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BackgroundApplying ultra-high dose rates to radiation therapy, otherwise known as FLASH, has been shown to be just as effective while sparing more normal tissue compared to conventional radiation therapy. However, there is a need for a dosimeter that is able to detect such high instantaneous dose, particularly in vivo. To fulfill this need, protoacoustics is introduced, which is an in vivo range verification method with submillimeter accuracy.PurposeThe purpose of this work is to demonstrate the feasibility of using protoacoustics as a method of in vivo real-time monitoring during FLASH proton therapy and investigating the resulting protoacoustic signal when dose per pulse and pulsewidth are varied through multiple simulation studies.MethodsThe dose distribution of a proton pencil beam was calculated through a Monte Carlo toolbox, TOPAS. Next, the k-Wave toolbox in MATLAB was used for performing protoacoustic simulations, where the initial proton dose deposition was inputted to model acoustic propagations, which were also used for reconstructions. Simulations involving the manipulation of the dose per pulse and pulsewidth were performed, and the temporal and spatial resolution for protoacoustic reconstructions were investigated as well. A 3D reconstruction was performed with a multiple beam spot profile to investigate the spatial resolution as well as determine the feasibility of 3D imaging with protoacoustics.ResultsOur results showed consistent linearity in the increasing dose-per-pulse, even up to rates considered for FLASH. The simulations and reconstructions were performed for a range of pulsewidths from 0.1 to 10 μs. The results show the characteristics of the proton beam after convolving the protoacoustic signal with the varying pulsewidths. 3D reconstruction was successfully performed with each beam being distinguishable using an 8 cm × 8 cm planar array. These simulation results show that measurements using protoacoustics has the potential for in vivo dosimetry in FLASH therapy during patient treatments in real time.ConclusionThrough this simulation study, the use of protoacoustics in FLASH therapy was verified and explored through observations of varying parameters, such as the dose per pulse and pulsewidth. 2D and 3D reconstructions were also completed. This study shows the significance of using protoacoustics and provides necessary information, which can further be explored in clinical settings.

Introduction: Financial toxicity has negative implications for patient well-being and health outcomes. There is a gap in understanding financial toxicity for patients undergoing palliative radiotherapy (RT). Methods: A review of patients treated with palliative RT was conducted from January 2021 to December 2022. The FACIT-COST (COST) was measured (higher scores implying better financial well-being). Financial toxicity was graded according to previously suggested cutoffs: Grade 0 (score ≥26), Grade 1 (14-25), Grade 2 (1-13), and Grade 3 (0). FACIT-TS-G was used for treatment satisfaction, and EORTC QLQ-C30 was assessed for global health status and functional scales. Results: 53 patients were identified. Median COST was 25 (range 0-44), 49% had Grade 0 financial toxicity, 32% Grade 1, 15% Grade 2, and 4% Grade 3. Overall, cancer caused financial hardship among 45%. Higher COST was weakly associated with higher global health status/Quality of Life (QoL), physical functioning, role functioning, and cognitive functioning; moderately associated with higher social functioning; and strongly associated with improved emotional functioning. Higher income or Medicare or private coverage (rather than Medicaid) was associated with less financial toxicity, whereas an underrepresented minority background or a non-English language preference was associated with greater financial toxicity. A multivariate model found that higher area income (HR .80, P = .007) and higher cognitive functioning (HR .96, P = .01) were significantly associated with financial toxicity. Conclusions: Financial toxicity was seen in approximately half of patients receiving palliative RT. The highest risk groups were those with lower income and lower cognitive functioning. This study supports the measurement of financial toxicity by clinicians.

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.To assess long-term risk of local tumor regrowth, we report updated organ preservation rate and oncologic outcomes of the OPRA trial (ClinicalTrials.gov identifier: NCT02008656). Patients with stage II/III rectal cancer were randomly assigned to receive induction chemotherapy followed by chemoradiation (INCT-CRT) or chemoradiation followed by consolidation chemotherapy (CRT-CNCT). Patients who achieved a complete or near-complete response after finishing treatment were offered watch-and-wait (WW). Total mesorectal excision (TME) was recommended for those who achieved an incomplete response. The primary end point was disease-free survival (DFS). The secondary end point was TME-free survival. In total, 324 patients were randomly assigned (INCT-CRT, n = 158; CRT-CNCT, n = 166). Median follow-up was 5.1 years. The 5-year DFS rates were 71% (95% CI, 64 to 79) and 69% (95% CI, 62 to 77) for INCT-CRT and CRT-CNCT, respectively (P = .68). TME-free survival was 39% (95% CI, 32 to 48) in the INCT-CRT group and 54% (95% CI, 46 to 62) in the CRT-CNCT group (P = .012). Of 81 patients with regrowth, 94% occurred within 2 years and 99% occurred within 3 years. DFS was similar for patients who underwent TME after restaging (64% [95% CI, 53 to 78]) and patients in WW who underwent TME after regrowth (64% [95% CI, 53 to 78]; P = .94). Updated analysis continues to show long-term organ preservation in half of the patients with rectal cancer treated with total neoadjuvant therapy. In patients who enter WW, most cases of tumor regrowth occur in the first 2 years.

IntroductionCancer combination treatments involving immunotherapies with targeted radiation therapy are at the forefront of treating cancers. However, dosing and scheduling of these therapies pose a challenge. Mathematical models provide a unique way of optimizing these therapies.MethodsUsing a preclinical model of multiple myeloma as an example, we demonstrate the capability of a mathematical model to combine these therapies to achieve maximum response, defined as delay in tumor growth. Data from mice studies with targeted radionuclide therapy (TRT) and chimeric antigen receptor (CAR)-T cell monotherapies and combinations with different intervals between them was used to calibrate mathematical model parameters. The dependence of progression-free survival (PFS), overall survival (OS), and the time to minimum tumor burden on dosing and scheduling was evaluated. Different dosing and scheduling schemes were evaluated to maximize the PFS and optimize timings of TRT and CAR-T cell therapies.ResultsTherapy intervals that were too close or too far apart are shown to be detrimental to the therapeutic efficacy, as TRT too close to CAR-T cell therapy results in radiation related CAR-T cell killing while the therapies being too far apart result in tumor regrowth, negatively impacting tumor control and survival. We show that splitting a dose of TRT or CAR-T cells when administered in combination is advantageous only if the first therapy delivered can produce a significant benefit as a monotherapy.DiscussionMathematical models are crucial tools for optimizing the delivery of cancer combination therapy regimens with application along the lines of achieving cure, maximizing survival or minimizing toxicity.

BackgroundNeuroblastoma is the most common extra-cranial pediatric solid tumor. 131I-metaiodobenzylguanidine (MIBG) is a targeted radiopharmaceutical highly specific for neuroblastoma tumors, providing potent radiotherapy to widely metastatic disease. Aurora kinase A (AURKA) plays a role in mitosis and stabilization of the MYCN protein in neuroblastoma. We aimed to study the impact of AURKA inhibitors on DNA damage and tumor cell death in combination with 131I-MIBG therapy in a pre-clinical model of high-risk neuroblastoma.ResultsUsing an in vivo model of high-risk neuroblastoma, we demonstrated a marked combinatorial effect of 131I-MIBG and alisertib on tumor growth. In MYCN amplified cell lines, the combination of radiation and an AURKA A inhibitor increased DNA damage and apoptosis and decreased MYCN protein levels.ConclusionThe combination of AURKA inhibition with 131I-MIBG treatment is active in resistant neuroblastoma models.

Targeted alpha particle therapy (TAT) has emerged as a promising strategy for the treatment of prostate cancer (PCa). Actinium-225 (225Ac), a potent alpha-emitting radionuclide, may be incorporated into targeting vectors, causing robust and in some cases sustained antitumor responses. The development of radiolabeling techniques involving EDTA, DOTA, DOTPA, and Macropa chelators has laid the groundwork for advancements in this field. At the forefront of clinical trials with 225Ac in PCa are PSMA-targeted TAT agents, notably [225Ac]Ac-PSMA-617, [225Ac]Ac-PSMA-I&T and [225Ac]Ac-J591. Ongoing investigations spotlight [225Ac]Ac-hu11B6, [225Ac]Ac-YS5, and [225Ac]Ac-SibuDAB, targeting hK2, CD46, and PSMA, respectively. Despite these efforts, hurdles in 225Ac production, daughter redistribution, and a lack of suitable imaging techniques hinder the development of TAT. To address these challenges and additional advantages, researchers are exploring alpha-emitting isotopes including 227Th, 223Ra, 211At, 213Bi, 212Pb or 149Tb, providing viable alternatives for TAT.

ObjectivesImmunotherapy with immune checkpoint inhibitors has shown only limited success in the management of metastatic soft tissue sarcoma. Overall response rates (ORR) with single agent pembrolizumab were 18% and median PFS was 18 weeks on the clinical trial SARC028. One strategy to improve the responses to immunotherapy is with stereotactic body radiation therapy (SBRT), which can enhance the antitumor CD8 T cell response through the release of tumor-specific antigens, potentially priming a more diverse class of T cell receptors.MethodsThis is a phase 0, pilot prospective study taking place at a single center with 2 arms. In Arm A, patients are treated with pembrolizumab 400 mg IV infusion on day 1 of a 42-day cycle. Stereotactic body radiation therapy (SBRT) is delivered in 1-5 fractions starting on C1D15-28 and given every other day. In Arm B, patients who have started an immune checkpoint inhibitor within 60 days are treated with SBRT in addition to the current therapy.ResultsIn this study we outline testing the feasibility of adding SBRT to pembrolizumab.ConclusionThe ultimate goal of combination therapy is improved overall response, including tumors not treated with SBRT. This trial can be found registered online: NCT05488366.

PurposeThe objectives of this study were to identify key dosimetric parameters associated with postradiation therapy lymphopenia and uncover any effect on clinical outcomes.Methods and materialsThis was a retrospective review of 69 patients (between April 2010 and January 2023) who underwent radiation therapy (RT) as a part of curative intent for soft tissue sarcoma (STS) at a single academic institution. All patients with treatment plans available to review and measurable absolute lymphocyte count (ALC) nadir within a year after completion of RT were included.ResultsMedian follow-up was 22 months after the start of RT. A decrease in lymphocyte count was noted as early as during treatment and persisted at least 3 months after the completion of RT. On multivariable linear regression, the strongest correlations with ALC nadir were mean body dose, body V10 Gy, mean bone dose, bone V10 Gy, and bone V20 Gy. Five-year overall survival was 60% and 5-year disease-free survival was 44%. Advanced T-stage, chemotherapy use, use of intensity-modulated RT, lower ALC nadir, and the development of grade ≥2 lymphopenia at nadir were associated with worse overall survival and disease-free survival.ConclusionsPost-RT lymphopenia was associated with worse outcomes in STS. There were associations between higher body V10 Gy and bone V10 Gy and lower post-RT ALC nadir, despite the varying sites of STS presentation, which aligns with the well-known radiosensitivity of lymphocyte cell lines. These findings support efforts to reduce treatment-related hematopoietic toxicity as a way to improve oncologic outcomes. Additionally, this study supports the idea that the effect of radiation on lymphocyte progenitors in the bone marrow is more significant than that on circulating lymphocytes in treatments with limited involvement of the heart and lung.

Radiation-induced acoustics (RIA) shows promise in advancing radiological imaging and radiotherapy dosimetry methods. However, RIA signals often require extensive averaging to achieve reasonable signal-to-noise ratios, which increases patient radiation exposure and limits real-time applications. Therefore, this paper proposes a discrete wavelet transform (DWT) based filtering approach to denoise the RIA signals and avoid extensive averaging. The algorithm was benchmarked against low-pass filters and tested on various types of RIA sources, including low-energy X-rays, high-energy X-rays, and protons. The proposed method significantly reduced the required averages (1000 times less averaging for low-energy X-ray RIA, 32 times less averaging for high-energy X-ray RIA, and 4 times less averaging for proton RIA) and demonstrated robustness in filtering signals from different sources of radiation. The coif5 wavelet in conjunction with the sqtwolog threshold selection algorithm yielded the best results. The proposed DWT filtering method enables high-quality, automated, and robust filtering of RIA signals, with a performance similar to low-pass filtering, aiding in the clinical translation of radiation-based acoustic imaging for radiology and radiation oncology.

Normal tissue tolerance dose limits to the heart have been established to reduce the risk of radiation‐induced cardiac disease (RICD). Dose constraints have been developed based on either the mean dose delivered to the whole heart (MHD) or the dose delivered to a specific volume, for example, volume of heart receiving equal to or greater than 30 Gy (V30). There is increasing evidence that the impact of thoracic radiation on cardiac morbidity and mortality has been underestimated. Consequently, there is a need to reduce the dose delivered to the heart in radical radiotherapy treatment planning. The pathophysiology of RICD may relate to dose to specific cardiac substructures (CS) rather than the traditionally observed MHD for common toxicities. The MHD or V30 Gy threshold dose rarely represents the true dose delivered to individual CS. Studies have shown the dose to specific areas may be more strongly correlated with overall survival (OS). With advances in modern radiotherapy techniques, it is vital that we develop robust, evidence‐based dose limits for CS, to fully understand and reduce the risk of RICD, particularly in high‐risk populations with cardiac risk factors. The following review will summarise the existing evidence of dose limits to CS, explain how dose limits may vary according to different disease sites or radiation techniques and propose how radiotherapy plans can be optimised to reduce the dose to these CS in clinical practice. [ABSTRACT FROM AUTHOR]

Background: This case study discusses a 37-year-old man who presented with stage IV (cT3N1M1a) sigmoid colon cancer that had metastasized to the liver. The patient underwent stereotactic body radiation therapy using real-time, fiducial-based, triggered-imaging guidance and amplitude-based respiratory gating at exhalation. In addition to the cancer diagnosis, the patient was deaf and had a substantial medical and surgical history for other comorbidities. Discussion: Although deaf patients account for a small percentage of those undergoing radiation therapy, this treatment has the potential to be more inclusive to this group, which the authors accomplished using a novel approach. Providing instructions to enable the patient to breathe in a consistent, periodic, and reproducible manner via sign-language interpretation and visual setup was key to providing equitable care. Conclusion: The multidisciplinary team must work to ensure that deaf patients are not excluded from gating treatment protocols typically achieved through verbal coaching. With appropriate visual setup, sign-language interpretation, and coaching through translation, culturally competent care can be provided successfully and seamlessly. [ABSTRACT FROM AUTHOR]

Workforce modelling for Radiation Oncology Medical Physicists (ROMPs) is evolving and challenging, prompting the development of the 2021 Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) ROMP Workforce (ARW) Model. In the exploration of this model at Sir Charles Gairdner Hospital, a comprehensive productivity exercise was conducted to obtain a detailed breakdown of ROMP time at a granular level. The results provide valuable insights into ROMP activities and enabled an evaluation of ARW Model calculations. The findings also capture the changing ROMP role as evidenced by an increasing involvement in consultation and advisory tasks with other professionals in the field. They also suggest that CyberKnife QA time requirements in the data utilised by the model may need to be revised. This study emphasises features inherent in the model, that need to be understood if the model is to be applied correctly. [ABSTRACT FROM AUTHOR]

