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The purpose of this work is to establish an automated approach for a multiple isocenter volumetric arc therapy (VMAT)-based TBI treatment planning approach. Five anonymized full-body CT imaging sets were used. A script was developed to automate and standardize the treatment planning process using the Varian Eclipse v15.6 Scripting API. The script generates two treatment plans: a head-first VMAT-based plan for upper body coverage using four isocenters and a total of eight full arcs; and a feet-first AP/PA plan with three isocenters that covers the lower extremities of the patient. PTV was the entire body cropped 5 mm from the patient surface and extended 3 mm into the lungs and kidneys. Two plans were generated for each case: one to a total dose of 1200 cGy in 8 fractions and a second one to a total dose of 1320 cGy in 8 fractions. Plans were calculated using the AAA algorithm and 6 MV photon energy. One plan was created and delivered to an anthropomorphic phantom containing 12 OSLDs for in-vivo dose verification. For the plans prescribed to 1200 cGy total dose the following dosimetric results were achieved: median PTV V100% = 94.5%; median PTV D98% = 89.9%; median lungs Dmean = 763 cGy; median left kidney Dmean = 1058 cGy; and median right kidney Dmean = 1051 cGy. For the plans prescribed to 1320 cGy total dose the following dosimetric results were achieved: median PTV V100% = 95.0%; median PTV D98% = 88.7%; median lungs Dmean = 798 cGy; median left kidney Dmean = 1059 cGy; and median right kidney Dmean = 1064 cGy. Maximum dose objective was met for all cases. The dose deviation between the treatment planning dose and the dose measured by the OSLDs was within ±4%. In summary, we have demonstrated that scripting can produce high-quality plans based on predefined dose objectives and can decrease planning time by automatic target and optimization contours generation, plan creation, field and isocenter placement, and optimization objectives setup., (© 2021 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals LLC on behalf of AmericanAssociation of Physicists in Medicine.)

The American Association of Physicists in Medicine (AAPM) has established a comprehensive Code of Ethics for its members. The Code is a formal part of AAPM governance, maintained as Professional Policy 24, and includes both principles of ethical practice and the rules by which a complaint will be adjudicated. The structure and content of the Code have been crafted to also serve the much broader purpose of giving practical ethical guidance to AAPM members for making sound decisions in their professional lives. The Code is structured in four major parts: a Preamble, a set of ten guiding Principles, Guidelines that elucidate the application of the Principles in various practice settings, and the formal Complaint process. Guidelines have been included to address evolving social and cultural norms, such as the use of social media and the broadening scope of considerations important in an evolving workplace. The document presented here is the first major revision of the AAPM Code of Ethics since 2008. This revision was approved by the Board of Directors to become effective 1 January 2019., (© 2018 American Association of Physicists in Medicine.)

The goal of this study was to implement and validate a noninvasive, quantitative ultrasonic technique for accurate and reproducible measurement of normal-tissue toxicity in radiation therapy. The authors adapted an existing ultrasonic tissue characterization (UTC) technique that used a calibrated 1D spectrum based on region-of-interest analysis. They modified the calibration procedure by using a reference phantom instead of a planar reflector. This UTC method utilized ultrasonic radiofrequency echo signals to generate spectral parameters related to the physical properties (e.g., size, shape, and relative acoustic impedance) of tissue microstructures. Three spectral parameters were investigated for quantification of normal-tissue injury: Spectral slope, intercept, and midband fit. They conducted a tissue-mimicking phantom study to verify the reproducibility of UTC measurements and initiated a clinical study of radiation-induced breast-tissue toxicity. Spectral parameter values from measurements on two phantoms were reproducible within 1% of each other. Eleven postradiation breast-cancer patients were studied and significant differences between the irradiated and untreated (contralateral) breasts were observed for spectral intercept (p = 0.003) and midband fit (p < 0.001) but not for slope (p = 0.14). In comparison to the untreated breast, the average difference in the spectral intercept was 2.99 +/- 0.75 dB and the average difference in the midband fit was 3.99 +/- 0.65 dB. The preliminary clinical study demonstrated the feasibility of using the quantitative ultrasonic method to evaluate normal-tissue toxicity in radiation therapy.

