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Noelle Deiter

DOS 711

4/4/2019

Identification of Literature Gaps

Article 1 Summary

A study by Wu et al1 identifies a lack of research on whole brain radiation therapy

(WBRT) and its effect on parotid dose and xerostomia. This specific article aimed to analyze the
impact of inferior field length on parotid dose. The study looked at patients from 2011-2014
treated with inferior field borders at C1 as well as C2. Nineteen patients were treated with field
borders at C1 while 26 patients received fields extending to C2. Parotid constraint doses were
compared to Radiation Therapy Oncology Group (RTOG) guidelines. To compare shorter
fractionation with WBRT, a biologically effective dose (BED) mean of less than 32.83 Gy was
calculated. Results showed that mean parotid doses with WBRT to C1 fields were achievable and
lower than C2 extended fields. In the conclusion of the study, Wu1 opens the door for future
studies on assessing xerostomia in relation to WBRT and parotid dose.

Article 1 Future Research

Previous WBRT research on minimizing parotid dose suggests inferior field borders
should be limited to C1. However, there is no current study which specifically analyzes the
impact of field borders on xerostomia side effects. This goal of this study aims to compare the
xerostomia side effects of patients receiving WBRT to C1 and WBRT to C2 radiation fields.

Article 2 Summary

Proton post mastectomy patient position is typically verified with daily AlignRT (ART)
surface imaging and daily radiographic imaging.2 In 2018, Batin et al2 studied patient position
with daily surface imaging and once weekly X-ray imaging. The goal of the study was to assess
weather daily surface imaging with weekly X-rays would be adequate for routine positioning.
The 28 patients in the study were simulated with 3 radiopaque markers at tattoo locations.
Markers were placed on tattoos each treatment day for imaging as well. This allowed setup
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differences and surface statistics to be compared at the treatment angle after surface imaging to
the final X-ray position. The majority of results showed small differences within normal
3mm/2degree robustness constraints. This data supports a decrease in daily X-ray imaging.
However, the study found higher discrepancies in patients with large implants and in patients
without any implants. An X-ray image prompted a re-plan on a new computed tomography (CT)
scan for 1 patient with a large implant. The X-ray demonstrated significant lateral shifting of the
implant. This shift was not detectable on ART due to lateral imaging limitations. Although the
research implies ART is accurate for daily imaging, limitations of the system and accuracy with
large breast implants require further research.

Article 2 Future Research

Previous research on ART surface imaging for proton post mastectomy patients suggests
the system is reliable and could eliminate daily X-ray imaging. However, limitations of the prior
study exist for patients with large breast implants. These patients may have significant lateral
implant shifting which is not detectable by ART. This study aims to measure implant position for
post mastectomy proton patients throughout treatment using verification CT on rails. The CT on
rails would be acquired once weekly and compared to the original CT. Measurements of CT to
CT lateral implant shifting could then be compared to daily ART surface statistics and X-ray
shifts to determine accuracy of surface imaging.

Article 3 Summary

Manual contouring has long been the traditional practice for lung tumors with 4-
dimensional computed tomography (4DCT). However, this process can be quite labor and time
intensive. New methods of auto-contouring may save time and reduce errors. The study by
Yuzhen et al3 analyzed newer auto and semi-auto-contouring strategies and compared them to
manual target delineation in 2019. The review looked at 13 total 4DCT lung studies and
compared tumor contour accuracy, variability, and length of time to perform contouring. The
studies varied in tumor stage, location, auto-contour algorithm, and or professional who
completed the contouring. The manual contours were considered the “gold standard” and these
were the comparison for the auto-contours. Many different metrics were used to assess the
accuracy and variability between contours while timing recorded in minutes. The qualitative
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analysis results showed that there was a high level of agreement between the two types of
contours and indicated auto-contours are accurate while requiring less time. However, the study
is limited by many factors with retrospective data. It was not able to directly compare different
algorithms, control window/level setting or level of professional experience. Therefore, future
studies should be controlled to provide more consistent data.