Background/Aim: To evaluate the safety and efficacy of lattice radiotherapy (LRT) for large, inoperable breast cancers. Patients and Methods: In this prospective study, patients who underwent LRT for breast tumors that were ulcerating/fungating/extensively eroding the chest wall, and were ineligible/unwilling for surgery, were enrolled from May 2021 to Nov 2023. Baseline Eastern Cooperative Oncology Group (ECOG) status, pre- and post-LRT numerical rating scale (NRS), and post-LRT changes in quality of life (QoL) were recorded. Survival outcomes were reported at 6 months and 1-year. Median rates of survival and dosimetric parameters were calculated. Kaplan–Meier curves for overall survival (OS), cancer-specific survival (CSS), and failure of local control (LC) were constructed. Results: Ten patients (8 females) underwent LRT. The median age was 76 years (range=57-99 years) and the median ECOG performance status was 2.5 (range=1-4). The planned schedule was completed by 9/10 patients, accounting for a 90% compliance rate. Among patients with pain (n=7), NRS rapidly reduced from 7 (range=5-10) to 3 (range=1-6). The median equivalent uniform dose was 0.71 Gy (0.09-1.59 Gy). The actuarial rates of 6-month LC, CSS, and OS were 75%, 89%, and 61%, respectively, with only LC rate changing to 50% at 1 year. Two patients had local relapse at the six-month and 1-year follow-up, respectively, after having achieved a complete response at three months, and two others died of COVID-19 infection and ischemic stroke. Conclusion: LRT was found to be effective and safe in palliating symptoms among patients with large inoperable breast tumors. [ABSTRACT FROM AUTHOR]

Purpose and objective: To develop expert consensus statements on multiparametric dose prescriptions for stereotactic body radiotherapy (SBRT) aligning with ICRU report 91. These statements serve as a foundational step towards harmonizing current SBRT practices and refining dose prescription and documentation requirements for clinical trial designs. Materials and methods: Based on the results of a literature review by the working group, a two-tier Delphi consensus process was conducted among 24 physicians and physics experts from three European countries. The degree of consensus was predefined for overarching (OA) and organ-specific (OS) statements (≥ 80%, 60–79%, < 60% for high, intermediate, and poor consensus, respectively). Post-first round statements were refined in a live discussion for the second round of the Delphi process. Results: Experts consented on a total of 14 OA and 17 OS statements regarding SBRT of primary and secondary lung, liver, pancreatic, adrenal, and kidney tumors regarding dose prescription, target coverage, and organ at risk dose limitations. Degree of consent was ≥ 80% in 79% and 41% of OA and OS statements, respectively, with higher consensus for lung compared to the upper abdomen. In round 2, the degree of consent was ≥ 80 to 100% for OA and 88% in OS statements. No consensus was reached for dose escalation to liver metastases after chemotherapy (47%) or single-fraction SBRT for kidney primaries (13%). In round 2, no statement had 60–79% consensus. Conclusion: In 29 of 31 statements a high consensus was achieved after a two-tier Delphi process and one statement (kidney) was clearly refused. The Delphi process was able to achieve a high degree of consensus for SBRT dose prescription. In summary, clear recommendations for both OA and OS could be defined. This contributes significantly to harmonization of SBRT practice and facilitates dose prescription and reporting in clinical trials investigating SBRT. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion This study compared the predictive ability of radiation‐induced cataract between maximum point dose of the lens (Lens Dmax) ≥7 Gy, mean lens dose (Lens Dmean) ≥7 Gy, Lens Dmax ≥10 Gy, and Lens Dmean ≥10 Gy.Patients aged 3–18 years received cranial irradiation or radiation therapy at head and neck area between January 2010 and December 2019 at our institute were included. Patients without baseline and/or follow‐up eye examination were excluded. Receiver operating characteristic (ROC) curves identified potential predictors and Cox regression analysed correlations between potential factors and cataract occurrence.Sixty‐three patients (122 eyes) were analysed. Cataracts were detected in 14 eyes (11.5%). Median follow‐up time was 4 years (range 0.5–10 years), with cataract developing in a median of 2.5 years (range 0.3–7 years). Three patients (21.4%) developed grade ≥3 cataract. Lens Dmean ≥10 Gy was associated with cataract formation.Lens Dmean ≥10 Gy showed the highest ability for predicting radiation‐induced cataract in paediatric patients. Net reclassification improvement (NRI) suggested that changing lens dose constraint from Dmax <7 Gy to Dmean <10 Gy would miss 7% of cataract cases but avoid 28% of unnecessary restrictions. Adopting a mean lens dose <10 Gy was suggested as a constraint for lens dose. [ABSTRACT FROM AUTHOR]

This work aimed to characterize a dedicated phantom for assessing the dose near metal implants for radiotherapy with photons and protons. A dosimetry audit phantom was redesigned to position a Gafchromic EBT-3 film within a bisected titanium pedicle screw (6.5 mm diameter). The mass density and the water equivalent thickness (WET) of the phantom material were determined. The phantom was irradiated using a photon arc and a horizontal proton beam in combination with a couch rotation of 20°, with three repeated measurements each. Treatment plans utilizing a single field covering the screw and the EBT-3 film were optimized to deliver a physical dose of 2 Gy using a collapsed cone and Monte Carlo dose engine for photons and protons, respectively. The mass density and the WET of the phantom were determined as (1.033 ± 0.010) gcm-3 and (1.022 ± 0.013), respectively. Ionisation chamber measurements agreed within 1% (photons) and 0.5% (protons) with the calculated dose values. Relative photon dosimetry measurements using EBT-3 films revealed an agreement between measured and calculated horizontal profiles within the confidence interval for areas beyond 5 mm from the center. For photon plans, significant deviations of more than 10% were found at the interfaces between phantom material and screw. The proton measurements showed a gradual decrease of 3% across both profiles. In contrast to photon plans, no dose increase was measured within the screw, but significant dose fluctuations (>5%) in the beam's exit region. This study showed that the behavior of dose engine is affected by metal implants and thus dosimetric measurements are highly recommended. The presented phantom can serve as foundation for dedicated end-2-end phantoms. [ABSTRACT FROM AUTHOR]