Skin injury is a common side effect of breast-cancer radiation therapy. Although physicians often observe skin toxicity, quantifying its severity remains a challenge. We present a novel quantitative ultrasonic technique to evaluate skin changes associated with radiotherapy. An in vivo study with twelve breast-cancer patients was conducted. All patients received a standard course of post-surgery radiation therapy. Each patient received ultrasound scans to the irradiated breast and the untreated (contra-lateral) breast. Radio-frequency (RF) backscatter signals and B-mode images were acquired simultaneously. To quantify the severity of skin injury, two metrics were calculated from the RF signals: skin thickness and Pearson correlation coefficient of the subcutaneous layer. Comparing to the non-irradiated skin, the average thickness of the irradiated skin increased by 40% (p=0.005) and the average correlation coefficient of the irradiated hypodermis decreased by 35% (p=0.02). This study demonstrates the feasibility of using a non-invasive ultrasonic technique to detect and quantify radiation-induced skin changes.

Purpose: To investigate how the performance characteristics of ultrasound tissue typing (UTT) affect the design of a population-based prostate dose-painting protocol., Methods and Materials: The performance of UTT is evaluated using the receiver operating characteristic curve. As the imager's sensitivity increases, more tumors are detected, but the specificity worsens, causing more false-positive results. The UTT tumor map, obtained with a specific sensitivity and specificity setup, was used with the patient's CT image to guide intensity-modulated radiotherapy (IMRT) planning. The optimal escalation dose to the UTT positive region, as well as the safe dose to the negative background, was obtained by maximizing the uncomplicated control (i.e., a combination of tumor control probability and weighted normal tissue complication probability). For high- and low-risk tumors, IMRT plans guided by conventional ultrasound or UTT with a one-dimensional or two-dimensional spectrum analysis technique were compared with an IMRT plan in which the whole prostate was dose escalated., Results: For all imaging modalities, the specificity of 0.9 was chosen to reduce complications resulting from high false-positive results. If the primary tumors were low risk, the IMRT plans guided by all imaging modalities achieved high tumor control probability and reduced the normal tissue complication probability significantly compared with the plan with whole gland dose escalation. However, if the primary tumors were high risk, the accuracy of the imaging modality was critical to maintain the tumor control probability and normal tissue complication probability at acceptable levels., Conclusion: The performance characteristics of an imager have important implications in dose painting and should be considered in the design of dose-painting protocols.

A detailed understanding of non-targeted normal tissue response is necessary for the optimization of radiation treatment plans in cancer therapy. In this study, we evaluate the ability of electrical impedance spectroscopy (EIS) to non-invasively determine and quantify the injury response in soft tissue after high dose rate (HDR) irradiation, which is characterized by large localized dose distributions possessing steep spatial gradients. The HDR after-loading technique was employed to irradiate small volumes of muscle tissue with single doses (26-52 Gy targeted 5 mm away from the source). Impedance measurements were performed on 29 rats at 1, 2 and 3 month post-irradiation, employing 31 frequencies in the 1 kHz to 1 MHz range. Over the first 3 months, conductivity increased by 48% and 26% following target doses of 52 Gy and 26 Gy 5 mm from the HDR source, respectively. Injury, assessed independently through a grid-based scoring method showed a quadratic dependence on distance from source. A significant injury (50% of cells atrophied, necrotic or degenerating) in 1.2% of the volume, accompanied by more diffuse injury (25% of cells atrophied, necrotic or degenerating) in 9% of the tissue produced a conductivity increase of 0.02 S m(-1) (8% over a baseline of 0.24 S m(-1)). This was not statistically significant at p = 0.01. Among treatment groups, injury differences in 22% of the volume led to statistically significant differences in conductivity of 0.07 S m(-1) (23% difference in conductivity). Despite limitations, the success of EIS in detecting responses in a fraction of the tissue probed, during these early post-irradiation time-points, is encouraging. Electrical impedance spectroscopy may provide a useful metric of atrophy and the development of fibrosis secondary to radiation that could be further developed into a low-cost imaging method for radiotherapy monitoring and assessment.

