Research Organization Document

Section 1
The purpose of this document is to organize your ideas and keep in mind the key research
components as you begin working through your research. Please refer to this document often so
that you remember the key questions you are answering and to update the research components
as you research them.

First, you will outline the 3 key components to selecting a research topic: a problem that
needs to be solved, evidence of gap in the literature (a summary of different journal articles that
support a similar topic or a journal article that says further research should be conducted on the
topic you are interested in researching), an active references page that you update continuously
to keep track of your research information.

For the problem that needs to be solved section, you need to decide what the problem is
for your research. This includes addressing a set of 5-7 questions that you need to refer to often
in your research to make sure that you are staying on topic. Key questions should be your active
research questions. When you have finished writing your research paper, you reader should be
able to address and answer these questions easily.For the problem that needs to be solved
section, you need to decide what the problem is for your research. This includes addressing a set
of 5-7 questions that you need to refer to often in your research to make sure that you are staying
on topic. Key questions should be your active research questions. When you have finished
writing your research paper, you reader should be able to address and answer these questions
easily.

For the evidence of gap in the literature section, you should include a paragraph written
in your own words with referenced superscripts to the references page so that the instructor can
look at the article you are using to support your research.

The references to support your research section should include all of the references you
have used for your research in AMA formatting. Use this as a place to keep track of your articles
and update this often as you get into your research. This shouldnt necessarily include all of the
references that you sent to the instructor for the conference call. Since your topic was likely
tweaked during the conference call, only include the references that pertain directly to your topic.
This is important because there is a limit to the number of references you can have depending on
the type of paper you decide to write.

Finally, you will indicate the title of your official research topic. This may change as you
begin your research so it is important that you keep your topic updated so that the instructor may
track your progress through the research paper progression. Finally, you will indicate the title of
your official research topic. This may change as you begin your research so it is important that
you keep your topic updated so that the instructor may track your progress through the research
paper progression.

For most groups, this information was decided in the conference call with the instructor
so it should be easy to answer these questions. For most groups, this information was decided in
the conference call with the instructor so it should be easy to answer these questions.

RapidPlan (Conformal Breast planning)

Research Organization Document
Section 1

Problem that needs to be solved:

RapidPlan is a fairly new software from Varian. There is not a great deal of published research
on RapidPlans accuracy and potential advantages or disadvantages.
o Breast: For left-sided supine breast patients, many centers simulate the patient with a
free-breathing and DIBH technique. Deciding which scan to plan on (or creating
multiple plans) decreases efficiency.

o Can the DVH from RapidPlan inform us on which scan would be better to plan
on (DIBH or FB)?

Key Questions that need to be answered:

Breast:
o Can RapidPlan be used to accurately predict a DVH for breast treatment plans?
o Is this a problem that other cancer centers have? (i.e. is the research relevant?)

o Can RapidPlan be used to predict DVHs for conformal plans?

o Is there an anatomic measurement that is able to determine if a patient will benefit

from DIBH?

o Do OR and PTV volumes that are significantly different affect the ability to accurately
determine DIBH vs. Free breathing?

o How accurate can RapidPlan be when choosing what scan to plan on?
o How does the predicted DVH compare to the manual plan?
Evidence of a gap in the literature:

It has been shown many times that the deep inspiration breath-hold (DIBH) technique is beneficial
in reducing doses to the heart and ipsilateral lung for left-sided supine breast patients. One systematic
review indicated that the DIBH technique decreases the mean heart by up to 3.4 Gy relating to a 13.6%
reduction in risk of heart disease. 1 Another review compared mortality ratios between left and right sided
breast patients and showed that mortality from heart disease and lung cancer following radiation therapy
was increased in the left-sided group.2 However, even with the published benefits of utilizing DIBH,
reproducing the breath-hold over the course of treatment can be an issue. For this reason, cancer centers
tend to perform simulations with a free-breathing CT and a DIBH CT with the intention of using the free-
breathing for planning due to its reproducibility. This often creates a major decrease in efficiency,
requiring a plan to be made before knowing the DIBH scan needs to be used for treatment.
Some studies have been completed attempting to evaluate anatomical metrics to predict which
patients would benefit from using a DIBH scan. 3,4 These articles either did not find a reliable metric, or the
evaluation required treatment planning on both scans. The accuracy of RapidPlan has been evaluated for
disease sites involving head and neck, lung, liver, prostate, and esophageal cancers. Only one study
completed by Fogliata et al5 focused on the accuracy of RapidPlan for VMAT planning of breast cancer
patients. Most of these studies have shown that RapidPlan produced plans with equivalent target
coverage and improved organ sparing. Our study would be testing whether or not RapidPlan can
accurately predict organs at risk (OR) doses for conformal plans when a model is built from left-sided
conformal patients. This would be beneficial for the field since this could give centers the advantage of
knowing if a patient will benefit from the DIBH scan without having to create multiple treatment plans.

