Intra-fraction motion of pelvic oligometastases and feasibility of PTV margin reduction using MRI guided adaptive radiotherapy

Purpose

This study assesses the impact of intra-fraction motion and PTV margin size on target coverage for patients undergoing radiation treatment of pelvic oligometastases. Dosimetric sparing of the bowel as a function of the PTV margin is also evaluated.

Materials and methods

Seven patients with pelvic oligometastases previously treated on our MR-linac (35 Gy in 5 fractions) were included in this study. Retrospective adaptive plans were created for each fraction on the daily MRI datasets using PTV margins of 5 mm, 3 mm, and 2 mm. Dosimetric constraint violations and GTV coverage were measured as a function of PTV margin size. The impact of intra-fraction motion on GTV coverage was assessed by tracking the GTV position on the cine MR images acquired during treatment delivery and creating an intra-fraction dose distribution for each IMRT beam. The intra-fraction dose was accumulated for each fraction to determine the total dose delivered to the target for each PTV size.

Results

All OAR constraints were achieved in 85.7%, 94.3%, and 100.0% of fractions when using 5 mm, 3 mm, and 2 mm PTV margins while scaling to 95% PTV coverage. Compared to plans with a 5 mm PTV margin, there was a 27.4 ± 12.3% (4.0 ± 2.2 Gy) and an 18.5 ± 7.3% (2.7 ± 1.4 Gy) reduction in the bowel D_0.5cc dose for 2 mm and 3 mm PTV margins, respectively. The target dose (GTV V_{35 Gy}) was on average 100.0 ± 0.1% (99.6 - 100%), 99.6 ± 1.0% (97.2 - 100%), and 99.0 ± 1.4% (95.0 - 100%), among all fractions for the 5 mm, 3 mm, and 2 mm PTV margins on the adaptive plans when accounting for intra-fraction motion, respectively.

Conclusion

A 2 mm PTV margin achieved a minimum of 95% GTV coverage while reducing the dose to the bowel for all patients.

Technological drought: a new category of water scarcity

In this paper, we argue that current definitions of drought, especially in the context of small-scale agricultural production, are incomplete. We introduce the concept of 'technological drought' to account for crop failures, reduced yields or water scarcity, which are the consequence of an inability to supplement water when there is a lack of irrigation technology and/or existing poor water management. We illustrate the diversity of causes of technological drought, which can include shortages of fuel or electricity to operate pumps, problematically high costs to access irrigation infrastructure, or constrained access to pumps that have to be shared among multiple farmers. We argue that vulnerability to technological drought can be strongly conditioned by socio-economic conditions and that its impact can be magnified when population growth and the demand for food mean that any decline in yield can have serious consequences for food security. We show that technological drought is a complex phenomenon, and can be differentiated from the more widely-recognised classes of drought (meteorological, agricultural, hydrological, and socio-economic) in multiple ways. In particular, technological drought exhibits an important dependence on the socio-economic context of agricultural production. It is perhaps most evident in developing economies, especially where agricultural output depends strongly on the capacity of individual farmers to manage crop water supply on small holdings. Technological drought can follow from even brief interruptions to monsoon rainfall during critical stages of crop growth, such that technological droughts can be distinguished from other forms of drought by their brevity.

Initial clinical applications treating pediatric and adolescent patients using MR-guided radiotherapy

Purpose

To demonstrate the clinical applications and feasibility of online adaptive magnetic resonance image guided radiotherapy (MRgRT) in the pediatric, adolescent and young adult (AYA) population.

Methods

This is a retrospective case series of patients enrolled onto a prospective study. All pediatric (age < 18) and AYA patients (age< 30), treated on the Elekta Unity MR linear accelerator (MRL) from 2019 to 2021 were enrolled onto a prospective registry. Rationale for MRgRT included improved visualization of and alignment to the primary tumor, re-irradiation in a critical area, ability to use smaller margins, and need for daily adaptive replanning to minimize dose to adjacent critical structures. Step-and-shoot intensity-modulated radiation treatment (IMRT) plans were generated for all Unity patients with a dose grid of 3 mm and a statistical uncertainty of < 1% per plan.

Results

A total of 15 pediatric and AYA patients have been treated with median age of 13 years (range: 6 mos - 27 yrs). Seven patients were <10 yo. The clinical applications of MRgRT included Wilms tumor with unresectable IVC thrombus (n=1), Ewing sarcoma (primary and metastatic, n=3), recurrent diffuse intrinsic pontine glioma (DIPG, n=2), nasopharyngeal carcinoma (n=1), clival chordoma (n=1), primitive neuroectodermal tumor of the pancreas (n=1), recurrent gluteo-sacral germ cell tumor (n=1), C-spine ependymoma (n=1), and posterior fossa ependymoma (n=1). Two children required general anesthesia. One AYA patient could not complete the MRgRT course due to tumor-related pain exacerbated by longer treatment times. Two AYA patients experienced anxiety related to treatment on the MRL, one of which required daily Ativan. No patient experienced treatment interruptions or unexpected toxicity.

