Pub Date : 2025-12-10DOI: 10.1016/j.adro.2025.101971
Chang W. Song PhD , Lindsey Sloan MD, PhD , Stephanie Terezakis MD , Kyungmi Yang MD , Robert J. Griffin PhD
Purpose
This study aims to elaborate and further establish that indirect cell death secondary to vascular injury and stimulation of antitumor immunity plays a role in the tumor response to high-dose per fraction radiation therapy.
Methods and Materials
We reviewed literature available from the National Library of Medicine on the indirect death of tumor cells caused by high-dose per fraction irradiation in experimental tumors and human tumors. We then examined the implications of indirect/additional cell death in applying the LQ (Linear Quadratic) model for high-dose per fraction radiation therapy of human tumors.
Results
We found that numerous preclinical and clinical studies reported over the last 100 years clearly indicated that high-dose per fraction radiation therapy induces indirect tumor cell death by causing vascular damage and stimulating the immune system to varying degrees. On the other hand, a handful of studies have been reported that failed to observe significant indirect tumor cell death after high-dose per fraction irradiation. The LQ and associated models may be applicable to certain clinical situations, yet the inherent flaw of the LQ model overestimating cell death as the fraction dose increases is likely accommodated by the additional amount of indirect tumor cell death that occurs at these higher doses. Furthermore, the indirect effects of immune system stimulation are not accounted for by the LQ or other models.
Conclusions
Indirect tumor cell death due to tumor vascular injury from radiation exposure has been observed over the last ∼100 years. Vascular damage as well as stimulation of antitumor immunity contribute significantly to the response of tumors to many, if not all, high-dose per fraction radiation therapy regimens.
{"title":"Historical Review of the Role of Indirect Cell Death in High-Dose Per Fraction Radiation Therapy","authors":"Chang W. Song PhD , Lindsey Sloan MD, PhD , Stephanie Terezakis MD , Kyungmi Yang MD , Robert J. Griffin PhD","doi":"10.1016/j.adro.2025.101971","DOIUrl":"10.1016/j.adro.2025.101971","url":null,"abstract":"<div><h3>Purpose</h3><div>This study aims to elaborate and further establish that indirect cell death secondary to vascular injury and stimulation of antitumor immunity plays a role in the tumor response to high-dose per fraction radiation therapy.</div></div><div><h3>Methods and Materials</h3><div>We reviewed literature available from the National Library of Medicine on the indirect death of tumor cells caused by high-dose per fraction irradiation in experimental tumors and human tumors. We then examined the implications of indirect/additional cell death in applying the LQ (Linear Quadratic) model for high-dose per fraction radiation therapy of human tumors.</div></div><div><h3>Results</h3><div>We found that numerous preclinical and clinical studies reported over the last 100 years clearly indicated that high-dose per fraction radiation therapy induces indirect tumor cell death by causing vascular damage and stimulating the immune system to varying degrees. On the other hand, a handful of studies have been reported that failed to observe significant indirect tumor cell death after high-dose per fraction irradiation. The LQ and associated models may be applicable to certain clinical situations, yet the inherent flaw of the LQ model overestimating cell death as the fraction dose increases is likely accommodated by the additional amount of indirect tumor cell death that occurs at these higher doses. Furthermore, the indirect effects of immune system stimulation are not accounted for by the LQ or other models.</div></div><div><h3>Conclusions</h3><div>Indirect tumor cell death due to tumor vascular injury from radiation exposure has been observed over the last ∼100 years. Vascular damage as well as stimulation of antitumor immunity contribute significantly to the response of tumors to many, if not all, high-dose per fraction radiation therapy regimens.</div></div>","PeriodicalId":7390,"journal":{"name":"Advances in Radiation Oncology","volume":"11 3","pages":"Article 101971"},"PeriodicalIF":2.7,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145973959","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-09DOI: 10.1016/j.adro.2025.101970
Dante P.I. Capaldi PhD , Emily Hirata PhD , Alon Witztum PhD , Evan Porter PhD , Amy S. Yu PhD , Lawrie B. Skinner PhD , Steve E. Braunstein MD, PhD , Olivier Morin PhD , Nicolas D. Prionas MD, PhD
Purpose
Surface guided radiation therapy (SGRT) improves patient setup and motion monitoring, particularly for deep-inspiratory breath-hold (DIBH) maneuvers in left-sided breast cancer treatment. However, high costs and complexity limit widespread adoption, especially in low-resource settings. In this study, the purpose is to develop and validate a smartphone-based iOS SGRT application (iSGRT) leveraging Light-Detection-and-Ranging (LiDAR) sensors on smartphone-devices for accurate, low-cost surface tracking for radiation therapy.
