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Introduction: This study compared dose metrics between tangent breast plans calculated with the historical standard collapsed cone (CC) and the more accurate Monte Carlo (MC) algorithms. The intention was to correlate current plan quality metrics from the currently used CC algorithm with doses calculated using the more accurate MC algorithm. Methods: Thirteen clinically treated patients, whose plans had been calculated using the CC algorithm, were identified. These plans were copied and recalculated using the MC algorithm. Various dose metrics were compared for targets and the time necessary to perform each calculation. Special consideration was given to V105%, as this is increasingly being used as a predictor of skin toxicity and plan quality. Finally, both the CC and MC plans for 4 of the patients were delivered onto a dose measurement phantom used to analyse quality assurance (QA) pass rates. These pass rates, using various evaluation criteria, were also compared. Results: Metrics such as the PTVeval D95% and V95% showed a variation of 6% or less between the CC and MC plans, while the PTVeval V100% showed variation up to 20%. The PTVeval V105% showed a relative increase of up to 593% after being recalculated with MC. The time necessary to perform calculations was 76% longer on average for CC plans than for those recalculated using MC. On average, the QA pass rates using 2%2mm and 3%3mm gamma criteria for CC plans were lower (19·2% and 5·5%, respectively) than those recalculated using MC. Conclusion: Our study demonstrates MC-calculated PTVeval V105% values are significantly higher than those calculated using CC. PTVeval V105% is often used as a benchmark for acceptable plan quality and a predictor of acute toxicity. We have also shown that calculation times for MC are comparable to those for CC. Therefore, what is considered acceptable PTVeval V105% criteria should be redefined based on more accurate MC calculations.

Introduction: VT is often refractory to medical therapy and on rare but critical cases, even EP ablation. Despite investigation into endocardial, mesocardial and occasionally even epicardial ablation for these recalcitrant and deadly arrhythmias, there remains an inability to more effectively, non-invasively, treat VT. Hypothesis: We propose that, paralleling a Gamma Knife ® approach, the use of a novel MRI linear accelerator (MR Linac), the Unity ® (Elekta AB, Stockholm, Sweden), a proof of concept could be applied to highly selected pts with obstinate VT. Methods: A multi-center team with EP, Radiation Oncology and CMR (GE 1.5T) in joint development with Pittsburgh, PA and Utrecht, The Netherlands, developed a completely EP-CMR-guided method for non-invasive VT ablation utilizing S tereo T actic A rrhythmia R adioablation (STAR) with 25 Gy in a single fraction via MR Linac. Results: To evaluate deliverability and applicability of MR Linac plans, four IMRT per clinical scan were developed with varying delivery parameters (7A: 7-beams: 52 o in 70 segments (seg), 7B: 7-beams: 52 o in 100 seg, 15A: 15-beams: 24 o in 70 seg, and 15B: 15-beams: 24 o in 100 seg). We used a 0.2 cm dose grid and a 1% uncertainty via Monte Carlo ® dose calculation. Pt specific QA/QC used ArcCHECK ® (Sun Nuclear, FL) to evaluate individual IMRT plans. 3D CMR with LGE scar fusion for lesion integration guided non-invasive MR LinAc ablation. Accordingly, all IMRT plans were clinically acceptable (>97% of 7-beams and ≥98.0% of 15-beams in 3%/3mm gamma) for MR LinAc VT-ablation successfully with pt target effective arrhythmogenic myocardial ROI volume as ascertained via CMR of 63-99cm 3 . All 4 pts tolerated the 25±5min procedure without esophageal, pericardial or pro-arrhythmic complications and were alive at 30d FU with marked attenuation of VT burden. At 30d FU, no SAE's occurred to include pro-arrhythmias, pericardial effusions or esophageal fistulas. Conclusions: Refractory, complex and anatomically endocardially-remote VT has the potential to be curative, incorporating an analogous Gamma Knife ® approach via MR Linac radioablation heralding a migration to the Unity ® platform. This nearly first-in-man p r oof of concept approach may shepherd a new methodologic era into heretofore intractable VT.

Purpose To analyze the effect of post–radiation therapy (XRT) mammographic timing and radiation technique in relation to additional downstream workup for 569 breast conservation therapy patients treated with adjuvant XRT after their initial surveillance mammogram (MMG). Methods and Materials From January 2011 to December 2014, 569 breast cancer patients treated with breast conservation surgery and adjuvant XRT with a follow-up MMG were reviewed. Patients were stratified by the time interval until their first post-XRT MMG, and by XRT technique—whole breast (472), accelerated partial breast (96), conventional fractionation (373), hypofractionation (94), surgical cavity boosts (407), or no boost (66). The primary endpoint was further imaging after the initial MMG. Results Additional workup for those receiving an MMG within 3 months of completing XRT was 51% (73 of 143), compared with 40% (84 of 210) with MMG between 3 and 6 months and 34.5% (75 of 216) with MMG after 6 months (P=.04). Radiation boost to the postoperative bed was associated with further downstream imaging, whereas accelerated partial-breast irradiation and hypofractionated treatment were not. Conclusions Breast conservation therapy patients who underwent screening MMG before 6 months after completion of XRT were more likely to undergo downstream workup, including additional biopsies. Accelerated and hypofractionated radiation techniques were not associated with supplementary workup. Further study is needed to assess appropriate selection of high-risk patients and possible negative implications of earlier post-XRT screening MMG.