Conclusion

MRgRT was well-tolerated by pediatric and AYA patients. There was no increased use of anesthesia outside of our usual practice. Dosimetric advantages were seen for patients with tumors in critical locations such as adjacent to or involving optic structures, stomach, kidney, bowel, and heart.

Implementation of a real-time, ultrasound-guided prostate HDR brachytherapy program

This work presents a comprehensive commissioning and workflow development process of a real-time, ultrasound (US) image-guided treatment planning system (TPS), a stepper and a US unit. To adequately benchmark the system, commissioning tasks were separated into (1) US imaging, (2) stepper mechanical, and (3) treatment planning aspects. Quality assurance US imaging measurements were performed following the AAPM TG-128 and GEC-ESTRO recommendations and consisted of benchmarking the spatial resolution, accuracy, and low-contrast detectability. Mechanical tests were first used to benchmark the electronic encoders within the stepper and were later expanded to evaluate the needle free length calculation accuracy. Needle reconstruction accuracy was rigorously evaluated at the treatment planning level. The calibration length of each probe was redundantly checked between the calculated and measured needle free length, which was found to be within 1 mm for a variety of scenarios. Needle placement relative to a reference fiducial and coincidence of imaging coordinate origins were verified to within 1 mm in both sagittal and transverse imaging planes. The source strength was also calibrated within the interstitial needle and was found to be 1.14% lower than when measured in a plastic needle. Dose calculations in the TPS and secondary dose calculation software were benchmarked against manual TG-43 calculations. Calculations among the three calculation methods agreed within 1% for all calculated points. Source positioning and dummy coincidence was tested following the recommendations of the TG-40 report. Finally, the development of the clinical workflow, checklists, and planning objectives are discussed and included within this report. The commissioning of real-time, US-guided HDR prostate systems requires careful consideration among several facets including the image quality, dosimetric, and mechanical accuracy. The TPS relies on each of these components to develop and administer a treatment plan, and as such, should be carefully examined.

Trade-off between surface runoff and soil erosion during the implementation of ecological restoration programs in semiarid regions: A meta-analysis

The application of ecological restoration programs, related to water resources protection and soil erosion control, may have some undesirable outcomes. An important example is the effect that vegetation restoration may have in reducing surface water resources. After searching peer-reviewed articles, we selected 38 publications from 16 countries in comparable areas - semiarid conditions (aridity index <0.5), surface coverage >50% and fine soil texture - to evaluate the effectiveness of different types of vegetation (i.e., forestland, scrubland and grassland) in regulating runoff and sediment transport. In particular, we used three indices: the runoff reduction effect, the sediment reduction effect and the ratio between runoff and sediment reduction. These indices were calculated from measured data reported in the original articles. Results showed that scrubland had higher runoff reduction effect (59% in gentle slopes; 65% in steep slopes) than in grassland (39% on gentle slopes; 43% on steep slopes) and forestland (33% on gentle slopes; 51% on steep slopes). For the three types of vegetation, the sediment reduction effect was >70%. Concerning the ratios between runoff and sediment reduction, grassland showed the lowest ratios (56% on gentle slopes; 53% on steep slopes) compared to forestland (63% on gentle slopes; 65% on steep slopes) and scrubland (93% on gentle slopes; 81% on steep slopes). Our results indicate that low values of ratios between runoff and sediment reduction are the most suitable because they indicate an effective soil erosion and sediment delivery reduction but maintaining surface runoff. Overall, our study demonstrates that grassland may be the best choice for optimizing the trade-off between catchment water yield and soil conservation during the implementation of ecological restoration programs in semi-arid regions.

Evaluation of a commercial Monte Carlo dose calculation algorithm for electron treatment planning

The RayStation treatment planning system implements a Monte Carlo (MC) algorithm for electron dose calculations. For a TrueBeam accelerator, beam modeling was performed for four electron energies (6, 9, 12, and 15 MeV), and the dose calculation accuracy was tested for a range of geometries. The suite of validation tests included those tests recommended by AAPM's Medical Physics Practice Guideline 5.a, but extended beyond these tests in order to validate the MC algorithm in more challenging geometries. For MPPG 5.a testing, calculation accuracy was evaluated for square cutouts of various sizes, two custom cutout shapes, oblique incidence, and heterogenous media (cork). In general, agreement between ion chamber measurements and RayStation dose calculations was excellent and well within suggested tolerance limits. However, this testing did reveal calculation errors for the output of small cutouts. Of the 312 output factors evaluated for square cutouts, 20 (6.4%) were outside of 3% and 5 (1.6%) were outside of 5%, with these larger errors generally being for the smallest cutout sizes within a given applicator. Adjustment of beam modeling parameters did not fix these calculation errors, nor does the planning software allow the user to input correction factors as a function of field size. Additional validation tests included several complex phantom geometries (triangular nose phantom, lung phantom, curved breast phantom, and cortical bone phantom), designed to test the ability of the algorithm to handle high density heterogeneities and irregular surface contours. In comparison to measurements with radiochromic film, RayStation showed good agreement, with an average of 89.3% pixels passing for gamma analysis (3%/3mm) across four phantom geometries. The MC algorithm was able to accurately handle the presence of irregular surface contours (curved cylindrical phantom and a triangular nose phantom), as well as heterogeneities (cork and cortical bone).

Long-term dosimetric stability of multiple TomoTherapy delivery systems

The dosimetric stability of six TomoTherapy units was analyzed to investigate changes in performance over time and with system upgrades. Energy and output were tracked using monitor chamber signal, onboard megavoltage computed tomography (MVCT) detector profile, and external ion chamber measurements. The systems (and monitoring periods) include three Hi-Art (67, 61, and 65 mos.), two TomoHDA (31 and 26 mos.), and one Radixact unit (11 mos.), representing approximately 10 years of clinical use. The four newest systems use the Dose Control Stability (DCS) system and Fixed Target Linear Accelerator (linac) (FTL). The output stability is reported as deviation from reference monitor chamber signal for all systems and/or from an external chamber signal. The energy stability was monitored using relative (center versus off-axis) MVCT detector signal (beam profile) and/or the ratio of chamber measurements at 2 depths. The clinical TomoHDA data were used to benchmark the Radixact stability, which has the same FTL but runs at a higher dose rate. The output based on monitor chamber data of all systems is very stable. The standard deviation of daily output on the non-DCS systems was 0.94-1.52%. As expected, the DCS systems had improved standard deviation: 0.004-0.06%. The beam energy was also very stable for all units. The standard deviation in profile flatness was 0.23-0.62% for rotating target systems and 0.04-0.09% for FTL. Ion chamber output and PDD ratios supported these results. The output stability on the Radixact system during extended treatment delivery (20, 30, and 40 min) was comparable to a clinical TomoHDA system. For each system, results are consistent between different measurement tools and techniques, proving not only the dosimetric stability, but also these quality parameters can be confirmed with various metrics. The replacement history over extended time periods of the major dosimetric components of the different delivery systems (target, linac, and magnetron) is also reported.

Interorganizational Networks: A Case Study of Industrial Location

The recent interest in the literature on interorganizational relations is briefly reviewed and the so-called 'political economy' perspective is suggested as a helpful approach in conceptualizing the environments of organizations as a network in continuous negotia tions. A case study is presented of the negotiations between the British Government and the Ford Motor Company over the siting of a major engine plant in South Wales. The case study highlights the importance of choice and manipulation of environments; the extent to which organizations can control their environments; the importance of under standing organizational power; and the market position of the organization.

Ecogeomorphology in the Australian drylands and the role of biota in mediating the effects of climate change on landscape processes and evolution

Australian dryland landscape has developed under the influence of aridity, low relief, tectonic stability and biota adapted to nutrient and water scarcity. The biota in general, but notably the plants, mediates the impact of water scarcity and of climate change on ecohydrological and geomorphological processes. It reduce the partitioning of rain into overland flow, and so limit soil erosion, notably through the development of patch structures that partition the landscape into local runoff sources and runon sinks. In large rain events, when flow does reach ephemeral streams, channel-associated plants again modify flow conditions, reducing flow speeds and flow competence. Given the diverse influences of biota on landscape processes, it is argued that it likewise moderated the effects of Quaternary and Holocene climate change. Field evidence from Australian and other drylands suggests that the effect of changing land surface properties on runoff and erosion may exceed the effect of moderate climate change. Knowledge of the role of dryland biota and its role in land surface change is therefore a prerequisite to understanding the responses of landscapes to climate change, to understanding the complex spatio-temporal variability in landscape development, and to developing the ability to correctly interpret the alluvial record of changing geomorphological processes in terms of changes in climate and other external drivers.