A 71-year-old male with type 2 diabetes and hypertension was diagnosed with carcinoma of the pyriform fossa in 2019. The biopsy was reported as a moderately differentiated squamous cell carcinoma, and positron emission tomography-computed tomography (PET-CT) scan showed an fluorodeoxyglucose (FDG)-avid lesion in the pyriform fossa and the aryepiglottic fold with few nodes in level II and level III. The paitent was treated with radical chemoradiotherapy. A follow-up PET-CT scan done in 2022 revealed an FDG-avid soft tissue thickening in the left palatine tonsillar region and an uptake in the thyroid that was reported as not significant. A punch biopsy from the tonsillar fossa lesion revealed squamous cell carcinoma. The lesion was treated as a second primary and treated with radiotherapy with curative intent. The patient was complaining of dysphagia, difficulty in breathing, and weight loss around 6 months after treatment that were addressed medically. There was a significant reduction in size and FDG activity of the ill-defined thickening in the left tonsillar region which was seen in the response-assessment PET done 6 months after RT. A heterogeneously enhancing nodules were seen in both lobes of the thyroid in which the largest one measured 3.5 × 3.1 cm seen in the right lobe. The patient underwent a biopsy from the thyroid that revealed a benign thyroid gland infiltrated by clusters and nests of poorly differentiated malignant cells. The histomorphology was suggestive of a poorly differentiated carcinoma, likely anaplastic carcinoma thyroid, or metastasis of the squamous cell carcinoma. Curative treatment was ruled out in this case due to his comorbidities, pulmonary symptoms, and radiation delivered to the neck. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the perceptions of the coronavirus disease 2019 (COVID-19) initiated workplace strategies implemented in radiation oncology departments across Australia. Methods: A multidisciplinary team from Princess Alexandra Hospital developed a survey to address the impact of the pandemic strategies on areas such as patient care, staff education, well-being, flexible working arrangements, and research. The survey was conducted from November 2020 to April 2021. Results: Out of 210 respondents from seven institutions, 45% reported burnout and 57% experienced work work-related stress. A significant majority of respondents were in favour of continued remote work (86%, 131/153). Radiation oncologists identified administrative or non-clinical work (92%, 34/37), telehealth clinics (32%, 12/37), or radiation therapy planning (22%, 8/37) as suitable for remote work. Additionally, 54% (21/39) of the radiation oncologists plan to use telehealth more frequently, with 67% (26/39) feeling more confident with the technology. The majority (81%, 171/210) of participants favoured continuation of hybrid in-person and virtual meetings. Virtual solutions were adopted for quality assurance activities (72%, 118/165) and 52% (60/116) indicated preference for ongoing utility of virtual platforms. However, 38% (79/210) of the respondents expressed concerns about the negative impact on junior staff training. Conclusion: These findings reveal a strong inclination towards technological advancements and remote work arrangements to enable flexible working conditions. Our study suggests the need for ongoing reforms, focusing on improving clinical service delivery efficiencies and enhancing job satisfaction among clinicians. What is known about the topic? During the coronavirus disease 2019 (COVID-19) pandemic there were significant adaptations required to the delivery of clinical care. What does this paper add? There is a strong preference for ongoing work from home arrangements, especially for administrative and non-clinical work. Most radiation oncologists feel more confident using telehealth and favour its ongoing use post-pandemic. Burnout and stress remain prevalent within the workforce. What are the implications for practitioners? There is a high demand among the radiation oncology workforce for adoption of technological advances to improve work satisfaction including remote access to enable flexible work arrangements. [ABSTRACT FROM AUTHOR]

The article explores AI and ML's transformative potential in reshaping the radiation therapy landscape. The article navigates through the evolving field of radiation oncology, highlighting the constant influx of information facilitated by advanced imaging techniques. The technical scrutiny of AI's potential within radiation oncology is explored, contrasting definitions by Russell and Norvig with Goel's more insightful perspective. A detailed overview of the radiation therapy process, from diagnosis to follow-up, sets the stage for discussing the role of AI and ML. The utilities of AI in radiation oncology are dissected, emphasizing the reduction of clinical load through decision support systems, streamlined treatment planning, and the automated enhancement of radiation therapy. The article showcases various AI algorithms deployed in the workflow, their applications, and the promising results they offer. While acknowledging the challenges, including the opaque nature of AI and the critical need for clinical adoption, the article outlines criteria for evaluating AI tools in clinical settings. It stresses the importance of trust-building, transparency and overcoming challenges to harness AI's full potential in radiation oncology. In conclusion, the article advocates for a proactive integration of AI and ML, envisioning a future where these technologies empower radiation oncologists to enhance patient care, optimize workflows, and advance the field. [ABSTRACT FROM AUTHOR]

Radiomics is a promising tool for the development of quantitative biomarkers to support clinical decision-making. It has been shown to improve the prediction of response to treatment and outcome in different settings, particularly in the field of radiation oncology by optimising the dose delivery solutions and reducing the rate of radiation-induced side effects, leading to a fully personalised approach. Despite the promising results offered by radiomics at each of these stages, standardised methodologies, reproducibility and interpretability of results are still lacking, limiting the potential clinical impact of these tools. In this review, we briefly describe the principles of radiomics and the most relevant applications of radiomics at each stage of cancer management in the framework of radiation oncology. Furthermore, the integration of radiomics into clinical decision support systems is analysed, defining the challenges and offering possible solutions for translating radiomics into a clinically applicable tool. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion Cranio‐spinal radiotherapy (CSI) is used to treat central nervous system malignancies in paediatric, adolescent/young adult (AYA), and adult patients. Its delivery in the paediatric/AYA population is particularly challenging across different age groups. This study aims to assess the setup variations and dosimetric impact of CSI in paediatric and AYA patients.This retrospective analysis included, 10 paediatric and AYA patients (aged 4–25) who underwent volumetric modulated arc therapy (VMAT) CSI between 2016 and 2022. Patient characteristics, diagnoses, prescribed CSI doses, and fractionation details were assessed. CT simulation and treatment planning followed standard protocols with setup errors were quantified by comparing daily treatment setup images with the planned position. The study evaluated the dosimetric impact on target volumes and organs at risk (OARs).The setup errors were identified, ranging from 0.5 to 6.2 mm in different directions, especially in the cranio‐caudal direction. Despite these variations, there was minimal impact observed on the coverage of clinical target volumes (CTV) and doses to OARs (<1% relative change).Ensuring precise setup in paediatric and AYA patients undergoing CSI is essential to maintain adequate CTV coverage. Although occasional substantial setup variations occurred during treatment, they had a limited impact on CTV coverage and OAR doses when infrequent. Appropriate planning target volume (PTV) margins can effectively compensate for occasional shifts. However, systematic errors could compromise treatment quality if undetected. Regular off‐line review of patient set‐up trends is recommended. [ABSTRACT FROM AUTHOR]

Cardiac risk mitigation is a major priority in improving outcomes for cancer survivors as advances in cancer screening and treatments continue to decrease cancer mortality. More than half of adult cancer patients will be treated with radiotherapy (RT); therefore it is crucial to develop a framework for how to assess and predict radiation‐induced cardiac disease (RICD). Historically, RICD was modelled solely using whole heart metrics such as mean heart dose. However, data over the past decade has identified cardiac substructures which outperform whole heart metrics in predicting for significant cardiac events. Additionally, non‐RT factors such as pre‐existing cardiovascular risk factors and toxicity from other therapies contribute to risk of future cardiac events. In this review, we aim to discuss the current evidence and knowledge gaps in predicting RICD and provide a roadmap for the development of comprehensive models based on three interrelated components, (1) baseline CV risk assessment, (2) cardiac substructure radiation dosimetry linked with cardiac‐specific outcomes and (3) novel biomarker development. [ABSTRACT FROM AUTHOR]

Background: Cystic, sporadic hemangioblastomas (HBLs) represent a unique, therapeutically challenging subset of central nervous system tumors, mainly due to their unpredictable growth patterns and potential for symptomatic progression. This study aims to explore the complexities surrounding the diagnosis, treatment, and long-term management of these lesions. Methods: A comprehensive literature review was performed, and a detailed case study of a 56-year-old patient with a cystic, sporadic cerebellar HBL was produced. Results: The case highlights the multiphasic growth pattern typical of cystic, sporadic HBLs, characterized by periods of dormancy and subsequent rapid expansion. An initial surgical intervention offered temporary control. Tumor recurrence, mainly through cystic enlargement, was treated by SRS. A subsequent recurrence, again caused by cystic growth, eventually led to the patient's death. The intricacies of treatment modalities, focusing on the transition from surgical resection to stereotactic radiosurgery (SRS) upon recurrence, are discussed. Parameters indicating impending tumor growth, coupled with symptomatic advances, are also explored. Conclusions: The management of cystic, sporadic cerebellar HBLs requires a strategic approach that can be informed by radiological characteristics and tumoral behavior. This study underscores the importance of a proactive, individualized management plan and suggests guidelines that could inform clinical decision making. [ABSTRACT FROM AUTHOR]

