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Rahimi R, Taylor M, Li X, Chen KL, MacLennan G, Murdoch E, Chang L, Parniani A, Wang P, Chawla A, Fan J, Kim D. Fetal dose assessment in a pregnant patient with brain tumor: A comparative study of proton PBS and 3DCRT/VMAT radiation therapy techniques. J Appl Clin Med Phys 2024; 25:e14394. [PMID: 38887816 PMCID: PMC11302808 DOI: 10.1002/acm2.14394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/11/2024] [Accepted: 04/23/2024] [Indexed: 06/20/2024] Open
Abstract
PURPOSE The treatment of brain tumors in pregnant patients poses challenges, as the out-of-field dose exposure to the fetus can potentially be harmful. A pregnant patient with prior radiation treatment was presented with a brain tumor at our clinic. This work reports on our pre-treatment study that compared fetal dose exposure between intensity-modulated proton therapy (IMPT) using pencil beam scanning (PBS) and conventional photon 3D conformal radiation therapy (3DCRT) and volumetric-modulated arc therapy (VMAT), and the subsequent pregnant patient's radiation treatment. MATERIALS AND METHODS Pre-treatment measurements of clinical plans, 3DCRT, VMAT, and IMPT, were conducted on a phantom. Measurements were performed using a device capable of neutron detections, closely following AAPM guidelines, TG158. For photon measurements, fetus shielding was utilized. On patient treatment days, which was determined to be proton treatment, shielding was used only during daily imaging for patient setup. Additionally, an in vivo measurement was conducted on the patient. RESULTS Measurements showed that IMPT delivered the lowest fetal dose, considering both photon and neutron out-of-field doses to the fetus, even when shielding was implemented for photon measurements. Additionally, the proton plans demonstrated superior treatment for the mother, a reirradiation case. CONCLUSION The patient was treated with proton therapy, and the baby was subsequently delivered at full term with no complications. This case study supports previous clinical findings and advocates for the expanded use of proton therapy in this patient population.
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Affiliation(s)
- Robabeh Rahimi
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Michael Taylor
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Xing Li
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Kuan Ling Chen
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | | | - Erin Murdoch
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Lienard Chang
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Ashkan Parniani
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Peng Wang
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Ashish Chawla
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Jiajin Fan
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
| | - Daniel Kim
- Radiation Oncology DepartmentInova Health SystemFairfaxVirginiaUSA
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Woon W, Samuel J, Wahab K, Zaini F, Hamadi F, Ck AL, Ramamurthy V, Bohari S. A phantom study investigating effective strategies for reducing fetal dose in pregnant patients with head and neck cancer. J Med Imaging Radiat Sci 2024; 55:264-271. [PMID: 38553300 DOI: 10.1016/j.jmir.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/06/2024] [Accepted: 02/28/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE To measure the out-of-field doses for various treatment planning techniques and assess the impact on fetal dose with and without the use of custom shielding. MATERIALS AND METHODS A total of six treatment plans were generated with different treatment techniques such as 3-dimensional conformal radiation therapy (3DCRT), intensity modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT), utilizing both 6 MV flattened beams and flattening filter-free (FFF) beams. The measurements were carried out both out-of-field at the surface and at depth to assess the dose reduction achieved by removing the flattening filter and incorporating shielding. RESULTS The custom-made frame shielding can effectively reduce the surface dose with a maximum reduction of 15.2% observed in VMAT plans and achieve a maximum reduction of 100% for cone beam computed tomography (CBCT) imaging. Out-of-field dose measurements conducted at depth, positioned 58 cm inferior to the target isocenter, reveal that the shielding effectiveness consistently remains the greatest for 3DCRT technique. A maximum reduction of 21% is observed when utilizing a flattening filter-free beam. CONCLUSION The results of this study indicate that the 3DCRT technique exhibits the least amount of scatter radiation both near and far from the treatment isocenter, which is the most suitable approach for radiation therapy of pregnant patients. In cases where meeting dose constraints for critical organs becomes challenging, VMAT technique emerges as the most suitable treatment technique for reducing out-of-field doses. Additionally, a flattening filter-free beam significantly reduces out-of-field doses due to lower contributions from head scatter.
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Affiliation(s)
- WuiAnn Woon
- Department of Radiation Oncology, The Brunei Cancer Center, Bandar Seri Begawan, BG3122, Brunei Darussalam.
| | - Jacob Samuel
- Department of Radiation Oncology, The Brunei Cancer Center, Bandar Seri Begawan, BG3122, Brunei Darussalam
| | - Khairina Wahab
- Department of Radiation Oncology, The Brunei Cancer Center, Bandar Seri Begawan, BG3122, Brunei Darussalam
| | - Farhan Zaini
- Department of Radiation Oncology, The Brunei Cancer Center, Bandar Seri Begawan, BG3122, Brunei Darussalam
| | - Fatin Hamadi
- Department of Radiation Oncology, The Brunei Cancer Center, Bandar Seri Begawan, BG3122, Brunei Darussalam
| | - Andrew Lee Ck
- Department of Radiation Oncology, The Brunei Cancer Center, Bandar Seri Begawan, BG3122, Brunei Darussalam
| | - Vedapriya Ramamurthy
- Department of Radiation Oncology, The Brunei Cancer Center, Bandar Seri Begawan, BG3122, Brunei Darussalam
| | - Shahidda Bohari
- Department of Radiation Oncology, The Brunei Cancer Center, Bandar Seri Begawan, BG3122, Brunei Darussalam
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Fagerstrom JM. Radiation oncology department policy development for patients who may become pregnant. J Appl Clin Med Phys 2024; 25:e14256. [PMID: 38175957 PMCID: PMC10860450 DOI: 10.1002/acm2.14256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 12/07/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024] Open
Abstract
In the context of radiation oncology, radiation exposure from radiation therapy simulation, image guidance, and radiation therapy procedures can have severe adverse biological effects on a developing embryo or fetus. Patients who may be pregnant are screened for the possibility of pregnancy to prevent unnecessary or excessive exposure of radiation in utero. Some radiation therapy patients for whom a pregnancy test is indicated may elect to decline the test. In addition, some patients who are found upon screening to be pregnant may decide, with their attending radiation oncologist, to continue with treatment. A radiation oncology department policy was developed to provide guidelines regarding screening and consent. The policy was designed to prevent unnecessary exposure to patients who may be pregnant, and to limit dose to the embryo or fetus in patients for whom treatment is medically indicated. The policy is presented as an example for physicists intending to develop or revise their own practice's policy regarding patients who may become pregnant.
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Affiliation(s)
- Jessica M. Fagerstrom
- Department of Radiation OncologyUniversity of WashingtonSeattleWashingtonUSA
- Department of Radiation OncologyKaiser PermanenteSeattleWashingtonUSA
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Wong YM, Koh CWY, Lew KS, Chua CGA, Nei W, Tan HQ, Lee JCL, Mazonakis M, Damilakis J. A review on fetal dose in Radiotherapy: A historical to contemporary perspective. Phys Med 2023; 105:102513. [PMID: 36565555 DOI: 10.1016/j.ejmp.2022.102513] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/09/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
This paper aims to review on fetal dose in radiotherapy and extends and updates on a previous work1 to include proton therapy. Out-of-field doses, which are the doses received by regions outside of the treatment field, are unavoidable regardless of the treatment modalities used during radiotherapy. In the case of pregnant patients, fetal dose is a major concern as it has long been recognized that fetuses exposed to radiation have a higher probability of suffering from adverse effects such as anatomical malformations and even fetal death, especially when the 0.1Gy threshold is exceeded. In spite of the low occurrence of cancer during pregnancy, the radiotherapy team should be equipped with the necessary knowledge to deal with fetal dose. This is crucial so as to ensure that the fetus is adequately protected while not compromising the patient treatment outcomes. In this review paper, various aspects of fetal dose will be discussed ranging from biological, clinical to the physics aspects. Other than fetal dose resulting from conventional photon therapy, this paper will also extend the discussion to modern treatment modalities and techniques, namely proton therapy and image-guided radiotherapy, all of which have seen a significant increase in use in current radiotherapy. This review is expected to provide readers with a comprehensive understanding of fetal dose in radiotherapy, and to be fully aware of the steps to be taken in providing radiotherapy for pregnant patients.
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Affiliation(s)
- Yun Ming Wong
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore
| | | | - Kah Seng Lew
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | - Wenlong Nei
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.
| | - James Cheow Lei Lee
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore; Division of Physics and Applied Physics, Nanyang Technological University, Singapore
| | - Michael Mazonakis
- Department of Medical Physics, School of Medicine, University of Crete, Greece
| | - John Damilakis
- Department of Medical Physics, School of Medicine, University of Crete, Greece
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Kanchaveli D, Hellman S, Lovelock D, Archuadze G, Biancia CD. Design and standard utilization of safety devices for the radiation treatment management of heavy patients. J Appl Clin Med Phys 2022; 23:e13616. [PMID: 35488728 PMCID: PMC9195014 DOI: 10.1002/acm2.13616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 01/26/2022] [Accepted: 03/29/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose Increasing number of heavy cancer patients has created challenges in diagnostic imaging and radiation oncology. Practical weight limits of the equipment can become an obstacle both for imaging and treatment of these patients. Most magnetic resonance imaging and computed tomography (CT) tables’ static load capacities are between 450 and 500 pounds, and linear accelerator tables can support similar weights depending on the type of the table and manufacturer. One recurring issue we encountered was failure of the treatment couch's longitudinal drive belt due to heavy patients’ sudden movement. In several cases, snapping of the longitudinal drive belt occurred when the patient's weight was under 300 lbs (below the rated weight limit). Additionally, we observed vertical deflection of the couch when extended/cantilevered with heavy patients. The purpose of this work was to implement immobilization methods and safety devices for radiation treatment management of heavy patients in order to increase patient/provider safety, prevent treatment couch damage, and reduce treatment disruptions. Materials and methods We created three safety devices for treatment management of heavy patients. Wooden brace and Scissor jack were used to lock the couch longitudinal axis (while the couch longitudinal drive was floated) during the setup of a heavy patient and absorb the mechanical impulse applied to the couch longitudinal drive belt. Wooden brace was built in house and positioned in between the wall and treatment couch to lock the longitudinal axis. Commercially available 10 in × 10 in scissor jack lift with adjustable height 3 ½ in – 13 in was modified to increase effectiveness and safety. An additional stand was created with adjustable height and rolling rubber wheels to support the couch when extended/cantilevered with heavy patients. Results Using these devices prevented the longitudinal belt from breaking and improved the patient/therapist safety at eight treatment sites within our network. No farther couch belt failures were observed since devices were introduced for clinical use. All three devices can be used and removed without any modifications done to the treatment couch.
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Affiliation(s)
- David Kanchaveli
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Samuel Hellman
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dale Lovelock
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Giorgi Archuadze
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Cesar Della Biancia
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Tillery H, Moore M, Gallagher KJ, Taddei PJ, Leuro E, Argento DC, Moffitt GB, Kranz M, Carey M, Heymsfield S, Newhauser WD. Personalized 3D-printed anthropomorphic whole-body phantom irradiated by protons, photons, and neutrons. Biomed Phys Eng Express 2022; 8. [PMID: 35045408 DOI: 10.1088/2057-1976/ac4d04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/19/2022] [Indexed: 11/12/2022]
Abstract
The objective of this study was to confirm the feasibility of three-dimensionally-printed (3D-printed), personalized whole-body anthropomorphic phantoms for radiation dose measurements in a variety of charged and uncharged particle radiation fields. We 3D-printed a personalized whole-body phantom of an adult female with a height of 154.8 cm, mass of 90.7 kg, and body mass index of 37.8 kg/m2. The phantom comprised of a hollow plastic shell filled with water and included a watertight access conduit for positioning dosimeters. It is compatible with a wide variety of radiation dosimeters, including ionization chambers that are suitable for uncharged and charged particles. Its mass was 6.8 kg empty and 98 kg when filled with water. Watertightness and mechanical robustness were confirmed after multiple experiments and transportations between institutions. The phantom was irradiated to the cranium with therapeutic beams of 170-MeV protons, 6-MV photons, and fast neutrons. Radiation absorbed dose was measured from the cranium to the pelvis along the longitudinal central axis of the phantom. The dose measurements were made using established dosimetry protocols and well-characterized instruments. For the therapeutic environments considered in this study, stray radiation from intracranial treatment beams was the lowest for proton therapy, intermediate for photon therapy, and highest for neutron therapy. An illustrative example set of measurements at the location of the thyroid for a square field of 5.3 cm per side resulted in 0.09, 0.59, and 1.93 cGy/Gy from proton, photon, and neutron beams, respectively. In this study, we found that 3D-printed personalized phantoms are feasible, inherently reproducible, and well-suited for therapeutic radiation measurements. The measurement methodologies we developed enabled the direct comparison of radiation exposures from neutron, proton, and photon beam irradiations.
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Affiliation(s)
- Hunter Tillery
- Radiation Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, KPV4, Portland, Oregon, 97239-3098, UNITED STATES
| | - Meagan Moore
- Louisiana State University, 439-B Nicholson Hall, Tower Dr., Baton Rouge, Louisiana, 70803-4001, UNITED STATES
| | - Kyle Joseph Gallagher
- Radiation Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, KPV4, Portland, Oregon, 97239-3098, UNITED STATES
| | - Phillip J Taddei
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota, 55905, UNITED STATES
| | - Eric Leuro
- Seattle Cancer Care Alliance, 1570 N 115th St, Seattle, Washington, 98133, UNITED STATES
| | - David C Argento
- Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, Washington, 98195, UNITED STATES
| | - Gregory B Moffitt
- Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, Washington, 98195, UNITED STATES
| | - Marissa Kranz
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, Washington, 98195, UNITED STATES
| | - Margaret Carey
- Louisiana State University, 439-B Nicholson Hall, Tower Dr., Baton Rouge, Louisiana, 70803-4001, UNITED STATES
| | - Steven Heymsfield
- Louisiana State University, 439-B Nicholson Hall, Tower Dr., Baton Rouge, Louisiana, 70803-4001, UNITED STATES
| | - Wayne David Newhauser
- Louisiana State University, 439-B Nicholson Hall, Tower Dr., Baton Rouge, Louisiana, 70803-4001, UNITED STATES
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Assessment of Fetal Dose and Health Effect to the Fetus from Breast Cancer Radiotherapy during Pregnancy. Life (Basel) 2022; 12:life12010084. [PMID: 35054476 PMCID: PMC8780279 DOI: 10.3390/life12010084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/30/2021] [Accepted: 01/05/2022] [Indexed: 01/26/2023] Open
Abstract
Decision for radiotherapy during the first trimester of pregnancy may occur, as patients may not realize their pregnancy at the very early stage. Since radiation dose can affect fetal development, the aim of this study was to evaluate fetal dose and associated deterministic effects and risks to the fetus from breast cancer radiotherapy of an 8-week pregnant patient. PHITS (Particle and Heavy Ion Transport code System) Monte Carlo simulation and the J-45 computational pregnancy phantom were used to simulate breast cancer radiotherapy from a 6 MV TrueBeam linear accelerator using the three dimensional-conformal radiotherapy (3D-CRT) technique with a prescribed dose to the planning target volume (PTV) of 50 Gy. Once the fetal dose was evaluated, the occurrence of the deterministic effects and risks for developing stochastic effects in the fetus were assessed using the recommendations of NCRP Report No. 174, AAPM Report No. 50, and ICRP Publication 84. The fetal dose was evaluated to be 3.37 ± 2.66 mGy, suggesting that the fetus was expected to have no additional deterministic effects, while the risks for developing cancer and malfunctions were similar to that expected from exposure to background radiation. The comparison with the other studies showed that accurate consideration of fetal position and size was important for dose determination in the fetus, especially at the early pregnancy stage when the fetus is very small.
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Kang S, Kim KH, Kang SW, Shin DS, Lee S, Chung JB. Evaluation of a new foetal shielding device for pregnant brain tumour patients. Radiat Oncol 2021; 16:109. [PMID: 34120633 PMCID: PMC8201726 DOI: 10.1186/s13014-021-01836-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background The present study aimed to propose a new foetal shielding device for pregnant cancer patients to reduce the foetal dose associated with treatment techniques using multiple gantry angles, such as intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT). Methods Three shielding structures were designed to minimise the scattered and leaked radiation from various gantry angles and radiation scattering within the patient. The base-plate part that can be placed on the treatment couch was designed to reduce the scattered and leaked radiation generated at gantry angles located near 180°. A body shielding part that can cover the lower chest and abdomen was designed, and a neck-shielding structure was added to reduce the internal and external radiation scattering from the treatment area. Evaluation plans were generated to assess the foetal dose reduction by the foetal shielding device in terms of the shielding material thickness, distance from the field edge, and shielding component using the flattened 6 MV photon beam (6MV) and flattening filter-free 6 MV photon beam (6MV-FFF). In addition, the effectiveness of the foetal shielding device was evaluated in a pregnant brain tumour patient. Results The shielding material consisting of three parts was placed on frames composed of four arch shapes with a vertical curved structure, connection bar at the top position, and base plate. Each shielding part resulted in reductions in the radiation dose according to the treatment technique, as the thickness of the shielding material increased and the foetal dose decreased. In addition, a foetal dose reduction of approximately 50% was confirmed at 50 cm from the field edge by using the designed shielding device in most delivery techniques. In patients, the newly designed shielding structures can effectively eliminate up to about 49% of the foetal dose generated from various gantry angles used in VMAT or IMRT. Conclusions We designed a foetal shielding device consisting of three parts to effectively reduce the dose delivered to the foetus, and evaluated the device with various treatment techniques for a pregnant patient with brain tumour. The foetal shielding device shielded the scattered/leaked radiation from the treatment machine, and also effectively reduced internal scattering from the treatment area in the patient.
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Affiliation(s)
- Seonghee Kang
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.,Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyeong-Hyeon Kim
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Won Kang
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Seok Shin
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seungwan Lee
- Department of Radiological Science, Konyang University, Daejeon, Korea
| | - Jin-Beom Chung
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.
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Catusso L, Santos WS, da Silva RMV, Valença JVB. Mobile shielding evaluation on the fetal dose during a breast radiotherapy using Monte Carlo simulation. Phys Med 2021; 84:24-32. [PMID: 33826997 DOI: 10.1016/j.ejmp.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/10/2021] [Accepted: 03/20/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Evaluation of the out-of-field dose is an important aspect in radiotherapy. Due to the fetus radiosensitivity, this evaluation becomes even more conclusive when the patient is pregnant. In this work, a linear accelerator Varian Clinac 2100c operating at 6 MV, a pregnant anthropomorphic phantom (Maria), and different shields added above the abdominal region of the phantom were used for the analysis based on MCNPX. METHODS The simulations were performed for the medial and lateral projections, using either an open field collimation (10×16cm2) or a multileaf collimator. The added shields (M1 and M2) were designed based on models proposed by Stovall et al. [1], intending to reduce the deposited dose on the fetus and related structures. RESULTS The presence of the shields showed to be effective in reducing the doses on the fetus, amniotic sac, and placenta, for example. A reduction of about 43% was found in the dose on the fetus when M2 was added, using the open field collimation, in comparison with the situation with no shield, being the lateral projection the main responsible for the dose. The use of MLC significatively reduced the doses in different structures, including on the fetus and amniotic sac, for example, in comparison to the open field situation. A slight increment on the dose in organs such as the eyes, thyroid and brain was found in both collimation systems, due to the presence of the shields. The contribution of the leakage radiation from the tube head of the linear accelerator was found to be in the order of µGy, being reduced by the presence of the M2 shield. CONCLUSION Using the shields showed to be an essential feature in order to reduce the dose not only on the fetus, but also in important structures responsible to its development.
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Affiliation(s)
- Leonardo Catusso
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
| | - William S Santos
- Federal University of Uberlândia (INFIS/UFU), Uberlândia, MG, Brazil
| | | | - João V B Valença
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
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Craenen K, Verslegers M, Callaerts-Vegh Z, Craeghs L, Buset J, Govaerts K, Neefs M, Gsell W, Baatout S, D'Hooge R, Himmelreich U, Moons L, Benotmane MA. Folic Acid Fortification Prevents Morphological and Behavioral Consequences of X-Ray Exposure During Neurulation. Front Behav Neurosci 2021; 14:609660. [PMID: 33488367 PMCID: PMC7820780 DOI: 10.3389/fnbeh.2020.609660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/08/2020] [Indexed: 12/02/2022] Open
Abstract
Previous studies suggested a causal link between pre-natal exposure to ionizing radiation and birth defects such as microphthalmos and exencephaly. In mice, these defects arise primarily after high-dose X-irradiation during early neurulation. However, the impact of sublethal (low) X-ray doses during this early developmental time window on adult behavior and morphology of central nervous system structures is not known. In addition, the efficacy of folic acid (FA) in preventing radiation-induced birth defects and persistent radiation-induced anomalies has remained unexplored. To assess the efficacy of FA in preventing radiation-induced defects, pregnant C57BL6/J mice were X-irradiated at embryonic day (E)7.5 and were fed FA-fortified food. FA partially prevented radiation-induced (1.0 Gy) anophthalmos, exencephaly and gastroschisis at E18, and reduced the number of pre-natal deaths, fetal weight loss and defects in the cervical vertebrae resulting from irradiation. Furthermore, FA food fortification counteracted radiation-induced impairments in vision and olfaction, which were evidenced after exposure to doses ≥0.1 Gy. These findings coincided with the observation of a reduction in thickness of the retinal ganglion cell and nerve fiber layer, and a decreased axial length of the eye following exposure to 0.5 Gy. Finally, MRI studies revealed a volumetric decrease of the hippocampus, striatum, thalamus, midbrain and pons following 0.5 Gy irradiation, which could be partially ameliorated after FA food fortification. Altogether, our study is the first to offer detailed insights into the long-term consequences of X-ray exposure during neurulation, and supports the use of FA as a radioprotectant and antiteratogen to counter the detrimental effects of X-ray exposure during this crucial period of gestation.
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Affiliation(s)
- Kai Craenen
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (Studiecentrum voor Kernenergie; Centre d'étude de l'énergie nucléaire), Mol, Belgium
- Laboratory of Neural Circuit Development and Regeneration, Animal Physiology and Neurobiology Section, Department of Biology, Faculty of Science, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mieke Verslegers
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (Studiecentrum voor Kernenergie; Centre d'étude de l'énergie nucléaire), Mol, Belgium
| | - Zsuzsanna Callaerts-Vegh
- Laboratory of Biological Psychology, Faculty of Psychology and Educational Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Livine Craeghs
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (Studiecentrum voor Kernenergie; Centre d'étude de l'énergie nucléaire), Mol, Belgium
- Laboratory of Neural Circuit Development and Regeneration, Animal Physiology and Neurobiology Section, Department of Biology, Faculty of Science, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jasmine Buset
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (Studiecentrum voor Kernenergie; Centre d'étude de l'énergie nucléaire), Mol, Belgium
| | - Kristof Govaerts
- Molecular Small Animal Imaging Center, Biomedical MRI Unit, Department of Imaging and Pathology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mieke Neefs
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (Studiecentrum voor Kernenergie; Centre d'étude de l'énergie nucléaire), Mol, Belgium
| | - Willy Gsell
- Molecular Small Animal Imaging Center, Biomedical MRI Unit, Department of Imaging and Pathology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sarah Baatout
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (Studiecentrum voor Kernenergie; Centre d'étude de l'énergie nucléaire), Mol, Belgium
| | - Rudi D'Hooge
- Laboratory of Biological Psychology, Faculty of Psychology and Educational Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Uwe Himmelreich
- Molecular Small Animal Imaging Center, Biomedical MRI Unit, Department of Imaging and Pathology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lieve Moons
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (Studiecentrum voor Kernenergie; Centre d'étude de l'énergie nucléaire), Mol, Belgium
- Laboratory of Neural Circuit Development and Regeneration, Animal Physiology and Neurobiology Section, Department of Biology, Faculty of Science, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mohammed Abderrafi Benotmane
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (Studiecentrum voor Kernenergie; Centre d'étude de l'énergie nucléaire), Mol, Belgium
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11
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Eastwood-Wilshere N, Turner J, Oliveira N, Morton A. Cancer in Pregnancy. Asia Pac J Clin Oncol 2019; 15:296-308. [PMID: 31436920 DOI: 10.1111/ajco.13235] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 07/22/2019] [Indexed: 12/25/2022]
Abstract
Cancer in pregnancy may be increasing in incidence with advancing maternal age and higher rates of obesity. The diagnosis of cancer in pregnancy provokes complex management issues balancing short- and long-term risks for both mother and baby. Every case needs to be individualized, with a multidisciplinary team of midwives, obstetricians, oncologists, surgeons, radiation oncologists, and neonatologists assisting the family to make informed decisions regarding the best treatment course for the mother and baby. The present article reviews the evidence regarding the safety of diagnostic imaging, procedures and treatment modalities for cancer for the pregnant woman and fetus. The efficacy of novel anticancer therapies highlight the need for International Registries to accumulate safety data for these agents in pregnancy as expeditiously as possible.
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Affiliation(s)
- Naomi Eastwood-Wilshere
- Department of Obstetric Medicine, Mater Health Brisbane, South Brisbane, Queensland, Australia
| | - Jessica Turner
- Department of Medical Oncology, Mater Health Brisbane, South Brisbane, Queensland, Australia
| | - Niara Oliveira
- Department of Obstetrics and Gynaecology, Mater Health Brisbane, South Brisbane, Queensland, Australia
| | - Adam Morton
- Department of Obstetric Medicine, Mater Health Brisbane, South Brisbane, Queensland, Australia
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12
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Mazzola R, Corradini S, Eidemüeller M, Figlia V, Fiorentino A, Giaj-Levra N, Nicosia L, Ricchetti F, Rigo M, Musola M, Ceccaroni M, Gori S, Magrini SM, Alongi F. Modern radiotherapy in cancer treatment during pregnancy. Crit Rev Oncol Hematol 2019; 136:13-19. [PMID: 30878124 DOI: 10.1016/j.critrevonc.2019.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/10/2019] [Accepted: 02/04/2019] [Indexed: 12/30/2022] Open
Abstract
Breast cancer, gynecological malignancies and lymphomas are the most frequently diagnosed tumors in pregnant women. The feasibility of radiotherapy during pregnancy remains a subject of debate and clinicians continue to hesitate on this approach, trying to avoid radiotherapy in most cases. Since the 1990s, several technological advances, including intensity modulated and image guided radiation delivery, have been implemented in radiation oncology to improve the radiation treatment in terms of effectiveness and tolerability. It remains uncertain which short- and long-term health effects the radiation exposure of the fetus may have through advanced radiotherapy techniques. The present systematic literature review aims to summarize the limited current evidences of the feasibility and clinical results of "modern" radiotherapy procedures for the treatment of the most frequently diagnosed tumors in pregnant women.
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Affiliation(s)
- Rosario Mazzola
- Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy.
| | | | - Markus Eidemüeller
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Vanessa Figlia
- Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Alba Fiorentino
- Radiation Oncology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti-Bari, Italy
| | - Niccolò Giaj-Levra
- Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Luca Nicosia
- Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Francesco Ricchetti
- Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Michele Rigo
- Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Mariella Musola
- Department of Obstetrics and Gynecology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Stefania Gori
- Medical Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | | | - Filippo Alongi
- Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy; University of Brescia, Italy
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13
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Labby ZE, Barraclough B, Bayliss RA, Besemer AE, Dunkerley DAP, Howard SP. Radiation treatment planning and delivery strategies for a pregnant brain tumor patient. J Appl Clin Med Phys 2018; 19:368-374. [PMID: 30062720 PMCID: PMC6123144 DOI: 10.1002/acm2.12262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/07/2017] [Accepted: 12/18/2017] [Indexed: 11/12/2022] Open
Abstract
The management of a pregnant patient in radiation oncology is an infrequent event requiring careful consideration by both the physician and physicist. The aim of this manuscript was to highlight treatment planning techniques and detail measurements of fetal dose for a pregnant patient recently requiring treatment for a brain cancer. A 27-year-old woman was treated during gestational weeks 19-25 for a resected grade 3 astrocytoma to 50.4 Gy in 28 fractions, followed by an additional 9 Gy boost in five fractions. Four potential plans were developed for the patient: a 6 MV 3D-conformal treatment plan with enhanced dynamic wedges, a 6 MV step-and-shoot (SnS) intensity-modulated radiation therapy (IMRT) plan, an unflattened 6 MV SnS IMRT plan, and an Accuray TomoTherapy HDA helical IMRT treatment plan. All treatment plans used strategies to reduce peripheral dose. Fetal dose was estimated for each treatment plan using available literature references, and measurements were made using thermoluminescent dosimeters (TLDs) and an ionization chamber with an anthropomorphic phantom. TLD measurements from a full-course radiation delivery ranged from 1.0 to 1.6 cGy for the 3D-conformal treatment plan, from 1.0 to 1.5 cGy for the 6 MV SnS IMRT plan, from 0.6 to 1.0 cGy for the unflattened 6 MV SnS IMRT plan, and from 1.9 to 2.6 cGy for the TomoTherapy treatment plan. The unflattened 6 MV SnS IMRT treatment plan was selected for treatment for this particular patient, though the fetal doses from all treatment plans were deemed acceptable. The cumulative dose to the patient's unshielded fetus is estimated to be 1.0 cGy at most. The planning technique and distance between the treatment target and fetus both contributed to this relatively low fetal dose. Relevant treatment planning strategies and treatment delivery considerations are discussed to aid radiation oncologists and medical physicists in the management of pregnant patients.
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Affiliation(s)
- Zacariah E Labby
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - Brendan Barraclough
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - R Adam Bayliss
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - Abigail E Besemer
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - David A P Dunkerley
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - Steven P Howard
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
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14
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Mille MM, Jung JW, Lee C, Kuzmin GA, Lee C. Comparison of normal tissue dose calculation methods for epidemiological studies of radiotherapy patients. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2018; 38:775-792. [PMID: 29637904 PMCID: PMC6007019 DOI: 10.1088/1361-6498/aabd4f] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Radiation dosimetry is an essential input for epidemiological studies of radiotherapy patients aimed at quantifying the dose-response relationship of late-term morbidity and mortality. Individualised organ dose must be estimated for all tissues of interest located in-field, near-field, or out-of-field. Whereas conventional measurement approaches are limited to points in water or anthropomorphic phantoms, computational approaches using patient images or human phantoms offer greater flexibility and can provide more detailed three-dimensional dose information. In the current study, we systematically compared four different dose calculation algorithms so that dosimetrists and epidemiologists can better understand the advantages and limitations of the various approaches at their disposal. The four dose calculations algorithms considered were as follows: the (1) Analytical Anisotropic Algorithm (AAA) and (2) Acuros XB algorithm (Acuros XB), as implemented in the Eclipse treatment planning system (TPS); (3) a Monte Carlo radiation transport code, EGSnrc; and (4) an accelerated Monte Carlo code, the x-ray Voxel Monte Carlo (XVMC). The four algorithms were compared in terms of their accuracy and appropriateness in the context of dose reconstruction for epidemiological investigations. Accuracy in peripheral dose was evaluated first by benchmarking the calculated dose profiles against measurements in a homogeneous water phantom. Additional simulations in a heterogeneous cylinder phantom evaluated the performance of the algorithms in the presence of tissue heterogeneity. In general, we found that the algorithms contained within the commercial TPS (AAA and Acuros XB) were fast and accurate in-field or near-field, but not acceptable out-of-field. Therefore, the TPS is best suited for epidemiological studies involving large cohorts and where the organs of interest are located in-field or partially in-field. The EGSnrc and XVMC codes showed excellent agreement with measurements both in-field and out-of-field. The EGSnrc code was the most accurate dosimetry approach, but was too slow to be used for large-scale epidemiological cohorts. The XVMC code showed similar accuracy to EGSnrc, but was significantly faster, and thus epidemiological applications seem feasible, especially when the organs of interest reside far away from the field edge.