To establish the relationship among various skin dosimetric indices and different volumetric definitions of skin in high-dose-rate (HDR) balloon breast brachytherapy. Fifty breast cancer patients were treated with HDR balloon brachytherapy. The MammoSite® applicator was used for 40 patients and the Contura® applicator for 10 patients. Skin structure was retrospectively defined by expanding the skin surface internal to the body with a thickness of 1, 2, 3, 4, or 5 mm in one method. In another method, the skin was defined by expanding its external to the body to demonstrate the maximum point dose on the skin surface. For each skin structure defined by six different methods, three dosimetric data points extracted from dose-volume histograms were compared. Dmax was defined as the maximum point dose, and D1cc and D0.1cc were defined as the minimum dose to 1 cm3 and 0.1 cm3 of the most irradiated skin volume, respectively. The relationship among 18 dosimetric parameters was presented in graphs, and linear curve fitting was performed to provide mathematical formulas. For each skin definition, the Dmax, D1cc, and D0.1cc values show a linear relationship such that Dmax is the largest, D0.1cc is the next, and D1cc is the smallest value. For each dosimetric parameter, there was a linear relationship among the dosimetric indices for 6 different skin definitions. For clinical use, all linear relationships were displayed in graphs and two parameters for linear fitting were provided. Average R2 value for curve fitting was 0.978. The presented relationships can be developed in each individual institution and convert one dosimetric index to another for different skin definitions.

Purpose: Intraoperative planning with transrectal ultrasound (US) is used for accurate seed placement and optimal dosimetry in prostate brachytherapy. However, prostate magnetic resonance imaging (MRI) has shown superiority in delineation of prostate anatomy. Accordingly, MRI/US fusion may be useful for accurate intraoperative planning. We analyzed planning with MRI/US fusion to compare differences in dosimetry and volume to that derived from the postoperative computed tomography (CT). Material and methods: Twenty patients underwent preoperative prostate MRI, which was fused intraoperatively with US during prostate brachytherapy. Intraoperative 125I or 103Pd seed placement was modified by the use of MRI fusion when indicated. Following implantation, dose comparisons were made between data derived from MRI/US and that from post-operative CT scans. Plan parameters analyzed included the D90 (dose to 90% of the prostate), rectal D30, V30 (volume of the rectum receiving 30 percent of dose), and prostate V100. Results: The median number of seeds implanted per patient was seventy-six. The MRI measured prostate volume, which was on average 4.47 cc larger than the CT measured prostate volume. In 9 patients, the apex of the prostate was better identified under MRI with the fusion protocol, and an average of 4 fewer seeds were required to be placed in the apex/urinary sphincter region. Both MRI and US individually showed a reduced intraoperative prostate D90 in comparison to the postoperative CT, with a larger mean difference for MRI in comparison with US (9.71 vs. 4.31 Gy, p = 0.007). This was also true for the prostate V100 (5.18 vs. 2.73 cc, p = 0.009). Post-operative CT underestimated rectal D30 and V30 in comparison to both MRI and US with MRI showing a larger mean difference than US for D30 (40.64 vs. 35.92 Gy, p = 0.04) and V30 (50.20 vs. 44.38 cc, p = 0.009). Conclusions: The MRI/US fusion demonstrated greater prostate volume compared to standard CT/US based planning likely due to the better resolution of the prostate apex. Furthermore, rectal dose was underestimated with CT vs. MRI based planning. Additional study is required to assess long-term clinical implications of disease control and effects on long-term toxicity, especially as related to the rectum and urinary sphincter. MRI/US intraoperative fusion may improve prostate dosimetry while sparing the rectum and urethra, potentially impacting disease control and late toxicity.

Postmastectomy chest wall radiation therapy has historically used bolus to increase dose at the skin surface. Despite the theoretical benefits of bolus, the clinical implications of locoregional tumor control, cosmesis, and the incidence of radiodermatitis are less well characterized. We hypothesized that treatment in the presence or absence of bolus results in equivalent chest wall recurrence rates, but its presence results in more severe acute dermatologic toxicity.Locally advanced breast cancer patients undergoing chest wall radiation therapy were retrospectively reviewed from 2005 to 2015 (n = 106; 53 with bolus, 53 without). Outcomes including local failure, acute skin toxicity, and treatment interruptions were recorded. Median age was 59 years (range, 28-91) and median follow-up was 34 months. Histology was invasive ductal carcinoma (73%), invasive lobular carcinoma (20%), inflammatory (6%), and neuroendocrine (1%). Fifty-nine percent were T3/T4 primary tumors and 29.2% had clinical/pathologic skin involvement. Node-positive patients accounted for 80.2%. Chemotherapy was administered in 84.0%. All patients had 3-dimensional conformal radiation therapy and received a median dose of 61Gy (range, 50-63 Gy).Local failure was 6.6% (n = 7) overall, with 4 failures in the bolus group and 3 in the no bolus group. No pathological factors were associated with local failure. Acute grade 2 and 3 skin toxicities (37 vs 22) and treatment interruptions (20 vs 3) were more common in the bolus group (P.05). Mean treatment interruption (14.5 vs 5 days) was longer for patients receiving bolus. Patients undergoing treatment interruption were more likely to fail locally than patients not requiring a treatment interruption (17.4% vs 3.6%, P = .0322).Bolus omission in adjuvant chest wall radiation therapy may be a reasonable approach to avoid acute skin toxicity and treatment interruptions while preserving local control; however, further study will be needed to reach a definitive conclusion.