References to support your research:

1. Smyth LM, Knight KA, Aarons YK, Wasiak J. The cardiac dose-sparing benefits of deep inspiration
breath-hold in left breast irradiation: a systematic review. J Med Radiat Sci. 2015;62(1):66-73.
http://dx.doi.org/10.1002/jmrs.89
2. Darby SC, McGale P, Taylor CW, Peto R. Long-term mortality from heart disease and lung cancer
after radiotherapy for early breast cancer: prospective cohort study of about 300000 women in US
SEER cancer registries. Lancet Oncol. 2005;6(8):557-565. http://dx.doi.org/10.1016/S1470-
2045(05)70251-5
3. Register S, Takita C, Reis I, Zhao W, Amestoy W, Wright J. Deep inspiration breath-hold technique
for left-sided breast cancer: An analysis of predictors for organ-at-risk sparing. Med Dosim.
2015;40(1):89-95. http://dx.doi.org/10.1016/j.meddos.2014.10.005
 4. Rochet N, Drake JI, Harrington K, et al. Deep inspiration breath-hold technique in left-sided breast
cancer radiation therapy: Evaluating cardiac contact distance as a predictor of cardiac exposure for
patient selection. Pract Radiat Oncol. 2015;5(3):e127-e134.
http://dx.doi.org/10.1016/j.prro.2014.08.003
5. Fogliata A, Nicolini G, Bourgier C, et al. Performance of a Knowledge-Based Model for
Optimization of Volumetric Modulated Arc Therapy Plans for Single and Bilateral Breast Irradiation.
PLoS One. 2015;10(12):e0145137. http://dx.doi.org/10.1371/journal.pone.0145137

Articles Assessing RapidPlan across various disease sites:

Rectal

1. Wu H, Jiang F, Yue H, Zhang H, Wang K, Zhang Y. Applying a RapidPlan model trained on a

technique and orientation to another: a feasibility and dosimetric evaluation. Radiat Oncol.
2016;11(1):108. http://dx.doi.org/10.1186/s13014-016-0684-9
2. Wu H, Jiang F, Yue H, Li S, Zhang Y. A dosimetric evaluation of knowledge-based VMAT planning
with simultaneous integrated boosting for rectal cancer patients. J Appl Clin Med Phys.
2016;17(6):78-85. http://dx.doi.org/10.1120/jacmp.v17i6.6410
Prostate and cervical

3. Hussein M, South CP, Barry MA, et al. Clinical validation and benchmarking of knowledge-based
IMRT and VMAT treatment planning in pelvic anatomy. Radiother Oncol. 2016;120(3):473-479.
http://dx.doi.org/10.1016/j.radonc.2016.06.022
4. Appenzoller L, Michalski J, Thorstad W, Mutic S, Moore K. Predicting dose-volume histograms for
organs at risk in IMRT planning. Med Phys. 2012; 39(12): 7446-61.
http://dx.doi.org/10.1118/1.4761864.
Lung and prostate:

5. Fogliata A, Belosi F, Clivio A, et al. On the pre-clinical validation of a commercial model-based

optimisation engine: application to volumetric modulated arc therapy for patients with lung or
prostate cancer. Radiother Oncol. 2014;113(3):385-91. http://dx.doi.org/10.1016/j.radonc.2014.11.009
Prostate:

6. Nwankwo O, Mekdash H, Sihono DS, Wenz F, Glatting G. Knowledge-based radiation therapy

(KBRT) treatment planning versus planning by experts: validation of a KBRT algorithm for prostate
cancer treatment planning. Radiat Oncol. 2015;10:111. http://dx.doi.org/10.1186/s13014-015-0416-6
Head and neck:
 7. Tol JP, Dahele M, Delaney AR, Slotman BJ, Verbakel WFAR. Can knowledge-based DVH predictions
be used for automated, individualized quality assurance of radiotherapy treatment plans? Radiat
Oncol. 2015;10:234. http://dx.doi.org/10.1186/s13014-015-0542-1
8. Chang ATY, Hung AWM, Cheung FWK, et al. Comparison of Planning Quality and Efficiency
Between Conventional and Knowledge-based Algorithms in Nasopharyngeal Cancer Patients
Using Intensity Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys. 2016;95(3):981-990.
http://dx.doi.org/10.1016/j.ijrobp.2016.02.017
9. Tol JP, Delaney AR, Dahele M, Slotman BJ, Verbakel WF. Evaluation of a knowledge-based
planning solution for head and neck cancer. Int J Radiat Oncol Biol Phys. 2015;91(3):612-20.
http://dx.doi.org/10.1016/j.ijrobp.2014.11.014
10. Delaney AR, Tol JP, Dahele M, Cuijpers J, Slotman BJ, Verbakel WF. Effect of Dosimetric Outliers on
the Performance of a Commercial Knowledge-Based Planning Solution. Int J Radiat Oncol Biol
Phys. 2016;94(3):469-77. http://dx.doi.org/10.1016/j.ijrobp.2015.11.011
Esophageal

11. Fogliata A, Nicolini G, Clivio A, et al. A broad scope knowledge based model for optimization of
VMAT in esophageal cancer: validation and assessment of plan quality among different treatment
centers. Radiat Oncol. 2015;10:220. http://dx.doi.org/10.1186/s13014-015-0530-5
Breast

12. Fogliata A, Nicolini G, Bourgier C, et al. Performance of a Knowledge-Based Model for

Optimization of Volumetric Modulated Arc Therapy Plans for Single and Bilateral Breast Irradiation.
PLoS One. 2015;10(12):e0145137. http://dx.doi.org/10.1371/journal.pone.0145137
Liver

13. Fogliata A, Wang PM, Belosi F, et al. Assessment of a model based optimization engine for
volumetric modulated arc therapy for patients with advanced hepatocellular cancer. Radiat Oncol.
2014;9:236. http://dx.doi.org/10.1186/s13014-014-0236-0
Spine

14. Foy JJ, Marsh R, Ten haken RK, et al. An analysis of knowledge-based planning for stereotactic
body radiation therapy of the spine . Pract Radiat Oncol. 2017.
http://dx.doi.org/10.1016/j.prro.2017.02.007
TOMOTHERAPY: prostate

15. Cagni E, Botti A, Micera R, et al. Knowledge-based treatment planning: An inter-technique and
inter-system feasibility study for prostate cancer. Phys Med. 2017;36:38-45.
Research Topic:
Using knowledge-based DVH predictions to determine whether to use free-breathing or DIBH

scans for conformal left-sided breast patients with nodal involvement.

Research approach
Section 2
The next section of your research organization document contains your research template to
follow as you begin your data collection. This section will change often but it will help you to
follow your goals closely as you progress and for the instructor to track your progress.

Study Details:
Retrospective

Do any group members need to obtain additional IRB approval?Do any group members need to
obtain additional IRB approval? Yes, Aubrie and Ian obtained IRB approval

Number of patients:

Breast:
o >30 retrospective patients to build database.
o 20 (new or retrospective) to determine accuracy of RapidPlan prediction

Type of study: Research paper

Roles of each group memberRoles of each group member (some members may have multiple
roles)

NOTE: We added our names here since we know we will be doing the data collection at our site. We

wanted to leave it open for you two to choose what role you want. We would be open to taking on other
rolls as well.

Dannyl: Wouldn't consider myself the best writer but would be happy take on any roll.

Kevin: I am definitely not a statistics expert but I can do my best and seek out assistance when needed. I

will also help with writing whenever needed.

