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Madeline Doberstein

April 2, 2019

DOS 711

Identifying Gaps in Literature

It is important to keep up to date on new research and literature being done. Often times
researchers can discover gaps or further research through previous research articles. The goal of
this assignment was to read through current research to discover where gaps occur and what
possible research could be done to better investigate a topic. This paper analyzes 5 research
papers and attempts to expand on researchers ideas for possible research topics.

The article titled “Skin recurrence in the radiation treatment of breast cancer” published in
July, 2018 reviewed a case in which a 34 year old female patient was diagnosed with Stage IA,
well differentiated invasive ductal carcinoma in the left breast. The patient had a lumpectomy
and was treated with radiation therapy (RT) in the prone position to a dose of 4256 centigray
(cGy) in 16 fractions using 6 megavoltage (MV) photon beams. There was no boost and no bolus
was used. 4 years later superficial masses were noticed by the patient and it was determined there
was recurrent invasive ductal carcinoma. When the patient was originally treated in the prone
position it was found that the skin dose was only 60% of the prescribed dose. The prone position
is beneficial in lowering the dose to lung and heart however it also lowers the dose to the skin
surface. It may be more beneficial to treat patients supine with deep-inspiration breath hold and
bolus than use the prone board. The author also suggests that a boost could have been utilized in
the supine position.1

The author suggests future research to be done on the comparison of prone breast treatment
and supine breast treatment on the skin dose. A future research project could be to compare the
skin, heart and lung dose of a breast treatment with prone only, supine only, and prone with a
supine boost. In an effort to minimize heart and lung dose in the prone position it is possible that
skin dose is being overlooked as there is not often accurate representation of skin dose in the
treatment planning algorithm. The purpose of this research is to find the optimal treatment
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position for tumors that present superficially in the skin while providing maximum skin dose and
sparing heart and lung tissue.1

In the research titled “Adaptive treatment planning may reduce parotid gland atrophy in
patients receiving head and neck radiation therapy” a study was done to determine the difference
in mean dose of the parotid glands between patients who needed to be resimulated due to weight
loss or anatomical changes and patients who did not get resimulated throughout their treatment.
According to Ennis et al. parotid gland radiation can cause side effects such as alterations in
taste, dysphagia, odynophagia, dental caries, and ulcerations.2 In a study of 86 patients, half who
were resimulated and replanned mid treatment and half who were not replanned mid treatment, it
determined that there was a mean difference in parotid gland dose of 30.64% in the left parotid
gland and 45.63% in the right parotid gland.2

Based on this research, the authors suggest future research on whether or not this adaptive
planning influences the quality of life. I would design a survey research project following up
with these patients asking about various side effects and to what degree these patients have these
side effects as well as how they feel it is affecting their daily life. Side effects of head and neck
irradiation can be painful, uncomfortable, and alter a patient’s daily life. The purpose of this
research is to determine whether or not adaptive planning in a head and neck treatment with the
intention of sparing dose to the parotid gland affects a patient’s quality of life.2

An article titled “To prep or not to prep- that is the question: A randomized trial on the use
of anitflatulent medication as part of bowel preparation for patients having image guided external
beam radiation therapy to the prostate” compared the daily diameter of the rectum on patients
who took an anitflatulent medication daily and those who did not on a daily cone beam CT
(CBCT). Because the prostate sits anterior to the rectum, size of the rectum can displace the
prostate as well as increase toxicity to the rectum. Studies have shown that a daily laxative
significantly decreased the amount of gas and feces. Another study had shown that the use of
milk of magnesia with an antiflatulent diet did not have a significant effect. For this study
patients were randomly assigned groups (whether or not they were to take the medication daily).
Results showed that there was no significant difference in patients that needed a resimulation due
to change in rectum size. There was a no significant difference between the diameter of the
rectum of patients who were taking the medication and those who not. However there was a
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significant difference over time as the diameter was smaller for the rectum on the last day of
treatment compared to the first week.3