We investigated the downstream workup and costs associated with digital breast tomosynthesis (DBT) compared with 2-dimensional full field digital mammogram (FFDM) when employed as initial follow-up imaging in breast conservation therapy.Between the years 2015 and 2017, 450 consecutive breast conservation therapy patients, ages 32 to 89, with a follow-up DBT (n=162) or FFDM (n=288) were retrospectively reviewed. The primary endpoints were further workup after follow-up mammogram and associated health care costs at 1 year. A single DBT costs an estimated $149 compared with $111 for FFDM, based on Centers for Medicare claims data from the Oncology Care Model.The first posttreatment mammogram was received within 3 (20%), 3 to 6 (32%), or after 6 months (48%) following radiation. Younger patients and those undergoing hypofractionated radiation were more likely to get DBT. There were no differences in stage, receptor status, or mammogram timing between those in the FFDM and DBT groups.The following downstream workup ensued for DBT compared with FFDM imaging: 18% versus 29% short-interval (6-mo) mammogram (odds ratio=1.83, P=0.01), 6% versus 11% breast magnetic resonance imaging (odds ratio=1.90, P=0.08), 4% ultrasound for each, and 3% biopsy for each (1 positive in the FFDM group). Including downstream workup, the estimated cost per patient in the DBT group was $216.14 compared with $237.83 in the FFDM group. Independent predictors for reduced downstream workup per multivariable analysis were the use of DBT and first follow-up mammogram at least 6 months after radiation (P0.05).Excess workup was reduced with DBT compared with FFDM in the posttreatment setting, which translated to an improvement in cost efficiency in this study.

Breast cancer is the most common malignancy diagnosed in women (http://seer.cancer.gov/statfacts/html/breast.html). Today, with the widespread generalization of mammography, it is most frequently diagnosed at an early stage (Nystrom et al. 2002). The outcomes of those early-stage cancers are excellent, with local control above 98% and a risk of dying of cancer at 5 years below 2% (http://seer.cancer.gov/statfacts/html/breast.html; Strnad et al. 2016). Clinical researches since the 1980s have aimed at optimizing the cosmetic outcome, minimizing the long-term side effects, and reducing the treatment burden. Several randomized clinical trials and meta-analyses have shown that breast-conserving surgery followed by adjuvant radiotherapy (XRT) to the whole breast achieves local control rate and survival equivalent to mastectomy, with the advantage of allowing breast conservation and hence improved quality of life (Fisher et al. 2002; Veronesi et al. 2002; Clark et al. 1996; EBCTCG et al. 2011).

Rarely since the introduction of breast-conserving therapy in the 1980s has the breast radiation oncology community been so passionately divided and arguing for the introduction of a new concept as for accelerated partial breast irradiation (APBI). The idea looks a priori counterintuitive—limiting the concept of clinical target volume (CTV) and hence the irradiated volume within anatomical breast boundaries. The passion in published opinions possibly comes from a strange mix of financial interest, competition between techniques, and the extensive use of patient’s advertisements and press releases instead of clinical evidence and data (Smith et al. JAMA 307:1827–1837, 2012; Khan et al. JAMA 308:567, 2012). It is striking that in 2016 two articles reviewing the best available evidence, one by Vicini et al. and the other from the Cochrane Library (Vicini et al. Brachytherapy 15:607–615, 2016; Hickey et al. Cochrane Database System Review 7:CD007077, 2016), had exactly opposite conclusions. The former concluded that “Four contemporary trials with over 2000 patients comparing APBI and whole breast irradiation (WBI) have been published and demonstrate no differences in the rates of local/regional recurrence or survival though long-term follow-up is limited to one study. In addition, reductions in the rates of acute and chronic toxicity and improvements in cosmetic outcome were noted in two of these trials.” The latter concluded that “It appeared that local recurrence and 'elsewhere primaries’ (new primaries in the ipsilateral breast) are increased with PBI/APBI (the difference was small), but we found no evidence of detriment to other oncological outcomes. It appeared that cosmetic outcomes and some late effects were worse with PBI/APBI but its use was associated with less acute skin toxicity.” There is one thing most experts would agree on: that almost 25 years after the first mention of partial breast irradiation by Bethune in the Journal of the National Medical Association (Bethune Journal of the National Medical Association 83:768, 800–808, 1991), evidence is now emerging that the APBI paradigm is safe for highly selected patients. This chapter reviews a selection of the available evidence.

The near-miraculous discovery of the X-ray by Wilhelm Roentgen in 1895 (University of Wurzburg-Bavaris n.d.) was coincidentally coupled with the most recent developments in rapid long-distance communication abilities. Those simultaneous discoveries made it quickly possible to propel forth a new discipline of research into the possible applications of this new radiation breakthrough. From the outset, radiation was thought to be not only an important diagnostic tool—evaluating fractures without the then standard-of-care painful manipulations—but also as a possible therapeutic option, especially for cancer. Following Emil Grubbe’s discovery that radiation exposure adversely affected cancerous growths (Grubbe 1903), the medical world became almost immediately excited that a new therapy option could become a surgical accessory, if not an alternative, for the treatment of cancers. There were big questions to answer: What to treat, who to treat, and how to treat? The intent of this book focuses on the latter question since at this point within the modern era of radiation therapy, there is little doubt in the therapeutic advantages of radiation, especially for the curative and conservation techniques (Chou et al. 2001).

No text related to altered fractionation would be complete without the recognition that the original short-course (altered fractionation) radiotherapy was the initial form of any type of radiotherapy. From the discovery of polonium and radium by Marie and Pierre Curie in the late nineteenth century (Curie and Curie, Proceedings of the academy of science, 1898) and the first use of radium in the treatment of cancer in the late nineteenth century (Eve, Madame Curie: a biography by Eve Curie, Country Life Press, Garden City, NY, 1937), brachytherapy (as it would eventually be termed) used in focused and short treatment courses was established as the original “altered fractionation.” As radiation oncology has metamorphosed from brachytherapy alone to the development of crude contact devices to the evolution to megavoltage 60Co devices and now to the modern platform of artificially produced multi-fraction megavoltage photons over many weeks (to months) of therapy, the paradigm has shifted backwards. As Dr. Ted Yaeger has so eloquently termed this paradigm shift in the Introduction of this book, “We wish this book to be atouch-stoneto re-kindle interest in the development of a new paradigm in radiotherapy … altered fractionation.” The “touchstone” term is deliberately used to identify a refocusing of our efforts toward a new fractionation which is, in the most basic sense, a return to our roots. From the historic to the modern treatment of cervical cancer where brachytherapy is essential, to the modern treatment of breast cancer, where brachytherapy is a now accepted option for early-stage disease (Polgar et al., Radiother Oncology, 108:197–202, 2013; Strnad et al., Lancet, 387: 229–238, 2016; Wenz et al., Breast Care, 10:247S2, 2015; Cuttino et al., International Journal of Radiation Oncology, Biology, Physics, 90(5):1025–1029, 2014; Shah et al., Brachytherapy, 12:267–277, 2013; Polgar et al., Brachytherapy: an international perspective, Springer, Berlin, 2016), this altered fraction modality has maintained a prominent place in the armamentarium of radiation oncology.

The objective of this work is to evaluate dosimetric impact of multilumen balloon applicator rotation in high‐dose‐rate (HDR) brachytherapy for breast cancer. Highly asymmetrical dose distribution was generated for patients A and B, depending upon applicator proximity to skin and rib. Both skin and rib spacing was ≤0.7 cm for A; only rib spacing was ≤0.7 cm for B. Thirty‐five rotation scenarios were simulated for each patient by rotating outer lumens every 10° over ±180∘ range with respect to central lumen using mathematically calculated rotational matrix. Thirty‐five rotated plans were compared with three plans: 1) original multidwell multilumen (MDML) plan, 2) multidwell single‐lumen (MDSL) plan, and 3) singledwell single‐lumen (SDSL) plan. For plan comparison, planning target volume for evaluation (PTV_EVAL) coverage (dose to 95% and 90% volume of PTV_EVAL) (D95 and D90), skin and rib maximal dose (Dmax), and normal breast tissue volume receiving 150% (V150) and 200% (V200) of prescribed dose (PD) were evaluated. Dose variation due to device rotation ranged from −5.6% to 0.8% (A) and −6.5% to 0.2% (B) for PTV_EVAL D95; −5.2% to 0.4% (A) and −4.1% to 0.7% (B) for PTV_EVAL D90; −2.0 to 18.4% (A) and −7.8 to 17.5% (B) for skin Dmax; −11.1 to 22.8% (A) and −4.7 to 55.1% (B) of PD for rib Dmax, respectively. Normal breast tissue V150 and V200 variation was

In this chapter, we present an alternative management of ipsilateral breast tumor recurrence following conservation therapy for early breast cancer. We will present the evidence to date and hope to establish this alternative approach as a plausible option for women affected by in-breast recurrence, but desirous of breast preservation. We discuss this option presenting the established standard of care and the alternatives, as well as the specific concerns related to retreatment.

PURPOSE: To retrospectively report pacemaker (PM)/implantable cardioverteredefibrillator (ICD) dose in balloon high-dose-rate (HDR) brachytherapy and provide distanceedose graph and table to approximately estimate the maximal device dose. METHODS AND MATERIALS: For 3 patients (A, B, and C), PM/ICD was retrospectively contoured on planning computed tomography images and its maximal dose was extracted from a doseevolume histogram. The surface of 1 cm expansion from balloon was prescribed to 34 Gy and the inverse square law was dominant factor in dose calculation. Therefore, the maximal PM/ICD dose was approximately estimated from the distanceedose graph or table and compared with that of the treatment plan. RESULTS: The minimal deviceeballoon surface distance was 10.9, 18.4, and 4.3 cm for patient A, B, and C, respectively. The maximal dose estimated from the proposed table/graph was 2.1 vs. 1.61 Gy for patient A, 0.87 vs. 0.49 Gy for patient B, and 8.9 vs. 9.14 Gy for patient C compared with that from the treatment plan. CONCLUSIONS: Depending on the location of PM/ICD relative to the tumor bed, balloon HDR brachytherapy is feasible if the maximal dose is less than or equal to the dose limit. The proposed distanceedose graph and/or table enable to approximately predict the maximal device dose based on the measurement of minimal distance between lumpectomy and the device before balloon implantation for the suitability of balloon HDR brachytherapy. 2012 American Brachytherapy

Purpose: To investigate radiation dose to the heart in 60 patients with left-sided breast cancer who were treated with balloon-based high-dose-rate brachytherapy using MammoSite or Contura applicators. Methods and Materials: We studied 60 consecutive women with breast cancer who were treated with 34 Gy in 10 twice-daily fractions using MammoSite (n = 37) or Contura (n = 23) applicators. The whole heart and the left and right ventricles were retrospectively delineated, and dose–volume histograms were analyzed. Multiple dosimetrics were reported, such as mean dose (Dmean); relative volume receiving 1.7, 5, 10, and 20 Gy (V1.7, V5, V10, and V20, respectively); dose to 1 cc (D1cc); and maximum point dose (Dmax). Biologic metrics, biologically effective dose and generalized equivalent uniform dose were computed. The impact of lumpectomy cavity location on cardiac dose was investigated. Results: The average ± standard deviation of Dmean was 2.45 ± 0.94 Gy (range, 0.56–4.68) and 3.29 ± 1.28 Gy (range, 0.77–6.35) for the heart and the ventricles, respectively. The average whole heart V5 and V10 values were 10.2% and 1.3%, respectively, and the heart Dmax was >20 Gy in 7 of 60 (11.7%) patients and >25 Gy in 3 of 60 (5%) patients. No cardiac tissue received $30 Gy. The V1.7, V5, V10, V20, and Dmean values were all higher for the ventricles than for the whole heart. For balloons located in the upper inner quadrant of the breast, the average whole heart Dmean was highest. The Dmean, biologically effective dose, and generalized equivalent uniform dose values for heart and ventricles decreased with increasing minimal distance from the surface of the balloon. Conclusions: On the basis of these comprehensive cardiac dosimetric data, we recommend that cardiac dose be routinely reported and kept as low as possible in balloon-based high-dose-rate brachytherapy treatment planning for patients with left-sided breast cancer so the correlation with future cardiac toxicity data can be investigated. 2012 Elsevier Inc. Cardiac dose, Heart, High-dose-rate brachytherapy, Balloon, MammoSite, Contura.

Objectives To retrospectively compare radiation toxicity in patients treated with concurrent anastrozole and whole breast irradiation versus women treated sequentially with whole breast irradiation followed by hormonal suppression. Methods The records of 249 consecutive estrogen or progesterone receptor positive breast cancer patients treated with breast-conserving surgery and postoperative whole breast irradiation were reviewed. Of total, 57 patients (the concurrent anastrozole group) received concurrent anastrozole prior to and during radiotherapy. In 126 patients (the sequential group), adjuvant hormone suppression therapy (anastrozole, other aromatase inhibitors, or tamoxifen) was administered after the completion of breast irradiation. In 66, women either concurrent tamoxifen was given with radiation or the sequence of hormonal therapy was not known. These women were excluded from the analysis. Results The frequency of acute grade 2 radiation dermatitis (24.6% in the concurrent anastrozole group vs. 20.6% in the sequential group; P = 0.55), grade 3 radiation dermatitis (8.8% vs. 7.1%; P = 0.77) and treatment interruptions due to skin reactions (14.0% vs. 11.2%; P = 0.69) did not differ between groups. The rates of clinically detectable breast fibrosis were not different (24.2% vs. 24.7%; P = 0.97). With a median follow-up of 28 months and 30.8 months, respectively, 1 local failure occurred in the concurrent anastrozole group and 5 in the sequential group. Conclusions Anastrozole, administered concurrently with whole breast irradiation, did not increase acute or late morbidity when compared with sequential administration of radiation and hormonal suppression therapy.

The objective of this study was to evaluate the safety, toxicity, and planning concerns involved in accelerated partial breast irradiation (APBI) for patients with breast cancer who have a pacemaker or an automatic implantable cardioverter-defibrillator (AICD) and who desire breast conservation.We performed a review of prospectively obtained data for patients with early-stage breast cancer with a pacemaker or AICD treated between April 2007 and July 2010. Patients were treated with either 3D conformal external beam irradiation (3D-CRT) or high-dose rate balloon brachytherapy (HDRBB) as performed in the National Surgical Adjuvant Breast and Nowel Project (NSABP) B-39/Radiation Therapy Oncology Group (RTOG) 0413 protocol. Device interrogation was performed after the first and last radiation treatment, with comparative cardiac monitoring performed before and after the first three treatments.Eight patients were treated and have a mean follow-up of 6 months. Three patients received HDRBB delivering 34 Gy in 10 fractions. Mean planning target volume for evaluation (PTV_EVAL) coverage was 93.6%. The maximum radiation dose delivered to any device was 1.03 Gy, with a mean pacemaker distance to lumpectomy cavity (DLC) of 9.1 cm. Five patients received 3D-CRT consisting of 38.5 Gy in 10 fractions. The mean 90% PTV_EVAL coverage was 97.3%. Maximum dose delivered to any device was 1.68 Gy at a DLC of 9 cm. Local toxicity did not exceed grade 1, and no adverse device events were noted.APBI in patients with pacemakers or AICDs who desire breast preservation seems to be a technically safe and reasonable application of targeted radiation therapy.

Purpose: An objective method was proposed and compared with a manual selection method to determine planner-independent skin and rib maximal dose in balloon-based high dose rate (HDR) brachytherapy planning. Methods: The maximal dose to skin and rib was objectively extracted from a dose volume histogram (DVH) of skin and rib volumes. A virtual skin volume was produced by expanding the skinsurface in three dimensions (3D) external to the breast with a certain thickness in the planning computed tomography(CT)images. Therefore, the maximal dose to this volume occurs on the skinsurface the same with a conventional manual selection method. The rib was also delineated in the planning CTimages and its maximal dose was extracted from its DVH. The absolute ( Abdiff = | D max Man − D max DVH | ) and relative ( Rediff [ % ] = 100 × ( | D max Man − D max DVH | ) / D max DVH ) maximal skin and rib dose differences between the manual selection method ( D max Man ) and the objective method ( D max DVH ) were measured for 50 balloon-based HDR (25 MammoSite® and 25 Contura®) patients. Results: The average ± standard deviation of maximal dose difference was 1.67 % ± 1.69 % of the prescribed dose (PD). No statistical difference was observed between MammoSite® and Contura® patients for both Abdiff and Rediff[%] values. However, a statistically significant difference ( p value 0.0001 ) was observed in maximal rib dose difference compared with maximal skindose difference for both Abdiff ( 2.30 % ± 1.71 % vs 1.05 % ± 1.43 % ) and Rediff[%] ( 2.32 % ± 1.79 % vs 1.21 % ± 1.41 % ). In general, rib has a more irregular contour and it is more proximally located to the balloon for 50 HDR patients. Due to the inverse square law factor, more dose difference was observed in higher dose range ( D max > 90 % ) compared with lower dose range ( D max 90 % ) : 2.16 % ± 1.93 % vs 1.19 % ± 1.25 % with p value of 0.0049. However, the Rediff[%] analysis eliminated the inverse square factor and there was no statistically significant difference ( p value = 0.8931 ) between high and low dose ranges. Conclusions: The objective method using volumetric information of skin and rib can determine the planner-independent maximal dose compared with the manual selection method. However, the difference was 2 % of PD, on average, if appropriate attention is paid to selecting a manual dose point in 3D planning CTimages.

