Intensity modulated radiation therapy (IMRT) is increasingly used for total body irradiation (TBI) due to its ability to deliver myeloablative doses while sparing radiosensitive organs. To enable consistent evaluation in future National Clinical Trials Network (NCTN) studies, the NRG Hematologic Malignancies Working Group (HMWG) convened IMRT-TBI experts and NCTN leaders to develop consensus recommendations for standardized multi-institutional implementation. A 47-question survey was distributed to NRG institutions utilizing total body irradiation treated with intensity modulated radiation therapy (IMRT-TBI) to characterize current planning and delivery practices. Responses were analyzed for commonalities and variations. A multidisciplinary working group reviewed survey findings, developed consensus-based technical and clinical recommendations, and created a standardized template for IMRT-TBI integration into NCTN protocols. Topics included simulation, contouring, planning, organ-at-risk (OAR) constraints, quality assurance (QA), image guided radiation therapy, commissioning, credentialing, and safeguards for clinical trial conduct. Eight institutions with collective experience treating more than 750 patients with IMRT-TBI responded. Most centers used volumetric modulated arc therapy (VMAT) to the upper body with anteroposterior/posteroanterior fields to the lower body, 3 to 9 isocenters, lower dose rates for lung fields (100-200 MU/min), and no physical bolus. Common OAR constraints included lungs mean dose <8 Gy, kidneys mean dose <6 to 8 Gy, and lenses maximum dose <90% of prescription. All respondents used auto-segmentation; 50% used auto-planning. QA practices varied, but patient-specific QA passing rates were high (>95% with 3%/2 mm gamma). Consensus recommendations for clinical trial use were established, including standardized planning target volume definitions, OAR sparing goals, dosimetric constraints, QA requirements, and credentialing processes. IMRT-TBI offers the potential for reduced toxicity and improved dose precision compared with total body irradiation treated with a 2-dimensional technique, but its complexity requires careful standardization in multi-institutional trials. The NRG HMWG and collaborating NCTN experts developed the consensus-based technical and clinical framework for incorporating IMRT-TBI into cooperative group protocols. Adoption of these recommendations will facilitate consistent implementation and enable rigorous evaluation of outcomes.

Radiation-induced xerostomia remains a common and debilitating side effect in head-and-neck cancer radiotherapy, despite advances in volumetric modulated arc therapy (VMAT). Traditional dose-volume histogram (DVH) metrics capture only part of the variation in toxicity, motivating the use of multimodal imaging biomarkers such as dosiomics and radiomics to characterize dose distribution and tissue response better. In this pilot study, we present an integrated framework combining DVH metrics, 3D dosiomics features, baseline planning CT (pCT) radiomics, and novel longitudinal delta-radiomics derived from daily cone-beam CT-based synthetic CT (sCT) images to predict post-treatment xerostomia severity. In a cohort of ten high-risk oropharyngeal cancer patients treated with VMAT at the Cleveland Clinic, wrapper-based feature selection yielded a compact set of 15 predictors (5 DVH, 3 dosiomics, 4 pCT radiomics, 3 Δ-sCT radiomics). Using cross-validation, four classifiers, including support-vector machine (SVM), regularized logistic regression (GLMnet), Naïve Bayes, and k-nearest neighbors, achieved consistently strong performance for discriminating grade I vs. grade II xerostomia, with AUC of 0.97-1.00, accuracy of 0.90-0.93, uniformly high sensitivity (1.00), specificity of 0.75-0.83, and F1 scores of 0.923-0.945. SVM and GLMnet showed the best overall balance of discrimination and robustness. These results demonstrate the potential of integrating dosiomics with multiphase radiomics, particularly time-resolved delta-radiomics, for individualized xerostomia risk prediction.

