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Primary cutaneous anaplastic large cell lymphoma (pcALCL) is a rare form of non-Hodgkins lymphoma. Current frontline treatments for pcALCL include surgical resection, anthracycline-based chemotherapy, and/or radiation therapy (RT) depending on disease severity. While brentuximab vedotin (BV) has been used for refractory/relapsed cases, it recently received Food and Drug Administration (FDA) approval for use in combination with chemotherapy for peripheral T-cell lymphomas. In this case report, we utilized a combined modality therapy of RT and BV for a limited stage aggressive pcALCL presentation for which routine management is contraindicated. A 59-year-old man with a history of peripheral vascular disease (PVD) presented with an aggressive pcALCL involving the left inferior eyelid and small ipsilateral level II hypermetabolic lymph nodes at stage IIE. Due to the patient's history of PVD, the tumor's rapid growth, possible lymph node involvement, and eye proximity, BV was chosen as the initial chemotherapy treatment followed by RT. Complete metabolic resolution of the primary cutaneous lesion and lymphadenopathy was reached after BV treatment alone; complete clinical response of the primary tumor was reached following radiation therapy. Relapse occurred within 7 months. Salvage cyclophosphamide, vincristine, etoposide, and prednisone were not effective. Retreatment with BV + RT is currently being used to treat the new lesions. Our case illustrates that a combination of BV and RT can be a safe and effective initial treatment in patients with limited stage pcALCL who cannot tolerate anthracycline-based chemotherapy. Our patient had a complete response but ultimately relapsed; thus larger clinical trials are needed to better understand early-stage disease.

Mycosis fungoides in palmoplantar localization (MFPP) is a rare variant of MF that is confined to the hands and feet. Patients commonly receive treatment over many years for suspected palmoplantar dermatitis before the diagnosis is made. Most MFPP patients remain at patch or plaque stage, and often respond to treatment with radiotherapy. Herein, we describe a 77-year-old man who suffered 6 years of hand and foot dermatitis that failed multiple treatments, most notably TNF-α inhibitors and mycophenolate mofetil. He eventually developed a tumor on the hand, which was biopsied to reveal a dense dermal infiltrate of large lymphocytes (CD3+/CD4-/CD8-/TCR-BetaF1+/partial CD30+). A subsequent biopsy of an eczematous patch from his hand revealed an epidermotropic and syringotropic infiltrate comprised of smaller lymphocytes with a concordant immunophenotype and matching clonal peak with TCR gene rearrangement. He was diagnosed with MFPP and started on radiotherapy with a modest response; therefore, a decision was made to start brentuximab vedotin, which resulted in a complete response. MFPP is an exceedingly rare variant of MF that can show large-cell transformation and progress in stage. We highlight a possible association between disease progression and immunosuppressants and the potential role for treatment with brentuximab.