 Group Leader (someone who will keep the group on track, make sure group
members are adhering to deadlines, be the direct point of contact for the
instructor with overall questions, update the research organization document
throughout the course of research)throughout the course of research)

Aubrie
Data Collector(s) (someone who will be doing the data collection and data
reporting in excelreporting in excel; maintaining journal entries)
Aubrie and Ian
Data analysis (someone who will be responsible for analyzing the raw data,
running any statisticalrunning any statistical tests and providing conclusive data
for the writer)

Dannyl (& maybe Kevin)

Writer (someone who is responsible for writing the outline (later in the course)
and the paper; usually the best writer of the group takes this role)and the paper;
usually the best writer of the group takes this role)

Dannyl & Kevin

Editor (someone who is responsible for checking each draft for errors and
providing feedback and corrections to writer)providing feedback and corrections
to writer)

All group members

Data Collection Approach:

Indicate here what data you are looking to collect and your approach to collection:

Number of clinical sites for data collection:

1
What information are you interested in (if a planning study, list structures for evaluation; if a
study survey, list your study questions)What information are you interested in (if a planning
study, list structures for evaluation; if a study survey, list your study questions)
Breast topic: Doses to the Heart and ipsilateral lung, PTV coverage
Prescription(From RTOG protocol 1304)
Standard fractionation (Total dose 50 Gy for 25 fractions at 2 Gy per fraction)
> 95% of the Breast PTV Eval will receive > 95% (47.5 Gy) of the

prescribed dose of 50 Gy
 Variation Acceptable: > 90% of the Breast PTV Eval will receive > 90% (45

Gy) of the prescribed dose of 50 Gy

Overall Hot spot: < 108% (54 Gy) of the prescribed dose of 50 Gy
Critical structures (From RTOG protocol 1304)

Contralateral breast
Maximum does to contralateral breast is < 310 cGy
< 5% of right lung receives 186 cGy
Left lung

< 15% of the left lung should receive > 20 Gy

< 35% of the left lung should receive > 10 Gy

< 50% of the left lung should receive > 5 Gy

Right lung
< 10% of the left lung should receive > 5 Gy

Heart
< 5% of the whole heart should receive > 20 Gy

< 30% of the whole heart should receive > 10 Gy

Mean heart dose should be < 400 cGy

Are you interested in completing a statistical analysis on this data? If so, what parameters will
you be analyzing? (p-value, mean, t-test ect.).Are you interested in completing a statistical
analysis on this data? If so, what parameters will you be analyzing? (p-value, mean, t-test ect.).

Breast: Evaluating predicted DVH values to DVH values from the manually created physician

approved plans for these patients

What resources (in addition to the literature search) are available for you to use?What resources
(in addition to the literature search) are available for you to use?

The Writing Center at UWL along with Stats department if needed.

Previous research study that will be used for data analysis (ex: RTOG study
constraints):Previous research study that will be used for data analysis (ex: RTOG study
constraints):
 Loic F, Georges N, Jean-Jacques M, Pierre B. Conformity Index: A Review. Int. J. Radiation

Oncology Biol Phys. 2006: 64(2); 333-342. doi:10.1016/j.ijrobp.2005.09.028

Provides many volume-based conformity indices
Krishnan J, Shetty J, Rao S, Hegde S, Shambhavi C. Comparison of rapidarc and intensity

modulated radiotherapy plans using unified dosimetry index and the impact of unified
dosimetry index evaluation. J Med Phys. 2017. 42(1); 14-17.
http://dx.doi.org/10.4103/jmp.JMP_112_16.

Description of your data collection approach (Please provide the instructor with the
details you intend to use in your research and use the example to be your guide). Description of
your data collection approach (Please provide the instructor with the details you intend to use in
your research and use the example to be your guide).

We will be analyzing the accuracy of RapidPlan for breast cancer patients. We will compare the generated
predicted DVHs to manually created plans. We can compare the two DVHs coverage and dose to organs

at risk. All the plans used will receive either 50Gy in 25 fx or 42.7 Gy on 16 fx .The prescription for each plan
will be 95% of the prescription dose to cover 95% of the PTV. We can analyze OR constraints for heart and

left lung. By comparing all this data we can determine how if RapidPlan can accurately predict DVHs for

conformal breast plans and therefore determine whether or not the DIBH scan is needed for planning.

Additional details: