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ImportanceSpine metastasis can be treated with high-dose radiation therapy with advanced delivery technology for long-term tumor and pain control.ObjectiveTo assess whether patient-reported pain relief was improved with stereotactic radiosurgery (SRS) as compared with conventional external beam radiotherapy (cEBRT) for patients with 1 to 3 sites of vertebral metastases.Design, Setting, and ParticipantsIn this randomized clinical trial, patients with 1 to 3 vertebral metastases were randomized 2:1 to the SRS or cEBRT groups. This NRG 0631 phase 3 study was performed as multi-institutional enrollment within NRG Oncology. Eligibility criteria included the following: (1) solitary vertebral metastasis, (2) 2 contiguous vertebral levels involved, or (3) maximum of 3 separate sites. Each site may involve up to 2 contiguous vertebral bodies. A total of 353 patients enrolled in the trial, and 339 patients were analyzed. This analysis includes data extracted on March 9, 2020.InterventionsPatients randomized to the SRS group were treated with a single dose of 16 or 18 Gy (to convert to rad, multiply by 100) given to the involved vertebral level(s) only, not including any additional spine levels. Patients assigned to cEBRT were treated with 8 Gy given to the involved vertebra plus 1 additional vertebra above and below.Main Outcomes and MeasuresThe primary end point was patient-reported pain response defined as at least a 3-point improvement on the Numerical Rating Pain Scale (NRPS) without worsening in pain at the secondary site(s) or the use of pain medication. Secondary end points included treatment-related toxic effects, quality of life, and long-term effects on vertebral bone and spinal cord.ResultsA total of 339 patients (mean [SD] age of SRS group vs cEBRT group, respectively, 61.9 [13.1] years vs 63.7 [11.9] years; 114 [54.5%] male in SRS group vs 70 [53.8%] male in cEBRT group) were analyzed. The baseline mean (SD) pain score at the index vertebra was 6.06 (2.61) in the SRS group and 5.88 (2.41) in the cEBRT group. The primary end point of pain response at 3 months favored cEBRT (41.3% for SRS vs 60.5% for cEBRT; difference, −19 percentage points; 95% CI, −32.9 to −5.5; 1-sided P = .99; 2-sided P = .01). Zubrod score (a measure of performance status ranging from 0 to 4, with 0 being fully functional and asymptomatic, and 4 being bedridden) was the significant factor influencing pain response. There were no differences in the proportion of acute or late adverse effects. Vertebral compression fracture at 24 months was 19.5% with SRS and 21.6% with cEBRT (P = .59). There were no spinal cord complications reported at 24 months.Conclusions and RelevanceIn this randomized clinical trial, superiority of SRS for the primary end point of patient-reported pain response at 3 months was not found, and there were no spinal cord complications at 2 years after SRS. This finding may inform further investigation of using spine radiosurgery in the setting of oligometastases, where durability of cancer control is essential.Trial RegistrationClinicalTrials.gov Identifier: NCT00922974

The first case of COVID-19 was identified in December 2019. In just two years, the pandemic has wreaked a lot of havoc across the globe. Various determining factors will decide the fate of a looming third wave in India. Although there is no direct evidence of a third wave, many metro cities in India have reported a surge of new cases despite mass vaccination. The rapid development of vaccines and mass vaccination programmes has helped contain the crisis in the past. An updated and robust vaccination campaign along with public measures like the avoidance of large gatherings will help counter the third wave. Over 50% of the eligible population in India has been fully vaccinated to date. The emergence of new strains like the Alpha, Beta, Kappa, and Delta variants of concern, which may exhibit vaccine resistance, may complicate matters. Significant challenges include inadequate data collection, public unawareness, fake news, irregular vaccine supply, and the presence of mutant variants. Comorbidities like dengue complicate disease course. Travel restrictions, personal protective equipment shortages, and barriers to healthcare access are important obstacles to overcome. An increased focus on pandemic preparedness is needed. Targeted vaccination campaigns can help build a favorable public perspective. Data gathering and research need to be promoted. The nation's healthcare policy can benefit from relevant updates based on science and socio-cultural awareness. The fight against the pandemic needs to be cooperative at an international level, with adequate support meted out to resource-poor countries. Long-term structural changes to the healthcare system coupled with strategies for immediate relief will pave the way forward to a stronger system with better contingency planning.

Purpose To analyze clinical toxicity and quality-of-life (QOL) outcomes among patients with stage I non-small cell lung cancer (NSCLC) after stereotactic body radiation therapy (SBRT) as a function of radiation dose and volume parameters. Methods and Materials In this institutional review board–approved study, 55 patients with stage I NSCLC who received SBRT (12 Gy × 4) and completed QOL forms were analyzed. Clinical symptoms and QOL outcomes were measured at baseline and at 3, 6, 12, 18, 24, and 36 months after SBRT. Clinical toxicity was graded using the Common Terminology Criteria for Adverse Events, version 4.0. Quality of life was followed using the validated Functional Assessment of Cancer Therapy-Lung-Trial Outcome Index (FACT-L-TOI) instrument. Dosimetric parameters including the mean lung radiation dose and the volume of normal lung receiving greater than 5, 10, 13, or 20 Gy (V5, V10, V13, and V20) were measured from the radiation treatment plan. Student t tests and Pearson correlation analyses were used to examine the relationships between radiation lung metrics and clinically meaningful changes in QOL and/or clinical toxic effects. The Kaplan-Meier method was used to estimate rates of local control (LC), disease-free survival (DFS), and overall survival (OS). Results With a median follow-up of 24 months, the 3-year LC, DFS, and OS were 93%, 65%, and 84%, respectively, with a 5.5% rate of grade-3 toxic effects and no grade 4 or 5 toxic effects. Clinically meaningful declines in patient-reported QOL (FACT-L-TOI, lung cancer subscale, physical well-being, and/or functional well-being) posttreatment significantly correlated with increased dosimetric parameters such as V10, V13, and V20. Conclusion Although lung SBRT was associated with excellent LC and minimal clinical toxic effects for early-stage NSCLC, clinically meaningful declines in QOL were significantly correlated with increasing lung dose and volume parameters.

World Health Organization (WHO) grade I meningiomas are slow-growing and typically benign brain tumors that can often be easily removed by surgery and rarely become malignant. We report the case of a WHO grade I meningioma in a 67-year-old man with multiple extracranial metastases.

