Rodger Williams

April 9, 2018

Week 13: review of literature for future research to be done

Title: Comparing Critical Structure Dose: Prone vs Supine Breast Treatments

This article discusses three main components for breast treatments to see which technique, prone
or supine, offers the 1) lower V20 to the total lung volume, 2) lower hot spot for the breast and 3)
how the breast bridge correlates to the hot spot. The authors do a very good job of identifying the
three variables and how the hot spot relates to the dimension of the bridge.
The need for future research is clearly identified in the conclusion of the article.
The article indicates that further research is needed to review the treatment planning in the prone
and supine positions. If the only factor to change is the patient position, a comparison could
truly be made on the effects for patient positioning. Considerations for looking at the volume of
lung that could be spared or the amount of heart that could be eliminated from the field for left
sided patients could be two topics that could be further researched.

McKinnes, R. Collins, K. Comparing critical structures: prone vs supine breast treatments.

Radiat Therapist. 2011; 20(2): 103-107.

Title: The Role of 3-D Printing in Radiation Oncology: A Literature Review

This article gives a brief history of 3-D printing: when it was introduced and in what industry.
The article goes into the applications of how physics QA is performed in static phantoms where
we conform to the 3-dimentional object of a square phantom. They go on to discuss that more
accurate result if the phantom model could represent the model of the patient. Hence the onset of
the 3-D printing of the patient phantom. They discuss the use of 3-D printing in stereotactic
(cyberknife) and in bolus construction.
The need for further research is clearly stated in the abstract and the conclusion of the article.
Areas that could be explored could be the design and implementation of the construction of
bolus. Currently we either place bolus on during the simulation process and model the treatment
plan with the added bolus or have the treatment planning system add bolus to the surface of the
anatomy. The pitfall with this approach is that the bolus cannot be constructed exactly like the
computer of the treatment planning system can model the bolus. There are challenges to mimic
the thickness and especially the contour of the bolus to the anatomy.
Another topic that could be explored would be the 3-D printing of the anatomy to match the
densities of the CT data set. This would give an ‘exact’ model of the patient, but there would
have to be a cost analysis of the process to see if this is cost effective. With the reimbursements
that are received may not be sufficient to cover the expense of the process.

Ballard, S. Bartenhagen, L. The role of 3-D printing in radiation oncology: a literature review.
Radiat Therapist. 2018: 27(1): 10-19.
Title: The role of PET-CT in Radiation Therapy Planning

The article describes the planning process that the Radiation Oncologist and the Medical
Dosimetrist go through to develop a treatment plan. It is common to use the CT scan to delineate
the planning treatment volume (s) as well as the organs at risk. The article states that Magnetic
Resonance scanning is used to identify the soft tissues helpful in treatment planning, but goes on
to say that PET-CT has a valuable role in denoting tissues that have an uptake of the
radionuclide.
The article does not explicitly recommend further research, but it identifies the need to become
more proficient with the use of PET-CT and the benefits of its use. More work needs to be done
to make this a common practice within the Radiation Therapy department.
As with many of the principles that are implemented into the treatment planning process, the
utilization of PET imaging would need to have the variables of PET avid areas evaluated on the
same scale. One of the challenges faced by many dosimetrists is contouring metrics. A study of
how to standardize the contouring of a PET GTV may need to be established. This would allow
for a study to be validated in comparison to the volume of the PET avid area.

Church, J. The role of PET-CT in radiation therapy planning. Radiat Therapist. 2018: 27(1): 65-
67

Title: Surface Imaging in Radiation Therapy

The article goes into detail of the different disciplines and the different systems that are used in
medicine and radiotherapy respective. It describes the 6 motions that are monitored and how the
systems work. The article also states the common anatomic sites: breast, brain, chest and pelvis.
Pediatric monitoring can lead to minimizing the dose to this population of patients.
We recently introduced the OSMS (Optical Surface Monitoring System) by Varian in one of our
clinics within the network. I have not had an opportunity to work directly with this system, but
the staff states that they are in favor of the procedures. It utilizes a CT study set as the basis of
the imaging. When we get our TruBeam in the fall of 2018, I look forward to learning this new
technology.
In the conclusion of the article, the author states that further research on this topic assist on the
challenges and advantages of using this tool.
One of the biggest advantages for using this technique is the exposure reduction. I discussed
with our therapist the process we are doing and it is all done with a camera and light system. It
does not incorporate any exposure to obtain the positioning accuracy. Research on the amount of
exposure saving could be conducted to estimate the reduction in exposure while at the same time
utilizing a image guided technique for treatment position localization.

Chlebik, A. Surface imaging in radiation therapy. Radiat Therapist. 2017: 26(1): 23-39

Title: Surface Dose Effects of Linen Coverings for Breast and Chest Wall Patients

This article does a good job of discussing and providing results to an age old question: does the
patient sheet/cover that we use add dose to the patient’s skin surface. We try to protect the
patient’s modesty, but instead we may be adding dose to the skin because of this. The authors
take a series of measurements, with various sheet/towel/cover materials and a variety of electron
energies. They discuss the difficulties in measuring the doses. Interesting enough, the authors
state that the results are inconclusive because of statistical uncertainty.
The authors do state that further study using a different measuring device could better assess the
effects of linen and dose on patient surfaces.
The article discusses the use of TLD’s and ion chambers. Further research could be conducted
with MOSFET diode devices. However, the short coming of the MOSFET diodes is that they
have a + accuracy of 10%. If trying to measure surface dose, a measurement that is already
difficult to measure, MOSFET measurements may not provide sufficient data for review.

Fagerstrom, J. Hirata, E. Surface dose effects of linen coverings for breast and chest wall
patients. Radiat Therapist. 2014: 23(2): 119-124