OBJECTIVE To compare tumor control and changes in audiometric parameters of acoustic neuroma patients treated with either linac-based stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) at Allegheny General Hospital. STUDY DESIGN Twenty-three patients with acoustic neuroma were treated between February 2003 and April 2009 with either SRS (n = 13) or SRT (n = 10). The median age for all patients was 69 years and the median size of lesions was 1.2 cm (range 0.5-2.2 cm). The prescribed dose was a single dose of 1250 cGy for all SRS patients compared to 2500 cGy in 5 daily fractions for SRT patients. All patients had pre- and post-procedure audiometry including hearing acuity assessed using pure tone average (PTA), speech discrimination score (SDS), and speech reception threshold (SR). The results of treatment type and tumor variables resulting in hearing degradation were evaluated and compared. RESULTS At a median follow-up of 13 months (range 3-36 months), only 1 of 13 patients treated with SRS and 2 of 10 patients treated with SRT develped progression of disease. However; all patients developed deterioration in PTA, SDS, or SR on the treated side. There were no statistically significant audiometric differences between patients treated with SRT or SRS and tumor response was similar regardless of irradiation technique. CONCLUSION Both SRS and SRT provide excellent local control rates for the treatment of acoustic neuroma. While SRS demonstrated a trend toward worsening of SDS and the treatment of lesions >1.2 cm demonstrated a trend toward worsening of PTA, neither reached statistical significance. Our data suggest that single dose irradiation using the SRS technique should be considered primarily for patient convenience. All patients treated with radiotherapy for acoustic neuromas should undergo formal hearing testing before and after treatment.

Paragangliomas or glomus tumors are usually low-grade hypervascular tumors occurring in various sites of the autonomic nervous system including the carotid body, glomus vagale and glomus tympanicum. Although the grading of the tumor suggests a benign clinical course, the tumor can be locally malignant and surgical management is sometimes difficult because of postoperative functional loss and local recurrence. In addition, the operative field is generally very bloody and tissue planes are not always well-defined.Though the optimal management of paraganglioma occurs in a multidisciplinary setting, considering the excellent local control rates with primary irradiation alone, a nonsurgical definitive approach should initially be considered.

In 1911, when the Nobel Foundation awarded its coveted Chemistry Prize to a 44 year old Polish born woman, it is likely they may not have expected the action ever duplicated in the more than 100 years that followed. In fact, it was the second Nobel Prize in the sciences awarded to Maria Sklodowska-Curie, whom the world would come to admire, know, and love as Madame Curie. In a time of science dominated by men, the diminutive in size but larger-than-life Curie would become the first women to be awarded the prize. To this date, she remains the only person in history to win two Nobel prizes in two different science fields, and only one of four persons to win more than one. In total, Mme. Curie and her immediate family would be awarded five Nobel prizes. As astonishing as these facts may be, Mme. Curie did not seek fame nor did she seek self aggrandizement. Her whole life was one of service to humanity, an indefatigable work ethic, and humility.

311 Background: We previously reported that premature (less than 6 months) follow-up screening mammography after radiotherapy in breast conservation therapy was associated with an increased rate of unnecessary downstream workup. We now present the results of a similar study conducted with follow-up tomosynthesis mammogram (TS). Methods: Between the years 2015-2017, 143 consecutive breast cancer patients between ages 33 – 82 were treated with lumpectomy and adjuvant radiotherapy with follow-up TS and reviewed in this IRB-approved study. Cases were stratified by time interval until the first post-radiation TS, and secondarily by radiation technique: conventional fractionation (n = 84), hypofractionation (n = 59), boost (n = 116), no boost (n = 27), and accelerated partial breast irradiation (n = 10). The primary endpoint was the rate of further imaging/workup following TS, correlated with clinical, treatment, and post-treatment timing related variables using multivariable binomial regression analysis. Results: The patient cohort included the following clinical characteristics: 6 patients with ductal carcinoma in-situ (the remaining demonstrated either invasive ductal or invasive lobular histology), Ninety-seven patients had stage T1 lesions, 34 had T2, and 4 had T3/T4 lesions. Eighteen patients were node+, 95 ER+/ Her2-, 13 were triple negative, and 13 triple positive. No patients had clinical suspicion of recurrence before their first follow-up TS. Conclusions: Unlike with post-treatment screening two-dimensional mammography, there was no association with post-treatment tomosynthesis timing and downstream workup. Further study should be considered to confirm these preliminary findings.

Purpose: Electron or photon boost immediately following whole-breast irradiation performed after conservation surgery for early-stage breast cancer is the accepted standard of care. This regimen frequently results in Grade III dermatitis, causing discomfort or treatment interruption. Herein, we compare patients treated with whole-breast irradiation followed by boost compared with a cohort with a planned intercurrent radiation boost. Methods and Materials: The records of 650 consecutive breast cancer patients treated at Allegheny General Hospital (AGH) between 2000 and 2008 were reviewed. Selected for this study were 327 patients with T1 or T2 tumors treated with external beam radiotherapy postlumpectomy. One hundred and sixty-nine patients were treated by whole-breast radiotherapy (WBRT) followed by boost at completion. One hundred fifty-eight were treated with a planned intercurrent boost (delivered following 3,600 cGy WBRT). The mean whole breast radiation dose in the conventionally treated group was 5,032 cGy (range, 4500-5400 cGy), and the mean whole breast dose was 5,097 cGy (range, 4860-5040 cGy) in the group treated with a planned intercurrent boost. Results: The occurrence of Grade III dermatitis was significantly reduced in the WBRT/intercurrent boost group compared with the WBRT/boost group (0.6% vs. 8.9%), as was the incidence of treatment interruption (1.9% vs. 14.2%).more » With a median follow-up of 32 months and 27 months, respectively, no significant difference in local control was identified. Conclusions: Patients treated with intercurrent boost developed less Grade III dermatitis and unplanned treatment interruptions with similar local control.« less

