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Purpose: Establishing the tolerance limits of patient‐specific quality assurance (PSQA) processes based on the gamma passing rate (GPR) by using normal statistical process control (SPC) methods involves certain problems. The aim of this study was threefold: (a) to show that the heuristic SPC method can replace the quantile method for establishing tolerance limits in PSQA processes and is more robust, (b) to introduce an iterative procedure of "Identify‐Eliminate‐Recalculate" for establishing the tolerance limits in PSQA processes with unknown states based on retrospective GPRs, and (c) to recommend a workflow to define tolerance limits based on actual clinical retrospective GPRs. Materials and Methods: A total of 1671 volumetric‐modulated arc therapy (VMAT) pretreatment plans were measured on four linear accelerators (linacs) and analyzed by treatment sites using the GPRs under the 2%/2 mm, 3%/2 mm, and 3%/3 mm criteria. Normality testing was performed using the Anderson‐Darling (AD) statistic and the optimal distributions of GPRs were determined using the Fitter Python package. The iterative "Identify‐Eliminate‐Recalculate" procedure was used to identify the PSQA outliers. The tolerance limits of the initial PSQAs, remaining PSQAs after elimination, and in‐control PSQAs after correction were calculated using the conventional Shewhart method, two transformation methods, three heuristic methods, and two quantile methods. The tolerance limits of PSQA processes with different states for the respective methods, linacs, and treatment sites were comprehensively compared and analyzed. Results: It was found that 75% of the initial PSQA processes and 63% of the in‐control processes were non‐normal (AD test, p < 0.05). The optimal distributions of GPRs for the initial and in‐control PSQAs varied with different linacs and treatment sites. In the implementation of the "Identify‐Eliminate‐Recalculate" procedure, the quantile methods could not identify the out‐of‐control PSQAs effectively due to the influence of outliers. The tolerance limits of the in‐control PSQAs, calculated using the quantile of optimal fitting distributions, represented the ground truth. The tolerance limits of the in‐control PSQAs and remaining PSQAs after elimination calculated using the heuristic methods were considerably close to the ground truth (the maximum average absolute deviations were 0.50 and 1.03%, respectively). Some transformation failures occurred under both transformation methods. For the in‐control PSQAs at 3%/2 mm gamma criteria, the maximum differences in the tolerance limits for four linacs and different treatment sites were 3.10 and 5.02%, respectively. Conclusions: The GPR distributions of PSQA processes vary with different linacs and treatment sites but most are skewed. In applying SPC methodologies to PSQA processes, heuristic methods are robust. For in‐control PSQA processes, the tolerance limits calculated by heuristic methods are in good agreement with the ground truth. For unknown PSQA processes, the tolerance limits calculated by the heuristic methods after the iterative "Identify‐Eliminate‐Recalculate" procedure are closest to the ground truth. Setting linac‐ and treatment site‐specific tolerance limits for PSQA processes is necessary for clinical applications. [ABSTRACT FROM AUTHOR]

Abstract Background To study the set-up errors, PTV margin and toxicity of cone beam CT (CBCT) guided hypofractionated radiotherapy with active breathing control (ABC) for patients with non-small cell lung cancer (NSCLC) or metastatic tumors in lung. Methods 32 tumors in 20 patients were treated. Based on the location of tumor, dose per fraction given to tumor was divided into three groups: 12 Gy, 8 Gy and 6 Gy. ABC is applied for every patient. During each treatment, patients receive CBCT scan for online set-up correction. The pre- and post-correction setup errors between fractions, the interfractional and intrafractional, set-up errors, PTV margin as well as toxicity are analyzed. Results The pre-correction systematic and random errors in the left-right (LR), superior-inferior (SI), anterior-posterior (AP) directions were 3.7 mm and 5.3 mm, 3.1 mm and 2.1 mm, 3.7 mm and 2.8 mm, respectively, while the post-correction residual errors were 0.6 mm and 0.8 mm, 0.8 mm and 0.8 mm, 1.2 mm and 1.3 mm, respectively. There was an obvious intrafractional shift of tumor position. The pre-correction PTV margin was 9.5 mm in LR, 14.1 mm in SI and 8.2 mm in AP direction. After CBCT guided online correction, the PTV margin was markedly reduced in all three directions. The post-correction margins ranged 1.5 to 2.1 mm. The treatment was well tolerated by patients, of whom there were 4 (20%) grade1-2 acute pneumonitis, 3 (15%) grade1 acute esophagitis, 2 (10%) grade1 late pneumonitis and 1 (5%) grade 1 late esophagitis. Conclusion The positioning errors for lung SBRT using ABC were significant. Online correction with CBCT image guidance should be applied to reduce setup errors and PTV margin, which may reduce radiotherapy toxicity of tissues when ABC was used.

