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Sherif RS, Elshemey WM, Attalla EM. The risk of secondary cancer in pediatric medulloblastoma patients due to three-dimensional conformal radiotherapy and intensity-modulated radiotherapy. Indian J Cancer 2019; 55:372-376. [PMID: 30829273 DOI: 10.4103/ijc.ijc_410_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Craniospinal irradiation (CSI) is the standard radiation therapy treatment for medulloblastoma. The aim of this study was to estimate and compare the lifetime risk of radiation-induced secondary cancer in pediatric medulloblastoma patients using three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS 3D-CRT and IMRT plans were performed for 10 CSI pediatric patients. The average absorbed doses for organs at risk (OARs) was calculated from dose-volume histograms on the treatment planning system. The average lifetime risk of radiation-induced secondary cancer was then calculated. RESULTS Lifetime risk of secondary cancer for CSI pediatric patients treated using IMRT decreases in some OARs compared with those treated using 3D-CRT. This is attributable to the decrease in the average absorbed dose in some OARs when using IMRT technique. CONCLUSION Follow-up of medulloblastoma pediatric patients should be performed after ending the treatment course in order to diagnose early secondary tumors. IMRT technique is substantially better than 3D-CRT in terms of lifetime risk of radiation-induced secondary cancer, probably due to reduced dose to OARs especially to the thyroid, which is the most sensitive organ to radiation.
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Affiliation(s)
- Reham S Sherif
- Department of Biophysics, Faculty of Science, Cairo University, Cairo, Egypt
| | - Wael M Elshemey
- Department of Biophysics, Faculty of Science, Cairo University, Cairo, Egypt
| | - Ehab M Attalla
- Department of Radiotherapy and Nuclear Medicine, National Cancer Institute, Cairo University, Giza; Department of Radiotherapy, Children Cancer Hospital, Cairo, Egypt
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Jouglar E, Wagner A, Delpon G, Campion L, Meingan P, Bernier V, Demoor-Goldschmidt C, Mahé MA, Lacornerie T, Supiot S. Can We Spare the Pancreas and Other Abdominal Organs at Risk? A Comparison of Conformal Radiotherapy, Helical Tomotherapy and Proton Beam Therapy in Pediatric Irradiation. PLoS One 2016; 11:e0164643. [PMID: 27764132 PMCID: PMC5072698 DOI: 10.1371/journal.pone.0164643] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/28/2016] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Late abdominal irradiation toxicity during childhood included renal damage, hepatic toxicity and secondary diabetes mellitus. We compared the potential of conformal radiotherapy (CRT), helical tomotherapy (HT) and proton beam therapy (PBT) to spare the abdominal organs at risk (pancreas, kidneys and liver- OAR) in children undergoing abdominal irradiation. METHODS We selected children with abdominal tumors who received more than 10 Gy to the abdomen. Treatment plans were calculated in order to keep the dose to abdominal OAR as low as possible while maintaining the same planned target volume (PTV) coverage. Dosimetric values were compared using the Wilcoxon signed-rank test. RESULTS The dose distribution of 20 clinical cases with a median age of 8 years (range 1-14) were calculated with different doses to the PTV: 5 medulloblastomas (36 Gy), 3 left-sided and 2 right-sided nephroblastomas (14.4 Gy to the tumor + 10.8 Gy boost to para-aortic lymphnodes), 1 left-sided and 4 right-sided or midline neuroblastomas (21 Gy) and 5 Hodgkin lymphomas (19.8 Gy to the para-aortic lymphnodes and spleen). HT significantly reduced the mean dose to the whole pancreas (WP), the pancreatic tail (PT) and to the ipsilateral kidney compared to CRT. PBT reduced the mean dose to the WP and PT compared to both CRT and HT especially in midline and right-sided tumors. PBT decreased the mean dose to the ispilateral kidney but also to the contralateral kidney and the liver compared to CRT. Low dose to normal tissue was similar or increased with HT whereas integral dose and the volume of normal tissue receiving at least 5 and 10 Gy were reduced with PBT compared to CRT and HT. CONCLUSION In children undergoing abdominal irradiation therapy, proton beam therapy reduces the dose to abdominal OAR while sparing normal tissue by limiting low dose irradiation.
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Affiliation(s)
- Emmanuel Jouglar
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
| | - Antoine Wagner
- Department of Medical Physics, Centre Oscar Lambret, 3 rue Frédéric Combemale, Lille, 59000 France
| | - Grégory Delpon
- Department of Medical Physics, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
| | - Loïc Campion
- Department of Statistics, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint-Herblain, 44800 France
| | - Philippe Meingan
- Department of Radiology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint-Herblain, 44800 France
| | - Valérie Bernier
- Department of Radiation Oncology, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, Vandœuvre-lès-Nancy, 54519 France
| | - Charlotte Demoor-Goldschmidt
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
| | - Marc-André Mahé
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
| | - Thomas Lacornerie
- Department of Medical Physics, Centre Oscar Lambret, 3 rue Frédéric Combemale, Lille, 59000 France
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, boulevard Jacques Monod, Saint Herblain, 44800 France
- * E-mail:
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Mounessi FS, Lehrich P, Haverkamp U, Willich N, Bölling T, Eich HT. Pelvic Ewing sarcomas. Three-dimensional conformal vs. intensity-modulated radiotherapy. Strahlenther Onkol 2013; 189:308-14. [PMID: 23443613 DOI: 10.1007/s00066-012-0304-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 12/20/2012] [Indexed: 12/21/2022]
Abstract
PURPOSE The goal of the present work was to assess the potential advantage of intensity-modulated radiotherapy (IMRT) over three-dimensional conformal radiotherapy (3D-CRT) planning in pelvic Ewing's sarcoma. PATIENTS AND METHODS A total of 8 patients with Ewing sarcoma of the pelvis undergoing radiotherapy were analyzed. Plans for 3D-CRT and IMRT were calculated for each patient. Dose coverage of the planning target volume (PTV), conformity and homogeneity indices, as well as further parameters were evaluated. RESULTS The average dose coverage values for PTV were comparable in 3D-CRT and IMRT plans. Both techniques had a PTV coverage of V95 > 98 % in all patients. Whereas the IMRT plans achieved a higher conformity index compared to the 3D-CRT plans (conformity index 0.79 ± 0.12 vs. 0.54 ± 0.19, p = 0.012), the dose distribution across the target volumes was less homogeneous with IMRT planning than with 3D-CRT planning. This difference was statistically significant (homogeneity index 0.11 ± 0.03 vs. 0.07 ± 0.0, p = 0.035). For the bowel, Dmean and D1%, as well as V2 to V60 were reduced in IMRT plans. For the bladder and the rectum, there was no significant difference in Dmean. However, the percentages of volumes receiving at least doses of 30, 40, 45, and 50 Gy (V30 to V50) were lower for the rectum in IMRT plans. The volume of normal tissue receiving at least 2 Gy (V2) was significantly higher in IMRT plans compared with 3D-CRT, whereas at high dose levels (V30) it was significantly lower. CONCLUSION Compared to 3D-CRT, IMRT showed significantly better results regarding dose conformity (p = 0.012) and bowel sparing at dose levels above 30 Gy (p = 0.012). Thus, dose escalation in the radiotherapy of pelvic Ewing's sarcoma can be more easily achieved using IMRT.
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Affiliation(s)
- F S Mounessi
- Department of Radiation Oncology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany.
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Shaffer R, Vollans E, Vellani R, Welsh M, Moiseenko V, Goddard K. A radiotherapy planning study of RapidArc, intensity modulated radiotherapy, three-dimensional conformal radiotherapy, and parallel opposed beams in the treatment of pediatric retroperitoneal tumors. Pediatr Blood Cancer 2011; 56:16-23. [PMID: 20949587 DOI: 10.1002/pbc.22649] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Accepted: 04/22/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND This planning study compared RapidArc, fixed-field IMRT (cIMRT), 3D conformal radiotherapy (3D-CRT), and a parallel-opposed pair (POP) for children with retroperitoneal tumors. PROCEDURE Plans were generated in eight patients to treat the PTV (dose range 19.8-45 Gy) while limiting kidney and liver doses. In selected patients, vertebral body (VB) dose heterogeneity was minimized. Cumulative DVH parameters, monitor units (MU), and treatment times were compared for the four techniques using the Wilcoxon matched pairs test. RESULTS RapidArc and cIMRT covered target volumes more conformally than 3D-CRT and POP (P = 0.012). There was no difference in the ability to meet kidney dose constraints. A significantly lower volume of the liver received 12 Gy with cIMRT or RapidArc compared with 3D-CRT (P = 0.028). Where VB was included in PTV, VB dose homogeneity was generally within 94-104% of the prescription dose. Time to deliver a single fraction with RapidArc, POP, 3D-CRT, and cIMRT was 1.25 ± 0.01, 1.38 ± 0.10, 2.6 ± 0.45, and 4.02 ± 1.12 min, respectively (P = 0.012). Monitor units for a single fraction with POP, 3D-CRT, RapidArc, and cIMRT were 203 ± 26, 235 ± 32, 325 ± 71, and 665 ± 215, respectively (P < 0.05). CONCLUSIONS POP resulted in favorable MU, treatment time and dosimetry but had poor conformality. 3D-CRT was more conformal but had higher MU and treatment time. RapidArc and cIMRT were generally no better dosimetrically than conformal techniques. RapidArc was dosimetrically very similar to cIMRT, but resulted in a major reduction in time and MU used to deliver the radiation.
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Affiliation(s)
- Richard Shaffer
- Department of Radiation Oncology, BC Cancer Agency, Vancouver, British Columbia, Canada.
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Salminen E, Anacak Y, Laskar S, Kortmann RD, Raslawski E, Stevens G, Ribeiro RC. Twinning partnerships through International Atomic Energy Agency (IAEA) to improve radiotherapy in common paediatric cancers in low- and mid-income countries. Radiother Oncol 2009; 93:368-71. [DOI: 10.1016/j.radonc.2009.08.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 08/12/2009] [Indexed: 11/29/2022]
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Sterzing F, Stoiber EM, Nill S, Bauer H, Huber P, Debus J, Münter MW. Intensity modulated radiotherapy (IMRT) in the treatment of children and adolescents--a single institution's experience and a review of the literature. Radiat Oncol 2009; 4:37. [PMID: 19775449 PMCID: PMC2760561 DOI: 10.1186/1748-717x-4-37] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Accepted: 09/23/2009] [Indexed: 11/22/2022] Open
Abstract
Background While IMRT is widely used in treating complex oncological cases in adults, it is not commonly used in pediatric radiation oncology for a variety of reasons. This report evaluates our 9 year experience using stereotactic-guided, inverse planned intensity-modulated radiotherapy (IMRT) in children and adolescents in the context of the current literature. Methods Between 1999 and 2008 thirty-one children and adolescents with a mean age of 14.2 years (1.5 - 20.5) were treated with IMRT in our department. This heterogeneous group of patients consisted of 20 different tumor entities, with Ewing's sarcoma being the largest (5 patients), followed by juvenile nasopharyngeal fibroma, esthesioneuroblastoma and rhabdomyosarcoma (3 patients each). In addition a review of the available literature reporting on technology, quality, toxicity, outcome and concerns of IMRT was performed. Results With IMRT individualized dose distributions and excellent sparing of organs at risk were obtained in the most challenging cases. This was achieved at the cost of an increased volume of normal tissue receiving low radiation doses. Local control was achieved in 21 patients. 5 patients died due to progressive distant metastases. No severe acute or chronic toxicity was observed. Conclusion IMRT in the treatment of children and adolescents is feasible and was applied safely within the last 9 years at our institution. Several reports in literature show the excellent possibilities of IMRT in selective sparing of organs at risk and achieving local control. In selected cases the quality of IMRT plans increases the therapeutic ratio and outweighs the risk of potentially increased rates of secondary malignancies by the augmented low dose exposure.
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Affiliation(s)
- Florian Sterzing
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.
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Sharma DS, Gupta T, Jalali R, Master Z, Phurailatpam RD, Sarin R. High-precision radiotherapy for craniospinal irradiation: evaluation of three-dimensional conformal radiotherapy, intensity-modulated radiation therapy and helical TomoTherapy. Br J Radiol 2009; 82:1000-9. [PMID: 19581313 DOI: 10.1259/bjr/13776022] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This study aimed to establish the feasibility of intensity-modulated radiation therapy (IMRT) in craniospinal irradiation (CSI) using conventional linear accelerator (IMRT_LA) and compare it dosimetrically with helical TomoTherapy (IMRT_Tomo) and three-dimensional conformal radiotherapy (3DCRT). CT datasets of four previously treated patients with medulloblastoma were used to generate 3DCRT, IMRT_LA and IMRT_Tomo plans. A CSI dose of 35 Gy was prescribed to the planning target volume (PTV). IMRT_LA plans for tall patients were generated using an intensity feathering technique. All plans were compared dosimetrically using standardised parameters. The mean volume of each PTV receiving at least 95% of the prescribed dose (V(95%)) was >98% for all plans. All plans resulted in a comparable dose homogeneity index (DHI) for PTV_brain. For PTV_spine, IMRT_Tomo achieved the highest mean DHI of 0.96, compared with 0.91 for IMRT_LA and 0.84 for 3DCRT. The best dose conformity index was achieved by IMRT_Tomo for PTV_brain (0.96) and IMRT_LA for PTV_spine (0.83). The IMRT_Tomo plan was superior in terms of reduction of the maximum, mean and integral doses to almost all organs at risk (OARs). It also reduced the volume of each OAR irradiated to various dose levels, except for the lowest dose volume. The beam-on time was significantly longer in IMRT_Tomo. In conclusion, IMRT_Tomo for CSI is technically easier and potentially dosimetrically favourable compared with IMRT_LA and 3DCRT. IMRT for CSI can also be realised on a conventional linear accelerator even for spinal lengths exceeding maximum allowable field sizes. The longer beam-on time in IMRT_Tomo raises concerns about intrafraction motion and whole-body integral doses.
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Affiliation(s)
- D S Sharma
- Department of Medical Physics, Tata Memorial Hospital, Parel, India.
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Fogliata A, Yartsev S, Nicolini G, Clivio A, Vanetti E, Wyttenbach R, Bauman G, Cozzi L. On the performances of Intensity Modulated Protons, RapidArc and Helical Tomotherapy for selected paediatric cases. Radiat Oncol 2009; 4:2. [PMID: 19144155 PMCID: PMC2672932 DOI: 10.1186/1748-717x-4-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Accepted: 01/14/2009] [Indexed: 11/27/2022] Open
Abstract
Background To evaluate the performance of three different advanced treatment techniques on a group of complex paediatric cancer cases. Methods CT images and volumes of interest of five patients were used to design plans for Helical Tomotherapy (HT), RapidArc (RA) and Intensity Modulated Proton therapy (IMP). The tumour types were: extraosseous, intrathoracic Ewing Sarcoma; mediastinal Rhabdomyosarcoma; metastastis of base of skull with bone, para-nasal and left eye infiltration from Nephroblastoma of right kidney; metastatic Rhabdomyosarcoma of the anus; Wilm's tumour of the left kidney with multiple liver metastases. Cases were selected for their complexity regardless the treatment intent and stage. Prescribed doses ranged from 18 to 53.2 Gy, with four cases planned using a Simultaneous Integrated Boost strategy. Results were analysed in terms of dose distributions and dose volume histograms. Results For all patients, IMP plans lead to superior sparing of organs at risk and normal healthy tissue, where in particular the integral dose is halved with respect to photon techniques. In terms of conformity and of spillage of high doses outside targets (external index (EI)), all three techniques were comparable; CI90% ranged from 1.0 to 2.3 and EI from 0 to 5%. Concerning target homogeneity, IMP showed a variance (D5%–D95%) measured on the inner target volume (highest dose prescription) ranging from 5.9 to 13.3%, RA from 5.3 to 11.8%, and HT from 4.0 to 12.2%. The range of minimum significant dose to the same target was: (72.2%, 89.9%) for IMP, (86.7%, 94.1%) for RA, and (79.4%, 94.8%) for HT. Similarly, for maximum significant doses: (103.8%, 109.4%) for IMP, (103.2%, 107.4%) for RA, and (102.4%, 117.2%) for HT. Treatment times (beam-on time) ranged from 123 to 129 s for RA and from 146 to 387 s for HT. Conclusion Five complex pediatric cases were selected as representative examples to compare three advanced radiation delivery techniques. While differences were noted in the metrics examined, all three techniques provided satisfactory conformal avoidance and conformation.
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Affiliation(s)
- Antonella Fogliata
- Oncology Institute of Southern Switzerland, Medical Physics Unit, Bellinzona, Switzerland.
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PLOWMAN PN, COOKE K, WALSH N. Indications for tomotherapy/intensity-modulated radiation therapy in paediatric radiotherapy: extracranial disease. Br J Radiol 2008; 81:872-80. [DOI: 10.1259/bjr/14878999] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Sharma SD, Upreti RR, Laskar S, Tambe CM, Deshpande DD, Shrivastava SK, Dinshaw KA. Estimation of risk of radiation-induced carcinogenesis in adolescents with nasopharyngeal cancer treated using sliding window IMRT. Radiother Oncol 2008; 86:177-81. [DOI: 10.1016/j.radonc.2007.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Revised: 11/13/2007] [Accepted: 11/19/2007] [Indexed: 11/25/2022]
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Fogliata A, Nicolini G, Alber M, Åsell M, Clivio A, Dobler B, Larsson M, Lohr F, Lorenz F, Muzik J, Polednik M, Vanetti E, Wolff D, Wyttenbach R, Cozzi L. On the performances of different IMRT Treatment Planning Systems for selected paediatric cases. Radiat Oncol 2007; 2:7. [PMID: 17302972 PMCID: PMC1803794 DOI: 10.1186/1748-717x-2-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Accepted: 02/15/2007] [Indexed: 11/16/2022] Open
Abstract
Background To evaluate the performance of seven different TPS (Treatment Planning Systems: Corvus, Eclipse, Hyperion, KonRad, Oncentra Masterplan, Pinnacle and PrecisePLAN) when intensity modulated (IMRT) plans are designed for paediatric tumours. Methods Datasets (CT images and volumes of interest) of four patients were used to design IMRT plans. The tumour types were: one extraosseous, intrathoracic Ewing Sarcoma; one mediastinal Rhabdomyosarcoma; one metastatic Rhabdomyosarcoma of the anus; one Wilm's tumour of the left kidney with multiple liver metastases. Prescribed doses ranged from 18 to 54.4 Gy. To minimise variability, the same beam geometry and clinical goals were imposed on all systems for every patient. Results were analysed in terms of dose distributions and dose volume histograms. Results For all patients, IMRT plans lead to acceptable treatments in terms of conformal avoidance since most of the dose objectives for Organs At Risk (OARs) were met, and the Conformity Index (averaged over all TPS and patients) ranged from 1.14 to 1.58 on primary target volumes and from 1.07 to 1.37 on boost volumes. The healthy tissue involvement was measured in terms of several parameters, and the average mean dose ranged from 4.6 to 13.7 Gy. A global scoring method was developed to evaluate plans according to their degree of success in meeting dose objectives (lower scores are better than higher ones). For OARs the range of scores was between 0.75 ± 0.15 (Eclipse) to 0.92 ± 0.18 (Pinnacle3 with physical optimisation). For target volumes, the score ranged from 0.05 ± 0.05 (Pinnacle3 with physical optimisation) to 0.16 ± 0.07 (Corvus). Conclusion A set of complex paediatric cases presented a variety of individual treatment planning challenges. Despite the large spread of results, inverse planning systems offer promising results for IMRT delivery, hence widening the treatment strategies for this very sensitive class of patients.
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Affiliation(s)
- Antonella Fogliata
- Oncology Institute of Southern Switzerland, Medical Physics Unit, Bellinzona, Switzerland
| | - Giorgia Nicolini
- Oncology Institute of Southern Switzerland, Medical Physics Unit, Bellinzona, Switzerland
| | - Markus Alber
- Biomedical Physics, Radiooncology Dept, Uniklinik für Radioonkologie Tübingen, Tübingen, Germany
| | - Mats Åsell
- Nucletron Scandinavia AB, Uppsala, Sweden
| | - Alessandro Clivio
- Oncology Institute of Southern Switzerland, Medical Physics Unit, Bellinzona, Switzerland
| | - Barbara Dobler
- Universitätsklinikum Mannheim, Klinik für Strahlentherapie und Radioonkologie, Mannheim, Germany
| | | | - Frank Lohr
- Universitätsklinikum Mannheim, Klinik für Strahlentherapie und Radioonkologie, Mannheim, Germany
| | - Friedlieb Lorenz
- Universitätsklinikum Mannheim, Klinik für Strahlentherapie und Radioonkologie, Mannheim, Germany
| | - Jan Muzik
- Biomedical Physics, Radiooncology Dept, Uniklinik für Radioonkologie Tübingen, Tübingen, Germany
| | - Martin Polednik
- Universitätsklinikum Mannheim, Klinik für Strahlentherapie und Radioonkologie, Mannheim, Germany
| | - Eugenio Vanetti
- Oncology Institute of Southern Switzerland, Medical Physics Unit, Bellinzona, Switzerland
| | - Dirk Wolff
- Universitätsklinikum Mannheim, Klinik für Strahlentherapie und Radioonkologie, Mannheim, Germany
| | - Rolf Wyttenbach
- Ospedale Regionale Bellinzona e Valli, Radiology Dept, Bellinzona, Switzerland
| | - Luca Cozzi
- Oncology Institute of Southern Switzerland, Medical Physics Unit, Bellinzona, Switzerland
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