The objective of this work is to evaluate the interfractional biological effective dose (BED) variation in MammoSite high dose rate (HDR) brachytherapy. Dose distributions of 19 patients who received 34 Gy in 10 fractions were evaluated. A method was employed to account for nonuniform dose distribution in the BED calculation. Furthermore, a range of α/β values was utilized for specific clinical end points: fibrosis, telangiectasia, erythema, desquamation and breast carcinoma. Two scenarios were simulated to calculate the BED value using: i) the same dose distribution of fraction 1 over fractions 2–10 (constant case, CC), and ii) the actual delivered dose distribution for each fraction 1–10 (interfraction dose variation case, IVC). Although the average BED difference (IVC – CC) was

This patient case-study represents the introduction of radiotherapy in the management of extra-cranial vascular malformations, a topic with virtually no supported literature before our case study. In those patients refractory to established therapies and facing the inevitability of mutilating amputation, radiotherapy may be a viable option to preserve the limb.

Purpose To examine the feasibility of using the MammoSite brachytherapy applicator in the retreatment of the previously irradiated breast. Methods and materials Between March 2004 and March 2007, three patients previously treated with external beam radiotherapy were retreated using the MammoSite brachytherapy device. Two patients were treated for an ipsilateral breast tumor recurrence after breast conservation surgery and postoperative irradiation, whereas the third patient developed an in-field breast cancer likely associated with Hodgkin's disease mantle irradiation 27 years before. The recurrent histology of two was ductal carcinoma in situ ([DCIS] one originally presenting as infiltrating ductal carcinoma [IDC] and the other as DCIS), whereas the Hodgkin's disease patient presented with IDC. All patients received a twice-daily tumor dose of 3400 cGy at 340 cGy/fraction. The mean maximum skin dose was 53.4% (range, 49.5–60.3%) of the prescribed dose. Results With a mean followup of 32 months, no patient developed a local recurrence. Cosmesis in all three cases as graded by the National Surgical Adjuvant Breast and Bowel Project, cosmesis criteria was excellent (Grade I) in all cases. Dosimetric calculations demonstrated that the device allows for appropriate local irradiation while sparing the previously irradiated skin of the involved breast as defined by the protocol standard. Conclusions Use of the MammoSite device in the treatment of the previously irradiated breast is feasible and may provide adequate local control as well as acceptable cosmesis in carefully selected patients.

Purpose To measure the interfraction changes of the MammoSite applicator and evaluate their dosimetric effect on target coverage and sparing of organs at risk. Methods and Materials A retrospective evaluation of the data from 19 patients who received 10 fractions (34 Gy) of high-dose-rate partial breast irradiation was performed. A computed tomography-based treatment plan was generated for Fraction 1, and a computed tomography scan was acquired just before the delivery of each fraction to ensure a consistent shape of the balloon. The eccentricity, asymmetry, and planning target volume (PTV) for plan evaluation purposes (PTV_EVAL), as well as trapped air gaps, were measured for all patients. Furthermore, 169 computed tomography-based treatment plans were retrospectively generated for Fractions 2–10. Interfraction dosimetric variations were evaluated using the %PTV_EVAL coverage, target dose homogeneity index, target dose conformal index, and maximum doses to the organs at risks. Results The average variation of eccentricity and asymmetry from Fraction 1 values of 3.5% and 1.1 mm was −0.4% ± 1.6% and −0.1 ± 0.6 mm. The average trapped air gap volume was dramatically reduced from before treatment (3.7 cm 3 ) to Fraction 1 (0.8 cm 3 ). The PTV_EVAL volume change was insignificant. The average variation for the %PTV_EVAL, target dose homogeneity, and target dose conformal index from Fraction 1 values of 94.7%, 0.64, and 0.85 was 0.15% ± 2.4%, −0.35 ± 2.4%, and −0.34 ± 4.9%, respectively. The average Fraction 1 maximum skin and ipsilateral lung dose of 3.2 Gy and 2.0 Gy varied by 0.08 ± 0.47 and −0.16 ± 0.29 Gy, respectively. Conclusion The interfraction variations were patient specific and fraction dependent. Although the average interfraction dose variations for the target and organs at risk were not clinically significant, the maximum variations could be clinically significant.

