Abstract Background Cancer-related fatigue is one of the most common and persistent issues experienced by cancer patients. Cancer-related fatigue is a distinct form of fatigue that is subjective, long-lasting and unalleviated by rest or sleep. Studies have shown that almost all cancer patients experience severe fatigue that disrupts the quality of life and physical function, but cancer-related fatigue remains under-addressed in clinical care, and only about half of all patients receive treatment. Methods To increase the awareness of cancer-related fatigue and improve current management, the Taiwan Society of Cancer Palliative Medicine and the Taiwan Oncology Nursing Society convened a consensus committee to develop recommendations for the screening, assessment and treatment of cancer-related fatigue. Results Thirteen consensus recommendations were subsequently developed based on the best available evidence and the clinical experience of committee members. Conclusions These recommendations are expected to facilitate the standardization of cancer-related fatigue management across Taiwan and may also serve as a reference for other clinicians.

Objectives: Breast reconstruction helps patients enhance their body image after mastectomy. Metallic ports in tissue expanders lead to dose attenuation during radiotherapy. Tissue expander volume shifts the metallic port position, possibly causing various dose alterations. This study aimed to evaluate the impact of the MAGNA-SITE TM tissue expander volume on tomotherapy. Methods: Boluses and MAGNA-SITE TM were placed on a Rando phantom to simulate the tissue expander under the pectoralis major. Computed tomography simulation images were transformed through replacing the electron density of (a) metallic artifact region only (Image metallic port) and (b) metallic port and artifact regions (Image Homo). Planning was calculated using fixed-beam and helical-mode techniques. Radiation was delivered with different volumes of the tissue expander. Results: Integrated 997 dose points were calculated. Planning with Image metallic port provided a calculated dose significantly closer to a realistic dose. The percentage of doses achieving the prescribed dose was significantly higher in the helical mode. In layer 2, the 100-mL tissue expander had a significantly lower measurement dose than all other volumes. Volume 150 mL had the highest increase in the measured dose difference from the plan dose at layer 2. Volume 250 mL had the highest percentage of measurement doses passing the 5% dose difference from plan dose. The coldest dose areas were noted in layers 1 and 2, especially in the metallic port–direct image mode. The average dose reduction of the measured cold areas was 6.03 ± 1.94%. Conclusion: Dose distribution was affected by the volume of the metallic port tissue expander. Tomotherapy with proper image heterogeneity correction and helical mode can reduce the attenuation from the metallic port. A tissue expander volume of 150 to 250 mL is suitable. Patients with high risk at the chest wall should be evaluated carefully to avoid underdosing. Radiation oncologists should closely cooperate with plastic surgeons to optimize treatment for each patient.

Breast cancer (BC) with cardiac metastases (CMs) is often associated with poor prognosis due to late stage of diagnosis.Palliative radiotherapy (RT) for CMs is generally used for symptomatic treatment and to maintain normal cardiac function.Palliative RT with hyperthermia (HT) or immunotherapy have been reported to be effective in prolonging the overall survival and progression-free survival in metastatic patients.In this case report, we present a heavily pretreated 51-year-old lady of metastatic BC presented with recurrent right breast mass with progressive exertional dyspnea caused by symptomatic CM.She received combined palliative low-dose palliative RT [20 Gray (Gy) in 12 fractions], combined with lowdose chemotherapy, biweekly HT treatment course, and low-dose "double blockade" immunotherapy by ipilimumab (0.3 mg/kg) and nivolumab (0.5 mg/kg).The irradiated right chest tumors responded rapidly to treatment.Interestingly, unirradiated metastatic lesions outside the RT and HT treatment field also demonstrated a sustained abscopal response.She continued monthly low-dose immunotherapy in conjunction with HT after RT.The posttreatment cardiac echography disclosed considerably reduced pericardial effusions without cardiac wall motion abnormalities.She remained stable for more than 6 months with no notable treatment-related toxicities.The combination of low-dose RT, low-dose immunotherapy, and HT protocol appears to be a safe method with promising efficacy in metastatic BC patients.