Background Non-small cell lung cancer ( NSCLC) harboring kinase-domain mutations in epidermal growth factor receptors ( EGFR) has been observed to be sensitive to ionizing radiation ( IR). We explore Rad51-dependent homologous recombination ( HR) DNA repair in regulating radiosensitivity in two NSCLC cell lines with different EGFR mutation status. Methods NSCLC cell lines, wild-type EGFR A549 and mutant EGFR H820 with an in-frame deletion in exon 19 of EGFR (Δ E746- E750), were cultured. Radiosensitivity was estimated by colony forming assay. Rad51 expression was evaluated by quantitative real time-polymerase chain reaction and Western-blot. Lentiviral small hairpin ribonucleic acid- Rad51 and Δ E746- E750 deletion mutant EGFR were constructed and transfected into cells. Flowcytometry assay was used to analyze DNA double strand breaks, cell cycle alterations, and apoptosis. Results A549 had a higher survival factor ( SF)2 (0.66 vs. 0.44) and lower α/β value (4.07 vs. 9.01). Compared with the A549 cell, the H820 cell exhibited defective arrest in the S-phase, a higher rate of G2/M accumulation, early apoptosis, and residual γ- H2AX. Downregulated Rad51 expression decreased SF2 (0.42 vs. 0.31) and increased the α/β ratio (7.51 vs. 10.5), G2/M accumulation, early apoptosis, and γ- H2AX in two cell lines. H820 had a low IR-induced Rad51 expression and nuclear translocation. Exogenous expression of the Δ E746- E750 deletion mutant EGFR caused the A549 cell to become more radiosensitive. Conclusions An EGFR mutated NSCLC cell line is sensitive to IR , which is correlated with reduced IR-induced Rad51 expression and nuclear translocation. The signaling pathway of EGFR maintaining Rad51 protein levels maybe a novel lung cancer therapeutic target to overcome radioresistance. [ABSTRACT FROM AUTHOR]

Glioblastoma multiforme (GBM), a common malignant neurological tumor, has boundaries indistinguishable from those of normal tissue, making complete surgical removal ineffective. The blood-brain barrier (BBB) further impedes the efficacy of radiotherapy and chemotherapy, leading to suboptimal treatment outcomes and a heightened probability of recurrence. Hydrogels offer multiple advantages for GBM diagnosis and treatment, including overcoming the BBB for improved drug delivery, controlled drug release for long-term efficacy, and enhanced relaxation properties of magnetic resonance imaging (MRI) contrast agents. Hydrogels, with their excellent biocompatibility and customizability, can mimic the in vivo microenvironment, support tumor cell culture, enable drug screening, and facilitate the study of tumor invasion and metastasis. This paper reviews the classification of hydrogels and recent research for the diagnosis and treatment of GBM, including their applications as cell culture platforms and drugs including imaging contrast agents carriers. The mechanisms of drug release from hydrogels and methods to monitor the activity of hydrogel-loaded drugs are also discussed. This review is intended to facilitate a more comprehensive understanding of the current state of GBM research. It offers insights into the design of integrated hydrogel-based GBM diagnosis and treatment with the objective of achieving the desired therapeutic effect and improving the prognosis of GBM.

This paper describes the design of an innovative linear accelerator image-guided radiosurgery (IGRS) device, which is based on a composite twofold rotary gantry structure. The paper discusses five aspects of the innovative device: its overall composition, the safety net space created by the accelerator radiation head as it rotates around the patient's longitudinal axis, the non-coplanar spherical coverage in the direction of the incidence angle for quasi-4π delivery, the structural features of the composite twofold rotary gantry, and the processes of treatment planning and implementation. It elaborates on the device's manufacturing feasibility, safety, effectiveness, accuracy, and efficiency. The conclusion is that this innovative device design holds significant development value and market promotion potential.

Virtual monochromatic images (VMI) that reconstructed on dual-energy computed tomography (DECT) have further application prospects in radiotherapy, and there is still a lack of clinical dose verification. In this study, GE Revolution CT scanner was used to perform conventional imaging and gemstone spectral imaging on the simulated head and body phantom. The CT images were imported to radiotherapy treatment planning system (TPS), and the same treatment plans were transplanted to compare the CT value and the dose distribution. The results show that the VMI can be imported into TPS for CT value-relative electron density conversion and dose calculation. Compared to conventional images, the VMI varies from 70 to 140 keV, has little difference in dose distribution of 6 MV photon treatment plan.