Outcomes for patients with recurrent high-grade glioma (HGG) progressing on bevacizumab (BEV) are dismal. Fractionated stereotactic radiosurgery (FSRS) has been shown to be feasible and safe when delivered in this setting, but prospective evidence is lacking. This single-institution randomized trial compared FSRS plus BEV-based chemotherapy versus BEV-based chemotherapy alone for BEV-resistant recurrent malignant glioma. HGG patients on BEV with tumor progression after 2 previous treatments were randomized to 1) FSRS plus BEV-based chemotherapy or 2) BEV-based chemotherapy with irinotecan, etoposide, temozolomide, or carboplatin. FSRS was delivered as 32 Gy (8 Gy × 4 fractions within 2 weeks) to the gross target volume and 24 Gy (6 Gy × 4 fractions) to the clinical target volume (fluid-attenuated inversion recovery abnormality). The primary endpoints were local control (LC) at 2 months and progression-free survival (PFS). Of the 35 patients enrolled, 29 had glioblastoma (WHO IV) and 6 had anaplastic glioma (WHO III). The median number of prior recurrences was 3. Patients treated with FSRS had significantly improved PFS (5.1 vs 1.8 months, P

Purpose To evaluate the implementation of a magnetic resonance (MR)-only workflow (ie, implementing MR simulation as the primary planning modality) using failure mode and effects analysis (FMEA) in comparison with a conventional multimodality (MR simulation in conjunction with computed tomography simulation) workflow for pelvis external beam planning. Methods and Materials To perform the FMEA, a multidisciplinary 9-member team was assembled and developed process maps, identified potential failure modes (FMs), and assigned numerical values to the severity (S), frequency of occurrence (O), and detectability (D) of those FMs. Risk priority numbers (RPNs) were calculated via the product of S, O, and D as a metric for evaluating relative patient risk. An alternative 3-digit composite number (SOD) was computed to emphasize high-severity FMs. Fault tree analysis identified the causality chain leading to the highest-severity FM. Results Seven processes were identified, 3 of which were shared between workflows. Image fusion and target delineation subprocesses using the conventional workflow added 9 and 10 FMs, respectively, with 6 RPNs >100. By contrast, synthetic computed tomography generation introduced 3 major subprocesses and propagated 46 unique FMs, 15 with RPNs >100. For the conventional workflow, the largest RPN scores were introduced by image fusion (RPN range, 120-192). For the MR-only workflow, the highest RPN scores were from inaccuracies in target delineation resulting from misinterpretation of MR images (RPN = 240) and insufficient management of patient- and system-level distortions (RPN = 210 and 168, respectively). Underestimation (RPN = 140) or overestimation (RPN = 192) of bone volume produced higher RPN scores. The highest SODs for both workflows were related to changes in target location because of internal anatomy changes (conventional = 961, MR-only = 822). Conclusions FMEA identified areas for mitigating risk in MR-only pelvis RTP, and SODs identified high-severity process modes. Efforts to develop a quality management program to mitigate high FMs are underway.

PURPOSE: Magnetic resonance-guided radiation therapy (MRgRT) has shown great promise for localization and real-time tumor monitoring. However, to date, quantitative imaging has been limited for low field MRgRT. This work benchmarks quantitative T1, R2*, and Proton Density (PD)mapping in a phantom on a 0.35 T MR-linac and implements a novel acquisition method, STrategically Acquired Gradient Echo (STAGE). To further validate STAGE in a clinical setting, a pilot study was undertaken in a cohort of brain tumor patients to elucidate opportunities for longitudinal functional imaging with an MR-linac in the brain. METHODS: STAGE (two triple-echo gradient echo (GRE) acquisitions) was optimized for a 0.35T low-field MR-linac. Simulations were performed to choose two flip angles to optimize signal-to-noise ratio (SNR) and T1-mapping precision. Tradeoffs between SNR, scan time, and spatial resolution for whole-brain coverage were evaluated in healthy volunteers. Data were inputted into a STAGE processing pipeline to yield four qualitative images (T1-weighted, enhanced T1-weighted, proton-density (PD) weighted, and simulated FLuid-Attenuated Inversion Recovery (sFLAIR)), and three quantitative datasets (T1, PD, and R2*). A benchmarking ISMRM/NIST phantom consisting of vials with variable NiCl(2) and MnCl(2) concentrations was scanned using variable flip angles (VFA) (2-60 degrees) and inversion recovery (IR) methods at 0.35 T. STAGE and VFA T1 values of vials were compared to IR T1 values. As measures of agreement with reference values and repeatability, relative error (RE) and coefficient of variability (CV) were calculated, respectively, for quantitative MR values within the phantom vials (spheres). To demonstrate feasibility, longitudinal STAGE data (pretreatment, weekly, and ~ 2 months post-treatment) were acquired in an IRB-approved pilot study of brain tumor cases via the generation of temporal and differential quantitative MRI maps. RESULTS: In the phantom, RE of measured VFA T1 and STAGE relative to IR reference values were 7.0 ± 2.5% and 9.5 ± 2.2% respectively. RE for the PD vials was 8.1 ± 6.8% and CV for phantom R2* measurements was 10.1 ± 9.9%. Simulations and volunteer experiments yielded final STAGE parameters of FA = 50°/10°, 1 × 1 × 3 mm(3) resolution, TR = 40 ms, TE = 5/20/34 ms in 10 min (64 slices). In the pilot study of brain tumor patients, differential maps for R2* and T1 maps were sensitive to local tumor changes and appeared similar to 3 T follow-up MRI datasets. CONCLUSION: Quantitative T1, R2*, and PD mapping are promising at 0.35 T agreeing well with reference data. STAGE phantom data offer quantitative representations comparable to traditional methods in a fraction of the acquisition time. Initial feasibility of implementing STAGE at 0.35 T in a patient brain tumor cohort suggests that detectable changes can be observed over time. With confirmation in a larger cohort, results may be implemented to identify areas of recurrence and facilitate adaptive radiation therapy.

The QFix EncompassTM stereotactic radiosurgery (SRS) immobilization system consists of a thermoplastic mask that attaches to the couch insert to immobilize patients treated with intracranial SRS. This study evaluates the dosimetric impact and verifies a vendor provided treatment planning system (TPS) model in the Eclipse TPS. A thermoplastic mask was constructed for a Lucy 3D phantom, and was scanned with and without the EncompassTM system. Attenuation measurements were performed in the Lucy phantom with and without the insert using a pinpoint ion chamber for energies of 6xFFF, 10xFFF and 6X, with three field sizes (2 × 2, 4 × 4, and 6 × 6 cm2). The measurements were compared to two sets of calculations. The first set utilized the vendor provided Encompass TPS model (EncompassTPS), which consists of two structures: the Encompass and Encompass base structure. Three HU values for the Encompass (200, 300, 400) and Encompass Base (−600, −500, −400) structures were evaluated. The second set of calculations consists of the Encompass insert included in the external body contour (EncompassEXT) for dose calculation. The average measured percent attenuation in the posterior region of the insert ranged from 3.4%–3.8% for the 6xFFF beam, 2.9%–3.4% for the 10xFFF, and 3.3%–3.6% for the 6X beam. The maximum attenuation occurred at the region where the mask attaches to the insert, where attenuation up to 17% was measured for a 6xFFF beam. The difference between measured and calculated attenuation with either the EncompassEXT or EncompassTPS approach was within 0.5%. HU values in the EncompassTPS model that provided the best agreement with measurement was 400 for the Encompass structure and −400 for the Encompass base structure. Significant attenuation was observed at the area where the mask attaches to the insert. Larger differences can be observed when using few static beams compared to rotational treatment techniques.

Introduction The purpose of this study was to investigate the systematic localization accuracy, treatment planning capability, and delivery accuracy of an integrated magnetic resonance imaging guided Linear Accelerator (MR-Linac) platform for stereotactic radiosurgery. Materials and methods The phantom for the end-to-end test comprises three different compartments: a rectangular MR/CT target phantom, a Winston–Lutz cube, and a rectangular MR/CT isocenter phantom. Hidden target tests were performed at gantry angles of 0, 90, 180, and 270 degrees to quantify the systematic accuracy. Five patient plans with a total of eleven lesions were used to evaluate the dosimetric accuracy. Single-isocenter IMRT treatment plans using 10–15 coplanar beams were generated to treat the multiple metastases. Results The end-to-end localization accuracy of the system was 1.0 ± 0.1 mm. The conformity index, homogeneity index and gradient index of the plans were 1.26 ± 0.22, 1.22 ± 0.10, and 5.38 ± 1.44, respectively. The average absolute point dose difference between measured and calculated dose was 1.64 ± 1.90%, and the mean percentage of points passing the 3%/1 mm gamma criteria was 96.87%. Conclusions Our experience demonstrates that excellent plan quality and delivery accuracy was achievable on the MR-Linac for treating multiple brain metastases with a single isocenter.

Benign tumors of the spine pose unique challenges as they are typically located in proximity to the spinal cord and are relatively radio-resistant. Surgery is usually the first line of treatment, but recurrence can be common. Stereotactic radiosurgery (SRS) is an effective treatment for malignant spine lesions. However, patients with benign tumors generally have longer life expectancies and may develop long-term treatment side-effects. Our institutional experience in treating benign tumors with SRS is presented to display its utility for symptom and local control. A retrospective cohort analysis was performed at a single institution between 2001 and 2013. A total of 26 patients (61 vertebral levels) with benign spine tumors were treated. Electronic medical records were queried for clinical, neurological, and radiological examinations. Post-treatment pain, neurological, and radiographic control were the primary endpoints of this study. Five patients (19.2%) were deceased with a median survival time of 16.9 months. Follow-up to evaluate pain response was available for 23 (88%), neurological for 20 (77%), and radiographic for 23 patients (88%). Median follow-up time was 15.5 months. Total pain response was 82.6%. Neurological improvement and radiographic control were noted in 75 and 87% of patients. One case of radionecrosis of the sacrum and one case of axillary numbness were observed. The results of SRS for benign tumors of the spine appear to be promising, and as a result SRS may have a role in treating benign spinal tumors for patients who are not surgical candidates.

A substantial barrier to the single-and multi-institutional aggregation of data to supporting clinical trials, practice quality improvement efforts, and development of big data analytics resource systems is the lack of standardized nomenclatures for expressing dosimetric data. To address this issue, the American Association of Physicists in Medicine (AAPM) Task Group 263 was charged with providing nomenclature guidelines and values in radiation oncology for use in clinical trials, data-pooling initiatives, population-based studies, and routine clinical care by standardizing: (1) structure names across image processing and treatment planning system platforms; (2) nomenclature for dosimetric data (eg, doseevolume histogram [DVH]-based metrics); (3) templates for clinical trial groups and users of an initial subset of software platforms to facilitate adoption of the standards; (4) formalism for nomenclature schema, which can accommodate the addition of other structures defined in the future. A multisociety, multidisciplinary, multinational group of 57 members representing stake holders ranging from large academic centers to community clinics and vendors was assembled, including physicists, physicians, dosimetrists, and vendors. The stakeholder groups represented in the membership included the AAPM, American Society for Radiation Oncology (ASTRO), NRG Oncology, European Society for Radiation Oncology (ESTRO), Radiation Therapy Oncology Group (RTOG), Children's Oncology Group (COG), Integrating Healthcare Enterprise in Radiation Oncology (IHE-RO), and Digital Imaging and Communications in Medicine working group (DICOM WG); A nomenclature system for target and organ at risk volumes and DVH nomenclature was developed and piloted to demonstrate viability across a range of clinics and within the framework of clinical trials. The final report was approved by AAPM in October 2017. The approval process included review by 8 AAPM committees, with additional review by ASTRO, European Society for Radiation Oncology (ESTRO), and American Association of Medical Dosimetrists (AAMD). This Executive Summary of the report highlights the key recommendations for clinical practice, research, and trials. (C) 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

The aim of this retrospective analysis is to evaluate the role of stereotactic radiosurgery (SRS) in treating multiple myeloma (MM) of the spine. Medical records of MM patients who underwent single fraction spine SRS between 6/2001 and 12/2014 at our institution were retrospectively reviewed in this institutional review board-approved analysis. Post-treatment radiographic, neurologic, and pain response were the primary endpoints. Endpoints were evaluated with periodic clinical exams and imaging studies (magnetic resonance imaging and computed tomography). Median SRS dose was 16 Gy (10–18) in a single fraction. Seventy-eight patients (121 treatment sites) were treated. Clinical follow-up was available for 71 patients. Radiographic follow-up was available for 94 treatment sites. Median follow-up was 27.8 months (24 days–12.1 years). Radiographic control was observed in 89.4% of the treated sites. Pain relief occurred in 88.3% of the patients that presented with pain; pain progression occurred in 3.3%. Neurological improvement was observed in 63.6% of the patients that presented with a deficit. In sites where MM approached or compressed the epidural canal or the thecal sac, after SRS, evidence of radiographic regression was observed in 87.1%. Toxicities observed included one patient who experienced a tracheoesophageal fistula 2 years after SRS. After SRS, there were 39 VCFs that were potentially SRS-induced. SRS appears to be effective in the treatment of MM of the spine. To the best of our knowledge, this is the largest such experience reported.

Purpose To determine the potential benefits and adverse effects associated with reirradiating the spinal cord when at least 1 course of radiation therapy (RT) is stereotactic radiosurgery (SRS). Methods and materials This institutional review board–approved retrospective review included 162 patients (237 reirradiated spine lesions). All patients received SRS at our institution between 2001 and 2013. Electronic medical records were reviewed for clinical exams and radiologic tests (computed tomography/magnetic resonance imaging). Primary endpoints were pain, neurological, radiographic responses, and the development of adverse effects. Results A total of 120 patients (74.1%) were deceased with a median survival of 13 months. Time between courses of RT was a median of 10.2 months. Median SRS dose was 16 Gy in 1 fraction, whereas the median conventional external beam radiation therapy (cEBRT) dose was 30 Gy in 10 fractions. The median tumor equivalent dose in 2-Gy fractions (EQD2) for SRS doses was 34.7 Gy, whereas the median tumor EQD2 for cEBRT was 32.5 Gy, providing a median total tumor EQD2 of 69.3 Gy (22-145.6 Gy). The median critical nervous tissue EQD2 for SRS and cEBRT was 56 Gy and 37.5 Gy, respectively, resulting in a median total critical nervous tissue EQD2 of 93.5 Gy. Overall pain, neurological, and radiographic response rates were 81%, 82%, and 71%, respectively. Adverse effects occurred in 11 (6.8%) patients. Seventy-seven vertebral compression fractures were observed, 22 (9.3%) of which may be attributed to RT. Conclusions Our results demonstrate that reirradiation achieves favorable response rates with minimal toxicity if recommended dose constraints to the spinal cord with SRS are carefully observed. To the best of our knowledge, this is the largest reported single-institution experience analyzing the efficacy and toxicity of reirradiation of the spine when at least 1 course of RT is stereotactic radiosurgery.