Abstract Purpose The purpose of this study is to introduce half‐beam volumetric‐modulated arc therapy (HVMAT), an innovative treatment planning technique from our work, for reducing dose to the organs at risk (OAR) during adjuvant radiotherapy for gynecological cancers. Methods and materials Seventy‐two treatment plans of 36 patients with gynecological cancers receiving adjuvant radiotherapy were assessed. Among them, 36 plans were designed using HVMAT and paired with the other 36 traditional volumetric‐modulated arc therapy (VMAT) plans for each patient. The main uniqueness of the HVMAT designs was that it consisted of two opposite‐shielded half‐beam fields rotated inversely in two coplanar arcs, collocating with the specially‐devised avoidance structures to enhance the control of the OAR doses. The dose distributions in HVMAT and VMAT were evaluated and compared using the random effects model. Results The ratios of OAR doses in HVMAT compared with VMAT showed a comprehensive OAR dose reduction when using HVMAT (V 20Gy: bladder, 0.92; rectum, 0.95; V 30Gy: bowel, 0.91; femoral heads, 0.66), except for the ilium (V 30Gy: 1.12). The overall mean difference for each OAR across V 40Gy, V 30Gy, V 20Gy, and bowel V 15Gy was statistically significant (almost all p < 0.001). In addition, HVMAT promoted a better conformity index, homogeneity index, D 2%, and V 107% of the planning target volume (all p < 0.001). Conclusions HVMAT is capable of generating deep double‐concave dose distributions with the advantage of reducing dose to several OARs simultaneously. It is highly recommended for pelvic irradiation, especially for treating gynecological cancers in adjuvant radiotherapy.

Cervical cancer patients may sometimes experience subserosal tandem insertions during brachytherapy, which can lead to increased but unnoticed irradiations to the small bowel (SB). In this study, we aimed to quantify and further predict individual SB dose increase and to increase focus on the SB in subserosal tandem insertions. Images and dosimetry data of cervical cancer brachytherapy with subserosal insertion (SI) were reviewed. The percentage increases in the SB dose compared with intracavitary insertion (II) at 8 points of D(x)cc with 10 cc intervals were assessed. SI was classified into anterior and posterior SI according to the insertion site. The differences in minimum distance from the tandem tip to the SB on the axial view between these 2 insertions were tested using the Mann-Whitney test. The distance and D(x)cc were involved in the individual dose increase model by linear regression as prediction factors. A total of 27 insertions were evaluated, including 8 insertions with SI and 19 insertions with II. The median percentage increases in the normalized SB dose for all SI showed a logarithmic trend with a 55.4% increase at the hotspot. In contrast to posterior SI, anterior SI demonstrated a more significantly logarithmic trend, which featured highly increased doses at the hotspot (79.1% for the absolute SB dose and 137.8% for the normalized SB dose). The prediction models can predict the percentage dose increases in SI: Increased D(x)cc [%] = 31.370 - 7.865 ln(distance) - 3.949 ln(x) (absolute SB dose), and Increased D(x)cc [%] = 55.618 - 18.591 ln(distance) - 7.232 ln(x) (normalized SB dose). We developed prediction models for individual SB dose increase in SI in our study. SB hotspots in anterior SI require greater attention during cervical cancer brachytherapy. The models are new ones and are given for the first time. (C) 2019 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.