Article 3 Future Research

Prior reviews of the literature indicate a need for controlled studies to compare specific
auto-contouring algorithms to manual contouring for lung cancer in radiation oncology. This
study aims to assess the accuracy of MIM Maestro algorithm of auto-contouring against
manually contoured lung tumors on 4DCT.

Article 4 Summary

Permanent tattoos are a standard practice for reproducible patient setups in radiation
oncology. With an increase in daily surface imaging techniques as well as on board imaging
(OBI), permanent tattoos are not the sole method for aligning a patient. Does this idea prompt
reconsideration in regard to tattoo importance? In the article by Singh4, points are discussed
which both support and deny the need for tattoos. Patient perspectives of tattooing range from
“barbaric” to “no big deal”. Other concerns with tattoos include religious beliefs, skin color with
dark ink, psychological effects, self-image, and body habitus changes which impact tattoo
position. Alternatives to permanently visible tattoos include ultra-violet tattoos and semi-
permanent marks. However, research has shown that these techniques are less accurate than
permanent tattoos. Another alternative is surface-guided radiation therapy. This uses infrared
light to align the patient’s body contour. Several studies have demonstrated comparable treatment
setup times when using surface imaging without tattoos. Still, further investigation is needed to
assess patient tattoo experience and alternative methods to permanent tattooing.

Article 4 Future Research

Recent research shows surface imaging technology in radiation therapy has

reduced reliance on permanent tattoo markings. Previous surveys also indicate that patients have
mixed emotions regarding the tattoo process and the permanence of tattoos. Additional
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comparisons of surface imaging with and without tattoos may help change the standard of
practice of tattooing in radiation oncology departments. The purpose of this study is to use
surface imaging in order compare tattoo and non-tattoo patient setups. The comparison will
include analysis of setup times and table coordinate shifts.

Article 5 Summary

A radiation therapist is often the last individual to perform a chart check before a patient
receives treatment. However, interruptions and time constraints can make the chart check
difficult. Younge et al5 initiated a study to improve patient safety and department workflow
through implementation of a therapist pre-treatment checklist. The study gave therapists more
time and a designated area to perform the checklist items. Results over 1 year showed a decrease
in treatment delays as well as 30% decrease in scheduling errors. Using the checklist is highly
recommended to improve safety and workflow. Further studies should be performed to tailor
checklists for other radiation departments and continue improving safety.

Article 5 Future Research

Prior studies indicate therapist pre-treatment checklists improve efficiency and reduce
errors. However, checklists may vary from institution to institution along with patient volume
and number of therapists performing chart checks. Prior studies which show improvement
indicate therapists were placed in a quiet, designated space to perform checks. Thus, there is a
need to study pre-treatment checklist errors in conjunction with environment. This study aims to
assess how environment affects pre-treatment chart check errors. Therapists will have the option
complete a chart check in a private room or in the machine control area over the course of a year.
Location will be logged for each chart check and after 1 year the error ratio will be assessed.
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References

1. Wu C, Wuu Y, Jani A, et al. Whole-brain Irradiation Field Design: A Comparison of

Parotid Dos, Med Dosim. 2017;42(2):145-149.
https://doi.org/10.1016/j.meddos.2017.02.006
2. Batin E, Depauw N, Jimenez R, MacDonald S, Lu H. Reducing X-ray imaging for proton
post mastectomy chest wall patients. Pract Radiat Oncol. 2018;8(5):e266-e274.
https://doi.org/10.1016/j.prro.2018.03.002
3. Yuzhen N, Barrett S. A review of automatic lung tumour segmentation in the era of
4DCT. Rep Pract Oncol Radiother. 2019;24(2):208-220.
https://doi.org/10.1016/j.rpor.2019.01.003
4. Singh J. The Future of Tattooing in Radiation Therapy. Radiat Therapist. 2019; 28 (1):83-
86.
5. Younge K, Naheedy K, Wilkinson J, et al. Improving patient safety and workflow
efficiency with standardized pretreatment radiation therapist chart reviews. Pract Radiat
Oncol. 2017;7(5):339-345. https://doi.org/10.1016/j.prro.2017.01.015