Purpose/Objective(s) In the last decade, Cherenkov imaging has been demonstrated as a useful clinical technique both for real-time surface dose visualization during patient treatment and for various high-resolution QA measurements. However there remains much work to be done in the development of Cherenkov-based in vivo dosimetry. In this work, the concept of in vivo color Cherenkov imaging is introduced. It is hypothesized that Cherenkov images with sensitivity to the spectral quality of Cherenkov emission induced inside tissue can provide increased information about tissue composition as opposed to monochromatic, red-weighted images used in prior work. Materials/Methods A custom Color Cherenkov camera was created from three time-gated intensified CMOS cameras, each with varying spectral sensitivity of the photocathode, and sharing one imaging lens. A dichroic mirror assembly allowed for incoming Cherenkov light signals to be redirected according to wavelength to the appropriate camera resulting in three raw image stacks for each acquisition. These images were then reconstructed into three-channel color images via color calibration, summed, and background subtracted. In vivo color Cherenkov images of three right-sided breast patients were acquired for one treatment fraction each as part of an IRB-approved clinical trial. These images were interpreted alongside images of liquid tissue-simulating phantoms that matched tissue optical properties. Variations in oxygenation and blood volume were mimicked in this way, and the data was used to interpret the clinical images. Impacts on Cherenkov emission spectra from tissue under these various conditions were also estimated. Results The presence of oxygenated vs deoxygenated blood in tissue has a visible impact on the color of Cherenkov emission, leading to a redder hue due to decreased attenuation of red wavelengths by oxyhemoglobin, similar to erythema or blush of tissue. This was verified in the tissue phantoms. Variations in blood concentration produce a strong blue-red trend in color space (R2 = 0.96), as verified by detailed analysis. Color Cherenkov images of right breast radiotherapy treatments displayed pink regions across the breast coincident with the treated area for all three patients, and the variations in color were interpreted relative to the phantom data. Conclusion This first investigation of color Cherenkov imaging uncovered the natural relationship between tissue composition and the spectral quality of emitted Cherenkov light. The correlation between blood content and color will be translated in future work to in vivo sensing of variations in fat and fibroglandular content in irradiated tissues. These findings will allow for the correction of Cherenkov images to produce accurate in vivo surface dose maps during patient treatments.

Purpose: To identify achievable camera performance and hardware needs in a clinical Cherenkov imaging system for real-time, in vivo monitoring of the surface beam profile on patients, as novel visual information, documentation, and possible treatment verification for clinicians. Methods: Complementary metal-oxide-semiconductor (CMOS), charge-coupled device (CCD), intensified charge-coupled device (ICCD), and electron multiplying-intensified charge coupled device (EM-ICCD) cameras were investigated to determine Cherenkov imaging performance in a clinical radiotherapy setting, with one emphasis on the maximum supportable frame rate. Where possible, the image intensifier was synchronized using a pulse signal from the Linac in order to image with room lighting conditions comparable to patient treatment scenarios. A solid water phantom irradiated with a 6 MV photon beam was imaged by the cameras to evaluate the maximum frame rate for adequate Cherenkov detection. Adequate detection was defined as an average electron count in the background-subtracted Cherenkov image region of interest in excess of 0.5% (327 counts) of the 16-bit maximum electron count value. Additionally, an ICCD and an EM-ICCD were each used clinically to image two patients undergoing whole-breast radiotherapy to compare clinical advantages and limitations of each system. Results: Intensifier-coupled cameras were required for imaging Cherenkov emission on the phantom surface with ambient room lighting; standalone CMOS and CCD cameras were not viable. The EM-ICCD was able to collect images from a single Linac pulse delivering less than 0.05 cGy of dose at 30 frames/s (fps) and pixel resolution of 512 × 512, compared to an ICCD which was limited to 4.7 fps at 1024 × 1024 resolution. An intensifier with higher quantum efficiency at the entrance photocathode in the red wavelengths [30% quantum efficiency (QE) vs previous 19%] promises at least 8.6 fps at a resolution of 1024 × 1024 and lower monetary cost than the EM-ICCD. Conclusions: The ICCD with an intensifier better optimized for red wavelengths was found to provide the best potential for real-time display (at least 8.6 fps) of radiation dose on the skin during treatment at a resolution of 1024 × 1024.

Purpose Radiation therapy following resection of a brain metastasis increases the probability of disease control at the surgical site. We analyzed our experience with postoperative stereotactic radiosurgery (SRS) as an alternative to whole-brain radiotherapy (WBRT), with an emphasis on identifying factors that might predict intracranial disease control and overall survival (OS). Methods and Materials We retrospectively reviewed all patients through December 2008, who, after surgical resection, underwent SRS to the tumor bed, deferring WBRT. Multiple factors were analyzed for time to intracranial recurrence (ICR), whether local recurrence (LR) at the surgical bed or “distant” recurrence (DR) in the brain, for time to WBRT, and for OS. Results A total of 49 lesions in 47 patients were treated with postoperative SRS. With median follow-up of 9.3 months (range, 1.1-61.4 months), local control rates at the resection cavity were 85.5% at 1 year and 66.9% at 2 years. OS rates at 1 and 2 years were 52.5% and 31.7%, respectively. On univariate analysis (preoperative) tumors larger than 3.0 cm exhibited a significantly shorter time to LR. At a cutoff of 2.0 cm, larger tumors resulted in significantly shorter times not only for LR but also for DR, ICR, and salvage WBRT. While multivariate Cox regressions showed preoperative size to be significant for times to DR, ICR, and WBRT, in similar multivariate analysis for OS, only the graded prognostic assessment proved to be significant. However, the number of intracranial metastases at presentation was not significantly associated with OS nor with other outcome variables. Conclusions Larger tumor size was associated with shorter time to recurrence and with shorter time to salvage WBRT; however, larger tumors were not associated with decrements in OS, suggesting successful salvage. SRS to the tumor bed without WBRT is an effective treatment for resected brain metastases, achieving local control particularly for tumors up to 3.0 cm diameter.

Light scattering leads to a severe loss of axial and transverse resolution with depth into tissue, limiting accuracy and value of biomedical luminescence imaging techniques. High-resolution imaging beyond a few-millimeter depth is prohibited because diffusive transport dominates beyond a few scattering distances. In this study, light sheet imaging through scattering media is demonstrated using a radiotherapy linear accelerator to deliver well-defined thin scanned sheets of x-rays. These sheets produce Cherenkov light within the medium, which in turn excites luminescence of an optical probe across the sheet plane. This luminescence can then be imaged by an intensified camera positioned perpendicular to the sheet plane. The precise knowledge of the light sheet position within the medium allowed for efficient attenuation correction of the signal with depth as well as spatial deconvolution of the excitation light. Together these methods allowed for the first time, to the best of our knowledge, high-resolution imaging of tissue-equivalent phantoms up to 3 cm thick, yielding the precise position and shape of luminescent lesions located deep in tissue without the need for nonlinear image reconstruction.

Purpose To analyze 2 factors that influence timing of radiosurgery after surgical resection of brain metastases: target volume dynamics and intracranial tumor progression in the interval between surgery and cavity stereotactic radiosurgery (SRS). Methods and Materials Three diagnostic magnetic resonance imaging (MRI) scans were retrospectively analyzed for 41 patients with a total of 43 resected brain metastases: preoperative MRI scan (MRI-1), MRI scan within 24 hours after surgery (MRI-2), and MRI scan for radiosurgery planning, which is generally performed ≤1 week before SRS (MRI-3). Tumors were contoured on MRI-1 scans, and resection cavities were contoured on MRI-2 and MRI-3 scans. Results The mean tumor volume before surgery was 14.23 cm 3 , and the mean cavity volume was 8.53 cm 3 immediately after surgery and 8.77 cm 3 before SRS. In the interval between surgery and SRS, 20 cavities (46.5%) were stable in size, defined as a change of ≤2 cm 3 ; 10 cavities (23.3%) collapsed by >2 cm 3 ; and 13 cavities (30.2%) increased by >2 cm 3 . The unexpected increase in cavity size was a result of local progression (2 cavities), accumulation of cyst-like fluid or blood (9 cavities), and nonspecific postsurgical changes (2 cavities). Finally, in the interval between surgery and SRS, 5 cavities showed definite local tumor progression, 4 patients had progression elsewhere in the brain, 1 patient had both local progression and progression elsewhere, and 33 patients had stable intracranial disease. Conclusions In the interval between surgical resection and delivery of SRS, surgical cavities are dynamic in size; however, most cavities do not collapse, and nearly one-third are larger at the time of SRS. These observations support obtaining imaging for radiosurgery planning as close to SRS delivery as possible and suggest that delaying SRS after surgery does not offer the benefit of cavity collapse in most patients. A prospective, multi-institutional trial will provide more guidance to the optimal timing of cavity SRS.