Methods and Materials
iSGRT was developed in Xcode using Swift and Open3D, and captures 6-degrees-of-freedom (6DoF) motion for patient positioning and respiratory monitoring. Application was tested using the LiDAR camera on an Apple iPhone 15 Pro, with an Apple iPad Pro for remote monitoring. The system achieved a temporal resolution of ∼200 to 250 ms (4-5 Hz), comparable to clinical SGRT systems. Static accuracy was evaluated by comparing LiDAR-derived displacements with programmed couch movements on a Varian TrueBeam with a PerfectPitch 6DoF couch. Dynamic accuracy was assessed using a QUASAR respiratory motion phantom programmed with sinusoidal and patient-derived breathing waveforms. Motion tracking performance was analyzed using Pearson correlations and Bland–Altman agreement using GraphPad Prism. iSGRT was compared with SDX spirometry system in a healthy volunteer performing DIBH within the bore of a Varian Halcyon.
Results
iSGRT demonstrated strong correlations with couch displacements across all translational (r²≥ 0.995) and rotational (r² ≥ 0.975) axes, with minimal biases (≤0.9 mm, ≤0.4°). Dynamic motion evaluation showed high agreement between the application and ground-truth phantom motion (r² ≥ 0.963), with minimal angular dependence on displacement accuracy (r² ≥ 0.950). Breath-hold duration was comparable in the healthy volunteer between systems (ΔDIBH = DIBHSDX − DIBHiSGRT = 33.34seconds − 33.31 seconds = 0.03 seconds).
Conclusions
Feasibility of an iOS smartphone-based SGRT application to provide real-time respiratory motion is demonstrated in this study as a viable alternative motion monitoring system. The iSGRT application’s accuracy aligns with existing clinical SGRT systems while significantly reducing cost and complexity. This technology has the potential to expand SGRT accessibility, particularly in resource-limited settings.
{"title":"A Smartphone-Based Motion Monitoring System for Surface Guided Radiation Therapy","authors":"Dante P.I. Capaldi PhD , Emily Hirata PhD , Alon Witztum PhD , Evan Porter PhD , Amy S. Yu PhD , Lawrie B. Skinner PhD , Steve E. Braunstein MD, PhD , Olivier Morin PhD , Nicolas D. Prionas MD, PhD","doi":"10.1016/j.adro.2025.101970","DOIUrl":"10.1016/j.adro.2025.101970","url":null,"abstract":"<div><h3>Purpose</h3><div>Surface guided radiation therapy (SGRT) improves patient setup and motion monitoring, particularly for deep-inspiratory breath-hold (DIBH) maneuvers in left-sided breast cancer treatment. However, high costs and complexity limit widespread adoption, especially in low-resource settings. In this study, the purpose is to develop and validate a smartphone-based iOS SGRT application (iSGRT) leveraging Light-Detection-and-Ranging (LiDAR) sensors on smartphone-devices for accurate, low-cost surface tracking for radiation therapy.</div></div><div><h3>Methods and Materials</h3><div>iSGRT was developed in Xcode using Swift and Open3D, and captures 6-degrees-of-freedom (6DoF) motion for patient positioning and respiratory monitoring. Application was tested using the LiDAR camera on an Apple iPhone 15 Pro, with an Apple iPad Pro for remote monitoring. The system achieved a temporal resolution of ∼200 to 250 ms (4-5 Hz), comparable to clinical SGRT systems. Static accuracy was evaluated by comparing LiDAR-derived displacements with programmed couch movements on a Varian TrueBeam with a PerfectPitch 6DoF couch. Dynamic accuracy was assessed using a QUASAR respiratory motion phantom programmed with sinusoidal and patient-derived breathing waveforms. Motion tracking performance was analyzed using Pearson correlations and Bland–Altman agreement using GraphPad Prism. iSGRT was compared with SDX spirometry system in a healthy volunteer performing DIBH within the bore of a Varian Halcyon.</div></div><div><h3>Results</h3><div>iSGRT demonstrated strong correlations with couch displacements across all translational (<em>r²</em>≥ 0.995) and rotational (<em>r²</em> ≥ 0.975) axes, with minimal biases (≤0.9 mm, ≤0.4°). Dynamic motion evaluation showed high agreement between the application and ground-truth phantom motion (<em>r²</em> ≥ 0.963), with minimal angular dependence on displacement accuracy (<em>r²</em> ≥ 0.950). Breath-hold duration was comparable in the healthy volunteer between systems (ΔDIBH = DIBH<sub>SDX</sub> − DIBH<sub>iSGRT</sub> = 33.34seconds − 33.31 seconds = 0.03 seconds).</div></div><div><h3>Conclusions</h3><div>Feasibility of an iOS smartphone-based SGRT application to provide real-time respiratory motion is demonstrated in this study as a viable alternative motion monitoring system. The iSGRT application’s accuracy aligns with existing clinical SGRT systems while significantly reducing cost and complexity. This technology has the potential to expand SGRT accessibility, particularly in resource-limited settings.</div></div>","PeriodicalId":7390,"journal":{"name":"Advances in Radiation Oncology","volume":"11 3","pages":"Article 101970"},"PeriodicalIF":2.7,"publicationDate":"2025-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145973851","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-05DOI: 10.1016/j.adro.2025.101974
Dominic LaBella MD, Eileen Battershall, Zachary J. Reitman MD, PhD, Scott R. Floyd MD, PhD, Eugene J. Vaios MD, John P. Kirkpatrick MD, PhD, Paul Sperduto MD, Trey C. Mullikin MD
Purpose
Medicare Advantage operates under a capitated payment model, where Medicare Advantage Organizations (MAOs) must provide services that meet or exceed Medicare Parts A and B standards, ensuring actuarial equivalence. MAOs are mandated to base their coverage determinations on medical necessity, aligning with Medicare's national and local coverage determinations (LCD) policies.
