Background and Purpose: Adaptive radiotherapy (ART) involves treatment re-planning based on anatomical changes, which may improve target coverage and sparing of organs-at-risk (OARs). This study retrospectively assessed the technical feasibility and potential benefits of daily ART in combination with reduced planning target volume (PTV) margins for head and neck squamous cell carcinoma (HNSCC). Materials and Methods: Thirty-one patients, encompassing 902 treatment fractions, treated with radiotherapy to 60.0-68.0 Gy in 2 Gy/fraction were studied. Synthetic CTs (sCT) from daily kVCT images were created and contours propagated using deformable image registration (DIR). Target contours were reviewed and corrected. On the sCT, non-adapted delivered doses and ART-plans with 5 mm (clinical standard) and 2 mm PTV-margin were evaluated. All daily dose distributions were then accumulated. Results: Target contours required correction in 48 % of the fractions. Daily non-adapted D98%,CTV was > 95 % in 890 (5 mm) and 825 (2 mm) out of 902 fractions. All adapted plans achieved D98%,CTV > 95 %. Significant reductions in mean doses to OARs were observed for PTV = 2 mm ART-plans: 4.1 Gy for parotid, 2.6 Gy for submandibular, 3.3 Gy for oral cavity, 4.0 Gy for esophagus, and 3.8 Gy for larynx. Conclusion: ART-planning on sCT and DIR propagated contours was feasible and promising for further clinical testing. To obtain a potential clinical benefit of ART, a synchronous reduction of the PTV-margin was warranted. Daily ART can be used to maintain adequate target dosimetry for every fraction, though for the accumulated treatment, insufficient target coverage without ART is unlikely to occur.

As a component of myeloablative conditioning before allogeneic hematopoietic stem cell transplantation (HSCT), Total Body Irradiation (TBI) is employed in radiotherapy centers all over the world. In recent and coming years, many centers are changing their TBI setup to a conformal isocentric technique, providing superior homogeneity and control of the target prescription dose, and more freedom for individualized organ-at-risk sparing or dose escalation. Also, more specifically bone-marrow- and/or lymphatics-targeted therapies such as Total Marrow (+ Lymphoid) Irradiation (TMI / TMLI), and Total Lymphoid Irradiation (TLI) are established and prospectively evaluated in several centers. With each center developing their own methods, a new practice heterogeneity is arising, as was the case for decades with conventional TBI. To provide a ground base - and therefore more options for more homogeneous and comparable practice - for centers who are implementing conformal isocentric techniques, a group of early adopters of isocentric conformal TBI and TM(L)I came together to convey issues they encountered during clinical implementation, and form consensus recommendations for delineation and planning targets, based on available literature evaluation and shared experience. These recommendations follow previously published recommendations regarding technical setup of conformal isocentric TBI / TM(L)I techniques.

As a component of myeloablative conditioning before allogeneic hematopoietic stem cell transplantation (HSCT), Total Body Irradiation (TBI) is employed in radiotherapy centers all over the world. In recent and coming years, many centers are changing their technical setup from a conventional TBI technique to multi-isocenter conformal arc therapy techniques such as Volumetric Modulated Arc Therapy (VMAT) or Helical Tomotherapy (HT). These techniques allow better homogeneity and control of the target prescription dose, and provide more freedom for individualized organ-at-risk sparing. The technical design of multi-isocenter/multi-plan conformal TBI is complex and should be developed carefully. A group of early adopters with conformal TBI experience using different treatment machines and treatment planning systems came together to develop technical recommendations and share experiences, in order to assist departments wishing to implement conformal TBI, and to provide ideas for standardization of practices.

Objectives Total body irradiation (TBI) is commonly used prior to hematopoietic stem cell transplantation (HSCT) in myeloablative conditioning regimens. However, TBI may be replaced by total marrow irradiation (TMI) at centres with access to Helical TomoTherapy, a modality that has the advantage of delivering intensity-modulated radiotherapy to long targets such as the entire bone marrow compartment. Toxicity after organ sparing TMI prior to HSCT has not previously been reported compared to TBI or with regard to engraftment data. Methods We conducted a prospective observational study on 37 patients that received organ sparing TMI prior to HSCT and compared this cohort to retrospective data on 33 patients that received TBI prior to HSCT. Results The 1-year graft-versus-host disease-free, relapse-free survival (GRFS) was 67.5% for all patients treated with TMI and 80.5% for patients with matched unrelated donor and treated with TMI, which was a significant difference from historical data on TBI patients with a hazard ratio of 0.45 (P = .03) and 0.24 (P < .01). Engraftment with a platelet count over 20 [K/mu L] and 50 [K/mu L] was significantly shorter for the TMI group, and neutrophil recovery was satisfactory in both treatment cohorts. There was generally a low occurrence of other treatment-related toxicities. Conclusions Despite small cohorts, some significant differences were found; TMI as part of the myeloablative conditioning yields a high 1-year GRFS, fast and robust engraftment, and low occurrence of acute toxicity.

Abstract Purpose In this study, we have quantified the setup deviation and time gain when using fast surface scanning for daily setup/positioning with weekly megavoltage computed tomography (MVCT) and compared it to daily MVCT. Methods A total of 16 835 treatment fractions were analyzed, treated, and positioned using our TomoTherapy HD (Accuray Inc., Madison, USA) installed with a Sentinel optical surface scanning system (C‐RAD Positioning AB, Uppsala, Sweden). Patients were positioned using in‐room lasers, surface scanning and MVCT for the first three fractions. For the remaining fractions, in‐room laser was used for setup followed by daily surface scanning with MVCT once weekly. The three‐dimensional (3D) setup correction for surface scanning was evaluated from the registration between MVCT and the planning CT. The setup correction vector for the in‐room lasers was assessed from the surface scanning and the MVCT to planning CT registration. The imaging time was evaluated as the time from imaging start to beam‐on. Results We analyzed 894 TomoTherapy treatment plans from 2012 to 2018. Of all the treatment fractions performed with surface scanning, 90 % of the residual errors were within 2.3 mm for CNS (N = 284), 2.9 mm for H&N (N = 254), 8.7 mm for thorax (N = 144) and 10.9 for abdomen (N = 134) patients. The difference in residual error between surface scanning and positioning with in‐room lasers was significant (P < 0.005) for all sites. The imaging time was assessed as total imaging time per treatment plan, modality, and treatment site and found that surface scanning significantly reduced patient on‐couch time compared to MVCT for all treatment sites (P < 0.005). Conclusions The results indicate that daily surface scanning with weekly MVCT can be used with the current target margins for H&N, CNS, and thorax, with reduced imaging time.

PURPOSE:We performed an open-label randomized controlled phase III study comparing treatment outcome and toxicity between radiotherapy (RT) with concomitant cisplatin versus concomitant cetuximab in patients with locoregionally advanced head and neck squamous cell carcinoma (HNSCC; stage III-IV according to the Union for International Cancer Control TNM classification, 7th edition).MATERIALS AND METHODS:Eligible patients were randomly assigned 1:1 to receive either intravenous cetuximab 400 mg/m2 1 week before start of RT followed by 250 mg/m2/wk, or weekly intravenous cisplatin 40 mg/m2, during RT. RT was conventionally fractionated. Patients with T3-T4 tumors underwent a second random assignment 1:1 between standard RT dose 68.0 Gy to the primary tumor or dose escalation to 73.1 Gy. Primary end point was overall survival (OS) evaluated using adjusted Cox regression analysis. Secondary end points were locoregional control, local control with dose-escalated RT, pattern of failure, and adverse effects.RESULTS:Study inclusion was prematurely closed after an unplanned interim analysis when 298 patients had been randomly assigned. At 3 years, OS was 88% (95% CI, 83% to 94%) and 78% (95% CI, 71% to 85%) in the cisplatin and cetuximab groups, respectively (adjusted hazard ratio, 1.63; 95% CI, 0.93 to 2.86; P = .086). The cumulative incidence of locoregional failures at 3 years was 23% (95% CI, 16% to 31%) compared with 9% (95% CI, 4% to 14%) in the cetuximab versus the cisplatin group (Gray's test P = .0036). The cumulative incidence of distant failures did not differ between the treatment groups. Dose escalation in T3-T4 tumors did not increase local control.CONCLUSION:Cetuximab is inferior to cisplatin regarding locoregional control for concomitant treatment with RT in patients with locoregionally advanced HNSCC. Additional studies are needed to identify possible subgroups that still may benefit from concomitant cetuximab treatment.

Mycosis fungoides is a disease with manifestation of the skin that has traditionally been treated with electron therapy. In this paper, we present a method of treating the entire skin with megavoltage photons using helical tomotherapy (HT), verified through a phantom study and clinical dosimetric data from our first two treated patients. A whole body phantom was fitted with a wetsuit as bolus, and scanned with computer tomography. We accounted for variations in daily setup using virtual bolus in the treatment plan optimization. Positioning robustness was tested by moving the phantom, and recalculating the dose at different positions. Patient treatments were verified with in vivo film dosimetry and dose reconstruction from daily imaging. Reconstruction of the actual delivered dose to the patients showed similar target dose as the robustness test of the phantom shifted 10 mm in all directions, indicating an appropriate approximation of the anticipated setup variation. In vivo film measurements agreed well with the calculated dose confirming the choice of both virtual and physical bolus parameters. Despite the complexity of the treatment, HT was shown to be a robust and feasible technique for total skin irradiation. We believe that this technique can provide a viable option for Tomotherapy centers without electron beam capability.