This study's goal was to determine how Cherenkov radiation emission observed in radiotherapy is affected by predictable factors expected in patient imaging. Factors such as tissue optical properties, radiation beam properties, thickness of tissues, entrance/exit geometry, curved surface effects, curvature and imaging angles were investigated through Monte Carlo simulations. The largest physical cause of variation of the correlation ratio between of Cherenkov emission and dose was the entrance/exit geometry (˜50%). The largest human tissue effect was from different optical properties (˜45%). Beyond these, clinical beam energy varies the correlation ratio significantly (˜20% for X-ray beams), followed by curved surfaces (˜15% for X-ray beams and ˜8% for electron beams), and finally, the effect of field size (˜5% for X-ray beams). Other investigated factors which caused variations less than 5% were tissue thicknesses and source to surface distance. The effect of non-Lambertian emission was negligible for imaging angles smaller than 60 degrees. The spectrum of Cherenkov emission tends to blue-shift along the curved surface. A simple normalization approach based on the reflectance image was experimentally validated by imaging a range of tissue phantoms, as a first order correction for different tissue optical properties.

Ionizing radiation is commonly delivered by medical linear accelerators (LINAC) in the form of shaped beams, and it is able to induce Cherenkov emission in tissue. In fluorescence-based microscopy excitation from scanned spots, lines, or sheets can be used for fast high-resolution imaging. Here we introduce Cherenkov-excited luminescence scanned imaging (CELSI) as a new imaging methodology utilizing 2-dimensional (∼5-mm-thick) sheets of LINAC radiation to produce Cherenkov photons, which in turn excite luminescence of probes distributed in biological tissues. Imaging experiments were performed by scanning these excitation sheets in three orthogonal directions while recording Cherenkov-excited luminescence. Tissue phantom studies have shown that single luminescent inclusions ∼1 mm in diameter can be imaged within 20-mm-thick tissue-like media with minimal loss of spatial resolution. Using a phosphorescent probe for oxygen, PtG4 with the CELSI methodology, an image of partial pressure of oxygen (pO2) was imaged in a rat lymph node, quantitatively restoring pO2 values in differently oxygenated tissues.

Although there is agreement on the oncologic management of patients with glioma, few guidelines exist to standardize other aspects of care, including supportive care.A quality improvement (QI) project was chartered to improve the care provided to patients with glioma. A multidisciplinary team was convened and identified 10 best-practice measures. Using a plan-do-study-act framework, the team brainstormed and implemented various improvement interventions between June 2011 and October 2012. Statistical process control charts were used to evaluate progress. A dashboard of quality measures was generated to allow for ongoing measurement and reporting.The retrospective assessment phase consisted of 43 patients with diagnosis of glioma. A manual medical record review for these patients showed that compliance with 10 best-practice measures ranged from 23% to 100%. Several factors contributed to less-than-ideal process performance, including poor communication among disciplines and lack of familiarity with the larger system of care. After implementing improvement interventions, performance was measured in 96 consecutive patients with glioma. The proportion of patients who met criteria for 10 practice measures significantly improved (pre-QI work, 63%; post-QI work, 85%; P = .003). The largest improvement was observed in the measure assessing for preoperative notification of the neuro-oncology program (pre-QI work, 39%; post-QI work, 97%; P.001).QI principles were used by a multidisciplinary team to improve the quality of care for patients with glioma during the perioperative period. Leadership involvement, ongoing dialogue across departments, and reporting of system performance were important for sustaining process improvements.

Purpose: To evaluate treatment field heterogeneity resulting from gantry angle choice in total skin electron beam therapy (TSEBT) following a modified Stanford dual-field technique, and determine a relationship between source to surface distance (SSD) and optimized gantry angle spread. Methods: Cherenkov imaging was used to image 62 treatment fields on a sheet of 1.2m x 2.2m x 1.2cm polyethylene following standard TSEBT setup at our institution (6 MeV, 888 MU/min, no spoiler, SSD=441cm), where gantry angles spanned from 239.5° to 300.5° at 1° increments. Average Cherenkov intensity and coefficient of variation in the region of interest were compared for the set of composite Cherenkov images created by summing all unique combinations of angle pairs to simulate dual-field treatment. The angle pair which produced the lowest coefficient of variation was further studied using an ionization chamber. The experiment was repeated at SSD=300cm, and SSD=370.5cm. Cherenkov imaging was also implemented during TSEBT of three patients. Results: The most uniform treatment region from a symmetric angle spread was achieved using gantry angles +/−17.5° about the horizontal axis at SSD=441cm, +/−18.5° at SSD=370.5cm, and +/−19.5° at SSD=300cm. Ionization chamber measurements comparing the original treatment spread (+/−14.5°) and the optimized angle pair (+/−17.5°) at SSD=441cm showed no significant deviation (r=0.999) in percent depth dose curves, and chamber measurements from nine locations within the field showed an improvement in dose uniformity from 24.41% to 9.75%. Ionization chamber measurements correlated strongly (r=0.981) with Cherenkov intensity measured concurrently on the flat Plastic Water phantom. Patient images and TLD results also showed modest uniformity improvements. Conclusion: A decreasing linear relationship between optimal angle spread and SSD was observed. Cherenkov imaging offers a new method of rapidly analyzing and optimizing TSEBT setup geometry by providing a 2D image of the treatment plane as a sum of the two fields. This study has been funded by NIH grants R21EB17559 and R01CA109558 as well as Norris Cotton Cancer Center Pilot funding.

Purpose: A new imaging modality Cherenkov-excited luminescence scanned imaging (CELSI) is demonstrated illustrating that LINAC beams induce Cherenkov emission within tissue, and that in-turn can excite luminescence of optical probes. This is achieved in a highly spatially confined fashion thereby allowing scanned imaging of distributions of luminescent sources. Methods: A 5 mm thick line-excitation megavoltage X-ray beam (6 MV) was collimated and moved by the multi-leaf collimator (MLC) of a linear accelerator (LINAC), to scan in 3 orthogonal directions. The scan in this demonstration was through a rat abdomen for lymph node imaging. The node was injected with oxygen-sensitive phosphor (Oxyphor PtG4), having strong luminescence lifetime, which is sensitive to the local oxygen concentration. During the scanning, Cherenkov-excited luminescence was continuously integrated by an intensified charge-coupled device (ICCD) synchronized to radiation pulses, and the position of the total signal was back-projected to the position of the scanning beam. Results: The lymph node was accurately located in the axillary region by CELSI imaging. Through lifetime measurement of the luminescence signal from within the lymph node, the pO2 was found to be reporting the true oxygenation level. Phantom studies validated that an inclusion with size below 1 mm could be reconstructed through a layer of 20 mm thick tissue equivalent phantom material. Concentrations of PtG4 down to 100 nM were detectable and capillary tubes containing the probe with diameters down to 200 µm could be resolved by CELSI, at 5 mm depth in tissue equivalent phantoms. Conclusion: CELSI is reported here for the first time, as an innovative optical molecular imaging technique by utilizing the LINAC as an optical scanning and excitation device. Potential applications of CELSI include reconstructions of interested optical probes and recoveries of local physiological information with relatively high spatial resolution.

Purpose: To recover a three-dimensional density distribution of luminescent molecular probes located several centimeters deep within a highly scattering tissue. Methods: We developed a novel sheet beam Cherenkov-excited luminescence scanned imaging (CELSI) methodology. The sample was irradiated by a horizontally oriented, vertically scanned 6 MV X-ray sheet beam (200mm × 5mm, 0.2mm vertical step) from a radiotherapy linear accelerator. The resulting Cherenkov light emission – and thus luminescent probe excitation – occurred exclusively along the irradiation plane due to a short diffusion path of secondary particles and Cherenkov photons. Cherenkov-excited luminescence was detected orthogonally to the sheet beam by gated, intensified charge coupled device camera. Analogously to light sheet microscopy, a series of luminescence images was taken for varied axial positions (depths) of the Cherenkov light sheet in sample. Knowledge of the excitation plane position allowed a 3D image stack deconvolution and depth-variant attenuation correction. The 3D image post-processing yielded a true spatial density distribution of luminescent molecules in highly scattering tissue. Results: We recovered a three-dimensional shape and position of 400 µL lesion-mimicking phantom tubes containing 25 µM solution of PtG4 molecular probe from 3 centimeter deep tissue-like media. The high sensitivity of CELSI also allowed resolving 100 micron capillaries of test solution. Functional information of partial oxygen pressure at the site of PtG4 molecular probe was recovered from luminescence lifetime CELSI. Finally, in-vivo sheet beam CELSI localized milimeter-sized PtG4-labelled tumor phantoms in multiple biological objects (hairless mice) from single scan. Conclusion: Presented sheet beam CELSI technique greatly extended the useful depth range of luminescence molecular imaging. More importantly, the light sheet microscopy approach was successfully adapted to CELSI, providing means to recover a completely attenuation-corrected 3D image of luminescent probe distribution. Gated CELSI acquisition yielded functional information of a spatially resolved oxygen concentration map of deep lying targets. This work was supported by NIH research grant R01CA109558 and R21EB017559, as well as by Pilot Grant Funds from the Norris Cotton Cancer Center.

Purpose: To identify the optimum imaging sensor for a clinical system that would provide real-time imaging of the surface beam profile on patients as novel visual information to radiation therapy technologists, and more rapidly collect clinical data for large-scale studies of Cherenkov applications in radiotherapy. Methods: Four camera types, CMOS, CCD, ICCD and EMICCD, were tested to determine proficiency in the detection of Cherenkov signal in the clinical radiotherapy setting, and subsequent maximum supportable frame rate. Where possible, time-gating between the trigger signal from the LINAC and the intensifiers was implemented to detect signal with room lighting conditions comparable to patient treatment scenarios. A solid water phantom was imaged by the EM-ICCD and ICCD to evaluate the minimum number of accumulations-on-chip required for adequate Cherenkov detection, defined as >200% electron counts per pixel over background signal. Additionally, an ICCD and EM-ICCD were used clinically to image patients undergoing whole-breast radiation therapy, to understand the impact of the resolution limitation of the EM-ICCD. Results: The intensifier-coupled cameras performed best at imaging Cherenkov signal, even with room lights on, which is essential for patient comfort. The tested EM-ICCD was able to support single-shot imaging and frame rates of 30 fps, however, themore » current maximum resolution of 512 × 512 pixels was restricting. The ICCD used in current clinical trials was limited to 4.7 fps at a 1024 × 1024 resolution. An intensifier with higher quantum efficiency at the entrance photocathode in the red wavelengths (30% QE vs current 7%) promises 16 fps at the same resolution at lower cost than the EM-ICCD. Conclusion: The ICCD with the better red wavelength QE intensifier was determined to be the best suited commercial-off-the-shelf camera to detect real-time Cherenkov signal and provide the best potential for real-time display of radiation dose on the skin during treatment. Funding is from grants from the NIH numbers R01CA109558 and R21EB017559.« less

Purpose: To investigate the positional accuracy possible with real time Cherenkov video imaging based patient positioning and movement tracking during EBRT. Methods: In a phase 1 clinical trial, including 12 patients undergoing post-lumpectomy whole breast irradiation, Cherenkov emission was imaged with a time-gated ICCD camera synchronized to the LINAC pulse output, during different fractions of the treatment. Patients were positioned with the aid of the AlignRT system. Inter-fraction setup variation was studied by rigid image registrations between images acquired at individual treatments to the average image from all imaged treatment fractions. The amplitude of respiratory motion was calculated from the registration of each frame of Cherenkov images to the reference. A Canny edge detection algorithm was utilized to highlight the beam field edges and biological features provided by major blood vessels apparent in the images. Results: Real-time Cherenkoscopy could monitor the treatment delivery, patient motion and alignment of the beam edge to the treatment region simultaneously. For all the imaged fractions, the patient positioning errors were within our clinical tolerances (3 mm in shifts and 3 degree in pitch angle rotation), with 4.60% exceeding no more than 1 mm in shifts. The averaged error of repetitive patient positioning was 1.2 mm in linear shift and 0.34 degrees in rotational pitch, consistent with the accuracy reported by the AlignRT system. The edge detection algorithm enhanced features such as field edges and blood vessels. Patient positioning errors and respiratory motion retrieved from rigid image registration were consistent with the edge enhanced images. Besides positioning errors caused by global inaccurate setups, edge enhanced blood vessels indicate the existence of deformations Conclusion: Real-time Cherenkoscopy imaging during EBRT is a novel imaging tool that can be used for treatment monitoring, patient positioning and motion tracking with approximately 1.2mm displacement and 0.34 degree rotational accuracy.

Water content and sebum amount of irradiated and non-irradiated stratum corneum was measured by corneometer and sebumeter on the first and last day of RT, at 2 weeks, 4 weeks, and 3 months after RT. Sebum composition was analyzed by chromatography. Symptoms (pain and pruritus) were measured by Visual Analog Scale (VAS) and signs (erythema, dryness, and desquamation) were graded blind by a dermatologist. Eligibility criteria included women aged between 30 to 65 years and no surgical resection in the measurement site. The primary endpoint was the water content recovery rate between Weeks 2 and 4 post-RT (B vs C). The recovery rate was analyzed by Wilcoxon signed-rank test. Results: Seventy-six patients were analyzed. On the last day of RT and at 2 weeks post RT, water content was significantly decreased in group B (n Z 30) and C (n Z 32) vs A (n Z 14) (p < 0.05). At 4 weeks post RT, water content in group B returned to pre RT levels without significantly difference from group A (P Z 0.70), and reduction in water content was sustained in group C (p < 0.05). At 3 months post RT, the differences between three groups were not statistically significant. No adverse effects related to a moisturizer were noted. The water content recovery rate between Weeks 2 4 was significantly improved in group B vs C (0.242 vs 0.055, p < 0.05). The sebum amount and proportion of wax ester were markedly decreased in both irradiated and non-irradiated side after RT. The decrease of sebum sustained to 3 months post RT in irradiated side. Pain VAS score was improved in group A vs C on the last day of RT (p < 0.05) and in group B vs C at 3 months post-RT (p < 0.05). No difference was found on pruritus. Dryness and desquamation were significantly improved with moisturizer application (p < 0.05), but no effect on erythema. Conclusions: RT significantly reduced stratum corneum water content and induced quantifiable persistent sebaceous gland damage. Two week treatment of a heparinoid moisturizer after RT effectively improved RT-induced skin dryness. The prophylactic application of a moisturizer prevented severe skin dryness and can improve symptoms related to RD. Author Disclosure: M. Ogita: None. K. Sekiguchi: None. K. Akahane: None. J. Kawamori: None. R. Ito: None. C. Haga: None. S. Arai: None. O. Takahashi: None.