The authors of this article addressed the fact that there has been research on many methods
to decrease dose to the rectum such as diets, laxatives, and invasive procedures. Although the
current study did not show an effect using the laxatives, the researchers did give extensive
education on the importance of bowel preparation which they believe could have effects on
overall treatment. A future study would be done with the purpose of developing an optimal
educational program to emphasize the importance of a full bladder and empty rectum and
compare the results across patients who received various forms of education.3

In an article titled “Evaluation of MLC leaf transmission on IMRT treatment plan quality of
patients with advanced lung cancer” researchers determined the effect of different leaf
transmissions on an intensity modulated radiation therapy (IMRT) plan. Different machines offer
different multileaf collimator (MLC) sizes, some with thinner and greater number of leaves and
some with thicker and a smaller number of leaves. To test these variations 11 patients IMRT
lung plans were evaluated with 0.1%, 0.5%, 1.2%, 1.8%, and 3% transmission and dose to the
planning target volume (PTV), spinal cord, heart, total lung, and normal tissue was measured.
Each of these patients was treated to 60 Gy in 30 fractions. It was found that the interleaf
transmission values had no significant effect on the plans, but it did have an impact on total lung
sparing. Although it was not a significant statistically dosimetric difference, lung sparing can
help to improve a patients quality of life.4

This research was tested on 5 standard fractionated lung plans. The author suggests future
research could include differences between stereotactic body radiotherapy (SBRT) plans and
how interleaf transmission affects the dose to organs at risk (OAR). The goal of radiation therapy
is to adequately treat the tumor while sparing as much normal tissue as possible. Radiation
pneumonitis is an issue that can cause many severe symptoms that could possibly lead to death,
so it is important to attempt to reduce mean lung dose and the percent of total lung tissue
irradiated. The purpose of a new study would be to determine if these effects could be limited
even greater in hypo fractionated treatments to lung tumors through the use of lowered MLC
transmission.
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In an article titled “Whole-brain irradiation field design: A comparison of parotid dose”

researchers compared the parotid dose between patients who were treated with the inferior extent
of the whole brain to C1 compared with C2. 45 patients were enrolled in this study, 19 which
received whole brain radiation therapy with the field extending to C1 and 26 which received
whole brain radiation with the field extending inferiorly to C2. Treatment technique was a 3D
opposed laterals field design with MLC blocking with a dose of either 3000 cGy in 10 fractions
or 3750 cGy in 15 fractions. A biologically effective dose conversion was done to determine
dose constraints to the parotid gland based on the RTOG constraints for a nasopharyngeal
treatment. Results showed that extending the field to C2 significantly increased the dose to the
parotid gland. Researchers suggest adding parotid gland dose to critical structures for whole
brain.5

The author suggests future research should be done to determine if considering the parotid
gland as an OAR for whole brain treatments will limit risk for xerostomia. Xerostomia can occur
when the parotid gland is irradiated but in whole brain treatments the parotid gland is not
considered an organ at risk. I noticed this plan was done with an opposed lateral technique but
not with a field in field technique. The purpose of this future research idea would to determine if
field in field technique inherently limits the dose to the parotid gland in a sample of patients.5
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References

1. Katz L, Perez C, Gerber N, et al. Skin recurrence in the radiation treatment of breast
cancer. Adv Radiat Oncol. 2018;3(3):458-462.
2. Ennis W, Raymond A, Formica M, et al. Adaptive treatment planning may reduce parotid
gland atrophy in patients receiving head and neck radiation therapy. Int J Radiat Oncol
Biol Phys. 2019:103(55):e37.
3. McGuffin M, Devji N, Kehoe L, et al. To prep or not to prep-that is the question: A
randomized trial on the use of antiflatulent medication as part of bowel preparation for
patients having image guided external beam radiation therapy to the prostate. Pract
Radiat Oncol. 2018:8(2):116-122.
4. Chen J, Fu G, Li M, et al. Evaluation of MLC leaf transmission on IMRT treatment plan
quality of patients with advanced lung cancer. Med Dosim. 2018:43(4):313-318.
5. Wu C, Wuu Y, Jani A et al. Whole-brain irradiation field design: A comparison of
parotid dose. Med Dosi. 2017:42(2):145-149.