Background: To ensure high accuracy during radiation therapy (RT), the image-guided RT (IGRT) technique uses on-board cone-beam computed tomography (CBCT) scanning as an image guidance procedure for target localization before and during treatment. Adaptive RT aiming to modify RT target volumes according to kinetic changes in tumor shape during RT course is based on registration of CBCT and planning CT images. However, the re-contouring and re-planning procedures are extensively time and cost consuming. We developed a novel automatic contouring and image registration method to replace the manual re-contouring with accurate image registration. Methods: For the image sets with format of Digital Imaging and Communications in Medicine (DICOM) standard, we wrote a program in MATLAB language (Version R2016a) to read and convert CBCT images into cross-sectional (tomographic) images similar to those obtained via planning CT. For image enhancement, the active contouring by using Chan-Vese model with level set formulation was applied. To overcome the variations in spatial location of these two sets of CT images, the iterative closest point (ICP) algorithm was used for 3D model registration. The deformable image registration (DIR) with Double force Demons algorithm was performed for auto-transformation of contours from planning CT to CBCT images. Results: The customized program accurately converted the format of CBCT to planning CT. Image enhancement was achieved by our modified active contour model which solved the energy minimization problem. In 3D model registration, the variations in spatial location of the CBCT and planning CT images were corrected. After selection of most similar images, the planning CT images were registered to corresponding CBCT images. The registered images were clearer than CBCT images with removal of other confounding structures outside body contours. Conclusions: The planning CT and CBCT images could be precisely registered by using a novel established technique consisting of active contouring with 3D model and DIR. This technique would enable the on-line radiation treatment planning for adaptive radiotherapy.

Cervical cancer patients may sometimes experience different types of uterine perforation by a tandem during brachytherapy. The purpose of this study was to address possibly different management strategies regarding different tandem positions from a dosimetry aspect by evaluating radiation doses delivered to organs-at-risk (OAR) in order to help medical professionals handle different types of uterine perforation. Images and dosimetry data in cervical cancer brachytherapy with uterine perforation were reviewed. Uterine perforation was classified into anterior and posterior perforation according to their tandem positions. Radiation doses received by OAR, including D2cc and D1cc of the bladder, rectum, and sigmoid colon, were statistically compared with nonperforation. The doses of high-risk clinical target volume (HR-CTV) of cervical tumor and bilateral point A were also compared in order to assure that the plans had not compromised the treatment efficacy. A total of 21 applications were assessed, including 5 with anterior perforation, 4 with posterior perforation, and 12 without perforation. In anterior perforation, the bladder was the only organ that received a significantly increased dose about 30% at D2cc and D1cc. However, in posterior perforation, multiple OAR received significantly excessive doses: approximately 30% for the bladder, 37% for the rectum, and 100% for the sigmoid colon. The OAR dose assessment was based on a statistically equivalent cervical tumor dose. Different management strategies are possible for anterior vs posterior perforation during brachytherapy due to different detrimental extents on OAR dosimetry. The bladder warrants more attention in anterior perforation, without compromising target coverage in treatment planning. On the other hand, repositioning may be considered in posterior perforation due to relatively massive OAR detriments. This concept is a new one and is given for the first time.

Soft tissue sarcoma of the hand is rare, with synovial sarcoma being among the most common pathological diagnoses. As postoperative radiation therapy for synovial sarcoma, a 22-year-old male patient was treated with a total dose of 60 Gy, administered in 30 daily fractions. This report reviews the clinical outcome of the patient treated at our institution and discusses the appropriate treatment strategies for synovial sarcoma of the hand.

Background: Adjuvant radiotherapy reduces local recurrence and improves overall survival of breast cancer. But adjuvant radiotherapy also leads to excess mortality caused by heart and lung disease. Deep inspiration breath hold (DIBH) technique has been proven to reduce radiation exposure to heart and lung. However, effectiveness of DIBH variates from each patient. This study collected one institutional data and further analyzed associated physical factors. Methods: Left breast cancer patients received left partial mastectomy followed by adjuvant radiotherapy with DIBH technique between Sep 1, 2013 and Sep 1, 2014 were included. Treatment plans based on both free breathing (FB) and DIBH computed tomography scan image for each patient were constructed. Physical factors including chest wall expansion at different levels were measured. Dose of ipsilateral, contralateral, and total lung, and heart were compared between FB and DIBH. Correlation between normal organ irradiated dose and physical factors change were calculated by Pearson correlation test. Results: Anterior-to-posterior diameter (APd) increase of lung at half upper chest wall level, upper heart border level, and half lower chest wall level, and extra lung length of DIBH had positive correlation with the reduction of irradiated lung dose. The increase of APd of lung at upper heart border level, half lower chest wall level, and right-to-left diameter (RLd) at diaphragm level also had positive correlation with the reduction of Dmax of heart (Pearson correlation r=0.795, 0.835, 0.655; P=0.006, 0.003, and 0.04, respectively) and Dmax of left anterior descending artery (LAD) (r=0.788, 0.795, 0.673; P=0.007, 0.006, and 0.033, respectively). Increase of free-contour heart height had negative correlation with V30, Dmax of heart, and Dmax of LAD. Conclusions: DIBH can reduce dose to critical organs. One-point chest wall motion monitored by Real-time Position ManagementTM (RPM) system can only represent the change of APd at diaphragm level and part of the change of half of lower chest wall level. Respiration is a complicated motion and multiple level monitoring system was suggested. Patient education to explain the idealist chest wall expansion condition with DIBH is important. Our CT-based instruction model provides a clearer instruction. This study suggested a new direction to evaluate and enhance DIBH performance.

Tangent-based intensity modulated radiation therapy (TIMRT) is a common adjuvant radiotherapy strategy for breast cancer patients. This study compared the dosimetric characteristics of tangent-based volumetric modulated arc therapy (TVMAT) and TIMRT for left breast cancer patients during deep inspiration breath-hold (DIBH) and free breathing (FB) techniques.

Purpose.Joint estimation of risks of radiation-induced secondary lung cancer (SLC) and ischemic heart disease (IHD) modeled with consideration of patient-level risk factors and risk of cancer recurrence caused by compromising target coverage.Methods.Five patients with bilateral breast cancer were treated with postoperative radiotherapy in 2013-2016: two patients received chest wall and comprehensive nodal irradiation (2 Gy x 25), two patients received whole breast irradiation (2.67 Gy x 15) and one patient received whole breast and left-sided lymph node irradiation (2 Gy x 25).Two patients were treated with 3D-CRT, three patients with VMAT.All patients were re-planned with intensity modulated spotscanning proton therapy.One or three fields were used (anterior, left anterior oblique and right anterior oblique) with multi-field optimization.Models estimating risks of SLC and IHD were developed from published dose-response data and a model for risk of recurrence was derived based on hazard ratios from published randomized trials.Results.The average mean heart dose was 7.6 (range, 1.5-12.7)Gy for the photon plans while mean heart dose was below 0.4 Gy (RBE) for proton plans in all patients using protons (RBE, relative biological effectiveness, assuming RBE = 1.1).The average values of the mean lung dose and V20Gy were 12.2 (range, 5.2-16.3)Gy and 20.7% (range, 10.1%-27.4%)for photon plans, and 5.0 (range, 0.8-9.2) Gy (RBE) and 9.6% (range, 0.8%-19.1%)for proton plans.Median excess absolute risk (EAR) of SLC by age 80 for nonsmokers/smokers was 2.6% (range, 0.6%-2.8%)/5.3%(range, 1.1%-5.7%)with photon therapy and 1.2% (range, 0.1%-1.6%)/2.4% (range, 0.2%-3.2%)with proton therapy.For the photon plans median EAR of IHD by age 80 was 2.8% (range, 0.2%-3.2%)/4.5% (range, 0.5%-5.6%)without/with cardiac risk factors whereas risks were below 0.2% for both scenarios using protons.Median EAR of recurrence or death by ten years was 0.9% (range, 0.1%-1.9%)with photons and 0.1% (range, 0.1%-0.3%)with protons.Conclusions.Proton therapy did reduce the predicted risk of SLC and IHD by up to 3.3% and 5.5%, respectively, and the risk of recurrence by up to 1.6% in individual patients.

dictive of clinical acceptable agreement in the target and dose falloff regions.The difference between the performances of ArcCheck Sm and HDm acquisition modes was not clinically relevant.The Arc-Check Sm and EBT3 film PR were significantly correlated between them.An optimal LOA <5% was found between ArcCheck and EBT3 film PR setting the local gamma analysis DTA criterion to 1 mm and the DD% respectively to 4% and 3%.Conclusions.The ArcCheck diode arrays resulted suitable for PsQA at the accuracy level required by SBRT treatments.An optimal LOA <5%, was found between the ArcCheck and the EBT3 film PR with properly selected local gamma criteria.

