1

Nathan Jones
April 7, 2019
DOS 711 – Research Methodology I
Identifying Future Research Projects and Literature Gaps Exercise

Article 1 – Offline adaptive radiation therapy in the treatment of prostate cancer: a case
study1

The first article I reviewed dealt with managing the care of patients with prostate cancer.
This retrospective case study examined the daily dose distributions to targets and organs at risk
(OARs) due to setup variation and daily change in OAR geometry. The study utilized MIM
software to analyze single fraction doses received by targets and OARs based on daily CBCT
imaging. The aim of this study was to use this adaptive planning to help determine how the
planned dose for the entire initial phase of treatment differed from the actual delivered dose to
targets and critical structures. This study also sought to evaluate the efficiency of using adaptive
offline plan evaluation software to benefit patients in clinical scenarios. The data collected was
used for dosimetric research evaluation and was not evaluated by physicians.

The gap in this study is found in the absence of physician evaluation of the data
collection. Further research should be conducted to evaluate these findings with the input of the
physician. The purpose of continuing research is to determine with the aid of a physician
whether the differences in planned versus actual doses are clinically significant. Physicians input
could then be given to evaluate whether special considerations should be made in boost planning
in terms of dose escalation of the target or scaling back in order to constrain dose to OARs
overdosed in the initial phase.

Article 2 – Correlating the depth of compensation to the 3-D shape of the breast to achieve
homogenous dose distribution using the electronic tissue compensation treatment
technique2

This article aimed to correlate the overall 3-dimensional (3-D) shape of patient breast
tissue to the depth needed to compensate for the irregular surface slope.2 This study gathered
data from different breast sizes. It examined the relation of the separation to the radius from the
separation midpoint to the apex of the breast and how these values corresponded to transmission
penetration depths (TPDs). This study sought to use this data to identify optimum TPDs for
 2

breasts in a particular size range. The data was recorded in 3 axial segments along each breast
using semioval water phantoms.

The gap in this study is that patient breast tissue is also irregular from the superior to
inferior aspect. Further study could be conducted to evaluate the shape of breast tissue on
several or all available axial plains in order to develop data for future software implementation.
An inherent treatment planning software (TPS) module could then be developed to model this
information per case and determine a more accurate TPD to deliver an optimal dose distribution,
further aiding in planning using tangential electronic compensation technique.

Electron postmastectomy chest wall plus comprehensive nodal irradiation technique using
Electron Monte Carlo algorithm3

This study evaluated the clinical benefit of using multi energy electron fields combined
with supraclavicular photon fields in treating patients in need of post mastectomy chest wall
irradiation. The study compared target coverage and critical organ sparing using combinations
of 6MeV/9MeV/12MeV matched electron fields with a combined nodal photon component
versus traditional wide tangent photon fields. The study observed lower dose to critical OARs,
namely heart and lung while maintaining acceptable target coverage using a matched enface
electron technique.

This study only compares this matched electron technique to a traditional wide tangent
planning approach. For future study, this electron technique should be compared to newer
treatment techniques such as static intensity modulated radiation therapy (IMRT), volumetric
modulated arc therapy (VMAT), hybrid planning techniques using static and VMAT
optimization as well as proton therapy techniques. It would also be reasonable to study the
effects of combining these newer planning techniques with deep inspiration breath hold (DIBH)
in comparison to the matched electron field technique.

Cumulative dose radiation therapy of hepatocellular carcinoma patients and its

deterministic relation to radiation induced liver disease4

The study presented in this article focused on identifying the relationship between
radiation-induced liver disease (RILD) and the dose received throughout the course of a
 3

conventional fractionation radiation treatment. Pretreatment cone-beam computed tomography

(CBCT) images were used to calculate the actual daily dose received to the liver due to daily
variations in setup and patient anatomy. The CBCT images were retrofitted with the Hounsfield
units of the fan-beam computed tomography (FBCT) in order to calculate accurately due to the
difference in electron density scale between the two images. The study showed that there is a
significant difference in the mean dose to normal liver (MDTNL) between what was actually
planned and what is observed throughout treatment using adaptive planning. Among a sample
size of 23 patients, it was found that 21 patients (91%) showed higher than planned V20, V30,
V40 and mean liver doses and 6 of 7 patients with RILD showed an increase of >5% over the
MDTNL of 28 Gy.4

To elaborate on the findings of this study, data collection and clinical outcomes should be
repeated on a much larger sample size. The purpose of the study would be to statistically
confirm the validity of these findings in order to create a model to track MDTNL and predict the
risk of RILD during the course of treatment, and if necessary, adapt the patient planning
accordingly.

Radiation therapy of synchronous bilateral breast carcinoma (SBBC) using multiple

techniques5

The final article reviewed focused on comparing three dimensional conformal radiation
therapy (3DCRT), intensity modulated radiation therapy (IMRT) and VMAT techniques to treat
bilateral breast cancer. The 3DCRT plan consisted of multiple isocenters and was inferior in the
amount of high dose to OARs. IMRT was logistically improved over 3DCRT, utilizing a single
isocenter and consisting of twelve beams. Target coverage was greatly improved using IMRT
however OAR constraints when considering low dose values was inferior. VMAT was similar to
IMRT in comparison to 3DCRT and offered even less preferable results regarding dose to OARs.
Although more efficient in terms of treatment delivery, VMAT was not able to limit the low dose
to critical structures or cover the target as well as IMRT. IMRT was found to be the superior
planning method when treating synchronous bilateral breast cancer.

For future study, 3DCRT, IMRT and VMAT should also be compared to hybrid breast
planning techniques. Using a pair of static tangential fields complemented with partial VMAT
 4

arcs utilizing the same start and stop angles provides the benefits of low dose control found in
3DCRT while implementing the modulation necessary to sculpt dose to OARs while maximizing
target coverage. Using the same beginning and ending beam geometries would provide a quick
and efficient delivery, minimizing treatment time and stress on the patient. Utilizing this
technique bilaterally may offer a superior planning method when compared to 3DCRT, IMRT
and VMAT and should be further investigated.
 5

References

1. Nigay E, Bonsall H, Meyer B, Hunzeker A, Lenards N. Offline adaptive radiation therapy

in the treatment of prostate cancer: a case study. Med Dosim. 2019;44(1):1-6. https://doi-
org.libweb.uwlax.edu/10.1016/j.meddos.2017.12.005
2. Alghufaili A, Shanmugarajah L, Kumaraswamy L. Correlating the depth of compensation
to the 3-D shape of the breast to achieve homogenous dose distribution using the
electronic tissue compensation treatment technique. Med Dosim. 2019;44(1):30-34.
https://doi-org.libweb.uwlax.edu/10.1016/j.meddos.2018.01.001
3. Hong L, Ballangrud A, McCormick B, Mechalakos J. Electron postmastectomy chest
wall plus comprehensive nodal irradiation technique using Electron Monte Carlo
algorithm. Med Dosim. 2018;43(3):230-236. https://doi-
org.libweb.uwlax.edu/10.1016/j.meddos.2017.08.011
4. Huang P, Yu G, Knapp D, et al. Cumulative dose of radiation therapy of hepatocellular
carcinoma patients and its deterministic relation to radiation-induced liver disease. Med
Dosim. 2018;43(3):258-266. https://doi-
org.libweb.uwlax.edu/10.1016/j.meddos.2017.10.002
5. Kim SJ, Lee MJ, Youn SM. Radiation therapy of synchronous bilateral breast carcinoma
(SBBC) using multiple techniques. Med Dosim. 2018;43(1):55-68.
https://doi.org/10.1016/j.meddos.2017.08.003