Purpose: Given the increased risk of cardiac toxicity with higher doses, cardiac sparing is crucial for left-sided breast cancer patients. Deep inspiration breath hold (DIBH) is one approach, but its reproducibility is questioned. This study evaluates the reproducibility of DIBH with an active breathing coordinator (ABC) device, focusing on its dosimetric impact in maintaining consistent cardiac sparing for patients undergoing partial breast irradiation (PBI).Methods: Thirty-three patients undergoing PBI with a prescription dose of 30 Gy in five fractions were randomly selected. Each patient was treated with 6 MV photons using volumetric modulated arc therapy (VMAT) with DIBH using an ABC device. Prior to each fraction, kilo-voltage cone beam computed tomography (kV-CBCT) images were acquired to assess inter-fractional heart motion. Contours of the whole heart and left anterior descending artery (LAD) were transferred from the planning CT to CBCTs and back, using rigid alignment and isocentre shifts to represent treatment positions. Agreement between delivered and planned doses assessed DIBH reproducibility.Results: Throughout the entire treatment course, changes in mean and maximum cardiac doses were less than 164 cGy and 2648 cGy, respectively. Changes in mean and maximum LAD doses were less than 540 cGy and 1602 cGy, respectively. Overall, the mean cardiac dose increased by 24 +/- 66 cGy, and the maximum by 233 +/- 580 cGy. The mean LAD dose increased by 48 +/- 185 cGy, and the maximum by 170 +/- 510 cGy.Conclusions: DIBH can be effectively reproduced with the ABC device, limiting inter-fractional cardiac dose changes.

BACKGROUND:Multi-isocentric intensity-modulated (IM) total body irradiation (TBI), total marrow irradiation (TMI), and total marrow and lymphoid irradiation (TMLI) are gaining popularity. A question arises on the impact of the interplay between blood circulation and dynamic delivery on blood dose. PURPOSE:This study answers the question by introducing a new whole-body blood circulation modeling technique. METHODS:A whole-body CT with intravenous contrast was used to develop the blood circulation model. Fifteen organs and tissues, heart chambers, and great vessels were segmented using a deep-learning-based auto-contouring software. The main blood vessels were segmented using an in-house algorithm. Blood density, velocity, time-to-heart, and perfusion distributions were derived for systole, diastole, and portal circulations and used to simulate trajectories of blood particles during delivery. With the same prescription of 12 Gy in 8 fractions, doses to circulating blood were calculated for three plans: (1) an IM-TBI plan prescribing uniform dose to the whole body while reducing lung and kidney doses; (2) a TMI plan treating all bones; and (3) a TMLI plan treating all bones, major lymph nodes, and spleen; TMI and TMLI plans were optimized to reduce doses to non-target tissue. RESULTS:Circulating blood received 1.57 ± 0.43 Gy, 1.04 ± 0.32 Gy, and 1.09 ± 0.32 Gy in one fraction and 12.60 ± 1.21 Gy, 8.34 ± 0.88 Gy, and 8.71 ± 0.92 Gy in 8 fractions in IM-TBI, TMI, and TMLI, respectively. The interplay effect of blood motion with IM delivery did not change the mean dose, but changed the dose heterogeneity of the circulating blood. Fractionation reduced the blood dose heterogeneity. CONCLUSIONS:A novel whole-body blood circulating model was developed based on patient-specific anatomy and realistic blood dynamics, concentration, and perfusion. Using the blood circulation model, we developed a dosimetry tool for circulating blood in IM-TBI, TMI, and TMLI.

Purpose: To investigate the impact of delivery techniques and planning parameters on interplay effect in lung SBRT. Methods: A dynamic virtual patient model containing normal structures and a tumor with adjustable sizes, locations, and 3D breathing motion was utilized. SBRT plans were developed using both step-and-shoot IMRT and VMAT with different planning parameters (energy, isocenter location, PTV margin, and PTV dose heterogeneity). 4D doses were calculated by simulating synchronized delivery of SBRT to the virtual patient model with random initial positions of tumor motion. The expected dose (average) and the standard deviation of the 4D doses were obtained. The relative difference between the expected GTV minimal/mean (GTVMin/GTVMean) dose and the planned ITVMin/ITVMean dose (denoted by Results: The (0.5 DRx in 9.4 GTVMin was 14.1 heterogeneity to be achieved in PTV can result in significant difference (p<0.05) in motion interplay depending on delivery techniques. Conclusion: Motion interplay may cause the expected GTVMin to be less than the planned ITV minimal dose and DRx for both IMRT and VMAT plans. The differences between the expected GTV dose and the ITV dose depended on the delivery technique and planning parameters. Overall, VMAT is less prone to motion interplay than IMRT.