Total Marrow Irradiation (TMI) with Helical Tomotherapy is a radiotherapy treatment technique that targets bone marrow and sanctuary sites prior to stem cell or bone marrow transplantation (SCT/BMT). TMI is a complex procedure that involves several critical steps that all need to be carefully addressed for a successful implementation, such as dose homogeneity in field junctions, choice of target margins, integrity of treatment and back-up planning. In this work we present our solution for a robust and reproducible workflow throughout the treatment chain and data for twenty-three patients treated to date.MATERIAL & METHODS:Patients were immobilized in a whole body vacuum cushion and thermoplastic mask. CT-scanning and treatment were performed in two parts with field matching at the upper thigh. Target consisted of marrow containing bone and sanctuary sites. Lungs, kidneys, bowel, heart and liver were defined as organs at risk (OAR). A fast surface scanning system was used to position parts of the body not covered by the imaging system (MVCT) as well as to reduce treatment time.RESULTS:All patients completed their treatment and could proceed with SCT/BMT. Doses to OARs were significantly reduced and target dose homogeneity was improved compared to TBI. Robustness tests performed on field matching and patient positioning support that the field junction technique is adequate. Replacing MVCT with optical surface scanning reduced the treatment time by 25 min per fraction.CONCLUSION:The methodology presented here has shown to provide a safe, robust and reproducible treatment for Total Marrow Irradiation using Tomotherapy.

Allogenic and autologous stemcell transplantations have been a standard procedure at the department for more than 30 years. For patients receiving irradiation as part of the pre-transplant conditioning, Total Body Irradiation (TBI) has been the irradiation technique until 2015 when we implemented Total Marrow Irradiation (TMI) using helical tomotherapy. There are limited clinical experiences reported with TMI, and the experiences we report for pediatric patients may be of value to other centers considering TMI.

Dose mimicking allows for the automatic creation and optimization of coplanar/non-coplanar three dimensional conformal radiation therapy (3DCRT), step-and-shoot intensity-modulated radiation therap...

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Background and purposeThe purpose of this study was to investigate the correlation between the haematological toxicity observed in patients treated with craniospinal irradiation, and the dose distribution in normal tissue, specifically the occurrence of large volumes exposed to low dose.Materials and methodsTwenty adult male patients were included in this study; eight treated with helical tomotherapy (HT), and twelve with three-dimensional conformal radiation therapy. The relative volume of red bone marrow and body that was exposed to low dose (i.e. the so-called dose bath) was evaluated and correlated with nadir blood values during treatment, i.e. the severity of anaemia, leukopaenia, and thrombocytopaenia. The correlation was tested for different dose levels representing the dose bath using the Pearson product-moment correlation method.ResultsWe found a significant correlation between the volume of red bone marrow exposed to low dose and the severity of thrombocytopaenia during treatment. Furthermore, for the HT patients, a significant correlation was found between the relative volume of the body exposed to low dose and the severity of anaemia and leukopenia.ConclusionsThe severity of haematological toxicity correlated with the fraction of red bone marrow or body that was exposed to low dose.

Purpose. In this work we explore a method named clinical grading analysis (CGA) which is based on clinical assessments performed by radiation oncologists (ROs). The purpose is to investigate how useful the method is for treatment plan comparisons, and how the CGA results correlate with dosimetric evaluation parameters, traditionally used for treatment plan comparisons. Material and methods. Helical tomotherapy (HTT) and seven-beam step-and-shoot intensity modulated radiation therapy (SS-IMRT) plans were compared and assessed by 10 experienced ROs for 23 patient cases. A CGA was performed where the plans were graded based on how the ROs thought they compared to each other. The resulting grades from the CGA were analyzed and compared to dose-volume statistics and equivalent uniform dose (EUD) data. Results. For eight of the 23 cases the CGA revealed a significant difference between the HTT and the SS-IMRT plans, five cases were in favor of HTT, and three in favor of SS-IMRT. Comparing the dose-volume statistics and EUD-data with the result from the CGA showed that CGA results correlated well with dose-volume statistics for cases regarding difference in target coverage or doses to organs at risk. The CGA results also correlated well with EUD-data for cases with difference in clinical target volume (CTV) coverage but the correlation for cases with difference in planning target volume (PTV) coverage was not as clear. Conclusions. This study presents CGA as a useful method of comparing radiotherapy treatment plans. The proposed method offers a formalized way of introducing and evaluating the implementation of new radiotherapy techniques in a clinical setting. The CGA identify patients that have a clinical benefit of one or the other of the advanced treatment techniques available to them, i.e. in this study HTT and SS-IMRT, which facilitates a more optimal use of a clinics' advanced treatment resources.