Purpose This study aims to extend the observation that the 12Gy-radiosurgical-volume (V12Gy) correlates with the incidence of radiation necrosis in patients with intracranial tumors treated with radiosurgery by using target volume to predict V12Gy. V12Gy based on the target volume was used to predict the radiation necrosis probability (P) directly. Also investigated was the reduction in radiation necrosis rates (ΔP) as a result of optimizing the prescription isodose lines for linac-based SRS. Methods Twenty concentric spherical targets and 22 patients with brain tumors were retrospectively studied. For each case, a standard clinical plan and an optimized plan with prescription isodose lines based on gradient index were created. V12Gy were extracted from both plans to analyze the correlation between V12Gy and target volume. The necrosis probability P as a function of V12Gy was evaluated. To account for variation in prescription, the relation between V12Gy and prescription was also investigated. Results A prediction model for radiation-induced necrosis was presented based on the retrospective study. The model directly relates the typical prescribed dose and the target volume to the radionecrosis probability; V12Gy increased linearly with the target volume (R2>0.99). The linear correlation was then integrated into a logistic model to predict P directly from the target volume. The change in V12Gy as a function of prescription was modeled using a single parameter, s (= -1.15). Relatively large ΔP was observed for target volumes between 7 and 28 cm3 with the maximum reduction (8-9%) occurring at approximately 18 cm3. Conclusions Based on the model results, optimizing the prescription isodose line for target volumes between 7 and 28 cm3 results in a significant reduction in necrosis probability. V12Gy based on the target volume could provide clinicians a predictor of radiation necrosis at the contouring stage thus facilitating treatment decisions. This article is protected by copyright. All rights reserved.

The purpose of this study was to develop metrics to evaluate uncertainties in deformable dose accumulation for patients with non-small cell lung cancer (NSCLC). Initial treatment plans (primary) and cone-beam CT (CBCT) images were retrospectively processed for seven NSCLC patients, who showed significant tumor regression during the course of treatment. Each plan was developed with IMRT for 2 Gy × 33 fractions. A B-spline-based DIR algorithm was used to register weekly CBCT images to a reference image acquired at fraction 21 and the resultant displacement vector fields (DVFs) were then modified using a finite element method (FEM). The doses were calculated on each of these CBCT images and mapped to the reference image using a tri-linear dose interpolation method, based on the B-spline and FEM-generated DVFs. Contours propagated from the planning image were adjusted to the residual tumor and OARs on the reference image to develop a secondary plan. For iso-prescription adaptive plans (relative to initial plans), mean lung dose (MLD) was reduced, on average from 17.3 Gy (initial plan) to 15.2, 14.5 and 14.8 Gy for the plans adapted using the rigid, B-Spline and FEM-based registrations. Similarly, for iso-toxic adaptive plans (considering MLD relative to initial plans) using the rigid, B-Spline and FEM-based registrations, the average doses were 69.9 ± 6.8, 65.7 ± 5.1 and 67.2 ± 5.6 Gy in the initial volume (PTV1), and 81.5 ± 25.8, 77.7 ± 21.6, and 78.9 ± 22.5 Gy in the residual volume (PTV21), respectively. Tumor volume reduction was correlated with dose escalation (for isotoxic plans, correlation coefficient = 0.92), and with MLD reduction (for iso-fractional plans, correlation coefficient = 0.85). For the case of the iso-toxic dose escalation, plans adapted with the B-Spline and FEM DVFs differed from the primary plan adapted with rigid registration by 2.8 ± 1.0 Gy and 1.8 ± 0.9 Gy in PTV1, and the mean difference between doses accumulated using the B-spline and FEM DVF's was 1.1 ± 0.6 Gy. As a dose mapping-induced energy change, energy defect in the tumor volume was 20.8 ± 13.4% and 4.5 ± 2.4% for the B-spline and FEM-based dose accumulations, respectively. The energy defect of the B-Spline-based dose accumulation is significant in the tumor volume and highly correlated to the difference between the B-Spline and FEM-accumulated doses with their correlation coefficient equal to 0.79. Adaptive planning helps escalate target dose and spare normal tissue for patients with NSCLC, but deformable dose accumulation may have a significant loss of energy in regressed tumor volumes when using image intensity-based DIR algorithms. The metric of energy defect is a useful tool for evaluation of adaptive planning accuracy for lung cancer patients.

Purpose To determine our institutional vertebral compression fracture (VCF) rate after spine stereotactic radiosurgery (SRS) and determine contributory factors. Methods and Materials Retrospective analysis from 2001 to 2013 at a single institution was performed. With institutional review board approval, electronic medical records of 1905 vertebral bodies from 791 patients who were treated with SRS for the management of primary or metastatic spinal lesions were reviewed. A total of 448 patients (1070 vertebral bodies) with adequate follow-up imaging studies available were analyzed. Doses ranging from 10 Gy in 1 fraction to 60 Gy in 5 fractions were delivered. Computed tomography and magnetic resonance imaging were used to evaluate the primary endpoints of this study: development of a new VCF, progression of an existing VCF, and requirement of stabilization surgery after SRS. Results A total of 127 VCFs (11.9%; 95% confidence interval [CI] 9.5%-14.2%) in 97 patients were potentially SRS induced: 46 (36%) were de novo, 44 (35%) VCFs progressed, and 37 (29%) required stabilization surgery after SRS. Our rate for radiologic VCF development/progression (excluding patients who underwent surgery) was 8.4%. Upon further exclusion of patients with hematologic malignancies the VCF rate was 7.6%. In the univariate analyses, females (hazard ratio [HR] 1.54, 95% CI 1.01-2.33, P =.04), prior VCF (HR 1.99, 95% CI 1.30-3.06, P =.001), primary hematologic malignancies (HR 2.68, 95% CI 1.68-4.28, P P =.02), and lytic lesions had a significantly increased risk for VCF after SRS. On multivariate analyses, prior VCF and lesion type remained contributory. Conclusions Single-fraction SRS doses of 16 to 18 Gy to the spine seem to be associated with a low rate of VCFs. To the best of our knowledge, this is the largest reported experience analyzing SRS-induced VCFs, with one of the lowest event rates reported.

The purpose of this study was to evaluate the role of stereotactic radiosurgery in the treatment of primary tumors of the spine and spinal cord.An Institutional Review Board approved retrospective analysis of 30 patients with primary spine tumors treated at a single institution was performed. Post-treatment pain, neurological, and radiographic responses were the endpoints.Nine patients were treated for benign tumors, and 21 patients were treated for malignant tumors. The median dose delivered was 16 Gy in one fraction. Median follow up was 13.13 months (range, 1 month-84 months). Pain relief was 88% initially. Pain recurred in five patients with a median time to recurrence of 5 months (range, 3.6 months - 80 months). Neurological improvement was achieved in 65% of patients. Three patients experienced a recurrence in their neurological deficit (at 3.6 months, 1.6 years, and 3.7 years after SRS). Radiographic control was achieved in 77% of sites treated with SRS. Thirteen of the treated sites recurred with a median time of 9.9 months. Two long-term toxicities were observed (asymptomatic radio-necrosis of the erector spinae muscle and foot drop).Our results suggest that SRS is a safe and effective treatment option for primary tumors of the spine and spinal cord.