High dose rate (HDR) brachytherapy procedures for cervical cancer require multiple applicator insertions for multiple (typically 5) fractions of a single plan, which carries a risk for variability in applicator position between fractions. Due to applicator displacement relative to patient anatomy, the dose to nearby organs-at-risk (OARs) may vary significantly from one fraction to the next. The purpose of this study was to evaluate the effect of changes in HDR tandem and ring (T&R) applicator position on doses to nearby OARs and to present a quick and simple method to estimate doses to OARs inter-fractionally without having to perform a re-plan. Ninety CT image sets for 20 patients, ages 44 to 86, undergoing T&R-based HDR for cervical cancer were used retrospectively for this study. Measures of applicator positional and angular changes relative to the bony anatomy were obtained using image fusion in MIM software, between the planning CT (plan CT) and the CT on the treatment day (CT-TX). Dosimetric data were determined, also using MIM software, using the original (first fraction) dose distribution applied to organs at risk (rectum and bladder), transferred via rigid registration from the plan CT to each CT-TX. Bladder and rectum contours were also transferred from each plan CT to each CT-TX and were tweaked manually to match anatomy on each CT-TX and examined visually for appropriateness. Differences in translation and rotation of the T&R applicator between the planning CT and subsequent individual fractions were recorded and plotted against dose differences between each fraction of treatment and the original (first) fraction. Absolute dose (D2cc) and volume (V50) differences vs positional shifts were calculated and plotted, and the Pearson Product-Moment correlation coefficient between dose parameters and measured positional shifts was determined. Average dosimetric differences between planned dose and subsequent fractional doses obtained through rigid registration were 1.48 ± 1.92 Gy, 14.91 ± 11.92 cm3, 0.56 ± 0.93 Gy, and 1.77 ± 2.18 cm3 for Bladder D2cc, Bladder V50, Rectum D2cc, and Rectum V50, respectively. Correlation between Bladder V50 and sagittal plane rotation gave an r2 of 0.4, showing the most correlation of all parameters studied. Bladder dose and volume increased by a maximum of about 2.7 Gy and 50 cm3 overall for Bladder D2cc and Bladder V50, respectively. Bladder V50 was most sensitive to T&R applicator displacements. We have quantified the effects of applicator positional changes on dose changes for the bladder and rectum. Even large changes in applicator position between fractions did not result in significant changes in dose to these normal tissues, indicating that adaptive re-planning is not necessary.

Stereotactic Body Radiation Therapy (SBRT) can be a precise, minimally invasive treatment method for liver cancer and liver metastases. However, the effectiveness of SBRT relies on the accurate delivery of the dose to the tumor while sparing healthy tissue. Challenges persist in ensuring breath-hold reproducibility, with current methods often requiring manual verification of liver dome positions from kV-triggered images. To address this, we propose a proof-of-principle study of a deep learning-based pipeline to automatically delineate the liver dome from kV-planar images. From 24 patients who received SBRT for liver cancer or metastasis inside liver, 711 KV-triggered images acquired for online breath-hold verification were included in the current study. We developed a pipeline comprising a trained U-Net for automatic liver dome region segmentation from the triggered images followed by extraction of the liver dome via thresholding, edge detection, and morphological operations. The performance and generalizability of the pipeline was evaluated using 2-fold cross validation. The training of the U-Net model for liver region segmentation took under 30 minutes and the automatic delineation of a liver dome for any triggered image took less than one second. The RMSE and rate of detection for Fold1 with 366 images was (6.4 +/- 1.6) mm and 91.7 with 345 images, the RMSE and rate of detection was (7.7 +/- 2.3) mm and 76.3 respectively.