Methods and Materials
This study evaluates coverage policies for stereotactic radiosurgery (SRS) for brain metastases (BM) across our institution's local LCD and various MAOs, including Cigna, Aetna, UnitedHealthcare, Humana, and Anthem. The CMS LCD L39553 (CMS) serves as the benchmark, deeming SRS medically necessary for new BM and repeat BM therapy if the patient has each of the following: good performance status (Karnofsky Performance Status ≥70 or Eastern Cooperative Oncology Group Performance Status 0-2), absence of leptomeningeal metastases, and no primary diagnosis of lymphoma, germ cell tumor, or small cell carcinoma. For repeat BM, CMS also requires stable extracranial disease and a life expectancy over 6 months. Additionally, SRS may be indicated for relapses in previously irradiated cranial fields to minimize normal tissue injury. Five MAO policies were reviewed, revealing alignment with LCD criteria in several areas but also presenting additional, sometimes more restrictive, requirements.
Results
For new BM, all MAOs required good performance status, with most also considering histology and absence of leptomeningeal metastases. Some MAOs introduced criteria like systemic therapy options, lesion number/volume, and BM size. For repeat BM, most MAOs required stable extracranial disease and occasionally considered life expectancy. Additional criteria included the number of BM over a year and postoperative SRS guidelines for lesion size and number.
Conclusions
Despite general concordance, the added criteria by MAOs could impose more stringent requirements than CMS, potentially resulting in coverage denials. It is important that MAO policies remain consistent with evidence-based guidelines to avoid disparities that could impact patient treatments.
{"title":"Comparison of Local Medicare Guidance and Medicare Advantage Plans for Stereotactic Radiosurgery for Brain Metastases","authors":"Dominic LaBella MD, Eileen Battershall, Zachary J. Reitman MD, PhD, Scott R. Floyd MD, PhD, Eugene J. Vaios MD, John P. Kirkpatrick MD, PhD, Paul Sperduto MD, Trey C. Mullikin MD","doi":"10.1016/j.adro.2025.101974","DOIUrl":"10.1016/j.adro.2025.101974","url":null,"abstract":"<div><h3>Purpose</h3><div>Medicare Advantage operates under a capitated payment model, where Medicare Advantage Organizations (MAOs) must provide services that meet or exceed Medicare Parts A and B standards, ensuring actuarial equivalence. MAOs are mandated to base their coverage determinations on medical necessity, aligning with Medicare's national and local coverage determinations (LCD) policies.</div></div><div><h3>Methods and Materials</h3><div>This study evaluates coverage policies for stereotactic radiosurgery (SRS) for brain metastases (BM) across our institution's local LCD and various MAOs, including Cigna, Aetna, UnitedHealthcare, Humana, and Anthem. The CMS LCD L39553 (CMS) serves as the benchmark, deeming SRS medically necessary for new BM and repeat BM therapy if the patient has each of the following: good performance status (Karnofsky Performance Status ≥70 or Eastern Cooperative Oncology Group Performance Status 0-2), absence of leptomeningeal metastases, and no primary diagnosis of lymphoma, germ cell tumor, or small cell carcinoma. For repeat BM, CMS also requires stable extracranial disease and a life expectancy over 6 months. Additionally, SRS may be indicated for relapses in previously irradiated cranial fields to minimize normal tissue injury. Five MAO policies were reviewed, revealing alignment with LCD criteria in several areas but also presenting additional, sometimes more restrictive, requirements.</div></div><div><h3>Results</h3><div>For new BM, all MAOs required good performance status, with most also considering histology and absence of leptomeningeal metastases. Some MAOs introduced criteria like systemic therapy options, lesion number/volume, and BM size. For repeat BM, most MAOs required stable extracranial disease and occasionally considered life expectancy. Additional criteria included the number of BM over a year and postoperative SRS guidelines for lesion size and number.</div></div><div><h3>Conclusions</h3><div>Despite general concordance, the added criteria by MAOs could impose more stringent requirements than CMS, potentially resulting in coverage denials. It is important that MAO policies remain consistent with evidence-based guidelines to avoid disparities that could impact patient treatments.</div></div>","PeriodicalId":7390,"journal":{"name":"Advances in Radiation Oncology","volume":"11 2","pages":"Article 101974"},"PeriodicalIF":2.7,"publicationDate":"2025-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145881111","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-04DOI: 10.1016/j.adro.2025.101967
Karishma George MD , Demetra Yannitsos MSc , Ashok Natarajan BSc , Siwei Qi MSc , Jackson Wu MD , Lisa Barbera BSc, MD, MPA, FRCPC
Purpose
Successful computed tomography (CT) simulation in prostate cancer radiation therapy relies on consistent bowel and bladder preparation. This study aimed to determine the first-attempt CT simulation success rate and identify factors associated with a successful simulation.
Methods and Materials
This single-institution, prospective cohort study recruited patients with prostate cancer undergoing CT simulation for pelvic radiation. We abstracted the success of CT simulation on the first attempt, the number of scan attempts in a single visit, the reason for failed attempt(s), and the frequency of rescheduled appointments. Patients completed a survey regarding their preparation experiences, demographic data, and patient-reported outcomes. The primary outcome was a successful first-attempt CT scan. A generalized estimating equation model evaluated factors associated with successful first scan, including age, CT appointment time, American Urological Association urinary symptom scores, constipation, diarrhea, and instruction format. Additionally, qualitative analysis of open-text patient feedback explored barriers to effective preparation.
Results
Among 247 patients, 31.2% had a successful first-attempt CT simulation, while 52.2% required multiple attempts on the same day, and 16.6% needed rescheduling. Bladder and bowel issues contributed to 30.8% and 22.7% of failed attempts, respectively. Patients who received both verbal and written instructions were significantly more likely to succeed (adjusted odds ratio 1.82, P = .01) compared to verbal instructions alone. Qualitative analysis of 118 patient comments revealed common barriers, including unclear preparation instructions (23.7%), difficulty timing bowel movements (10.2%), and confusion about expectations (14.4%).
Conclusions
Low CT simulation success rates emphasize the need for improved patient preparation strategies. Multimodal education significantly enhanced success rates. Addressing communication methods and, refining preparation protocols should reduce rescans, and optimize workflows.
{"title":"Predictors of Successful First-Attempt Prostate Cancer Computed Tomography Simulation: A Prospective Cohort Study","authors":"Karishma George MD , Demetra Yannitsos MSc , Ashok Natarajan BSc , Siwei Qi MSc , Jackson Wu MD , Lisa Barbera BSc, MD, MPA, FRCPC","doi":"10.1016/j.adro.2025.101967","DOIUrl":"10.1016/j.adro.2025.101967","url":null,"abstract":"<div><h3>Purpose</h3><div>Successful computed tomography (CT) simulation in prostate cancer radiation therapy relies on consistent bowel and bladder preparation. This study aimed to determine the first-attempt CT simulation success rate and identify factors associated with a successful simulation.</div></div><div><h3>Methods and Materials</h3><div>This single-institution, prospective cohort study recruited patients with prostate cancer undergoing CT simulation for pelvic radiation. We abstracted the success of CT simulation on the first attempt, the number of scan attempts in a single visit, the reason for failed attempt(s), and the frequency of rescheduled appointments. Patients completed a survey regarding their preparation experiences, demographic data, and patient-reported outcomes. The primary outcome was a successful first-attempt CT scan. A generalized estimating equation model evaluated factors associated with successful first scan, including age, CT appointment time, American Urological Association urinary symptom scores, constipation, diarrhea, and instruction format. Additionally, qualitative analysis of open-text patient feedback explored barriers to effective preparation.</div></div><div><h3>Results</h3><div>Among 247 patients, 31.2% had a successful first-attempt CT simulation, while 52.2% required multiple attempts on the same day, and 16.6% needed rescheduling. Bladder and bowel issues contributed to 30.8% and 22.7% of failed attempts, respectively. Patients who received both verbal and written instructions were significantly more likely to succeed (adjusted odds ratio 1.82, <em>P</em> = .01) compared to verbal instructions alone. Qualitative analysis of 118 patient comments revealed common barriers, including unclear preparation instructions (23.7%), difficulty timing bowel movements (10.2%), and confusion about expectations (14.4%).</div></div><div><h3>Conclusions</h3><div>Low CT simulation success rates emphasize the need for improved patient preparation strategies. Multimodal education significantly enhanced success rates. Addressing communication methods and, refining preparation protocols should reduce rescans, and optimize workflows.</div></div>","PeriodicalId":7390,"journal":{"name":"Advances in Radiation Oncology","volume":"11 3","pages":"Article 101967"},"PeriodicalIF":2.7,"publicationDate":"2025-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146034283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-29DOI: 10.1016/j.adro.2025.101895
Kristen A. McConnell PhD, MBA , Maria Valladares BS , Alonso N. Gutierrez PhD, MBA , Nicole Luther BS , Zachary Fellows BS , Lorrie LeGrand MHSc , Michael Chuong MD , Minesh P. Mehta MD , Andrew Wroe PhD
Purpose
Following the guidance of The American Association of Physicists in Medicine (AAPM) Medical Physics Practice Guideline (MPPG) 4a/4b, AAPM Task Groups 100/275, and American Society for Radiation Oncology’s Safety is No Accident, our institution focused on quality improvement to streamline clinical workflows, enable complex treatments, standardize procedures, and positively evolve our practice in proton radiation therapy. A retrospective institutional analysis was completed to map interventions identified prior to data analysis that were likely to affect the evolution of the treatment planning timelines.
Methods and Materials
Care Paths within our Oncology Information System were used to sequence and track clinical workflows since 2017. Data were mined between 2017 to 2023 to obtain the task’s completion and expected completion dates. The task completion offset was calculated to measure the number of days late or early the task was completed. Five quality management interventions were mapped onto control charts for each task to identify the evolution of the practice with each intervention. Average time, SDs, and statistical significance before and after each intervention were also computed. Additionally, total treatment planning times were computed for each patient and histograms, average time, median time, and standard error of the mean were computed and compared by year.
Results
Task completion offsets improved from being, on average, 1.59 to 2.63 days late to 0.06 to 2.25 days early, with control charts visually showing the reduction in mean value, reduction in SD, and ultimately, the processes falling more into control. Interventions 1, 2, and 3 showed the strongest overall statistical impact on task completion offsets. Overall, planning timelines improved from a median of 19 days to 11 days. More importantly, the distributions of overall planning time and spread of these times became Gaussian, demonstrating the characteristics of normalized activity patterns, with a reduction in variability.
Conclusions
The interventions identified before data collection were well associated with the evolution of the treatment planning timeline data. When quantifying with control charts, there were noted decreased task completion offset variabilities across many examined tasks. Additionally, the data showed shortened overall planning timelines during the time that the complexity of protons plans was increased, newer delivery approaches were made available, and more complex clinical scenarios were incorporated.
{"title":"Impact of Quality Improvement Interventions on the Efficiency of Treatment Planning Timelines in a Modern Proton Therapy Clinic","authors":"Kristen A. McConnell PhD, MBA , Maria Valladares BS , Alonso N. Gutierrez PhD, MBA , Nicole Luther BS , Zachary Fellows BS , Lorrie LeGrand MHSc , Michael Chuong MD , Minesh P. Mehta MD , Andrew Wroe PhD","doi":"10.1016/j.adro.2025.101895","DOIUrl":"10.1016/j.adro.2025.101895","url":null,"abstract":"<div><h3>Purpose</h3><div>Following the guidance of The American Association of Physicists in Medicine (AAPM) Medical Physics Practice Guideline (MPPG) 4a/4b, AAPM Task Groups 100/275, and American Society for Radiation Oncology’s <em>Safety is No Accident,</em> our institution focused on quality improvement to streamline clinical workflows, enable complex treatments, standardize procedures, and positively evolve our practice in proton radiation therapy. A retrospective institutional analysis was completed to map interventions identified prior to data analysis that were likely to affect the evolution of the treatment planning timelines.</div></div><div><h3>Methods and Materials</h3><div>Care Paths within our Oncology Information System were used to sequence and track clinical workflows since 2017. Data were mined between 2017 to 2023 to obtain the task’s completion and expected completion dates. The task completion offset was calculated to measure the number of days late or early the task was completed. Five quality management interventions were mapped onto control charts for each task to identify the evolution of the practice with each intervention. Average time, SDs, and statistical significance before and after each intervention were also computed. Additionally, total treatment planning times were computed for each patient and histograms, average time, median time, and standard error of the mean were computed and compared by year.</div></div><div><h3>Results</h3><div>Task completion offsets improved from being, on average, 1.59 to 2.63 days late to 0.06 to 2.25 days early, with control charts visually showing the reduction in mean value, reduction in SD, and ultimately, the processes falling more into control. Interventions 1, 2, and 3 showed the strongest overall statistical impact on task completion offsets. Overall, planning timelines improved from a median of 19 days to 11 days. More importantly, the distributions of overall planning time and spread of these times became Gaussian, demonstrating the characteristics of normalized activity patterns, with a reduction in variability.</div></div><div><h3>Conclusions</h3><div>The interventions identified before data collection were well associated with the evolution of the treatment planning timeline data. When quantifying with control charts, there were noted decreased task completion offset variabilities across many examined tasks. Additionally, the data showed shortened overall planning timelines during the time that the complexity of protons plans was increased, newer delivery approaches were made available, and more complex clinical scenarios were incorporated.</div></div>","PeriodicalId":7390,"journal":{"name":"Advances in Radiation Oncology","volume":"11 1","pages":"Article 101895"},"PeriodicalIF":2.7,"publicationDate":"2025-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145615560","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-29DOI: 10.1016/j.adro.2025.101940
Tanguy Perennec MD, MSc , Karine A. Al Feghali MD , Dorine de Jong PhD , Oluwaseyi M. Oderinde PhD , Grant Gibbard PhD , Mélanie Dore MD, MSc , Gregory Delpon PhD , Moignier Alexandra PhD , Yves Seroux , Ludovic Ferrer PhD , Matthieu Hatt PhD , Caroline Rousseau MD, PhD , Stéphane Supiot MD, PhD
Purpose
Hypoxia is a well-known major factor contributing to the radioresistance of prostate cancer, which could be counteracted by increasing the dose. This study aimed to demonstrate the dosimetric feasibility of a dose-painting radiation therapy plan for prostate cancer, using a novel ring gantry system, based on the localization of tumoral and hypoxic areas.