Our previous system covered the frequency range of 0 to 1 MHz. In this new design we propose to cover the range from 0 to 10 MHz. The higher frequencies have forced us to reconsider several design decisions in view of both the physics of the problem and the performance of available electronic components. In this presentation we examine in detail the constraints faced by the designer, starting from wiring consideration to measurement techniques. We will also present the solutions we selected to overcome the limitations we discovered. The problems include phase detection, amplitude measurements, system organization and layout and finally system calibration.

Isaacson, Cheney and Seager have demonstrated that simultaneously applying trigonometric patterns of current to a circular electrode array optimizes the sensitivity of EIT to inner structure. We have found that it is less desirable to measure voltage at an electrode that also applies a current due to variable contact impedance. In order to preserve the optimum sensitivity while minimizing the effect of electrode artefacts, we have devised an approach where we sequentially apply a current between each individual electrode and a separate, fixed ground while measuring voltages at all other electrodes for each consecutive current impulse. By adding weighted sums of both the applied currents and corresponding measured voltages from individual passes, we can synthesize trigonometric patterns of any spatial frequency. Since only one of the electrodes in any given acquired data set is used as a source, this approach significantly dilutes the effect of contact impedance on the resulting voltage measurements. We present simulated data showing the equivalency between the synthesized and actual trigonometric excitation patterns. In addition, we report experimental data, both in vitro and in vivo, that show improved results using this data acquisition technique.

The authors describe what is, to the best of their knowledge, the first quantitative hemoglobin concentration images of the female breast that were formed with model-based reconstruction of near-infrared intensity-modulated tomographic data. The results in 11 patients, including two with breast tumors with pathologic correlation, are summarized. Hemoglobin concentration appears to correlate with tumor vascularity without the need for exogenous contrast material and thereby has intrinsic diagnostic value.

We have recently built and tested a 32 channel, multi-frequency (1 kHz to 1 MHz) voltage mode system to investigate electrical impedance spectroscopy (EIS) imaging. We completed a series of phantom experiments to define the baseline imaging performance of our system. Our phantom consisted of a plastic circular tank (20 cm diameter) filled with 0.9% aqueous NaCl solution. Conductors and nonconductors of decreasing width (W5: 3.4 cm, W4: 2.54 cm, W3: 0.95 cm, W2: 0.64 cm and WI: 0.32 cm) were positioned at various distances from the tank edge (1 cm, 2 cm, 4 cm and 8 cm). The results suggest that the detection of objects less than 1 cm in width is limited to the first 1 to 2 cm from the tank edge for absolute images, but this depth can extend to 8 cm in difference images. Larger 3.4 cm wide objects can be detected in absolute images at depths up to 8 cm from the tank edge. Generally, conductor images were clearer than their nonconductor counterparts. Not only did electrode artefacts lessen as the frequency increased, but the system's maximum resolution was attained at the highest operating frequencies. Although the system recovered the value of the electrical conductivity at the correct order of magnitude, it tended to smooth out large property discontinuities. The calculated electrical permittivity in these phantom studies was inconclusive due to the presence of electrode artefacts.