To introduce the benefits of tangent-based volumetric modulated arc therapy (TVMAT), an innovative radiotherapy planning technique, compared with traditional volumetric modulated arc therapy (VMAT) for advanced left breast cancer needing nodal irradiation.

To analyze the respiratory-induced motion of each liver segment using helical computed tomography (helical CT) and 4-dimensional computed tomography (4DCT), and to establish the individual segment expansion margin of internal target volume (ITV) to facilitate target delineation of tumors in different liver segments.

Background: Planning skills such as skin flash in intensity-modulated radiation therapy (IMRT), virtual bolus in helical tomotherapy (HT) and tissue equivalent materials are widely used in breast cancer radiotherapy (RT) to ensure coverage of superficial target under respiration. This study was conducted to evaluate the exact skin dose under above treatment technique and planning skills. Methods: Women who received whole breast RT (WBRT) or post-mastectomy RT (PMRT) were included. Treatment machines included Synergy® (Elekta, Stockholm, Sweden) and TomoTherapy Hi-ART® (Accuray, Sunnyvale, CA, USA). For WBRT, 20 mm “skin flash” was used in IMRT, and 10 mm “virtual bolus” was used in HT. For PMRT, 5 mm bolus plus skin flash was used in IMRT and 10 mm bolus was used in HT. GafChromic EBT3 (International Specialty Products, Wayne, NJ, USA) films were placed on patient’s skin for measurement. Results: Between July 2012 and December 2013, 17 patients in WBRT group and 13 patients in PMRT group were included. In WBRT group, patients received higher skin dose with IMRT than with HT (86.57% and 79.69% of prescribed dose, respectively, P<0.0001). IMRT delivered 4–5% higher dose to central skin region than bilateral regions, while skin dose distribution of HT was relatively homogeneous. In PMRT group, IMRT delivered higher surface dose than HT did (107.34% and 100.28% of prescribed dose, respectively, P<0.0001). Conclusions: For WBRT, HT plus virtual bolus leads to homogeneous skin dose distribution and 7% lower skin dose than IMRT does. For PMRT, HT plus 10 mm bolus provides adequate surface dose which is close to 100% of prescribed dose; while IMRT plus 5 mm bolus and skin flash results in overdose with 7% more than prescribed dose. HT should be considered to be an option of breast RT.

The purpose of this study is to investigate the dose perturbation caused by the metal ovoid structures of a Henschke applicator using Monte Carlo simulation in a realistic phantom. The Henschke applicator has been widely used for gynecologic patients treated by brachytherapy in Taiwan. However, the commercial brachytherapy planning system (BPS) did not properly evaluate the dose perturbation caused by its metal ovoid structures. In this study, Monte Carlo N-Particle Transport Code eXtended (MCNPX) was used to evaluate the brachytherapy dose distribution of a Henschke applicator embedded in a Plastic water phantom and a heterogeneous patient computed tomography (CT) phantom. The dose comparison between the MC simulations and film measurements for a Plastic water phantom with Henschke applicator were in good agreement. However, MC dose with the Henschke applicator showed significant deviation (−80.6%±7.5%) from those without Henschke applicator. Furthermore, the dose discrepancy in the heterogeneous patient CT phantom and Plastic water phantom CT geometries with Henschke applicator showed 0 to −26.7% dose discrepancy (−8.9%±13.8%). This study demonstrates that the metal ovoid structures of Henschke applicator cannot be disregard in brachytherapy dose calculation.

Mucoepidermoid carcinoma of the orbit is an uncommon neoplasm. We report a 62-year-old Taiwanese man developed a painless proptosis for 8 years. He underwent tumor resection. By histopathology, mucoepidermoid carcinoma was diagnosed. Owing to the rare incidence, the role of adjuvant radiotherapy (RT) in the disease control has not been defined. Several episodes of recurrence developed despite repeated surgery in this case. The patient was treated with the adjuvant TomoTherapy afterwards. The results at 2 years image follow up revealed stationary tumor volume state after treatment. Therefore, adjuvant RT could be an option of treatment for recurrent mucoepidermoid carcinoma arising from the eye following surgery. Treatment decision making of this case is discussed and previous reports are reviewed in this article.