Methods and Materials
Seven patients from the Programme d’Action Intégré de Recherche-prostate study, who underwent external-beam radiation therapy for intermediate-risk prostate cancer and exhibited pretherapeutic fluromisonodazole positron emission tomography (PET) uptake in the tumor, were selected. The gross tumor volume (GTV) was delineated on the magnetic resonance imaging, and the hypoxic region within the planning target volume was delineated based on fluromisonodazole PET uptake. Intensity modulated radiation therapy planning was performed based on 3 different prescriptions: standard fractionation (77 Gy in 35 fractions to the planning target volume), with an integrated boost of 95 Gy and 118 Gy in 35 fractions to the GTV and the hypoxic region, moderate hypofractionation (60 Gy in 20 fractions) with a boost of 67 Gy and 91 Gy to the GTV and the hypoxic region, and high hypofractionation (40 Gy in 5 fractions) with a boost of 50 Gy to the GTV and as high as possible to the hypoxic region. Planning was performed on the research version of the RefleXion treatment planning system.
Results
We achieved the prescribed dose in all 7 patients while respecting the usual dose limits for organs at risk.
Conclusions
This study demonstrated the dosimetric feasibility of dose escalation in both the tumor and hypoxic regions in patients with prostate cancer using the RefleXion treatment planning system, without compromising the dose limits for organs at risks.
{"title":"Dosimetric Feasibility of Dose-Painting Radiation Therapy for Targeting Hypoxia in Prostate Cancer on a Novel Ring Gantry Radiation Therapy System","authors":"Tanguy Perennec MD, MSc , Karine A. Al Feghali MD , Dorine de Jong PhD , Oluwaseyi M. Oderinde PhD , Grant Gibbard PhD , Mélanie Dore MD, MSc , Gregory Delpon PhD , Moignier Alexandra PhD , Yves Seroux , Ludovic Ferrer PhD , Matthieu Hatt PhD , Caroline Rousseau MD, PhD , Stéphane Supiot MD, PhD","doi":"10.1016/j.adro.2025.101940","DOIUrl":"10.1016/j.adro.2025.101940","url":null,"abstract":"<div><h3>Purpose</h3><div>Hypoxia is a well-known major factor contributing to the radioresistance of prostate cancer, which could be counteracted by increasing the dose. This study aimed to demonstrate the dosimetric feasibility of a dose-painting radiation therapy plan for prostate cancer, using a novel ring gantry system, based on the localization of tumoral and hypoxic areas.</div></div><div><h3>Methods and Materials</h3><div>Seven patients from the Programme d’Action Intégré de Recherche-prostate study, who underwent external-beam radiation therapy for intermediate-risk prostate cancer and exhibited pretherapeutic fluromisonodazole positron emission tomography (PET) uptake in the tumor, were selected. The gross tumor volume (GTV) was delineated on the magnetic resonance imaging, and the hypoxic region within the planning target volume was delineated based on fluromisonodazole PET uptake. Intensity modulated radiation therapy planning was performed based on 3 different prescriptions: standard fractionation (77 Gy in 35 fractions to the planning target volume), with an integrated boost of 95 Gy and 118 Gy in 35 fractions to the GTV and the hypoxic region, moderate hypofractionation (60 Gy in 20 fractions) with a boost of 67 Gy and 91 Gy to the GTV and the hypoxic region, and high hypofractionation (40 Gy in 5 fractions) with a boost of 50 Gy to the GTV and as high as possible to the hypoxic region. Planning was performed on the research version of the RefleXion treatment planning system.</div></div><div><h3>Results</h3><div>We achieved the prescribed dose in all 7 patients while respecting the usual dose limits for organs at risk.</div></div><div><h3>Conclusions</h3><div>This study demonstrated the dosimetric feasibility of dose escalation in both the tumor and hypoxic regions in patients with prostate cancer using the RefleXion treatment planning system, without compromising the dose limits for organs at risks.</div></div>","PeriodicalId":7390,"journal":{"name":"Advances in Radiation Oncology","volume":"11 2","pages":"Article 101940"},"PeriodicalIF":2.7,"publicationDate":"2025-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145837458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The insertion of a hydrogel spacer between the rectum and prostate before stereotactic body radiation therapy (SBRT) for prostate cancer significantly reduces the radiation dose to the rectum. Despite the widespread use of this technique, clinical data remain sparse. The objective of this study was to investigate the clinical benefit of a hydrogel spacer in SBRT.