Targeting accuracy at all possible couch angles needs to be carefully evaluated prior to initiating a frameless image-guided stereotactic radiosurgery program on a Linac for treating functional disorders such as trigeminal neuralgia. In this study, we report positioning accuracy with stereoscopic x-ray imaging over the complete range of couch rotation using anthropomorphic head phantoms.An anthropomorphic head phantom with three 5 mm tungsten BBs as hidden targets was CT simulated. A group of 7 arcs was planned with couch angles from 0 to 90° in 15° increments. A pair of stereoscopic x-ray images that auto-matches to planning CT according to bony anatomy was utilized to position each BB to machine isocenter at all planned couch angles. Targeting accuracy was measured by stereoscopic x-ray imaging of the BB itself, which provides the distance from the centroid of BB to the x-ray imaging isocenter. For each BB, the hidden target test was repeated 5 times at couch 0° and 3 times at other couch angles, resulting in a total of 69 measurements, each with random initial setup deviation. Following the same workflow, a second anthropomorphic head phantom with two 5 mm BBs was utilized to evaluate localization accuracy at couch angles of 0 through 270° in 15° increments, resulting in another 18 measurements.Residual setup deviation following image guidance in the first head phantom was 0.6±0.1, 0.4±0.1, and 0.4±0.1 mm, respectively, at the three BBs, and 0.5±0.1 mm overall (N=69). Comparable results of 0.4±0.1 mm (N=18) were achieved with the second head phantom. Combining results from both phantoms, the targeting accuracy was 0.5±0.1 mm (range 0.2-0.8 mm). No apparent correlation was observed between targeting accuracy and couch rotation.Accurate positioning within 1 mm can be achieved with stereoscopic x-ray imaging at any couch angle. Frameless image-guided stereotactic radiosurgery could achieve targeting accuracy similar to that of frame-based systems for high dose treatment of trigeminal neuralgia.

Stereotactic body radiation therapy (SBRT) is an option for selected patients with metastatic disease. However, sometimes these lesions are located in such close proximity to critical normal structures that the use of safe tumoricidal SBRT doses is not achievable. Here we present a case in which real-time imaging and tracking with a magnetic resonance linear accelerator (MR-LINAC) provided a novel treatment approach and enabled safe treatment of the tumor using SBRT. Our case is a 69-year-old female who presented with localized recurrent small cell lung cancer with a retroperitoneal (FDG-avid) soft tissue lesion measuring 2.4 x 4.1 cm that was causing pain and right hydronephrosis. A Food and Drug Administration (FDA)-approved MR-LINAC system was utilized for planning and the delivery of 21 Gy in three fractions to the retroperitoneal lesion planning target volume (PTV), limited by the neighboring small bowel tolerance. The gross tumor volume (GTV) itself received 27 Gy (9 Gy per fraction). Simulation was performed using a volumetric MR imaging study in treatment position co-registered to a 4D-computed tomography (CT) image set for contouring of the target and organs at risk (OAR). Treatment planning was performed using the primary CT dataset. We developed a reasonable SBRT treatment plan to deliver the prescribed dose without exceeding tolerance doses to the right kidney, the small bowel and all other OAR's. Real-time MR imaging and tracking during treatment delivery enabled assessment of respiratory-induced target movement in relation to the small bowel and kidney. Gating was performed to halt treatment when PTV movement exceeded the 2-mm range as specified by the treating physician. The treatment course was concluded successfully. The patient denied any acute gastrointestinal or genitourinary toxicity. The pain was significantly improved within a short time following treatment. Follow-up CT showed a near complete response of the mass with total restoration of renal functions, allowing the ureteric stent to be removed. This response has been maintained for five months till the last follow-up. In conclusion, MR-guided planning and delivery using real-time MR imaging and tracking facilitated the treatment of the retroperitoneal mass accurately and efficiently with excellent clinical and radiological response and minimal to no toxicity. We would not discern it safe to treat this mass utilizing SBRT without this ability to accurately visualize the tumor boundary using magnetic resonance imaging (MRI), and offer tracking of the target within the millimeter of surrounding critical OAR's.

Sharp dose gradients between the target and the spinal cord are critical to achieve dose constraints in spine stereotactic radiosurgery (SRS), however the accuracy of the doses to the spinal cord at these high dose gradients is sensitive to the how the dose is sampled across the structure using a discretized isotropic calculation grid. In this study, the effect of the grid size (GS) on the dosimetric accuracy of volumetric modulated arc therapy (VMAT) spine SRS plans was investigated.The Eclipse v11.0 Anisotropic Analytical Algorithm (AAA) algorithm was used for dose calculation. Plan qualities of fifty treatment plans were evaluated with a GS of 2.5 (AAA's default value), 1.5 and 1mm. All plans were prescribed to the 90% isodose line in 1 fraction. Parameters used for plan comparison included the distance-to-fall-off (DTF) between the 90% and 50% isodose levels in the axial plane, planning tumor volume (PTV) coverage to 99%, 95%, 5% and 0.03cc, dose to 10% (Cord_D10%) and 0.03cc (Cord_D0.03cc) of the spinal cord sub volume. The dosimetric accuracy was evaluated based on film dosimetry percent gamma pass rate, line profile through the cord. Calculation times between different grid sizes as well as DVH algorithm differences between two treatment planning systems (Eclipse vs Velocity) were compared. Paired t-test was used to investigate the statistical significance.The DTF decreased for all plans with 1mm compared to 1.5mm and 2.5mm GS (2.52±0.54mm, 2.83±0.58mm, 3.30±0.64, p0.001). Relative to the 1mm GS, Cord_D0.03cc and Cord_D10% increased by 6.24% and 7.81% with the 1.5mm GS, and 9.80% and 13% with the 2.5mm GS. Film analysis demonstrated higher gamma pass rates for 1.5mm GS compared to 1 and 2.5mm GS (95.9%±5.4%, 94.3%±6.0%, 93.6%±5.4%, p0.001), however 1mm GS showed better agreement in the high dose gradient near the cord. Calculation times for 1mm GS plans increased for 1.5 and 2.5mm GS (61% and 84%, p0.001). The average difference between the two treatment planning systems was approximately 0-1.2%. A maximum difference of 5.9% occurred for Cord_D0.03cc for the 1mm GS.Plans calculated with a 1mm grid size resulted in the most accurate representation of the dose delivered to the cord, however resulted in less uniform dose distributions in the high dose region of the PTV. The use of a 1.5mm grid size may balance accurate cord dose and PTV coverage, while also being more practical with respect to computation time.

Purpose This study was conducted to evaluate the advantages of jaw tracking for intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) in spine radiosurgery. Methods and materials VMAT and IMRT plans were retrospectively generated for 10 RTOG 0631 spine radiosurgery protocol patients. A total of 8 plans for each patient were created for a Varian TrueBeam equipped with a Millennium 120 multileaf collimator. Plans were created to compare IMRT and VMAT plans with and without jaw tracking, as well as with different flattening-filter-free energies: 6 MV unflattened (6U) and 10 MV unflattened (10U). The plans were prescribed to the 90% isodose line to either 16 or 18 Gy in 1 fraction. Planning target volume coverage, conformity index, dose to the spinal cord, and distance to falloff from the 90% to 50% isodose line were evaluated. Ion chamber and film measurements were performed to verify calculated dose distributions. Results Jaw tracking decreased spinal cord dose for both IMRT and VMAT plans, but a larger decrease was seen with the IMRT plans ( P = .004 vs P = .04). The average D 10% for the spinal cord (dose that covered 10% of the spinal cord) was least for the 6U IMRT plan with jaw tracking and was greatest for the 10U IMRT plan without jaw tracking. Measurements showed greater than 98.5% agreement for planar dose gamma analysis and less than 2.5% for point dose analysis. Conclusions The addition of jaw tracking to IMRT and VMAT can decrease spinal cord dose without a change in calculation accuracy. A lower dose to the spinal cord was achieved with 6U than with 10U, although in some cases, 10U may be justified.