Background/Purpose: Evidence on the prevention of radiation dermatitis is lacking. The aim of this study was to investigate the effect of 3M Cavilon No Sting Barrier Film and topical corticosteroids on irradiated skin.Methods: Thirty-nine postoperative breast cancer patients were randomized into three groups for intraindividual comparison (skin to be irradiated was divided into 2 parts): (1) 3M No Sting Barrier Film versus no treatment; (2) corticosteroid versus no treatment; and (3) corticosteroid versus 3M No Sting Barrier Film. The primary end points monitored were the time to first occurrence of grade 1 pruritus, pain score of 3 and grade 2 radiation dermatitis. The secondary end points studied were the incidence of grade 3 radiation dermatitis and total pain scores. Data analysis was done using the SPSS software version 10.Results: Skin given the 3M barrier film experienced a later occurrence of pruritus compared to both corticosteroids and untreated, although this was statistically insignificant. Corticosteroids delayed the time to occurrence of grade 2 dermatitis compared to both untreated skin and 3M barrier film, (mean day of onset Z corticosteroid: 52 vs. untreated: 43, p = 0.092; corticosteroid: 53.4 vs. 3M barrier film: 44.5, p = 0.002, t test). Skin given corticosteroids had the lowest incidence of grade 3 dermatitis among all three conditions, although the differences were statistically insignificant. No statistically significant differences were noted in total pain scores.Conclusion: The 3M barrier film may be helpful against dermatitis associated pruritus. Corticosteroids may delay the time of onset of severe skin reactions and also reduce the incidence of severe radiation dermatitis. Copyright (C) 2013, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

Background: High pre-operative CA125 levels in women with endometrial cancer may be related to lymph node metastases and poor prognosis. Aim: To evaluate whether pre-operative cancer antigen 125 (CA125) levels are associated with lymph node metastases and prognosis in endometrial cancer.Methods: One hundred and twenty women with endometrial cancer were retrospectively reviewed for pre-operative CA125 levels. The results were then correlated with the clinicopathological outcome.Results: An elevated CA125 (>40 U/mL) was significantly correlated with higher stage, higher grade, increased depth of myometrial invasion, lymph node metastases and the presence of lympho-vascular space involvement in endometrial cancer. Five-year overall survival (OS) and recurrence-free survival (RFS) rates were significantly higher in women with endometrial cancer with CA125 <= 40 U/mL than those with CA125 > 40 U/mL (P < 0.001). When women were further stratified according to CA125 levels and lymph node status, OS and RFS were highest for those with CA125 <= 40 U/mL and without lymph node metastases, and lowest for those with lymph node metastases and CA125 > 40 U/mL (P < 0.001).Conclusion: The testing of pre-operative CA125 levels may a useful prognostic tool in endometrial cancer management.

Dose perturbation caused by the Henschke applicator is a major concern for the brachytherapy planning system (BPS) in recent years. To investigate dose impact owing to neglect of the metal shielding effect, Monte Carlo (MC) simulation, BPS calculation, and film measurement have been performed for dose assessment in a water phantom. Additionally, a cylindrical air cavity representing the rectum was added into the MC simulation to study its effect on dose distribution. Monte Carlo N-Particle Transport Code (MCNP) was used in this study to simulate the dose distribution using a mesh tally. This Monte Carlo simulation has been validated using the TG-43 data in a previous report. For the measurement, the Henschke applicator was placed in a specially-designed phantom, and Gafchromic films were inserted in the center plane for 2D dose assessment. Isodose distributions with and without the Henschke applicator by the MC simulation show significant deviation from those by the BPS. For MC simulation, the isodose curves shrank more significantly when the metal applicator was applied. For the impact of the added air cavity, the results indicate that it is hard to distinguish between with and without the cavity. Thus, the rectum cavity has little impact on the dose distribution around the Henschke applicator.