AbstractPurposesTo report our experience in a prospective study of implementing a transperineal ultrasound system to monitor intra‐fractional prostate motion for prostate stereotactic body radiotherapy (SBRT).Material and MethodsThis IRB‐approved prospective study included 23 prostate SBRT patients treated between 04/2016 and 11/2019 at our institution. The prescription doses were 36.25 Gy to the Low‐Dose planning target volume (LD‐PTV) and 40 Gy to the High‐Dose PTV (HD‐PTV) in five fractions with 3 mm planning margins. The transperineal ultrasound system was successfully used in 110 of the 115 fractions. For intra‐fraction prostate motion, the real‐time prostate displacements measured by ultrasound were exported for analysis. The percentage of time prostate movement exceeded a 2 mm threshold was calculated for each fraction of all patients. T‐test was used for all statistical comparisons.ResultsUltrasound image quality was adequate for prostate delineation and prostate motion tracking. The setup time for each fraction under ultrasound‐guided prostate SBRT was 15.0 ± 4.9 min and the total treatment time per fraction was 31.8 ± 10.5 min. The presence of an ultrasound probe did not compromise the contouring of targets or critical structures. For intra‐fraction motion, prostate movement exceeded 2 mm tolerance in 23 of 110 fractions for 11 of 23 patients. For all fractions, the mean percentage of time when the prostate moved more than 2 mm in any direction during each fraction was 7%, ranging from 0% to 62% of a fraction.ConclusionUltrasound‐guided prostate SBRT is a good option for intra‐fraction motion monitoring with clinically acceptable efficiency.

Purpose Success of auto-segmentation is measured by the similarity between auto and manual contours that is often quantified by Dice coefficient (DC). The dosimetric impact of contour variability on inverse planning has been rarely reported. The main aim of this study is to investigate whether automatically generated organs-at-risk (OARs) could be used in inverse prostate stereotactic body radiation therapy (SBRT) planning and whether the dosimetric parameters are still clinically acceptable after radiation oncologists modify the OARs. Methods and materials Planning computed tomography images from 10 patients treated with SBRT for prostate cancer were selected and automatically segmented by commercially available atlas-based software. The automatically generated OAR contours were compared with the manually drawn contours. Two volumetric modulated arc therapy (VMAT) plans, autoRec-VMAT (where only automatically generated rectums were used in optimization) and autoAll-VMAT (where automatically generated OARs were used in inverse optimization) were generated. Dosimetric parameters based on the manually drawn PTV and OARs were compared with the clinically approved plans. Results The DCs for the rectum contours varied from 0.55 to 0.74 with a mean value of 0.665. Differences of D-95 of the PTV between autoRec-VMAT and manu-VMAT plans varied from 0.03% to -2.85% with a mean value of -0.64%. Differences of D-0.03cc of manual rectum between the two plans varied from -0.86% to 9.94% with a mean value of 2.71%. D-95 of PTV between autoAll-VMAT and manu-VMAT plans varied from 0.28% to -2.9% with a mean value -0.83%. Differences of D-0.03cc of manual rectum between the two plans varied from -0.76% to 6.72% with a mean value of 2.62%. Conclusion Our study implies that it is possible to use unedited automatically generated OARs to perform initial inverse prostate SBRT planning. After radiation oncologists modify/approve the OARs, the plan qualities based on the manually drawn OARs are still clinically acceptable, and a re-optimization may not be needed.

We compiled a sampling of the treatment techniques of intensity-modulated total body irradiation, total marrow irradiation and total marrow and lymphoid irradiation utilized by several centers across North America and Europe. This manuscript does not serve as a consensus guideline, but rather is meant to serve as a convenient reference for centers that are considering starting an intensity-modulated program.