Methods and Materials
The database of a tertiary medical center was retrospectively searched for all patients with prostate cancer who underwent SBRT, with or without the insertion of a hydrogel spacer, between June 2013 and December 2018. The groups were compared for rectal and urinary toxicity (National Cancer Institute Common Terminology Criteria for Adverse Events v4) using the χ2 test and t test. In addition, a subgroup analysis limited to patients receiving 37.5 or 40 Gy in 5 fractions was performed to account for the possible confounding effect of dose variability between the groups. Complications related to the procedure were also evaluated.
Results
The cohort included 308 patients who underwent SBRT with (n = 227) or without (n = 75) the insertion of a hydrogel spacer. Rates of grade 2 or higher rectal toxicity were 31 of 223 patients (13.9%) in the spacer group and 9 of 75 patients (12%) in the nonspacer group. Corresponding rates of urinary grade 2 toxicity were 58 of 223 patients (26%) and 14 of 75 patients (18.6%), respectively. Neither difference was statistically significant. Similar findings were observed in the subgroup analysis. Severe complications related to the procedure occurred in 5 of 227 cases (2.2%).
Conclusions
This study did not demonstrate a significant effect of hydrogel spacer insertion on reducing rectal or urinary toxicity in patients with prostate cancer undergoing SBRT. Given the dual consideration of questionable clinical benefit and the risk of debilitating complications, additional studies should be performed on the selective use of this procedure.
{"title":"Hydrogel Spacer Insertion Prior to Stereotactic Body Radiation Therapy to the Prostate: A Comparative Study","authors":"Myroslav Lutsyk MD , Yosef Landman MD , Eyal Fenig MD","doi":"10.1016/j.adro.2025.101966","DOIUrl":"10.1016/j.adro.2025.101966","url":null,"abstract":"<div><h3>Purpose</h3><div>The insertion of a hydrogel spacer between the rectum and prostate before stereotactic body radiation therapy (SBRT) for prostate cancer significantly reduces the radiation dose to the rectum. Despite the widespread use of this technique, clinical data remain sparse. The objective of this study was to investigate the clinical benefit of a hydrogel spacer in SBRT.</div></div><div><h3>Methods and Materials</h3><div>The database of a tertiary medical center was retrospectively searched for all patients with prostate cancer who underwent SBRT, with or without the insertion of a hydrogel spacer, between June 2013 and December 2018. The groups were compared for rectal and urinary toxicity (National Cancer Institute Common Terminology Criteria for Adverse Events v4) using the χ<sup>2</sup> test and <em>t</em> test. In addition, a subgroup analysis limited to patients receiving 37.5 or 40 Gy in 5 fractions was performed to account for the possible confounding effect of dose variability between the groups. Complications related to the procedure were also evaluated.</div></div><div><h3>Results</h3><div>The cohort included 308 patients who underwent SBRT with (n = 227) or without (n = 75) the insertion of a hydrogel spacer. Rates of grade 2 or higher rectal toxicity were 31 of 223 patients (13.9%) in the spacer group and 9 of 75 patients (12%) in the nonspacer group. Corresponding rates of urinary grade 2 toxicity were 58 of 223 patients (26%) and 14 of 75 patients (18.6%), respectively. Neither difference was statistically significant. Similar findings were observed in the subgroup analysis. Severe complications related to the procedure occurred in 5 of 227 cases (2.2%).</div></div><div><h3>Conclusions</h3><div>This study did not demonstrate a significant effect of hydrogel spacer insertion on reducing rectal or urinary toxicity in patients with prostate cancer undergoing SBRT. Given the dual consideration of questionable clinical benefit and the risk of debilitating complications, additional studies should be performed on the selective use of this procedure.</div></div>","PeriodicalId":7390,"journal":{"name":"Advances in Radiation Oncology","volume":"11 2","pages":"Article 101966"},"PeriodicalIF":2.7,"publicationDate":"2025-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145788010","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-22DOI: 10.1016/j.adro.2025.101968
Ziye Zheng MD , Siqi Sun ME , Jiawei Zhu MD , Qingwei Jiang MD , Jing Shen MD , Hongnan Zhen MD , Hui Guan MD , Wenhui Wang MD , Xiaomin Hu PhD , Fuquan Zhang MD , Junfang Yan MD
Purpose
Acute radiation enteritis (RE), particularly diarrhea, remains a major dose-limiting complication in patients with locally advanced cervical cancer (LACC) undergoing concurrent chemoradiotherapy (CCRT). The study investigated the relationship between dynamic intestinal flora alterations and RE-related diarrhea in patients with LACC undergoing CCRT.
Methods and Materials
This prospective observational cohort study enrolled 83 patients with LACC receiving CCRT in a hospital setting. The patients were categorized into a Mild group (mild diarrhea, adverse events grade < 2, n = 47) and a Severe group (severe diarrhea, grade ≥ 2, n = 36). Fecal samples were collected at baseline (T0), week 4 (T4), and week 8 (T8) after radiation therapy initiation. 16S rRNA sequencing was performed to analyze the microbial composition. Alpha/beta diversity, taxonomic differences, functional pathways, and correlations with clinical indicators were also evaluated.
Results
During CCRT, diarrhea severity peaked at 4 to 5 weeks and gradually decreased in weeks 5 to 8. Significantly decreased alpha diversity at T4 in the Severe group (nadir: 51.10% Firmicutes and 39.10% Bacteroidetes) was partially restored at T8. Beta diversity revealed clustering between the groups at T4. The relative abundances of f__Bacteroidaceae, g__Bacteroides, g__Lachnoclostridium, and s__Bacteroides_vulgatus were higher in the Severe group than in the Mild group at T4, whereas the f__Ruminococcaceae abundance was lower in the Severe group than in the Mild group. g__Bacteroides and g__Lachnoclostridium abundances were significantly and positively correlated with the duration of grade 2 diarrhea. The Severe group demonstrated upregulated amino/nucleotide sugar metabolism and downregulated unsaturated fatty acid biosynthesis. Phenotypic prediction indicated higher pathogenic Bacteroidetes and reduced stress-tolerant Proteobacteria in the Severe group.
Conclusions
Acute RE-related diarrhea severity in patients with cervical cancer undergoing CCRT is associated with intestinal dysbiosis. Severe diarrhea was correlated with reduced alpha diversity, lower Firmicutes/Bacteroidetes ratio, and enriched proinflammatory taxa.
{"title":"Relationship Between Intestinal Flora and Acute Radiation Enteritis in Patients With Advanced Cervical Cancer Undergoing Concurrent Chemoradiotherapy","authors":"Ziye Zheng MD , Siqi Sun ME , Jiawei Zhu MD , Qingwei Jiang MD , Jing Shen MD , Hongnan Zhen MD , Hui Guan MD , Wenhui Wang MD , Xiaomin Hu PhD , Fuquan Zhang MD , Junfang Yan MD","doi":"10.1016/j.adro.2025.101968","DOIUrl":"10.1016/j.adro.2025.101968","url":null,"abstract":"<div><h3>Purpose</h3><div>Acute radiation enteritis (RE), particularly diarrhea, remains a major dose-limiting complication in patients with locally advanced cervical cancer (LACC) undergoing concurrent chemoradiotherapy (CCRT). The study investigated the relationship between dynamic intestinal flora alterations and RE-related diarrhea in patients with LACC undergoing CCRT.</div></div><div><h3>Methods and Materials</h3><div>This prospective observational cohort study enrolled 83 patients with LACC receiving CCRT in a hospital setting. The patients were categorized into a Mild group (mild diarrhea, adverse events grade < 2, n = 47) and a Severe group (severe diarrhea, grade ≥ 2, n = 36). Fecal samples were collected at baseline (T0), week 4 (T4), and week 8 (T8) after radiation therapy initiation. 16S rRNA sequencing was performed to analyze the microbial composition. Alpha/beta diversity, taxonomic differences, functional pathways, and correlations with clinical indicators were also evaluated.</div></div><div><h3>Results</h3><div>During CCRT, diarrhea severity peaked at 4 to 5 weeks and gradually decreased in weeks 5 to 8. Significantly decreased alpha diversity at T4 in the Severe group (nadir: 51.10% Firmicutes and 39.10% Bacteroidetes) was partially restored at T8. Beta diversity revealed clustering between the groups at T4. The relative abundances of f__Bacteroidaceae, g__<em>Bacteroides</em>, g__<em>Lachnoclostridium</em>, and s__<em>Bacteroides_vulgatus</em> were higher in the Severe group than in the Mild group at T4, whereas the f__Ruminococcaceae abundance was lower in the Severe group than in the Mild group. g__<em>Bacteroides</em> and g__<em>Lachnoclostridium</em> abundances were significantly and positively correlated with the duration of grade 2 diarrhea. The Severe group demonstrated upregulated amino/nucleotide sugar metabolism and downregulated unsaturated fatty acid biosynthesis. Phenotypic prediction indicated higher pathogenic Bacteroidetes and reduced stress-tolerant Proteobacteria in the Severe group.</div></div><div><h3>Conclusions</h3><div>Acute RE-related diarrhea severity in patients with cervical cancer undergoing CCRT is associated with intestinal dysbiosis. Severe diarrhea was correlated with reduced alpha diversity, lower Firmicutes/Bacteroidetes ratio, and enriched proinflammatory taxa.</div></div>","PeriodicalId":7390,"journal":{"name":"Advances in Radiation Oncology","volume":"11 2","pages":"Article 101968"},"PeriodicalIF":2.7,"publicationDate":"2025-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145788009","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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