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Affiliation(s)
- Matthew M Mille
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD 20850, United States of America
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15
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Owrangi AM, Roberts DA, Covington EL, Hayman JA, Masi KM, Lee C, Moran JM, Prisciandaro JI. Revisiting fetal dose during radiation therapy: evaluating treatment techniques and a custom shield [JACMP, 17(5), 2016]. J Appl Clin Med Phys 2017; 18:288. [PMID: 29125230 PMCID: PMC5689918 DOI: 10.1002/acm2.12191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Amir M. Owrangi
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
| | - Donald A. Roberts
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
| | | | - James A. Hayman
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
| | - Kathryn M. Masi
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
| | - Choonik Lee
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
| | - Jean M. Moran
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
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16
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Mazonakis M, Damilakis J. Estimation and reduction of the radiation dose to the fetus from external-beam radiotherapy. Phys Med 2017; 43:148-152. [DOI: 10.1016/j.ejmp.2017.09.130] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 07/18/2017] [Accepted: 09/17/2017] [Indexed: 01/18/2023] Open
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17
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Covington EL, Ritter TA, Moran JM, Owrangi AM, Prisciandaro JI. Technical Report: Evaluation of peripheral dose for flattening filter free photon beams. Med Phys 2017; 43:4789. [PMID: 27487896 DOI: 10.1118/1.4958963] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To develop a comprehensive peripheral dose (PD) dataset for the two unflattened beams of nominal energy 6 and 10 MV for use in clinical care. METHODS Measurements were made in a 40 × 120 × 20 cm(3) (width × length × depth) stack of solid water using an ionization chamber at varying depths (dmax, 5, and 10 cm), field sizes (3 × 3 to 30 × 30 cm(2)), and distances from the field edge (5-40 cm). The effects of the multileaf collimator (MLC) and collimator rotation were also evaluated for a 10 × 10 cm(2) field. Using the same phantom geometry, the accuracy of the analytic anisotropic algorithm (AAA) and Acuros dose calculation algorithm was assessed and compared to the measured values. RESULTS The PDs for both the 6 flattening filter free (FFF) and 10 FFF photon beams were found to decrease with increasing distance from the radiation field edge and the decreasing field size. The measured PD was observed to be higher for the 6 FFF than for the 10 FFF for all field sizes and depths. The impact of collimator rotation was not found to be clinically significant when used in conjunction with MLCs. AAA and Acuros algorithms both underestimated the PD with average errors of -13.6% and -7.8%, respectively, for all field sizes and depths at distances of 5 and 10 cm from the field edge, but the average error was found to increase to nearly -69% at greater distances. CONCLUSIONS Given the known inaccuracies of peripheral dose calculations, this comprehensive dataset can be used to estimate the out-of-field dose to regions of interest such as organs at risk, electronic implantable devices, and a fetus. While the impact of collimator rotation was not found to significantly decrease PD when used in conjunction with MLCs, results are expected to be machine model and beam energy dependent. It is not recommended to use a treatment planning system to estimate PD due to the underestimation of the out-of-field dose and the inability to calculate dose at extended distances due to the limits of the dose calculation matrix.
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Affiliation(s)
- E L Covington
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan 48109
| | - T A Ritter
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan 48109 and Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan 48105
| | - J M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan 48109
| | - A M Owrangi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan 48109
| | - J I Prisciandaro
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan 48109
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