Purpose: To introduce a new technique for online breath-hold verification for liver stereotactic body radiation therapy (SBRT) based on kilovoltage-triggered imaging and liver dome positions. Material and Methods: Twenty-five liver SBRT patients treated with deep inspiration breath-hold were included in this IRB-approved study. To verify the breath-hold reproducibility during treatment, a KV-triggered image was acquired at the beginning of each breath-hold. The liver dome position was visually compared with the expected upper/lower liver boundaries created by expanding/contracting the liver contour 5 mm in the superior-inferior direction. If the liver dome was within the boundaries, delivery continued; otherwise, beam was held manually, and the patient was instructed to take another breath-hold until the liver dome fell within boundaries. The liver dome was delineated on each triggered image. The mean distance between the delineated liver dome to the projected planning liver contour was defined as liver dome position error e(dome). The mean and maximum e(dome) of each patient were compared between no breath-hold verification (all triggered images) and with online breath-hold verification (triggered images without beam-hold). Results: Seven hundred thirteen breath-hold triggered images from 92 fractions were analyzed. For each patient, an average of 1.5 breath-holds (range 0-7 for all patients) resulted in beam-hold, accounting for 5% (0-18%) of all breath-holds; online breath-hold verification reduced the mean e(dome) from 3.1 mm (1.3-6.1 mm) to 2.7 mm (1.2-5.2 mm) and the maximum e(dome) from 8.6 mm (3.0-18.0 mm) to 6.7 mm (3.0-9.0 mm). The percentage of breath-holds with e(dome) >5 mm was reduced from 15% (0-42%) without breath-hold verification to 11% (0-35%) with online breath-hold verification. online breath-hold verification eliminated breath-holds with e(dome) >10 mm, which happened in 3% (0-17%) of all breath-holds. Conclusion: It is clinically feasible to monitor the reproducibility of each breath-hold during liver SBRT treatment using triggered images and liver dome. Online breath-hold verification improves the treatment accuracy for liver SBRT.

PURPOSE:Volumetric-modulated arc therapy for total body irradiation (VMAT-TBI) is a novel radiotherapy technique that has been implemented at our institution. The purpose of this work is to investigate possible failure modes (FMs) in the treatment process and to develop a quality control (QC) program for VMAT-TBI following TG-100 guidelines.METHODS:We formed a multidisciplinary team to map out the complete treatment process of VMAT-TBI following the AAPM TG-100 guidelines. This process map gives a visual representation of the VMAT-TBI workflow from the CT simulation, image processing, contouring, treatment planning, to treatment delivery. From the process map, potential FMs were identified. The occurrence (O), detectability (D), and severity of impact (S) of each FM were assigned according to scoring criteria (1-10) by the multidisciplinary team. A risk priority number (RPN) was calculated from average O, S, and D of each FM (RPN = O x S x D). High risk FMs were identified as 20% of the FMs having the highest RPN scores. After the FMEA analysis, fault-tree analysis (FTA) was performed for each major step of the treatment process to determine the effects of potential failures to the treatment outcome. Effective QC methods were identified to prevent the high risk failures and to improve the safety of the VMAT-TBI program.RESULTS:We identified a total of 55 sub-processes and 128 FMs from the VMAT-TBI workflow. The top five high-risk FMs were: (1) Prescription and/or OAR constraints changed during planning and not communicated to the planner, (2) Patient moves or breathes too heavily during the upper body CT scan (3) Patient moves during the lower body CT scan, (4) Treatment planning system not calculating total body DVH metrics correctly for TBI, (5) Improper optimization criteria used or not sufficient optimization, resulting in suboptimal dose coverage, OAR sparing or excessive hotspots during treatment planning. Two FMs have average severity scores ≥8: Incorrect PTV subdivision/isocenter placement and Prescription and/or OAR constraints changed during planning and not communicated to the planner. Quality assurance and QC interventions including staff training, standard operating procedures, and quality checklists were implemented based on the FMEA and FTA.CONCLUSION:FM and effect analysis was performed to identify high-risk FMs of our VMAT-TBI program. FMEA and FTA were effective in identifying potential FMs and determining the best quality management (QM) measures to implement in the VMAT-TBI program.

•Half patients with anti-mGluR5 encephalitis from publications developed seizures.•We report a case of anti-mGluR5 encephalitis presenting with focal motor seizures.•Isolated focal seizure highlights an unusual feature of anti-mGluR5 encephalitis.