In order to adapt to different target shapes and protect the surrounding normal tissues, the design of two-dimensional electron beam radiotherapy planning requires additional lead blocks. But the Pinnacle treatment planning system can not directly shape the lead block conformity to the size of the beam field given by the doctor. Every time, physicists need to manually drag the lead block to form the required beam field. When meeting a two-dimensional electron beam treatment planning with the same field parameters as before, physicists need to rearrange the field for dose calculation, which greatly reduces the design efficiency of the two-dimensional electron beam treatment planning. In this study, we independently developed a two-dimensional electron beam radiotherapy planning system based on Qt Creator. The system can quickly design a two-dimensional electron beam radiotherapy plan, which reduces the repeated work of physicists.

Interfractional variations of the bladder, rectum and vagina may affect the accuracy of postoperative intensity-modulated radiotherapy in patients with cervical cancer. This study aimed to assess the interfractional variations with daily kV cone-beam computed tomography (CBCT). All the patients were instructed to control the filling status of the bladder and rectum. CBCT images were obtained daily after set-up and the bladder, rectum and vagina were contoured on each CBCT scan. All the contours were transferred to the planning CT following image fusion. Interfractional variations in pelvic organs were assessed with CBCT based on two reference lines, which were identified as A (the midsaggital line across the superior border of pubic symphysis) and B (a parallel line 1.5 cm above line A). The mean volume (range) of the bladder and rectum was 156.5 (1.7-626.5) and 48.2 (11.3-139.7) ml, respectively. The uniform planning target volume (PTV) margin of 10 mm failed to encompass the vagina in 17.3 and 18.1% of the fractions on lines A and B, respectively. The motion of the vagina (standard deviation) was 0.3 (0.3) and 0.1 (0.5) cm on lines A and B, respectively. The anteroposterior dimension and position of the vagina were significantly affected by the filling status of the bladder (P<0.05), but not by that of the rectum. Although instructions were given, the interfractional variations of the vagina and other pelvic organs were significant, which may exceed the uniform PTV margin; therefore, more effective methods to decrease these variations should be investigated.

To investigate the impact of respiratory movement to determine the target volume on cone beam CT (CBCT) for lung tumor, we used CIRS dynamic thorax phantom (Model-CIRS008) to simulate the sinusoidal motion of lung tumor. With a constant amplitude, the ratio of the time of near-end-expiratory and near-end-inspiratory (E/I) changed when it was scanned with CBCT. We analyzed the contrast changes of target by extracting the CT value of each pixel on the center line of the target movement direction. The targets were contoured with region growing method and compared with the motion volume generated by the tumor trajectory method. The result showed that the contrast of near-end-expiratory increased and the contrast of near-end-inspiratory decreased with increasing E/I. The contoured volume generated by region growing method decreased with increasing E/I. When E/I = 4, the amplitude A = 1 cm, diameter of 1 cm and 3 cm target volumes were reduced by 48.2% and 22.7%. The study showed that CBCT was not suitable to be used to accurately determine the range of lung tumor movement. The internal target volume (ITV) may be underestimated in CBCT images.

Some patients who have neck tumor but cannot tolerate the thermoplastic immobilization may be supported by simple cushions, and are marked on the neck skin during CT simulation. We therefore set 5 mm as the spinal cord-planning risk volume margin in the intensity-modulated radiotherapy plans in our Centre. Cone beam CT (CBCT) scans were acquired for three times, and matched with the simulation CT images in each radiotherapy. The mean and the standard deviation of the individual, the root mean-square and the standard deviation of the individual were calculated. The matched results of the third CBCT were used to calculate the spinal cord- planning risk volume margin. The results showed that the interfraction error was significantly reduced and the intrafraction error was stable by CBCT guiding. CBCT and 5 mm spinal cord-planning organ is feasible and safe without threatening volume margin to high dose radiotherapy for the patients with neck tumor and not able to tolerate thermoplastic immobilization.

Background: Image guided radiotherapy (IGRT) is a new precise radiotherapy applied in clinic. The aim of this study is to evaluate the impact of using active breath control (ABC) and stereotactic body frame on reducing the positioning error and increasing treatment precision during radiotherapy for pulmonary cancer., Methods: Seven patients with pulmonary recurrences or metastasis after prior treatment were enrolled. A total number of 13 tumor targets received irradiation, with a fraction dose of 7Gy treated every other day to a total of 7 fractions. X-ray beam volume CT was done at every fraction for correction of positioning error at 3 dimensions., Results: The errors between pre-treatment positioning and treatment planning at left-right, anterior-posterior and cephalic-caudal directions were 0.30cm±0.14cm, 0.22cm±0.15cm and 0.28cm ±0.21cm, respectively. The positioning error was reduced after correction by volume CT and after treatment but the errors between pre-correction, post-correction and post-treatment had no statistical significance at all 3 directions. Eight targets had complete response, 4 targets had partial response, and 1 had no change., Conclusions: Image guided hypofractionation radiotherapy with ABC and stereotactic body frame has the advantage of increasing radiation dose and reducing overall treatment time and radiation toxicity.