Cerebral radiation necrosis (CRN) is a known complication of radiation therapy. Treatment options are limited and include steroids, bevacizumab, and surgery. This study seeks to determine the safety of laser interstitial thermal therapy (LITT) for CRN and identify the pattern of post-ablation volume change over time. Patients undergoing LITT for tumor treatment at Henry Ford Hospital between November 2013 and January 2016 with biopsy-confirmed CRN were prospectively collected and retrospectively reviewed with attention to ablation volume, survival, demographic data, steroid dose, and complications. Imaging occurred at set intervals beginning pre-ablation. Ten patients with 11 ablations were evaluated. Four patients had a primary diagnosis of high-grade glioma, while six had metastatic lesions. An average of 86% of CRN volume was ablated. Ablation volume increased to 430% of initial CRN volume at 1–2 weeks before decreasing to 69% after 6 months. No patient had a decline in baseline neurological examination while in the hospital. Four patients developed delayed neurological deficits likely due to post-operative edema, of which three improved back to baseline. The 6-month survival was 77.8% and the 1-year survival was 64.8% based on Kaplan–Meier curve estimates. In this study, LITT was a relatively safe treatment for CRN, providing both a diagnostic and therapeutic solution for refractory patients. Significant increase in ablation volume was noted at 1–2 months, gradually decreasing in size to less than the original volume by 6 months. Further studies are needed to better define the role of LITT in the treatment of CRN.

Recent advancements in synthetic computed tomography (synCT) from magnetic resonance (MR) imaging data have made MRI-only treatment planning feasible in the brain, although synCT performance for image guided radiation therapy (IGRT) is not well understood. This work compares geometric equivalence of digitally reconstructed radiographs (DRRs) from CTs and synCTs for brain cancer patients and quantifies performance for partial brain IGRT.Ten brain cancer patients (12 lesions, 7 postsurgical) underwent MR-SIM and CT-SIM. SynCTs were generated by combining ultra-short echo time, T1, T2, and fluid attenuation inversion recovery datasets using voxel-based weighted summation. SynCT and CT DRRs were compared using patient-specific thresholding and assessed via overlap index, Dice similarity coefficient, and Jaccard index. Planar IGRT images for 22 fractions were evaluated to quantify differences between CT-generated DRRs and synCT-generated DRRs in 6 quadrants. Previously validated software was implemented to perform 2-dimensional (2D)-2D rigid registrations using normalized mutual information. Absolute (planar image/DRR registration) and relative (differences between synCT and CT DRR registrations) shifts were calculated for each axis and 3-dimensional vector difference. A total of 1490 rigid registrations were assessed.DRR agreements in anteroposterior and lateral views for overlap index, Dice similarity coefficient, and Jaccard index were0.95. Normalized mutual information results were equivalent in 75% of quadrants. Rotational registration results were negligible (0.07°). Statistically significant differences between CT and synCT registrations were observed in 9/18 matched quadrants/axes (P.05). The population average absolute shifts were 0.77 ± 0.58 and 0.76 ± 0.59 mm for CT and synCT, respectively, for all axes/quadrants. Three-dimensional vectors were2 mm in 77.7 ± 10.8% and 76.5 ± 7.2% of CT and synCT registrations, respectively. SynCT DRRs were sensitive in postsurgical cases (vector displacements2 mm in affected quadrants).DRR synCT geometry was robust. Although statistically significant differences were observed between CT and synCT registrations, results were not clinically significant. Future work will address synCT generation in postsurgical settings.

Researchers have shown the importance of adopting multiple representations when teaching and learning science. In this study, we investigated how effectively students represented their understanding of optics concepts and the difficulties they faced when using multiple representations in an introductory university physics course. To this end, we observed the teaching of a physics course in an Australian university for four semesters, developed and administered an instrument to assess students’ use of written descriptions, diagrams, formula and graphs and compared conceptual pre-test and post-test data. We also interviewed students for their perceptions of the use of multiple representations when learning optics with this instrument. Prior to instruction, most items were answered with two representations – word and diagram. The instructor integrated all four representations into his lectures. After instruction, many more students adopted formula in their responses and the three-representations of word, diagram, and formula were the most frequent combination. In interviews, the majority of students commented that the question items with explicit emphasis on multiple representations were beneficial in improving their understanding of the optics concepts. We discuss students’ perceived difficulties and provide suggestions for future instruction with multiple representations in optics.

Purpose To retrospectively compute dose distributions for lung cancer patients treated with SABR, and to correlate dose distributions with outcome using a tumor control probability (TCP) model. Methods Treatment plans for 133 NSCLC patients treated using 12Gy/fxn×4 (BED=106Gy), and planned using a pencil-beam (1D-equivalent-path-length, EPL-1D) algorithm were retrospectively re-calculated using model-based algorithms (including convolution/superposition, Monte Carlo). 4D imaging was performed to manage motion. TCP was computed using the Marsden model and associations between dose and outcome were inferred. Results Mean D95 reductions of 20% (max.=33%) were noted with model-based algorithms (relative to EPL-1D) for the smallest tumors (PTV 3 ), corresponding to actual delivered D95 BEDs of ∼60–85Gy. For larger tumors (PTV>100cm 3 ), D95 reductions were ∼10% (BED>100Gy). Mean lung doses (MLDs) were 15% lower for model-based algorithms for PTVs 3 . No correlation between tumor size and 2-year local control rate was observed clinically, consistent with TCP calculations, both of which were ∼90% across all PTV bins. Conclusion Results suggest that similar control rates might be achieved for smaller tumors using lower BEDs relative to larger tumors. However, more studies with larger patient cohorts are necessary to confirm this possible finding.

The characteristics of the X-ray attenuation in electrospun nano(n)- and micro(m)-Bi2O3/polylactic acid (PLA) nanofibre mats with different Bi2O3loadings were compared as a function of energy using mammography (i.e.tube voltages of 22–49 kV) and X-ray absorption spectroscopy (XAS) (7–20 keV). Results indicate that X-ray attenuation by electrospun n-Bi2O3/PLA nanofibre mats is distinctly higher than that of m-Bi2O3/PLA nanofibre mats at all energies investigated. In addition, with increasing filler loading (n-Bi2O3or m-Bi2O3), the porosity of the nanofibre mats decreased, thus increasing the X-ray attenuation, except for the sample containing 38 wt% Bi2O3(the highest loading in the present study). The latter showed higher porosity, with some beads formed, thus resulting in a sudden decrease in the X-ray attenuation.

Samples of acrylic and glass were implanted with tungsten (W) and lead (Pb) to investigate their X-ray attenuation characteristics. The near-surface composition depth profiles of ion-implanted acrylic and glass samples were studied using ion-beam analysis (Rutherford backscattering spectroscopy—RBS). The effect of implanted ions on the X-ray attenuation ability was studied using a conventional laboratory X-ray machine with X-ray tube voltages ranging from 40 to 100 kV at constant exposure 10 mAs. The results were compared with previous work on ion-implanted epoxy. As predicted, the RBS results and X-ray attenuation for both ion-implanted acrylic and glass increase with the type of implanted ions when compared to the controls. However, since the glass is denser than epoxy or acrylic, it has provided the higher X-ray attenuation property and higher RBS ion concentration implanted with a shorter range of the ion depth profile when compared to epoxy and acrylic. A prolonged time is necessary for implanting acrylic with a very high nominal dose to minimize a high possibility of acrylic to melt during the process.