We have deployed a recently completed spectroscopic electrical impedance tomography (EITS) imaging system in a small series of women (13 participants accrued to date) in order to investigate the feasibility of delivering EITS breast examinations on a routine basis. Hardware is driven with sinusoidally varying spatial patterns of applied voltage delivered to 16 electrodes over the 10 kHz to 1 MHz spectral range using a radially translating interface which couples the electrodes to the breast through direct contact. Imaging examinations have consisted of the acquisition of multi-channel measurements at ten frequencies on both breasts. Participants lie prone on an examination table with the breast to be imaged pendant in the electrode array that is located below the table. Examinations were comfortable and easy to deliver (about 10 minutes per breast including electrode-positioning time). Although localized near-surface electrode artefacts are evident in the acquired images, several findings have emerged. Permittivity images have generally been more informative than their conductivity counterparts, except in the case of fluid-filled cysts. Specifically, the mammographically normal breast appears to have characteristic absolute EITS permittivity and conductivity images that emerge across subjects. Structural features in the EITS images have correlated with limited clinical information available on participants with benign and malignant abnormality, cysts and scarring from previous lumpectomy and follow-up radiation therapy. Several cases from this preliminary experience are described.

There is increasing evidence that alterations in the electrical property spectrum of tissues below 10 MHz is diagnostic for tissue pathology and/or pathophysiology. Yet, the complexity associated with constructing a high-fidelity multichannel, multifrequency data acquisition instrument has limited widespread development of spectroscopic electrical impedance imaging concepts. To contribute to the relatively sparse experience with multichannel spectroscopy systems this paper reports on the design, realization and evaluation of a prototype 32-channel instrument. The salient features of the system include a continuously selectable driving frequency up to 1 MHz, either voltage or current source modes of operation and simultaneous measurement of both voltage and current on each channel in either of these driving configurations. Comparisons of performance with recently reported fixed-frequency systems is favorable. Volts dc (VDC) signal-to-noise ratios of 75-80 dB are achieved and the noise floor for ac signals is near 100 dB below the signal strength of interest at 10 kHz and 60 dB down at 1 MHz. The added benefit of being able to record multispectral information on source and sense signal amplitudes and phases has also been realized. Phase-sensitive detection schemes and multiperiod undersampling techniques have been deployed to ensure measurement fidelity over the full bandwidth of system operation.

This study evaluates the potential of electrical impedance spectroscopy (EIS) as a noninvasive technique for tracking the progression of radiation-induced damage in normal muscle tissue. Male Sprague-Dawley rats were irradiated locally to the gastrocnemius and biceps femoris muscle. Single doses were administered using a procedure that spares skin and bone. Complex impedance spectral measurements (taken at 50 frequency points between 1 kHz and 1 MHz) were made at monthly intervals using recessed disk electrodes applied to the skin. A histological scoring scheme was developed for evaluation of injury. A strong dose-dependent progression of injury evident in both spectral measurements and histological scoring has been observed. Latent time also appears to be dependent on dose with changes induced by 70 Gy evident by 2 months, changes induced by 90 Gy observed by 1 month, and dramatic changes found within 3 weeks at 150 Gy. Injury was morphologically comparable to the type of damage that occurs in response to small, fractionated doses, but on a much shorter time scale. Increased spectral shift was a consistent indicator of the extent of tissue injury at the time of measurement. The use of a large single dose resulted in an excellent model in terms of inducing a significant progression in tissue injury over a short post-treatment follow-up period in the muscle mass while also providing a consistent location for in vivo electrical impedance measurements. The results show that EIS can follow radiation-induced tissue change, suggesting that EIS has the potential to monitor the types of injury observed in late radiation damage of muscle tissue noninvasively.

We have applied a number of modeling schemes to previously reported in vivo electrical impedance measurements on irradiated and normal muscle in the hind legs of rats. Specifically, seven-parameter parallel pathways and embedded membrane circuit models have been fit to group averages of impedance spectra measured at different doses and time points. Correlations between histologically scored tissue sections and model parameters have also been determined. The results show that both models produce good fits to the experimental observations, especially in the case of the irradiated tissues. The correlations between histology scores and circuit parameters were, however, higher with the embedded model. Trends in the spectra and the model parameters were found to agree with the expected changes in tissue pathophysiology associated with the progression of tissue injury from radiation exposure. Quantitative correlations with specific histological criteria were less conclusive, suggesting that more information may be needed to refine the model architecture if model parameters are to be explicitly related to the types and extent of tissue damage induced by radiation treatments.