Purpose of Review Hepatocellular carcinoma (HCC) is a rising cause of mortality and morbidity, and although surgical resection is the preferred curative local therapy, Recent Findings Multiple retrospective and prospective studies demonstrate that stereotactic body radiation therapy (SBRT) is an effective bridge for transplant candidates and local therapy for patients with inoperable early-, intermediate-, or advanced-stage disease. SBRT is associated with excellent local control, and it is well-tolerated despite study cohorts enriched with patients who failed prior therapies and had poor baseline liver function. Summary Additional randomized control trials are needed to determine the ideal treatment regimen and patient selection for SBRT.

Radiation therapy (RT) is used for pediatric craniopharyngioma in the definitive, adjuvant, or salvage settings. Proton RT may be useful owing to tumor proximity to eloquent anatomy. We report clinical outcomes for a large cohort treated with proton therapy.We conducted a retrospective review of pediatric patients (≤21 years) treated with surgery and proton therapy for craniopharyngioma between August 2002 and October 2018. Clinical characteristics, treatment course, and outcomes were recorded. Acute toxicity was graded using Common Terminology Criteria for Adverse Events, version 5.0. Late toxicity was assessed using neuroendocrine, neuro-ophthalmologic, and neuropsychological testing.Among 77 patients, median age at diagnosis was 8.6 years (range, 1.3-20); median age at radiation was 9.6 years (range, 2.3-20.5). Most common presenting symptoms were headache (58%), visual impairment (55%), and endocrinopathy (40%). Patients underwent a median of 2 surgical interventions (range, 1-7) before protons. At initial surgery, 18% had gross total resection, 60% had subtotal resection, and 22% had biopsy/cyst decompression. Median RT dose was 52.2 Gy (relative biologic effectiveness). Common acute toxicities were headache (29%), fatigue (35%), and nausea/vomiting (12%). Only 4% developed any acute grade 3 toxicity. Nine patients experienced cyst growth requiring replanning or surgical decompression. At a median of 4.8 years from RT (range, 0.8-15.6), there were 6 local failures and 3 deaths, 2 related to disease progression. Effect of tumor and treatment contributed to late toxicity including Moyamoya syndrome (13%), visual impairment (40%), and endocrine deficiency requiring hormone replacement (94%). Subclinical decline in functional independence and adaptive skills in everyday life was detected at follow-up.Surgery and proton therapy results in excellent disease control for pediatric craniopharyngioma. Severe acute toxicity is rare. Late toxicities from tumor, surgery, and radiation remain prevalent. Endocrine and ophthalmology follow-up is necessary, and neuropsychological testing may identify patients at risk for treatment-related cognitive and adaptive functioning changes.

Despite interest from both radiation oncology residents and program directors, many residency training programs lack a formalized introductory curriculum to orient incoming radiation oncology residents to the specialty.Using the 6-step model for medical education curriculum development, a structured introductory radiation oncology curriculum (IROC) was created for incoming post-graduate year 2 (PGY-2) radiation oncology residents to address foundational concepts including patient simulation, contouring, and plan evaluation. The curriculum was distributed to 55 training programs across the United States and Canada at the start of the 2018 to 2019 and 2019 to 2020 academic years. Feasibility of curriculum dissemination was assessed via a survey of participating program directors. Curriculum effectiveness was assessed using an anonymous survey of participating residents administered pre- and postcurriculum and consisting of both subjective and objective knowledge-based questions.A total of 236 residents participated in IROC at the start of the 2018 to 2019 and 2019 to 2020 academic years. Of those, 228 of 236 (97%) completed both the pre- and postcurriculum surveys. Of participating residents, the median residency program size was 10 (range, 2-28), and the median number of residents in each program per year was 3 (range, 1-7). At baseline, most PGY-2s (142 of 228, 62%) reported being "not at all" or "slightly" prepared to function in the radiation oncology clinic, and after IROC most (188 of 228, 82%) felt "moderately," "quite," or "extremely" prepared. Objective knowledge improved pre- to postcurriculum on a multiple-choice test from 70% to 81% (P.0001) correct, with improvements observed across all question items. Program directors also reported that the curriculum was easier to use and more effective than prior orientation materials.The implementation of an international introductory curriculum for PGY-2 radiation oncology residents is both feasible and effective. Similar strategies should be employed to enhance and standardize radiation oncology educational initiatives across training programs.

Purpose/Objective(s) In cases where wide margins are not readily achievable during limb-sparing surgery (LSS) for soft tissue sarcoma (STS) of the extremity, intraoperative radiation therapy (IORT) may be used either alone or in conjunction with post-operative radiation (PORT) to improve local control with potentially decreased toxicities. The aim of this study is to describe wound healing issues following IORT for extremity STS. Materials/Methods Retrospective analysis was performed for 92 patients treated with LSS and IORT for definitive management of extremity STS between 2012 and 2020 at a single institution. No patients received pre-operative RT. Major wound complications were classified as follows: secondary operation for wound repair requiring general/regional anesthesia, other invasive procedure for wound management, readmission for wound care, or persistent deep packing over 120 days. Univariate and multivariate binary logistic regression analyses were performed to identify factors associated with development of major wound complications. Results Median age at IORT was 58 years (IQR 35-71). Tumor distribution was 25% upper extremity and 75% lower extremity. The most common histologies were undifferentiated pleomorphic sarcoma (27%), synovial sarcoma (24%), and liposarcoma (18%). Tumors were grade 1 (14%), grade 2 (34%), and grade 3 (52%). 37% had received pre-operative chemotherapy. Median tumor size at resection was 7 cm (IQR 5-11), and 28% of patients had tumors over 10 cm in maximum dimension. The majority of patients received a prescribed IORT dose of 12 Gy (27%) or 15 Gy (66%). 30% of patients underwent complex surgical closure, as defined by use of a muscle flap (11%, n = 10), fasciocutaneous flap (5%, n = 5), and/or skin graft (16%, n = 15). 90% of patients were discharged in less than 1 week from LSS with IORT. 72% subsequently received PORT at a median time of 7 weeks from LSS (IQR 5-11). Overall, the rate of major wound complications was 18% (n = 17), of which 4 events occurred prior to PORT and 9 events occurred within 4 months from IORT. In total, 10% (n = 9) required a secondary operation for wound repair, 5% (n = 5) required an invasive procedure (commonly drainage of a seroma/hematoma), and 3% (n = 3) required readmission for wound care. None required persistent deep packing. On univariate analysis, factors predicting for development of a major wound complication included current smoking status (HR 15.86, P = 0.02) and complex wound closure (HR 3.32, P = 0.03), both of which remained significant on multivariate analysis. Factors that were not associated with wound complications included age, tumor size, IORT dose, pre-operative chemotherapy, and PORT. Conclusion Despite the bias of selective use of IORT for more challenging surgical cases, IORT was not associated with increased rates of wound complications as compared to historical reports, and patients were able to transition to the next phase of therapy in a timely manner as part of optimal interdisciplinary management of STS.