The effect of particle size, filler loadings and x-ray tube voltage on the x-ray transmission in WO 3 -epoxy composites has been investigated using the mammography unit and a general radiography unit. Results indicate that nano-sized WO 3 has a better ability to attenuate the x-ray beam generated by lower tube voltages (25–35 kV) when compared to micro-sized WO 3 of the same filler loading. However, the effect of particle size on x-ray transmission was negligible at the higher x-ray tube voltages (40–120 kV).

Lead chloride, bismuth oxide and tungsten oxide filled epoxy composites with different weight fractions were fabricated to investigate their x-ray transmission characteristics in the x-ray diagnostic imaging energy range (40–127 kV) by using a conventional laboratory x-ray machine. Characterizations of the microstructure properties of the synthesized composites were performed using synchrotron radiation diffraction, backscattered electron imaging microscopy, three-point bend test and Rockwell hardness test. As expected, the x-ray transmission was decreased by the increment of the filler loading. Meanwhile, the flexural modulus and hardness of the composites were increased through an increase in filler loading. However, the flexural strength showed a marked decrease with the increment of filler loading (≥30 wt%). Some agglomerations were observed for the composites having ≥50 wt% of filler.

Current commercially available planning systems with Monte Carlo (MC)‐based final dose calculation in IMRT planning employ pencil‐beam (PB) algorithms in the optimization process. Consequently, dose coverage for SBRT lung plans can feature cold‐spots at the interface between lung and tumor tissue. For lung wall (LW)‐seated tumors, there can also be hot spots within nearby normal organs (example: ribs). This study evaluated two different practical approaches to limiting cold spots within the target and reducing high doses to surrounding normal organs in MC‐based IMRT planning of LW‐seated tumors. First, “iterative reoptimization”, where the MC calculation (with PB‐based optimization) is initially performed. The resultant cold spot is then contoured and used as a simultaneous boost volume. The MC‐based dose is then recomputed. The second technique uses noncoplanar beam angles with limited path through lung tissue. Both techniques were evaluated against a conventional coplanar beam approach with a single MC calculation. In all techniques the prescription dose was normalized to cover 95% of the PTV. Fifteen SBRT lung cases with LW‐seated tumors were planned. The results from iterative reoptimization showed that conformity index (CI) and/or PTV dose uniformity (UPTV) improved in 12/15 plans. Average improvement was 13%, and 24%, respectively. Nonimproved plans had PTVs near the skin, trachea, and/or very small lung involvement. The maximum dose to 1cc volume (D1cc) of surrounding OARs decreased in 14/15 plans (average 10%). Using noncoplanar beams showed an average improvement of 7% in 10/15 cases and 11% in 5/15 cases for CI and UPTV, respectively. The D1cc was reduced by an average of 6% in 10/15 cases to surrounding OARs. Choice of treatment planning technique did not statistically significantly change lung V5. The results showed that the proposed practical approaches enhance dose conformity in MC‐based IMRT planning of lung tumors treated with SBRT, improving target dose coverage and potentially reducing toxicities to surrounding normal organs. PACS numbers: 87.55.de, 87.55.kh

Composite epoxy samples filled with PbO and Pb3O4 were fabricated to investigate the mass attenuation characteristics of the composites to X-rays in the diagnostic imaging energy range. The effect of density on the attenuation ability of the composites for radiation shielding purposes was studied using a calibrated X-ray machine. Characterization of the microstructure properties of the synthesized composites was performed using synchrotron radiation diffraction, optical microscopy, and scanning electron micros-copy. The results indicate that the attenuation ability of the composites increased with an increase in density. The particle size of WO3 fillers has a negligible effect on the value of mass attenuation coefficient. Microstructural analyses have confirmed the existence of uniform dispersion of fillers within the matrix of epoxy matrix with the average particle size of 1–5 μm for composites with filler loading of ≤30 wt% and 5–15 μm for composites with filler loading of ≥50 wt%.

The epoxy samples were implanted with heavy ions such as tungsten (W), gold (Au) and lead (Pb) to investigate the attenuation characteristics of these composites. Near-surface composition depth profiling of ion-implanted epoxy systems was studied using Rutherford Backscattering Spectroscopy (RBS). The effect of implanted ions on the X-ray attenuation was studied with a general diagnostic X-ray machine with X-ray tube voltages from 40 to 100 kV at constant exposure 10 mAs. Results show that the threshold of implanted ions above which X-ray mass attenuation coefficient, μm of the ion-implanted epoxy composite is distinguishably higher than the μm of the pure epoxy sample is different for W, Au and Pb.

2.5 MV electronic portal imaging, available on Varian TrueBeam machines, was characterized using various phantoms in this study. Its low‐contrast detectability, spatial resolution, and contrast‐to‐noise ratio (CNR) were compared with those of conventional 6 MV and kV planar imaging. Scatter effect in large patient body was simulated by adding solid water slabs along the beam path. The 2.5 MV imaging mode was also evaluated using clinically acquired images from 24 patients for the sites of brain, head and neck, lung, and abdomen. With respect to 6 MV, the 2.5 MV achieved higher contrast and preserved sharpness on bony structures with only half of the imaging dose. The quality of 2.5 MV imaging was comparable to that of kV imaging when the lateral separation of patient was greater than 38 cm, while the kV image quality degraded rapidly as patient separation increased. Based on the results of patient images, 2.5 MV imaging was better for cranial and extracranial SRS than the 6 MV imaging. PACS number(s): 87.57.C

PURPOSE: Outcomes for patients with recurrent malignant glioma are dismal. Fractionated radiosurgery (FSRS) has been shown to be feasible and safe when delivered in this setting, but prospective evidence is lacking. We conducted a single-institutional randomized trial on the use of FSRS versus chemotherapy for recurrent malignant glioma after second-line chemotherapy. METHODS: High-grade glioma patients with tumor progression after two previous treatment regimens were enrolled. They were randomized to FSRS with bevacizumab or bevacizumab with irinotecan, temozolomide, or carboplatin (discretion of the treating provider). FSRS was delivered as 32 Gy (8 Gy x 4 treatments within 2 weeks) to the gross target volume (gadolinium enhancing lesion and DWI abnormality), and 24 Gy (6 Gy x 4) to the clinical target volume (FLAIR abnormality). The primary endpoints were local tumor control (LC) at 2 months and progression-free survival (PFS). The study planned to accrue 78 patients total, but was closed early due to slow accrual. RESULTS: 34 patients were enrolled from February 2012 to December 2016. Twenty-seven patients had glioblastoma (WHO IV) and 7 had anaplastic glioma (WHO III). The median number of prior recurrences was 3. Patients on the FSRS arm had an improved PFS (5.3 vs 1.8 months, p< 0.001) and improved LC at 2 months (2/16 patients progressing at 2 months compared to 11/15 on chemotherapy alone) (p=0.001). The overall median survival was 6.4 months (7.1 months in the FSRS arm, 4.8 months in the chemotherapy arm, p=0.24). Five patients on the chemotherapy alone arm subsequently received FSRS at time of progression. CONCLUSION: Findings of our study suggest that FSRS in heavily pretreated patients with recurrent malignant glioma is feasible and improves LC and PFS when compared to treatment with next line chemotherapy alone.