Objective.To establish an open framework for developing plan optimization models for knowledge-based planning (KBP).Approach.Our framework includes radiotherapy treatment data (i.e. reference plans) for 100 patients with head-and-neck cancer who were treated with intensity-modulated radiotherapy. That data also includes high-quality dose predictions from 19 KBP models that were developed by different research groups using out-of-sample data during the OpenKBP Grand Challenge. The dose predictions were input to four fluence-based dose mimicking models to form 76 unique KBP pipelines that generated 7600 plans (76 pipelines × 100 patients). The predictions and KBP-generated plans were compared to the reference plans via: the dose score, which is the average mean absolute voxel-by-voxel difference in dose; the deviation in dose-volume histogram (DVH) points; and the frequency of clinical planning criteria satisfaction. We also performed a theoretical investigation to justify our dose mimicking models.Main results.The range in rank order correlation of the dose score between predictions and their KBP pipelines was 0.50-0.62, which indicates that the quality of the predictions was generally positively correlated with the quality of the plans. Additionally, compared to the input predictions, the KBP-generated plans performed significantly better (P< 0.05; one-sided Wilcoxon test) on 18 of 23 DVH points. Similarly, each optimization model generated plans that satisfied a higher percentage of criteria than the reference plans, which satisfied 3.5% more criteria than the set of all dose predictions. Lastly, our theoretical investigation demonstrated that the dose mimicking models generated plans that are also optimal for an inverse planning model.Significance.This was the largest international effort to date for evaluating the combination of KBP prediction and optimization models. We found that the best performing models significantly outperformed the reference dose and dose predictions. In the interest of reproducibility, our data and code is freely available.

AbstractIntroductionUsing multi‐isocenter volumetric‐modulated arc therapy (VMAT) for total body irradiation (TBI) may improve dose uniformity and vulnerable tissue protection compared with classical whole‐body field technique. Two drawbacks limit its application: (1) VMAT‐TBI planning is time consuming; (2) VMAT‐TBI plans are sensitive to patient positioning uncertainties due to beam matching. This study presents a robust planning technique with image‐guided delivery to improve dose delivery accuracy. In addition, a streamlined sim‐to‐treat workflow with automatic scripts is proposed to reduce planning time.MaterialsTwenty‐five patients were included in this study. Patients were scanned in supine head‐first and feet‐first directions. An automatic workflow was used to (1) create a whole‐body CT by registering two CT scans, (2) contour lungs, kidneys, and planning target volume (PTV), (3) divide PTV into multiple sub‐targets for planning, and (4) place isocenters. Treatment planning included feathered AP/PA beams for legs/feet and VMAT for the body. VMAT‐TBI was evaluated for plan quality, planning/delivery time, and setup accuracy using image guidance.ResultsVMAT‐TBI planning time can be reduced to a day with automatic scripts. Treatment time took around an hour per fraction. VMAT‐TBI improved dose coverage (PTV V100 increased from 76.8 ± 10.5 to 88.5 ± 2.6; p < 0.001) and reduced lung dose (lung mean dose reduced from 10.8 ± 0.7 Gy to 9.4 ± 0.8 Gy, p < 0.001) compared with classic AP/PA technique.ConclusionA VMAT‐TBI sim‐to‐treat workflow with robust planning and image‐guided delivery was proposed. VMAT‐TBI improved the plan quality compared with classical whole‐body field techniques.

5.7 years, three patients died of their cancers, two patients had local recurrences and three patients developed distant metastases.There was no regional relapse, contralateral breast cancer or second non-breast cancer.Five-year overall and metastasis-free survivals were both 88% [73%-100%], whereas 5-year locoregional and local controls were both 100%.In univariate analysis only, pathological tumor size was significantly associated with overall survival and metastasis-free survival (HR = 1.26 [95% CI: 1.00-1.58],P = 0.04 and HR = 1.13 [95% CI: 1.00-1.28],P = 0.04, respectively).No patients developed grade ≥2 toxicity.Two patients experienced a grade 1 fibrosis, 2 patients had a grade 1 breast pain on the last clinical evaluation and 1 patient had a persistent grade 1 breast oedema.Conclusion: Radiotherapy appears effective and well-tolerated for locoregional management of resectable neuroendocrine breast cancers, as a complement to surgery.