meaning no overlap if 0 and 100% concordance if 1. Paired samples t-test was performed to evaluate the changes in breast volumes. Results: The median interval between two scans was 90 days (range, 14170 days). Median age was 44 years (range, 29-69 years). The tumor was situated in the upper outer, retroareolar, lower outer, and lower inner quadrants in 16, 2, 2, and 2 patients, respectively. In 7 cases multifocality was present. Seven patients had excisional biopsy before the preoperative CT. Median pre and postoperative breast CTVs were 442 cc (range, 2761061 cc) vs 516 cc (range, 243-917 cc), respectively (p Z 0.132). A median of 4 surgical clips (range, 2-6) were inserted during the surgery. Median preoperative tumor volume and postoperative lumpectomy cavity volumes were 6.6cc (range, 0.4-49 cc) and 22.95 cc (range, 6.2-102.2 cc), respectively. Median CI was 0.07 (in 5 cases 1, and in 8 cases 0). Median shifts between the center of volumes were 1.02 cm (range, 0.4-4.43 cm) in x, 1.07cm (range, 0.05-5.67 cm) in y, and 1.12cm (range, 0-3.75 cm) in z directions. Conclusions: Our study shows that the tumor bed is remarkably replaced after oncoplastic surgery with latissimus dorsi mini-flaps. Only in 5 of 22 cases, preoperative tumor bed and postoperative lumpectomy cavity were fully superposed. In remaining cases there were remarkable shifts between two volumes. Special care should be given for defining lumpectomy cavity in radiation therapy planning. Author Disclosure: G. Alco: None. S. Igdem: None. S. Okkan: None. M. Dincer: None. F. Agacayak: None. D. Selamoglu: None. S. Ilgun: None. V. Ozmen: None.

Purpose: To show that Cherenkov emission generated by megavoltage X‐ray beams could be imaged in real time during external beam radiotherapy. Images of Cherenkov emission could be applied for quality assurance (QA) and estimate the superficial dose distribution for complex surface profiles. Methods: Cherenkov radiation has been documented to be generated by MeV external beam radiotherapy in both water and tissue. A typical breast cancer treatment plan was adopted to irradiate the breast and torso region of an anthropometric phantom. Images of Cherenkov emission have been taken by using a scientific‐grade time‐gated ICCD camera, synchronized to the LINAC pulse output, during treatment. Sampling depth depending on wavelength and angular distribution of Cherenkov photons (similar to Lambertian distribution) emitted from the surface have been investigated for different optical properties by Monte Carlo simulations in GAMOS and corresponding angular emission corrections have been applied. Registration of the 2‐D Cherenkov emission images to 3‐D surface profiles measured by motion monitoring system (Catalyst™, C‐RAD) has been investigated. Results: The images show that superficial dose varies dramatically with complex surface profiles. Imaging of this can be done, with a typical acquisition time of 2 sec, based upon Signal to noise ratio of SNR=30 for a 10 MeV beam, suggesting that near real time surface dosimetry is possible during the treatment time. The spatial resolution achieved here was approximately 1mm. Conclusion: Superficial dose can be imaged in realtime directly with a camera, capturing the Cherenkov emitted from the surface of the treatment region during external beam radiotherapy, and these surface dose images could potentially allow real time monitoring, quality assurance and decisions to be made about dose errors in complex treatment areas.

Purpose: To investigate the potential of FDG‐PET imaging for delineating the surgical cavity in post‐operative partial breast irradiation patients. Method and Materials: A DCIS breast cancer patient was imaged with a GE Discovery ST PET‐CT scanner approximately 2 weeks post lumpectomy. Following the treatment planningCT, a single‐bed (15 cm) FDG‐PET scan was dynamically acquired in 5‐sec intervals over 15 mins. The raw PET data was combined to form bins ranging from 30 sec to 15 min. These data were reconstructed by the GEscanner through an iterative OSEM algorithm, and hardware fused to the treatment planningCT. The value of PET in visualizing the lumpectomy cavity border was investigated through visual comparisons of fused PET‐CT images, the evolution of PET intensity for various breast points, and signal‐to‐noise measurements across the lesion. Results: The PETimage showed clear signal enhancement near the lumpectomy cavity. This enhancement formed a ring in each axial slice, matching the locations of surgical clips. Enhancement was also apparent where the cavity border was difficult to evaluate by CT density or clips alone. The ring presented a significantly higher SUV than other breast tissue (2.2 vs.