This study examined the response characteristics of three commercially available radiochromic films when exposed to low energy (50 kVp) X‐rays. The aim was to evaluate the films for potential use in 2D dosimetry for a low‐kV intraoperative radiotherapy (IORT) device known as the ‘Intrabeam’. Dose‐response relationships were obtained for Gafchromic EBT, XR‐RV2, and XR‐QA film in water at several distances from the Intrabeam device. It was found that the dose rates from the source were excessive for use of the XR‐QA film, and that all three film types showed significant energy dependence within the limits of measurement uncertainty. Basic modeling of primary X‐ray spectra indicated large changes in the lower energy components with distance from the source, and it is hypothesized that the changes in film response are a result of changes in film energy response. This is in contrast to previous studies indicating less or negligible energy response. All films showed non‐linearity in response over the ranges examined. These results imply significant limitations for the use of these films for low‐kV dosimetry. PACS number: 87.53.Bn

Background Magnetic resonance imaging (MRI) has been incorporated as an adjunct to CT to take advantage of its excellent soft tissue contrast for contouring. MR-only treatment planning approaches have been developed to avoid errors introduced during the MR-CT registration process. The purpose of this study is to evaluate calculated dose distributions after incorporating a novel synthetic CT (synCT) derived from magnetic resonance simulation images into prostate cancer treatment planning and to compare dose distributions calculated using three previously published MR-only treatment planning methodologies. Methods An IRB-approved retrospective study evaluated 15 prostate cancer patients that underwent IMRT (n = 11) or arc therapy (n = 4) to a total dose of 70.2-79.2 Gy. Original treatment plans were derived from CT simulation images (CT-SIM). T1-weighted, T2-weighted, and balanced turbo field echo images were acquired on a 1.0 T high field open MR simulator with patients immobilized in treatment position. Four MR-derived images were studied: bulk density assignment (10 HU) to water (MRW), bulk density assignments to water and bone with pelvic bone values derived either from literature (491 HU, MRW+B491) or from CT-SIM population average bone values (300 HU, MRW+B300), and synCTs. Plans were recalculated using fixed monitor units, plan dosimetry was evaluated, and local dose differences were characterized using gamma analysis (1 %/1 mm dose difference/distance to agreement). Results While synCT provided closest agreement to CT-SIM for D95, D99, and mean dose (

The proton beam energy of an isochronous 18MeV cyclotron was determined using a novel version of the stacked copper-foils technique. This simple method used stacked foils of natural copper forming 'thick' targets to produce Zn radioisotopes by the well-documented (p,x) monitor-reactions. Primary beam energy was calculated using the (65)Zn activity vs. depth profile in the target, with the results obtained using (62)Zn and (63)Zn (as comparators) in close agreement. Results from separate measurements using foil thicknesses of 100, 75, 50 or 25µm to form the stacks also concurred closely. Energy was determined by iterative least-squares comparison of the normalized measured activity profile in a target-stack with the equivalent calculated normalized profile, using 'energy' as the regression variable. The technique exploits the uniqueness of the shape of the activity vs. depth profile of the monitor isotope in the target stack for a specified incident energy. The energy using (65)Zn activity profiles and 50-μm foils alone was 18.03±0.02 [SD] MeV (95%CI=17.98-18.08), and 18.06±0.12MeV (95%CI=18.02-18.10; NS) when combining results from all isotopes and foil thicknesses. When the beam energy was re-measured using (65)Zn and 50-μm foils only, following a major upgrade of the ion sources and nonmagnetic beam controls the results were 18.11±0.05MeV (95%CI=18.00-18.23; NS compared with 'before'). Since measurement of only one Zn monitor isotope is required to determine the normalized activity profile this indirect yet precise technique does not require a direct beam-current measurement or a gamma-spectroscopy efficiency calibrated with standard sources, though a characteristic photopeak must be identified. It has some advantages over published methods using the ratio of cross sections of monitor reactions, including the ability to determine energies across a broader range and without need for customized beam degraders.

The purpose of this study is to characterize the dosimetric properties and accuracy of a novel treatment platform (Edge radiosurgery system) for localizing and treating patients with frameless, image‐guided stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT). Initial measurements of various components of the system, such as a comprehensive assessment of the dosimetric properties of the flattening filter‐free (FFF) beams for both high definition (HD120) MLC and conical cone‐based treatment, positioning accuracy and beam attenuation of a six degree of freedom (6DoF) couch, treatment head leakage test, and integrated end‐to‐end accuracy tests, have been performed. The end‐to‐end test of the system was performed by CT imaging a phantom and registering hidden targets on the treatment couch to determine the localization accuracy of the optical surface monitoring system (OSMS), cone‐beam CT (CBCT), and MV imaging systems, as well as the radiation isocenter targeting accuracy. The deviations between the percent depth‐dose curves acquired on the new linac‐based system (Edge), and the previously published machine with FFF beams (TrueBeam) beyond Dmax were within 1.0% for both energies. The maximum deviation of output factors between the Edge and TrueBeam was 1.6%. The optimized dosimetric leaf gap values, which were fitted using Eclipse dose calculations and measurements based on representative spine radiosurgery plans, were 0.700 mm and 1.000 mm, respectively. For the conical cones, 6X FFF has sharper penumbra ranging from 1.2−1.8 mm (80%‐20%) and 1.9−3.8 mm (90%‐10%) relative to 10X FFF, which has 1.2−2.2 mm and 2.3−5.1 mm, respectively. The relative attenuation measurements of the couch for PA, PA (rails‐in), oblique, oblique (rails‐out), oblique (rails‐in) were: −2.0%, −2.5%, −15.6%, −2.5%, −5.0% for 6X FFF and −1.4%, −1.5%, −12.2%, −2.5%, −5.0% for 10X FFF, respectively, with a slight decrease in attenuation versus field size. The systematic deviation between the OSMS and CBCT was −0.4±0.2 mm, 0.1±0.3 mm, and 0.0±0.1 mm in the vertical, longitudinal, and lateral directions. The mean values and standard deviations of the average deviation and maximum deviation of the daily Winston‐Lutz tests over three months are 0.20±0.03 mm and 0.66±0.18 mm, respectively. Initial testing of this novel system demonstrates the technology to be highly accurate and suitable for frameless, linac‐based SRS and SBRT treatment. PACS number: 87.56.J‐

The purpose of this study was to describe our experience with 1.0T MR‐SIM including characterization, quality assurance (QA) program, and features necessary for treatment planning. Staffing, safety, and patient screening procedures were developed. Utilization of an external laser positioning system (ELPS) and MR‐compatible couchtop were illustrated. Spatial and volumetric analyses were conducted between CT‐SIM and MR‐SIM using a stereotactic QA phantom with known landmarks and volumes. Magnetic field inhomogeneity was determined using phase difference analysis. System‐related, in‐plane distortion was evaluated and temporal changes were assessed. 3D distortion was characterized for regions of interest (ROIs) 5–20 cm away from isocenter. American College of Radiology (ACR) recommended tests and impact of ELPS on image quality were analyzed. Combined ultrashort echotime Dixon (UTE/Dixon) sequence was evaluated. Amplitude‐triggered 4D MRI was implemented using a motion phantom (2–10 phases, ~2 cm excursion, 3–5 s periods) and a liver cancer patient. Duty cycle, acquisition time, and excursion were evaluated between maximum intensity projection (MIP) datasets. Less than 2% difference from expected was obtained between CT‐SIM and MR‐SIM volumes, with a mean distance of