The Breast JournalVolume 26, Issue 12 p. 2444-2446 COMMENTARY Treatment of diffuse cutaneous metastases from breast cancer Sarah M. C. Sittenfeld MD, Sarah M. C. Sittenfeld MD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorEric Murray CMD, Eric Murray CMD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorBingqi Guo PhD, Bingqi Guo PhD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorRahul Tendulkar MD, Rahul Tendulkar MD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorPing Xia PhD, Ping Xia PhD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorChirag Shah MD, Corresponding Author Chirag Shah MD shahc4@ccf.org orcid.org/0000-0002-9295-5554 Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA Correspondence Chirag Shah, MD, Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA. Email: shahc4@ccf.orgSearch for more papers by this author Sarah M. C. Sittenfeld MD, Sarah M. C. Sittenfeld MD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorEric Murray CMD, Eric Murray CMD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorBingqi Guo PhD, Bingqi Guo PhD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorRahul Tendulkar MD, Rahul Tendulkar MD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorPing Xia PhD, Ping Xia PhD Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USASearch for more papers by this authorChirag Shah MD, Corresponding Author Chirag Shah MD shahc4@ccf.org orcid.org/0000-0002-9295-5554 Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA Correspondence Chirag Shah, MD, Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA. Email: shahc4@ccf.orgSearch for more papers by this author First published: 11 September 2020 https://doi.org/10.1111/tbj.14049Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume26, Issue12December 2020Pages 2444-2446 RelatedInformation

Purpose/objectives To report our experience of combining three approaches of an automatic plan integrity check (APIC), a standard plan documentation, and checklist methods to minimize errors in the treatment planning process. Materials/methods We developed APIC program and standardized plan documentation via scripting in the treatment planning system, with an enforce function of APIC usage. We used a checklist method to check for communication errors in patient charts (referred to as chart errors). Any errors in the plans and charts (referred to as the planning errors) discovered during the initial chart check by the therapists were reported to our institutional Workflow Enhancement (WE) system. Clinical Implementation of these three methods is a progressive process while the APIC was the major progress among the three methods. Thus, we chose to compared the total number of planning errors before (including data from 2013 to 2014) and after (including data from 2015 to 2018) APIC implementation. We assigned the severity of these errors into five categories: serious (S), near miss with safety net (NM), clinical interruption (CLI), minor impediment (MI), and bookkeeping (BK). The Mann-WhitneyUtest was used for statistical analysis. Results A total of 253 planning error forms, containing 272 errors, were submitted during the study period, representing an error rate of 3.8%, 3.1%, 2.1%, 0.8%, 1.9% and 1.3% of total number of plans in these years respectively. A marked reduction of planning error rate in the S and NM categories was statistically significant (P < 0.01): from 0.6% before APIC to 0.1% after APIC. The error rate for all categories was also significantly reduced (P < 0.01), from 3.4% before APIC and 1.5% per plan after APIC. Conclusion With three combined methods, we reduced both the number and the severity of errors significantly in the process of treatment planning.

AbstractPurposeTo develop an automated workflow for whole breast irradiation treatment planning using hybrid intensity modulated radiation therapy (IMRT) approach and to demonstrate that this workflow can improve planning quality and efficiency when compared to manual planning.MethodsThe auto planning framework was built based on scripting with MIM and Pinnacle systems. MIM workflows were developed to automatically segment normal structures and targets, identify landmarks for beam placement, select beam energies, and set beam configurations. Pinnacle scripts were generated from the MIM workflow to create hybrid IMRT plans automatically. Each hybrid IMRT plan included two prescriptions: a three‐dimensional (3D) prescription consisted of two open tangent beams, and an IMRT prescription consisted of two step‐and‐shoot IMRT beams. The 3D prescription delivered a full prescription dose to the maximum dose point, and the IMRT prescription was optimized to deliver a uniform dose to the entire breast while sparing dose to the normal structures. For 30 patients, the auto plans were compared with clinically accepted manual plans using the paired sample t‐test.ResultsThe auto planning process took approximately 8 min to complete. The mean dice coefficients between auto‐segmentation and manual contours were 0.98, 0.94 and 0.88 for the lungs, heart, and PTVeval_Breast, respectively. The MUs of the auto plans was on average 13% higher than that of the manual plans. Auto planning improved plan quality significantly: percentage volume receiving 95% of the prescription dose (V95%) of the PTVeval_Breast increased from 91.5% to 93.2% (P = 0.001), V105% of the PTVeval_Breast decreased from 7.2% to 1.2% (P = 0.013), V20Gy of the ipsilateral lung decreased from 13.1% to 10.4% (P = 0.001) and mean heart dose for left‐sided breast patients decreased from 1.2 Gy to 0.9 Gy (P < 0.001).ConclusionAn automated treatment planning process can make the planning process efficient with improved plan quality.