Nurses have a minimal introduction to the oncology specialty, and their exposure to radiation therapy is further limited to a superficial understanding of the patient experience. Radiation is a primary mode of oncologic treatment; thus, a comprehensive cancer center developed a 13-week training program to enhance education and clinical skills for nurses transitioning to the radiation subspecialty. Nursing retention rates were analyzed at 3, 6, 12, 18, and 24 months. Two-year postanalysis results show a 92.3% retention rate. With the cost of onboarding a single registered nurse (RN) ranging from $52,100 to $52,350, nursing leadership must develop innovative, evidence-based methods to support RN transition to practice. [ABSTRACT FROM AUTHOR]

The objective of this study was to develop a two-year overall survival model for inoperable stage I-III non–small cell lung cancer (NSCLC) patients using routine radiation oncology data over a federated (distributed) learning network and evaluate the potential of decision support for curative versus palliative radiotherapy. A federated infrastructure of data extraction, de-identification, standardisation, image analysis, and modelling was installed for seven clinics to obtain clinical and imaging features and survival information for patients treated in 2011–2019. A logistic regression model was trained for the 2011–2016 curative patient cohort and validated for the 2017–2019 cohort. Features were selected with univariate and model-based analysis and optimised using bootstrapping. System performance was assessed by the receiver operating characteristic (ROC) and corresponding area under curve (AUC), C-index, calibration metrics and Kaplan–Meier survival curves, with risk groups defined by model probability quartiles. Decision support was evaluated using a case-control analysis using propensity matching between treatment groups. 1655 patient datasets were included. The overall model AUC was 0.68. Fifty-eight percent of patients treated with palliative radiotherapy had a low-to-moderate risk prediction according to the model, with survival times not significantly different (p = 0.87 and 0.061) from patients treated with curative radiotherapy classified as high-risk by the model. When survival was simulated by risk group and model-indicated treatment, there was an estimated 11% increase in survival rate at two years (p < 0.01). Federated learning over multiple institution data can be used to develop and validate decision support systems for lung cancer while quantifying the potential impact of their use in practice. This paves the way for personalised medicine, where decisions can be based more closely on individual patient details from routine care. • Survival model for inoperable stage I-III nonsmall cell lung cancer. • Federated learning connects seven radiation oncology institutes. • Case-control propensity matched decision support simulation indicates a potential 11% increase in overall survival. [ABSTRACT FROM AUTHOR]

To determine medical students' views of various aspects of a career in radiation oncology (RO) to identify areas that may benefit from reform and to guide initiatives to stimulate broader and more diverse student interest in the specialty. An electronic survey was sent to student oncology interest group members at seven US medical schools. The survey asked students to rate 19 aspects of RO on a 5-point bipolar Likert-type scale. Descriptive statistics are reported, along with subgroup analyses based on participants' demographics. The response rate was 51.1% (n = 275 of 538). The most favorably rated aspects of RO were outpatient working hours (mean ± SD Likert-type rating of 4.51 ± 0.82), routinely working with other physicians (4.45 ± 0.76), and use of advanced technology to treat patients. The most unfavorably rated aspects of RO were less geographic flexibility for residency or employment (1.98 ± 1.04), spending a lot of time on a computer doing treatment planning (2.80 ± 1.21), and having a job that is not well understood by most doctors and the general public (2.89 ± 1.02). Gender was associated with significant differences in 8 of 19 questions in how each aspect of RO was viewed. Few differences were observed based on race or ethnicity, though Asian participants had a significantly more favorable view of RO being a more science-oriented specialty compared with White or underrepresented students, respectively (3.50 versus 3.21 versus 2.84, P =.01). These findings inform the RO community in the development of more effective initiatives to encourage students to fully explore the specialty. [Display omitted] [ABSTRACT FROM AUTHOR]

Since 2017, the specialty of radiation oncology has experienced its fifth consecutive year of decline in residency applicants, resulting in a high number of unmatched positions. The cause of this precipitous decline is multifactorial. Factors cited include concerns about future job opportunities, the decreased pass rate in the ABR radiation biology and physics boards examinations in 2018, and the continued lack of formal exposure to radiation oncology during medical school training. We summarize the issues facing the field of radiation oncology and discuss how we could learn from similar experiences in diagnostic radiology and other specialties to address these concerns. We propose potential solutions to ensure an adequate and diverse number of residency applicants to serve the future workforce needs in radiation oncology. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: For breast cancer with advanced regional lymph node involvement, axillary lymph node dissection (ALND) remains the standard of care for staging and treating the axilla despite the presence of undissected lymph nodes. The benefit of ALND in this setting is unknown. Objectives: We sought to describe national patterns of care of axillary surgery and its association with overall survival (OS) among women with cN2b–N3c breast cancer who receive adjuvant radiotherapy. Patients and Methods: We identified female patients with cN2b–N3c breast cancer from 2012 to 2017 from the National Cancer Database. Clinical and demographic information were analyzed using Wilcoxon rank sum and χ2 tests. Predictors of receipt of ALND and predictors of death were identified with multivariable logistic regression modeling. Inverse probability of treatment weighting was implemented to adjust for differences in treatment cohorts. The Kaplan–Meier method was used to evaluate OS. Results: We identified 7167 patients. Of these, 922 (13%) received SLNB and 6254 (87%) received ALND; 7% were cN2b, 19% cN3a, 24% cN3b, 19% cN3c, and 31% cN3, not otherwise specified. Predictors of receipt of ALND were age 50–69 years [odds ratio (OR) 1.3, p < 0.01], cN3a (OR 7.6, p < 0.01), cN3b (OR 2.8, p < 0.01), and cN3c (OR 4.2, p < 0.01). Predictors of death included cN3c (OR 1.9, p < 0.01), age 70–90 years (OR 1.5, p = 0.01), and positive surgical margins (OR 1.5, p < 0.01). After cohort balancing, ALND was not associated with improved OS when compared with SLNB (HR 0.99, p = 0.91). Conclusions: ALND in patients with advanced nodal disease was not associated with improved survival compared with SLNB for women who receive adjuvant radiotherapy. [ABSTRACT FROM AUTHOR]

Background The role of tyrosine kinase inhibitors (TKIs) in early-stage and metastatic oncogene-driven non–small cell lung cancer (NSCLC) is established, but it remains unknown how best to integrate TKIs with concurrent chemoradiotherapy (cCRT) in locally advanced disease. The phase 2 ASCENT trial assessed the efficacy and safety of afatinib and cCRT with or without surgery in locally advanced epidermal growth factor receptor (EGFR)-mutant NSCLC. Patients and Methods Adults ≥18 years with histologically confirmed stage III (AJCC 7th edition) NSCLC with activating EGFR mutations were enrolled at Mass General and Dana-Farber/Brigham Cancer Centers, Boston, Massachusetts. Patients received induction afatinib 40 mg daily for 2 months, then cisplatin 75 mg/m2 and pemetrexed 500 mg/m2 IV every 3 weeks during RT (definitive or neoadjuvant dosing). Patients with resectable disease underwent surgery. All patients were offered consolidation afatinib for 2 years. The primary endpoint was the objective response rate (ORR) to induction TKI. Secondary endpoints were safety, conversion to operability, progression-free survival (PFS), and overall survival (OS). Analyses were performed on the intention-to-treat population. Results Nineteen patients (median age 56 years; 74% female) were enrolled. ORR to induction afatinib was 63%. Seventeen patients received cCRT; 2/9 previously unresectable became resectable. Ten underwent surgery; 6 had a major or complete pathological response. Thirteen received consolidation afatinib. With a median follow-up of 5.0 years, median PFS and OS were 2.6 (95% CI, 1.4-3.1) and 5.8 years (2.9-NR), respectively. Sixteen recurred or died; 6 recurrences were isolated to CNS. The median time to progression after stopping consolidation TKI was 2.9 months (95% CI, 1.1-7.2). Four developed grade 2 pneumonitis. There were no treatment-related deaths. Conclusion We explored the efficacy of combining TKI with cCRT in oncogene-driven NSCLC. Induction TKI did not compromise subsequent receipt of multimodality therapy. PFS was promising, but the prevalence of CNS-only recurrences and rapid progression after TKI discontinuation speak to unmet needs in measuring and eradicating micrometastatic disease. [ABSTRACT FROM AUTHOR]

BackgroundResistance to existing therapies is a significant challenge in improving outcomes for glioblastoma (GBM) patients. Metabolic plasticity has emerged as an important contributor to therapy resistance, including radiation therapy (RT). Here, we investigated how GBM cells reprogram their glucose metabolism in response to RT to promote radiation resistance.MethodsEffects of radiation on glucose metabolism of human GBM specimens were examined in vitro and in vivo with the use of metabolic and enzymatic assays, targeted metabolomics, and FDG-PET. Radiosensitization potential of interfering with M2 isoform of pyruvate kinase (PKM2) activity was tested via gliomasphere formation assays and in vivo human GBM models.ResultsHere, we show that RT induces increased glucose utilization by GBM cells, and this is accompanied with translocation of GLUT3 transporters to the cell membrane. Irradiated GBM cells route glucose carbons through the pentose phosphate pathway (PPP) to harness the antioxidant power of the PPP and support survival after radiation. This response is regulated in part by the PKM2. Activators of PKM2 can antagonize the radiation-induced rewiring of glucose metabolism and radiosensitize GBM cells in vitro and in vivo.ConclusionsThese findings open the possibility that interventions designed to target cancer-specific regulators of metabolic plasticity, such as PKM2, rather than specific metabolic pathways, have the potential to improve the radiotherapeutic outcomes in GBM patients.

Background: Cystic, sporadic hemangioblastomas (HBLs) represent a unique, therapeutically challenging subset of central nervous system tumors, mainly due to their unpredictable growth patterns and potential for symptomatic progression. This study aims to explore the complexities surrounding the diagnosis, treatment, and long-term management of these lesions. Methods: A comprehensive literature review was performed, and a detailed case study of a 56-year-old patient with a cystic, sporadic cerebellar HBL was produced. Results: The case highlights the multiphasic growth pattern typical of cystic, sporadic HBLs, characterized by periods of dormancy and subsequent rapid expansion. An initial surgical intervention offered temporary control. Tumor recurrence, mainly through cystic enlargement, was treated by SRS. A subsequent recurrence, again caused by cystic growth, eventually led to the patient’s death. The intricacies of treatment modalities, focusing on the transition from surgical resection to stereotactic radiosurgery (SRS) upon recurrence, are discussed. Parameters indicating impending tumor growth, coupled with symptomatic advances, are also explored. Conclusions: The management of cystic, sporadic cerebellar HBLs requires a strategic approach that can be informed by radiological characteristics and tumoral behavior. This study underscores the importance of a proactive, individualized management plan and suggests guidelines that could inform clinical decision making.

Technological advances in MRI-guided radiation therapy (MRIgRT) have improved real-time visualization of the prostate and its surrounding structures over CT-guided radiation therapy. Seminal studies have demonstrated safe dose escalation achieved through ultrahypofractionation with MRIgRT due to planning target volume (PTV) margin reduction and treatment gating. On-table adaptation with MRI-based technologies can also incorporate real-time changes in target shape and volume and can reduce high doses of radiation to sensitive surrounding structures that may move into the treatment field. Ongoing clinical trials seek to refine ultrahypofractionated radiotherapy treatments for prostate cancer using MRIgRT. Though these studies have the potential to demonstrate improved biochemical control and reduced side effects, limitations concerning patient treatment times and operational workflows may preclude wide adoption of this technology outside of centers of excellence. In this review, we discuss the advantages and limitations of MRIgRT for prostate cancer, as well as clinical trials testing the efficacy and toxicity of ultrafractionation in patients with localized or post-prostatectomy recurrent prostate cancer.

Objective. To propose a mathematical model for applying ionization detail (ID), the detailed spatial distribution of ionization along a particle track, to proton and ion beam radiotherapy treatment planning (RTP).Approach. Our model provides for selection of preferred ID parameters (Ip) for RTP, that associate closest to biological effects. Cluster dose is proposed to bridge the large gap between nanoscopicIpand macroscopic RTP. Selection ofIpis demonstrated using published cell survival measurements for protons through argon, comparing results for nineteenIp:Nk,k= 2, 3, …, 10, the number of ionizations in clusters ofkor more per particle, andFk,k= 1, 2, …, 10, the number of clusters ofkor more per particle. We then describe application of the model to ID-based RTP and propose a path to clinical translation.Main results. The preferredIpwereN4andF5for aerobic cells,N5andF7for hypoxic cells. Significant differences were found in cell survival for beams having the same LET or the preferredNk. Conversely, there was no significant difference forF5for aerobic cells andF7for hypoxic cells, regardless of ion beam atomic number or energy. Further, cells irradiated with the same cluster dose for theseIphad the same cell survival. Based on these preliminary results and other compelling results in nanodosimetry, it is reasonable to assert thatIpexist that are more closely associated with biological effects than current LET-based approaches and microdosimetric RBE-based models used in particle RTP. However, more biological variables such as cell line and cycle phase, as well as ion beam pulse structure and rate still need investigation.Significance. Our model provides a practical means to select preferredIpfrom radiobiological data, and to convertIpto the macroscopic cluster dose for particle RTP.

Near-infrared color centers in silicon are emerging candidates for on-chip integrated quantum emitters, optical-access quantum memories, and sensing. We access ensemble G-color-center formation dynamics and radiation-induced atomic disorder in silicon for a series of megaelectronvolt proton-flux conditions. The photoluminescence results reveal that the G centers are formed more efficiently by pulsed-proton irradiation than by continuous-wave proton irradiation. The enhanced transient excitations and dynamic annealing within nanoseconds allows optimization of the ratio of G-center formation to nonradiative defect accumulation. The G centers preserve narrow line widths of about 0.1 nm when they are generated by moderate pulsed-proton fluences, while the line width broadens significantly as the pulsed-proton fluence increases. This implies vacancy or interstitial clustering by overlapping collision cascades. The tracking of G-center properties for a series of irradiation conditions enables sensitive probing of atomic disorder, serving as a complementary analytical method for sensing damage accumulation. Aided by ab initio electronic structure calculations, we provide insight into the atomic disorder induced inhomogeneous broadening by introducing vacancies, silicon interstitials, and oriented strain fields in the vicinity of a G center. A vacancy leads to a tensile strain and can result in either a red shift or a blue shift of the G-center emission, depending on its position relative to the G center. Meanwhile, Si interstitials lead to compressive strain, which results in a monotonic red shift. High-flux and tunable ion pulses enable the exploration of the fundamental dynamics of radiation-induced defects as well as methods for the optimization of G-center formation and qubit synthesis for quantum information processing.

Abstract Purpose To address a gap in radiation oncology education in low- and middle-income countries (LMICs), we sought to evaluate the effectiveness and generalizability of a refined curriculum on intensity modulated radiotherapy (IMRT) offered to existing radiation therapy (RT) clinics across Africa and Latin America (LATAM) at no cost. Methods A curriculum was created based on prior needs assessments and adapted for participating medical physicists, radiation oncologists, radiation therapists, and trainees in LMICs. English-speaking and Spanish-speaking teams of volunteer educators delivered 27 hour-long sessions 1–2 times weekly for 4 months using video conferencing to African and LATAM cohorts, respectively. Pre- and post-course multiple-choice examinations were administered to LATAM participants, and pre- and post-course self-confidence (1–5 Likert-scale) and open-ended feedback were collected from all participants. Results Twenty-five centers across Africa (13) and LATAM (12) participated, yielding a total of 332 enrolled participants (128 African, 204 LATAM). Sessions were delivered with a mean of 44 (22.5) and 85 (25.4) participants in the African and LATAM programs, respectively. Paired pre and post-course data demonstrated significant (p

Hepatocellular carcinoma is one of the most common malignancies worldwide. However, brain metastases from this cancer are incredibly rare. While the hepatocellular carcinoma mortality rate in the United States has been increasing, hepatocellular carcinoma is rare among patients without underlying liver disease. Here we present a patient with a history of left optic nerve meningioma treated with stereotactic radiosurgery who presented with acute vision loss. Magnetic resonance imaging revealed an enhancing mass lesion in the region of the sella turcica. Neurosurgical histopathology revealed a metastatic lesion consistent with hepatocellular carcinoma. Systemic workup failed to identify a primary liver lesion.

Summary Increased survivorship, improvements in cancer treatments, and the potential for cardiac side effects from cancer treatments have resulted in increased collaboration between oncologists and cardiologists and the development of cardio‐oncology clinics. This collaboration is important given its role in ensuring greater patient satisfaction, aiding teams of clinicians in making complex treatment decision, and ensuring cardiac complications are diagnosed at an early stage. The particularities of implementing this collaboration in the field of radiation oncology and how this setting is different from other areas of cardio‐oncology have not been well detailed in the literature. This paper will discuss what is currently understood about the need for and role of cardio‐oncology and what a cardio‐oncology services involves, with a particular emphasis on patient and clinician needs in the field of radiation oncology. The literature and recent guidelines do advocate for a detailed baseline assessment of cancer patients undergoing radiotherapy, especially patients with treatment or patient risk factors that increase their risk of cancer‐therapy related cardiotoxicity. Advancements in cardiac imaging techniques will be discussed as these may help to diagnose cardiac side effects of certain cancer treatments, including radiotherapy, at an early stage. A multi‐disciplinary and collaborative approach is well received by patients and such an approach, guided by the aim of maintaining a patient's cancer treatment wherever possible, should be the cornerstone of cardio‐oncology clinics regardless of the patient's treatment regime. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusions Communication and collaboration are integral in radiation oncology practice. A recently published qualitative study identified several deficiencies in skills development for Australian/New Zealand trainees. We aim to validate these findings to guide curriculum development.A quantitative survey was developed through an iterative process, using themes identified in the previous qualitative investigation. This survey was distributed to radiation oncologists and trainees across Australia and New Zealand via email. Data collection and management utilised the REDCap system. Question types varied to maximise richness of data, including ranking, likert‐scales and free‐text questions. Results are primarily reported descriptively.Totally 35 participants submitted completed survey responses with broad representation across geography, gender and clinician seniority. To learn communication, participants reported strong preferences towards informal observation (60% agreement) and self‐reflection (49% agreement), and against online learning (77% disagreement) methodologies. Nearly 35% acknowledge poor communication at least weekly, with time pressure being a major barrier (63% agreement). Clinical uncertainty and existing patient/family assumptions (both 74% agreement) contribute to difficulties in breaking bad news, with online learning being the only negatively perceived training modality (23% agreement). No participants reported any formal training/mentoring in multi‐disciplinary team (MDT) engagement. Conflict was commonly witnessed/experienced (97%) and 26% of participants avoid MDTs due to difficulties experienced.This study validates the themes previously identified. We identified a strong preference for informal learning methodologies and against online modules, discordant to published literature. Effective collaboration within MDTs is identified as a particular area of need. We recommend future curriculum modification considers these results to maximise efficacy. [ABSTRACT FROM AUTHOR]

Background: The use of Computed Tomography (CT) imaging data to create 3D printable patient‐specific devices for radiation oncology purposes is already well established in the literature and has shown to have superior conformity than conventional methods. Using non‐ionizing radiation imaging techniques such as photogrammetry or laser scanners in‐lieu of a CT scanner presents many desirable benefits including reduced imaging dose and fabrication of the device can be completed prior to simulation. With recent advancements in smartphone‐based technology, photographic and LiDAR‐based technologies are more readily available than ever before and to a high level of quality. As a result, these non‐ionizing radiation imaging methods are now able to generate patient‐specific devices that can be acceptable for clinical use. Purpose: In this work, we aim to determine if smartphones can be used by radiation oncologists or other radiation oncology staff to generate bolus or brachytherapy surface moulds instead of conventional CT with equivalent or comparable accuracy. Methods: This work involved two separate studies: a phantom and participant study. For the phantom study, a RANDO anthropomorphic phantom (limited to the nose region) was used to generate 3D models based on three different imaging techniques: conventional CT, photogrammetry & LiDAR which were both acquired on a smartphone. Virtual boli were designed in Blender and 3D printed from PLA plastic material. The conformity of each printed boli was assessed by measuring the air gap volume and approximate thickness between the phantom & bolus acquired together on a CT. For the participant study, photographs, and a LiDAR scan of four volunteers were captured using an iPhone 13 Pro™ to assess their feasibility for generating human models. Each virtual 3D model was visually assessed to identify any issues in their reconstruction. The LiDAR models were registered to the photogrammetry models where a distance to agreement analysis was performed to assess their level of similarity. Additionally, a 3D virtual bolus was designed and printed using ABS material from all models to assess their conformity onto the participants skin surface using a verbal feedback method. Results: The photogrammetry derived bolus showed comparable conformity to the CT derived bolus while the LiDAR derived bolus showed poorer conformity as shown by their respective air gap volume and thickness measurements. The reconstruction quality of both the photogrammetry and LiDAR models of the volunteers was inadequate in regions of facial hair and occlusion, which may lead to clinically unacceptable patient‐specific device that are created from these areas. All participants found the photogrammetry 3D printed bolus to conform to their nose region with minimal room to move while three of the four participants found the LiDAR was acceptable and could be positioned comfortably over their entire nose. Conclusions: Smartphone‐based photogrammetry and LiDAR software show great potential for future use in generating 3D reference models for radiation oncology purposes. Further investigations into whether they can be used to fabricate clinically acceptable patient‐specific devices on a larger and more diverse cohort of participants and anatomical locations is required for a thorough validation of their clinical usefulness. [ABSTRACT FROM AUTHOR]

Commercial vendors have created artificial intelligence (AI) tools for use in all aspects of life and medicine, including radiation oncology. AI innovations will likely disrupt workflows in the field of radiation oncology. However, limited data exist on using AI-based chatbots about the quality of radiation oncology information. This study aims to assess the accuracy of ChatGPT, an AI-based chatbot, in answering patients' questions during their first visit to the radiation oncology outpatient department and test knowledge of ChatGPT in radiation oncology. Expert opinion was formulated using a set of ten standard questions of patients encountered in outpatient department practice. A blinded expert opinion was taken for the ten questions on common queries of patients in outpatient department visits, and the same questions were evaluated on ChatGPT version 3.5 (ChatGPT 3.5). The answers by expert and ChatGPT were independently evaluated for accuracy by three scientific reviewers. Additionally, a comparison was made for the extent of similarity of answers between ChatGPT and experts by a response scoring for each answer. Word count and Flesch-Kincaid readability score and grade were done for the responses obtained from expert and ChatGPT. A comparison of the answers of ChatGPT and expert was done with a Likert scale. As a second component of the study, we tested the technical knowledge of ChatGPT. Ten multiple choice questions were framed with increasing order of difficulty – basic, intermediate and advanced, and the responses were evaluated on ChatGPT. Statistical testing was done using SPSS version 27. After expert review, the accuracy of expert opinion was 100%, and ChatGPT's was 80% (8/10) for regular questions encountered in outpatient department visits. A noticeable difference was observed in word count and readability of answers from expert opinion or ChatGPT. Of the ten multiple-choice questions for assessment of radiation oncology database, ChatGPT had an accuracy rate of 90% (9 out of 10). One answer to a basic-level question was incorrect, whereas all answers to intermediate and difficult-level questions were correct. ChatGPT provides reasonably accurate information about routine questions encountered in the first outpatient department visit of the patient and also demonstrated a sound knowledge of the subject. The result of our study can inform the future development of educational tools in radiation oncology and may have implications in other medical fields. This is the first study that provides essential insight into the potentially positive capabilities of two components of ChatGPT: firstly, ChatGPT's response to common queries of patients at OPD visits, and secondly, the assessment of the radiation oncology knowledge base of ChatGPT. [ABSTRACT FROM AUTHOR]

Simple Summary: Patients undergoing radiation therapy can experience stress because of the fear of treatment. Stress can reduce the accuracy of the patient setup. In this study, we used biological signals to identify the stress response and artificial intelligence to predict this response during radiation therapy. Stress was calculated by analyzing biological signals measured before and during radiation therapy. We used various artificial intelligence models to verify those that were optimized for stress prediction. Our findings indicate that over 90% of patients experience stress during treatment and artificial intelligence can predict this stress with over 80% accuracy. And we validated the impact of stress on respiratory irregularity. This study is pivotal for identifying patients requiring stress reduction before treatment, potentially enhancing the precision of cancer radiation therapy. This study aimed to predict stress in patients using artificial intelligence (AI) from biological signals and verify the effect of stress on respiratory irregularity. We measured 123 cases in 41 patients and calculated stress scores with seven stress-related features derived from heart-rate variability. The distribution and trends of stress scores across the treatment period were analyzed. Before-treatment information was used to predict the stress features during treatment. AI models included both non-pretrained (decision tree, random forest, support vector machine, long short-term memory (LSTM), and transformer) and pretrained (ChatGPT) models. Performance was evaluated using 10-fold cross-validation, exact match ratio, accuracy, recall, precision, and F1 score. Respiratory irregularities were calculated in phase and amplitude and analyzed for correlation with stress score. Over 90% of the patients experienced stress during radiation therapy. LSTM and prompt engineering GPT4.0 had the highest accuracy (feature classification, LSTM: 0.703, GPT4.0: 0.659; stress classification, LSTM: 0.846, GPT4.0: 0.769). A 10% increase in stress score was associated with a 0.286 higher phase irregularity (p < 0.025). Our research pioneers the use of AI and biological signals for stress prediction in patients undergoing radiation therapy, potentially identifying those needing psychological support and suggesting methods to improve radiotherapy effectiveness through stress management. [ABSTRACT FROM AUTHOR]

Advances in radiotherapy (RT) technologies permit significant decreases in the dose delivered to organs at risk (OARs) for patients with esophageal cancer (EC). Novel RT modalities such as proton beam therapy (PBT) and magnetic resonance-guided radiotherapy (MRgRT), as well as motion management techniques including breath hold (BH) are expected to further improve the therapeutic ratio. However, to our knowledge, the dosimetric benefits of PBT vs MRgRT vs volumetric-modulated arc therapy (VMAT) have not been directly compared for EC. We performed a retrospective in silico evaluation using the images and datasets of nine distal EC patients who were treated at our institution with a 0.35-Tesla MR linac to 50.4 Gy in 28 fractions in mid-inspiration BH (BH-MRgRT). Comparison free-breathing (FB) intensity-modulated PBT (FB-IMPT) and FB-VMAT plans were retrospectively created using the same prescription dose, target volume coverage goals, and OAR constraints. A 5 mm setup margin was used for all plans. BH-IMPT and BH-VMAT plans were not evaluated as they would not reflect our institutional practice. Planners were blinded to the results of the treatment plans created using different radiation modalities. The primary objective was to compare plan quality, target volume coverage, and OAR doses. All treatment plans met pre-defined target volume coverage and OAR constraints. The median conformity and homogeneity indices between FB-IMPT, BH-MRgRT and FB-VMAT were 1.13, 1.25, and 1.43 (PITV) and 1.04, 1.15, 1.04 (HI), respectively. For FB-IMPT, BH-MRgRT and FB-VMAT the median heart dose metrics were 52.8, 79.3, 146.8 (V 30Gy, cc), 35.5, 43.8, 77.5 (V 40Gy, cc), 16.9, 16.9, 32.5 (V 50Gy, cc) and 6.5, 14.9, 17.3 (mean, Gy), respectively. Lung dose metrics were 8.6, 7.9, 18.5 (V 20Gy , %), and 4.3, 6.3, 11.2 (mean, Gy), respectively. The mean liver dose (Gy) was 6.5, 19.6, 22.2 respectively. Both FB-IMPT and BH-MRgRT achieve substantial reductions in heart, lung, and liver dose compared to FB-VMAT. We plan to evaluate dosimetric outcomes across these RT modalities assuming consistent use of BH. [ABSTRACT FROM AUTHOR]

Introduction: The main mission of the Australian and New Zealand Children's Haematology and Oncology Group (ANZCHOG) is to develop and facilitate local access to the world's leading evidence‐based clinical trials for all paediatric cancers, including brain tumours, as soon as practically possible. Diffuse intrinsic pontine gliomas (DIPGs) — a subset of a larger group of tumours now termed diffuse midline glioma, H3K27‐altered (DMG) — are paediatric brain cancers with less than 10% survival at two years. In the absence of any proven curative therapies, significant recent advancements have been made in pre‐clinical and clinical research, leading many to seek integration of novel therapies early into standard practice. Despite these innovative therapeutic approaches, DIPG remains an incurable disease for which novel surgical, imaging, diagnostic, radiation and systemic therapy approaches are needed. Main recommendations: All patients with DIPG should be discussed in multidisciplinary neuro‐oncology meetings (including pathologists, neuroradiologists, radiation oncologists, neurosurgeons, medical oncologists) at diagnosis and at relapse or progression.Radiation therapy to the involved field remains the local and international standard of care treatment.Proton therapy does not yield a superior survival outcome compared with photon therapy and patients should undergo radiation therapy with the available modality (photon or proton) at their treatment centre.Patients may receive concurrent chemotherapy or radiation‐sensitising agents as part of a clinical trial.Biopsy should be offered to facilitate consideration of experimental therapies and eligibility for clinical trial participation.After radiation therapy, each patient should be managed individually with either observation or considered for enrolment on a clinical trial, if eligible, after full discussion with the family.Re‐irradiation can be considered for progressive disease. Changes in management as a result of the guideline: Every child diagnosed with DIPG should be offered enrolment on a clinical trial where available. Access to investigational drugs without biological rationale outside the clinical trial setting is not supported. In case of potentially actionable target identification with molecular profiling and absence of a suitable clinical trial, rational targeted therapies can be considered through compassionate access programs. [ABSTRACT FROM AUTHOR]