PURPOSE: To evaluate lumpectomy followed by interstitial brachytherapy as an acceptable sal- vage therapy for women who have developed localized recurrence of breast cancer after conserva- tion surgery and postoperative external radiotherapy. METHODS AND MATERIALS: Between 1/1998 and 10/2006, 21 patients with T0 or T1 in- breast recurrence of carcinoma were offered interstitial low-dose rate brachytherapy after tumor re-excision as an alternative to salvage mastectomy. All patients had failed lumpectomy followed by standard postoperative external beam radiotherapy (range, 5000e6040 cGy) as treatment for the initial breast carcinoma. Seven recurred as ductal carcinoma in situ, 2 as infiltrating lobular car- cinoma, and 12 as recurrent invasive carcinoma. The recurrent tumors were excised with final mar- gins of resection free of residual disease per National Surgical Adjuvant Breast and Bowel Project definition. Tumor bed implantation was then carried out with an interstitial technique using 192 Ir with the target volume consisting of the tumor bed plus a minimum 1.0-cm clinical margin. The required minimum dose delivered to the target volume was 4500e5000 cGy (range, 4500e5530). RESULTS: Twenty of 21 patients were free of local disease with a median observation time of 40 months (range, 3e69). The single patient who developed a second local recurrence was treated suc- cessfully with simple mastectomy. Two patients succumbed to systemic disease at 17 and 24 months after salvage implant therapy. One patient developed a contralateral breast cancer. Cosmetic results defined by the National Surgical Adjuvant Breast and Bowel Project cosmesis scale were acceptable. One patient developed a localized seroma requiring multiple needle aspirations before complete resolution. Two patients developed localized skin breakdown in the tumor bed. One healed after 6 months of conservative treatment. The other healed 9 months later with Grade II cosmesis. This patient also developed a concurrent postoperative wound infection. CONCLUSIONS: Repeat lumpectomy followed by brachytherapy is feasible and may be an ac- ceptable alternative to salvage mastectomy in patients who locally fail conservation breast therapy; however, longer followup and greater patient numbers may be needed to better define the role of salvage brachytherapy. 2008 American Brachytherapy Society. All rights reserved.

A dosimetric comparison was performed on external-beam three-dimensional conformal partial breast irradiation (PBI) and whole breast irradiation (WBI) plans for patients enrolled in the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-39/Radiation Therapy Oncology Group (RTOG) 0413 protocol at our institution. Twenty-four consecutive patients were treated with either PBI (12 patients) or WBI (12 patients). In the PBI arm, the lumpectomy cavity was treated to a total dose of 38.5 Gy at 3.85 Gy per fraction twice daily using a four-field noncoplanar beam setup. A minimum 6 h interval was required between fractions. In the WBI arm, the whole breast including the entirety of the lumpectomy cavity was treated to a total dose of 50.4 Gy at 1.8 Gy per fraction daily using opposed tangential beams. The lumpectomy cavity volume, planning target volume for evaluation (PTV_EVAL), and critical structure volumes were contoured for both the PBI and WBI patients. Dosimetric parameters, dose volume histograms (DVHs), and generalized equivalent uniform dose (gEUD) for target and critical structures were compared. Dosimetric results show the PBI plans, compared to the WBI plans, have smaller hot spots in the PTV_EVAL (maximum dose: 104.2 % versus 110.9 % ) and reduced dose to the ipsilateral breast ( V 50 : 48.6 % versus 92.1 % and V 100 : 10.2 % versus 50.5 % ), contralateral breast ( V 3 : 0.16 % versus 2.04 % ), ipsilateral lung ( V 30 : 5.8 % versus 12.7 % ), and thyroid (maximum dose: 0.5 % versus 2.0 % ) with p values ≤ 0.01 . However, similar dose coverage of the PTV_EVAL ( 98 % for PBI and 99 % for WBI, on average) was observed and the dose difference for other critical structures was clinically insignificant in both arms. The gEUD data analysis showed the reduction of dose to the ipsilateral breast and lung, contralateral breast and thyroid. In addition, preliminary dermatologic adverse event assessment data suggested reduced skin toxicity for patients treated with the PBI technique.

Initial treatment outcome data from our institution for stage I non-small cell lung cancer (NSCLC) patients have shown that sublobar resection in combination with iodine-125 (I-125) brachytherapy is associated with recurrence rates of 2.0%, compared to 18.6% with sublobar resection alone. In this work, the technical and dosimetric aspects required to execute this procedure from the radiation oncology perspective as well as an analysis of the dose distributions of patients treated with this technique are presented. In this treatment technique, I-125 seeds in vicryl suture are embedded into vicryl mesh and surgically inserted providing a 2.0 cm margin on each side of the resection staple line. A nomogram is developed to determine the suture spacing in the vicryl mesh, as a function of seed activity in order to deliver 120 Gy at a distance of 0.5 cm above and below the seed array. Post-operative dosimetry consists of a CT-based planning and dose volume analysis. Dose distributions, dose volume histograms and mean dose data for lung are analysed in a group of patients. Dosimetric results show significant lung sparing with only a small volume of lung irradiated for all patients with mean lung dose values ranging from 1.5 Gy to 5.4 Gy. Lung brachytherapy with I-125 at the time of sublobar resection is a highly conformal option of dose delivery for stage I NSCLC patients with compromised physiologic reserve. Patient-related toxicity clinically measured by loss of pulmonary function and radiation-induced pneumonitis have not been linked to this procedure.

Bullous pemphigoid is an unusual condition that occurs rarely as a complication following radiotherapy. Because of the difficulties in the diagnosis of this disease and the need for raising awareness of such as a complication of therapeutic intervention we present a case report and review of the literature with discussion to highlight this disease which can confound the management of breast cancer.

Background Sublobar resection (SR) can be performed in high-risk non–small-cell lung carcinoma (NSCLC) patients but is associated with an increased local recurrence. This abstract reviews our intraoperative 125Iodine brachytherapy experience after SR in high-risk Stage I NSCLC patients and compares these results with our previous series of SR alone in similar patients. Methods One hundred two Stage I NSCLC patients who underwent SR alone were compared with 101 Stage I patients who underwent SR and intraoperative 125Iodine brachytherapy placed over the SR staple line. Conclusion Local recurrence after SR and 125Iodine brachytherapy (2%) in high-risk Stage I NSCLC patients was significantly less than after SR alone (18.6%). This safe, pulmonary function–preserving and practical intraoperative brachytherapy method should be considered when SR is used as a “compromise” therapy in these patients.