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Sara Long
Literature Review Activity
4/7/2019
Literature Review Activity

1. 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

Article Summary

This article explored the use of parameters used in the electronic tissue compensation

(ECOMP) treatment technique to treat the whole breast. ECOMP is the use of dynamic

MLCs to improve dose uniformity. The study used the Eclipse TPS. This TPS uses a

function called the predetermined transmission penetration depth (TPD) to define the

path length of rays in the beam. In this system, the planner selects penetration depth, runs

the function, then manually adjusts hot and cold spots. Previous studies evaluated breast

separation, a parameter measured from medial to lateral along the width of the breast.

The purpose of the article is to show that the inclusion of a second parameter, a radius,

which measures chestwall to breast apex can aid in the selection of appropriate TPD for

ECOMP plans.

To test the hypothesis that breast radius is important, the researchers created various sized

electronic semi-oval water phantoms to mimic breast tissue. They then created multiple

plans and evaluated dose uniformity and hot spot. They plotted the results and found as

separation increases then optimum TPD decreases linearly; they also found as the radius
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Literature Review Activity
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increases the optimum TPD increases. The researchers then applied their findings

retrospectively to a random selection of patients who had received RT to the breast. For

each plan 3 plans were created. Each plan created a fluence to evaluate either the medial,

central, or lateral target. All three fluence plans were combined to a single plan and

compared to the standard plan for the patient (considered the original treatment plan).

The researchers show that the inclusion of the radius metric of the breast into ECOMP

plans optimizes TPD, and may allow the TPS user to better use the TPS system.

The authors suggest that future directions related to their research could lead to a module

incorporated into the TPS to automatically assign optimum TPD values in the superior

and inferior axis of the breast. Additionally, comparisons of the technique outlined by the

authors and IMRT could be performed to understand if OAR sparing is greater. OAR

sparing was not changed between the two methods outlined in the study.

Future Research Summary

It is unknown what effect the superior to inferior measure of the breast has on TPD

values in the Eclipse TPS for ECOMP 3D breast plans. To investigate the superior to

inferior measure of the breast on TPD value several semi-oval water phantoms must be

created to have volume in the axial, sagittal and coronal dimensions. Fluence maps

evaluating the superior, central, and inferior aspects of the target must be created and

combined then plotted. The technique will then be tested retrospectively on real patients.

To evaluate the effect the superior to inferior dimension has on the plan, the plans with
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Literature Review Activity
4/7/2019
this dimension incorporated into the TPD will be compared to standard plans created by

the planner and used in treatment.

2. A feasibility study of independent verification of dose calculation for Vero4DRT

using a Clarkson-based algorithm.

Article Summary

The purpose of this article was to investigate the use of a Clarkson method based second

check system for a Vero4DRT system. The authors say the second check methods most

commonly used for this purpose are Monte Carlo based, but these methods take longer to

compute than the Clarkson method. The authors also claim there is no second check

commercial software for the Vero4DRT system. To test the Clarkson method, the

researchers imported CT image data, MLC configuration, and jaw settings into a

modified commercial second check system. They then evaluated the accuracy of the

modified software.

The authors found ~1.5% agreement between the TPS MU values and those of their test

system for most tests. However, the authors found higher percent difference when they

ran actual clinical cases through their Clarkson method software. They hypothesized this

larger difference could be due to the lack of the inclusion of the effect of MLC penumbra.
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Literature Review Activity
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The authors suggest the lack of planning variation presents a future direction for the

study. They suggest the use of a multi-institutional study to further evaluate the role of

their Clarkson second check method for the Vero4DRT system.

Future Research Summary

A second check system using the Clarkson method will be created to verify dose from the

Vero4DRT system. The original study was limited and contained some errors in

calculation, so the software will need to be updated to include penumbra from MLC

leaves. Once the software has been updated and tested, a multi-institutional study can be

performed. To validate the legitimacy of the modified second check software which uses

the Clarkson method, a multi-institutional study will be created. All data collected from

individual centers will be conglomerated into a single data collection center and

interpreted.

3. Analysis of ion beam teletherapy patient-specific quality assurance

Article Summary

This article studied measures of patient-specific quality assurance of modulated scanned

and energy stacked proton and carbon ion beams. The authors present the patient-specific

quality assurance records of a period of time for a facility which uses the aforementioned

techniques and ion teletherapies.

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Literature Review Activity
4/7/2019

Patient specific QA is a safety technique using ion chambers, a water phantom, and the

treatment plan designed for a patient to evaluate the dose and delivery of the treatment

prior to the treatment of the actual patient. This method is termed portal verification. The

authors describe the phantom used and the ion chambers, and describe how the array of

ion chambers was arranged within the phantom. The dose for each chamber was recorded

and a dose gradient provided. Measurements for each chamber for proton and carbon

beams were plotted to better understand the effect location within the phantom may have

on individual readings. The mean dose of these chamber readings must be within 3% of

the predicted plan dose. The authors found proton portal verification doses for their

facility to be within 1%, and carbon ion portal verifications within 2%. They also found

the actual delivered doses were slightly lower than planned dose.

The difference in the expected and delivered doses may be due to the size of the beam

compared to the size of the ion chambers. The authors point out the TPS dose

calculations may have neglected to include the effects air cavities or phantom material

may have on dose computation.

