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Title: eNAL: An Extension of the NAL Setup Correction Protocol for Effective Use of Weekly Follow-up Measurements

Abstract

Purpose: The no action level (NAL) protocol reduces systematic displacements relative to the planning CT scan by using the mean displacement of the first few treatment fractions as a setup correction in all subsequent fractions. This approach may become nonoptimal in case of time trends or transitions in the systematic displacement of a patient. Here, the extended NAL (eNAL) protocol is introduced to cope with this problem. Methods and Materials: The initial setup correction of eNAL is the same as in NAL. However, in eNAL, additional weekly follow-up measurements are performed. The setup correction is updated after each follow-up measurement based on linear regression of the available measured displacements to track and correct systematic time-dependent changes. We investigated the performance of eNAL with Monte Carlo simulations for populations without systematic displacement changes over time, with large gradual changes (time trends), and with large sudden changes (transitions). Weekly follow-up measurements were simulated for 35 treatment fractions. We compared the outcome of eNAL with NAL and optimized shrinking action level (SAL) protocol with weekly measurements. Results: Without time-dependent changes, eNAL, SAL, and NAL performed comparably, but SAL required the largest imaging workload. For time trends and transitions, eNAL performed superiorly to themore » other protocols and reduced systematic displacements to the same magnitude as in case of no time-dependent changes (SD {approx}1 mm). Conclusion: Extended NAL can reduce systematic displacements to a minor level irrespective of the precise nature of the systematic time-dependent changes that may occur in a population.« less

Authors:
 [1];  [2]
  1. Division of Medical Physics, Department of Radiation Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam (Netherlands). E-mail: j.deboer@erasmusmc.nl
  2. Division of Medical Physics, Department of Radiation Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam (Netherlands)
Publication Date:
OSTI Identifier:
20951607
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 67; Journal Issue: 5; Other Information: DOI: 10.1016/j.ijrobp.2006.11.050; PII: S0360-3016(06)03656-X; Copyright (c) 2007 Elsevier Science B.V., Amsterdam, Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; COMPUTERIZED SIMULATION; COMPUTERIZED TOMOGRAPHY; CORRECTIONS; IMAGES; MONTE CARLO METHOD; PARTICLE TRACKS; PATIENTS; PERFORMANCE; PLANNING; RADIOTHERAPY; TIME DEPENDENCE

Citation Formats

Boer, Hans C.J. de, and Heijmen, Ben J.M. eNAL: An Extension of the NAL Setup Correction Protocol for Effective Use of Weekly Follow-up Measurements. United States: N. p., 2007. Web. doi:10.1016/j.ijrobp.2006.11.050.
Boer, Hans C.J. de, & Heijmen, Ben J.M. eNAL: An Extension of the NAL Setup Correction Protocol for Effective Use of Weekly Follow-up Measurements. United States. doi:10.1016/j.ijrobp.2006.11.050.
Boer, Hans C.J. de, and Heijmen, Ben J.M. Sun . "eNAL: An Extension of the NAL Setup Correction Protocol for Effective Use of Weekly Follow-up Measurements". United States. doi:10.1016/j.ijrobp.2006.11.050.
@article{osti_20951607,
title = {eNAL: An Extension of the NAL Setup Correction Protocol for Effective Use of Weekly Follow-up Measurements},
author = {Boer, Hans C.J. de and Heijmen, Ben J.M.},
abstractNote = {Purpose: The no action level (NAL) protocol reduces systematic displacements relative to the planning CT scan by using the mean displacement of the first few treatment fractions as a setup correction in all subsequent fractions. This approach may become nonoptimal in case of time trends or transitions in the systematic displacement of a patient. Here, the extended NAL (eNAL) protocol is introduced to cope with this problem. Methods and Materials: The initial setup correction of eNAL is the same as in NAL. However, in eNAL, additional weekly follow-up measurements are performed. The setup correction is updated after each follow-up measurement based on linear regression of the available measured displacements to track and correct systematic time-dependent changes. We investigated the performance of eNAL with Monte Carlo simulations for populations without systematic displacement changes over time, with large gradual changes (time trends), and with large sudden changes (transitions). Weekly follow-up measurements were simulated for 35 treatment fractions. We compared the outcome of eNAL with NAL and optimized shrinking action level (SAL) protocol with weekly measurements. Results: Without time-dependent changes, eNAL, SAL, and NAL performed comparably, but SAL required the largest imaging workload. For time trends and transitions, eNAL performed superiorly to the other protocols and reduced systematic displacements to the same magnitude as in case of no time-dependent changes (SD {approx}1 mm). Conclusion: Extended NAL can reduce systematic displacements to a minor level irrespective of the precise nature of the systematic time-dependent changes that may occur in a population.},
doi = {10.1016/j.ijrobp.2006.11.050},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 5,
volume = 67,
place = {United States},
year = {Sun Apr 01 00:00:00 EDT 2007},
month = {Sun Apr 01 00:00:00 EDT 2007}
}
  • Purpose: Weekly paclitaxel, concurrent radiation, and androgen deprivation (ADT) were evaluated in patients with high-risk prostate cancer (PC) with or without prior prostatectomy (RP). Methods and Materials: Eligible post-RP patients included: pathological T3 disease, or rising prostate-specific antigen (PSA) {>=}0.5 ng/mL post-RP. Eligible locally advanced PC (LAPC) patients included: 1) cT2b-4N0N+, M0; 2) Gleason score (GS) 8-10; 3) GS 7 + PSA 10-20 ng/mL; or 4) PSA 20-150 ng/mL. Treatment included ADT (4 or 24 months), weekly paclitaxel (40, 50, or 60 mg/m{sup 2}/wk), and pelvic radiation therapy (total dose: RP = 64.8 Gy; LAPC = 70.2 Gy). Results: Fifty-ninemore » patients were enrolled (LAPC, n = 29; RP, n = 30; ADT 4 months, n = 29; 24 months, n = 30; whites n = 29, African Americans [AA], n = 28). Baseline characteristics (median [range]) were: age 67 (45-86 years), PSA 5.9 (0.1-92.1 ng/mL), GS 8 (6-9). At escalating doses of paclitaxel, 99%, 98%, and 95% of doses were given with radiation and ADT, respectively, with dose modifications required primarily in RP patients. No acute Grade 4 toxicities occurred. Grade 3 toxicities were diarrhea 15%, urinary urgency/incontinence 10%, tenesmus 5%, and leukopenia 3%. Median follow-up was 75.3 months (95% CI: 66.8-82.3). Biochemical progression occurred in 24 (41%) patients and clinical progression in 11 (19%) patients. The 5- and 7-year OS rates were 83% and 67%. There were no differences in OS between RP and LAPC, 4- and 24-month ADT, white and AA patient categories. Conclusions: In addition to LAPC, to our knowledge, this is the first study to evaluate concurrent chemoradiation with ADT in high-risk RP patients. With a median follow-up of 75.3 months, this trial also represents the longest follow-up of patients treated with taxane-based chemotherapy with EBRT in high-risk prostate cancer. Concurrent ADT, radiation, and weekly paclitaxel at 40 mg/m{sup 2}/week in RP patients and 60 mg/m{sup 2}/week in LAPC patients is feasible and well-tolerated.« less
  • Purpose: To describe the practical use of the extended No Action Level (eNAL) setup correction protocol for breast cancer patients with surgical clips and evaluate its impact on the setup accuracy of both tumor bed and whole breast during simultaneously integrated boost treatments. Methods and Materials: For 80 patients, two orthogonal planar kilovoltage images and one megavoltage image (for the mediolateral beam) were acquired per fraction throughout the radiotherapy course. For setup correction, the eNAL protocol was applied, based on registration of surgical clips in the lumpectomy cavity. Differences with respect to application of a No Action Level (NAL) protocolmore » or no protocol were quantified for tumor bed and whole breast. The correlation between clip migration during the fractionated treatment and either the method of surgery or the time elapsed from last surgery was investigated. Results: The distance of the clips to their center of mass (COM), averaged over all clips and patients, was reduced by 0.9 {+-} 1.2 mm (mean {+-} 1 SD). Clip migration was similar between the group of patients starting treatment within 100 days after surgery (median, 53 days) and the group starting afterward (median, 163 days) (p = 0.20). Clip migration after conventional breast surgery (closing the breast superficially) or after lumpectomy with partial breast reconstructive techniques (sutured cavity). was not significantly different either (p = 0.22). Application of eNAL on clips resulted in residual systematic errors for the clips' COM of less than 1 mm in each direction, whereas the setup of the breast was within about 2 mm of accuracy. Conclusions: Surgical clips can be safely used for high-accuracy position verification and correction. Given compensation for time trends in the clips' COM throughout the treatment course, eNAL resulted in better setup accuracies for both tumor bed and whole breast than NAL.« less
  • One hundred out of 136 patients who had received either 1600 rad or more to the face, 1500 rad or more to the hands, 1600 rad or more to the finger nails, or 1600 rad or more to the feet for benign dermatoses during the years 1930 to 1964 were examined. Four patients had developed basal cell carcinomata of the face and one had developed a squamous cell carcinoma of the hands. Atrophy of the face and keratoses and telangiectasia of the hands occurred more frequently than in controls. It is concluded that superficial radiotherapy is a safe procedure formore » the treatment of benign dermatoses provided that no more than 1200 rad is given in fractionated doses to any area of skin over a lifetime. Recommendations are put forward to ensure that damage does not result from radiation. (auth)« less