Purpose/Objective(s) While rapid innovations in radiation treatment improve tumor controls and minimize toxicity, there is a dearth of quality training in resource-limited settings globally to ensure all radiation oncologists keep pace with the latest advances. We aim to create a learning platform shared by centers in Southeast Asia and to deliver quality training to participants with a curated virtual curriculum. To produce a comprehensive curriculum for countries enrolling in a non-profit organization training program, a needs assessment was conducted for registered participants. Materials/Methods Participants interested in a 12-week virtual training program completed a needs assessment survey via a data collection web application. The survey included demographics, practice characteristics, and interests in contouring and plan evaluation education and training. Herein we provide descriptive statistics of the reports from participant surveys. Results Across Thailand, Myanmar, Malaysia, Indonesia, and Nepal, 116 participants (82 attendings, 33 residents, 1 other) responded from 23 participating medical institutions (20 public, 3 private). The average number of radiation oncologists per medical institution was 6.81 (range 1-30) and radiation oncology residents was 17.50 (range 2-56). In the 7 centers with residency programs, 0 (0%) indicated that residents were solely involved in contouring, 5 (71.4%) that residents were jointly involved in contouring with attendings, and 2 (28.6%) that attendings contour without residents. Commonly cited obstacles to providing radiotherapy included: patient financial barriers (61.4%), inadequate training (51.8%), too many patients (48.2%), lack of modern equipment (40.4%), shortage of staff (39.5%), and malfunctioning equipment (36.8%). The most common, top-rated obstacle was inadequate training (24.8%). The most seen disease sites were head and neck (38.2%) and breast (30.3%). Respondent time spent contouring the target was greatest for head and neck, pediatric, and lymphoma disease sites with 66 (56.9%), 59 (50.8%), and 46 (29.3%) indicating more than 1 hour, respectively. Respondent time spent contouring the normal tissues was greatest for head and neck, pediatric, and CNS disease sites with 51 (44%), 46 (39.7%), and 30 (26.1%) indicating more than 1 hour. For head and neck cases, 34 (29.3%) respondents typically contour 6-10 Organs at Risk (OARs), 47 (40.5%) contour 11-15 OARs, 18 (15.5%) contour 16-20 OARs, and 15 (12.9%) contour > 20 OARs. 85 (76.3%) respondents believe their practice would most benefit from head and neck contouring education, while 114 (98.3%) were interested in receiving contouring and plan evaluation training. Conclusion The biggest physician-reported obstacle to providing radiotherapy in Southeast Asian practices is inadequate training. There is both high need and interest for well-developed virtual training, particularly in head and neck contouring, which currently appears time-intensive and heterogeneous among practices.

Purpose/Objective(s) The 2019 coronavirus pandemic (COVID-19) had a broad impact on the care of cancer patients, including the rapid adoption of telehealth video visits. On March 15, 2020, our institutional leadership recommended transition to video visits, which posed a risk of altering patients’ access to care. We assessed the impact of this rapid transition on demographic patterns in an urban academic radiation oncology department. Materials/Methods Consultation and follow-up visits from the pre-COVID-19 period (January 1, 2019 to March 14, 2020) and COVID-19 period (March 15, 2020 to August 31, 2020) in a single radiation oncology department were identified. Demographics and appointment data were abstracted from the institutional electronic health record. Time trends and patient and visit characteristics were compared across the pre-COVID-19 and COVID-19 periods. Results During the study period, 9,450 consult and follow-up visits were performed pre-COVID-19 and 3,298 visits in the COVID-19 period. The proportion of video visits increased markedly in the transition period, from 0.6% of all visits in the week of March 2, 2020, to 87% in the week of March 23, 2020. In-person visits decreased from 98% to 3%. Among all visits (in-person and telehealth), those during the COVID-19 period were less likely to be new consultations (43.1% from 60.1%; P < 0.001). There was a small and significant increase in the proportion of visits with patients who: identified as white (61.8% from 58.4%, P = 0.019), spoke English as their primary language (91.3% from 89.4%, P = 0.002), and had commercial insurance (34.1% from 32.0%; P = 0.009). Conclusion The overall COVID-19 clinic population retained demographic features similar to the pre-COVID-19 population despite a very rapid near-complete transition to telehealth. Nonetheless, the telehealth-predominant COVID-19 period had slightly increased visits with patients who were white or primarily English speaking or had commercial insurance. Strategies for ensuring telehealth is accessible to diverse populations should be a priority as telemedicine is integrated into long-term clinical operations.