Future Research Summary

The investigation of expected and delivered ion teletherapy beams resulted in the

prediction that the TPS may not accurately model scatter for certain phantom materials,

and the size and distribution of ion chambers within a phantom may not adequately
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Literature Review Activity
4/7/2019
model dose distribution. To further investigate the roles TPS, phantom material, and air

pockets may have in the deviation of planned and delivered dose, a phantom capable of

holding more and smaller ion chambers will be created. Additionally, the parameters of

the TPS will be evaluated to understand if the TPS has been coded to account for scatter

production in the phantom type used for patient-specific QA.

4. Modifiable risk factors for acute skin toxicity in adjuvant breast radiotherapy:

Dosimetric analysis and review of the literature

Article Summary

The authors of this study performed a retrospective study of women who received

adjuvant forward planned IMRT after breast conserving surgery to identify volumetric

metrics that correlate to higher rates of acute skin toxicity. The group evaluated V105

volumes of forward planned IMRT plans and compared acute skin toxicity outcomes

among several groups of patients. They compared patients on different chemotherapy

schedules and fractionation patterns. They determined the variables which resulted in

greatest risk of acute skin toxicity were conventional fractionation and V105 > 30cc.

The study had several limitations which could be clarified with future research. The

number of grade III toxicities was too low to understand the relationship between any

variable which may cause this toxicity level. Also, skin reaction may be underreported

since required follow up was only 6 weeks post RT. Patients were asked to report back if
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Literature Review Activity
4/7/2019
a significant skin reaction occurred but may not have reported. Lastly, the group

evaluated V105 but did not differentiate between contiguous or scattered regions in the

breast.

Future Research Summary

It has been shown V105 > 30cc has adverse effects on skin outcomes for patients

receiving breast RT. The authors of that study did not differentiate between contiguous

and scattered regions of V105 and the relationship such dose distributions could have on

skin outcomes. To investigate the role contiguous high dose regions may have on skin

reaction, and since a previous study has established V105>30cc correlates to increased

toxicity, a retrospective study will be designed to compare the dose distributions of

patients who received V105>30cc. In such a comparison it can be determined if toxic

events correlate to contiguous or scattered dose distributions.

5. Postradiation hypothyroidism in head and neck cancers: A department of Veterans

Affairs single-institution case-control dosimetry study

Article Summary

The purpose of this study was to evaluate the role head and neck radiotherapy has on the

development of hypothyroidism. The researchers compared rates of hypothyroidism and

euthyroidism pre and post RT using physical dose and BED analysis. The authors found a
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Literature Review Activity
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relationship between a history of radiotherapy and the development of a hypothyroid

condition. The authors also found a statistically insignificant relationship between

hypothyroidism and increased survival.

The authors question if by defining the thyroid as an avoidance structure and thereby

reducing dose to this structure if some under-dosing may occur to adjacent malignancy.

This reduced dose may lead to decreased survival. There are several limitations to the

study. The authors mention their cohort was small and selection bias may have occurred

where a disproportionate ratio of patients with hypothyroidism were included in the

study. Approximately 30% of patients who received RT developed hypothyroidism.

Additionally, the authors state confounding variables were not included in their

assessment.

Future Research Summary

A multi-institutional study to include more diverse planning patterns would help discern

the role RT in head and neck treatments has in the development of hypothyroidism. To

reduce bias in selection a double blind evaluation process could be developed. In this

process, treatment facilities would randomly select retrospective cases for dosimetric

evaluation, then send the data to a central data collection center for interpretation. Once

dosimetric evaluation has been made the results of hypothyroid condition can be

correlated to the dose analysis. Additionally, a long term study to evaluate the correlation

between hypothyroid development and increased survival could be evaluated.

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Literature Review Activity
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References

1. Alghufaili AH, Shanmugarajah L, Kumaraswamy LK. 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/10.1016/j.meddos.2018.01.001. Accessed 4/7/2019.

2. Yamashita M, Takahashi R, Kokubo M, Takayama K, Tanabe H, Sueoka M, Ishii M,

Tachibana H. A feasibility study of independent verification of dose calculation for

Vero4DRT using a Clarkson-based algorithm. Med Dosim. 2019; 44(1): 20-25.

https://doi.org/10.1016/j.meddos.2017.12.007. Accessed 4/7/2019.

3. Liu X, Deng Y, Schlegel N, Huang Z, Moyers M. Analysis of ion beam teletherapy

patient-specific quality assurance. Med Dosim. 2019; 44(1): 43-50.

https://doi.org/10.1016/j.meddos.2018.01.002. Accessed 4/7/2019.

4. Keenan LG, Lavan N, Dunne M, McArdle O. Modifiable risk factors for acute skin

toxicity in adjuvant breast radiotherapy: Dosimetric analysis and review of the literature.

Med Dosim. 2019; 44(1): 51-55. https://doi.org/10.1016/j.meddos.2018.01.004. Accessed

4/7/2019.

5. Lin AJ, Zhang J, Cho-Lim J, Inouye W, Lee SP. Postradiation hypothyroidism in head

and neck cancers: A department of Veterans Affairs single-institution case-control

dosimetry study. Med Dosim. 2019; 44(1): 56-60.

https://doi.org/10.1016/j.meddos.2018.02.001. Accessed 4/7/2019.