Savannah Coleman

Dos 711: Research Methodology

Week 13: Identifying Future Research
Article 1
Summary: Jones et al1 compared the rectal sparing capabilities of rectal balloons versus
injectable spacer gel in SBRT treatments for prostate cancer. The authors examined 36 patients
simulated, planned, and treated with rectal balloon placement, along with 36 patients simulated,
planned, and treated with spacer gel placement. Patients did not vary in BMI or prostate volumes
by a statistically significant margin. The injectable spacer gel was found to have dosimetric
advantage as compared to rectal balloons in the majority of dosimetrically relevant aspects of
comparison. Aspects compared included the maximum dose, the dose received by 33% of the
rectal volume, and the absolute volume of the rectum receiving dose. The rectal balloons did not
outperform the spacer gel in any aspects of comparison.
Future Research: The authors did not examine the day to day treatment impact of the two rectal
sparing options. Efficiency comparisons and patient comfort aspects were not assessed. A future
research study could quantitatively examine the two rectal sparing techniques in terms of their
impact on daily patient setup time.
Article 2
Summary: Pursley et al2 examined various VMAT techniques compared to IMRT planning for
bilateral and ipsilateral treatment of the head and neck. The authors retrospectively examined 14
patients who had undergone ipsilateral irradiation and 10 patients who had undergone bilateral
irradiation to the head and neck. For the ipsilateral cases, IMRT planning was compared with
two 360° arcs, two 360° arcs with avoidance sectors around the contralateral parotid, two 270°
arcs, and two 210° arcs. For the bilateral cases, IMRT planning was compared with two 360°
arcs, two 360° arcs with avoidance sectors around the shoulders, and 3 arcs. The authors found
that for ipsilateral planning the two 360° arcs with parotid avoidance sectors was dosimetrically
comparable to IMRT but achieved better conformity and lower mean dose on the contralateral
parotid. For bilateral planning, the authors concluded that 2 or 3 arcs are comparable
dosimetrically to IMRT but could not specify optimal techniques.
Future Research: The authors listed the diversity of patient population and range of primary
treatment sites as a limitation to this study, especially when comparing the bilateral head and
neck planning. Future research could use similar VMAT planning techniques in comparison to
IMRT but broken down into specific treatment primaries. For example, technique comparison
could be researched specifically for the planning of nasopharyngeal cases.
Article 3
Summary: McCall et al3 examined the consistency of thoracic organ at risk (OAR) contouring
among medical dosimetrists and looked to determine how education and experience affected
contouring. A total of 3 CT data sets were contoured by 13 dosimetrists from 5 different
institutions. Each dosimetrist was asked to contour the heart, lungs, spinal cord and esophagus,
and was also asked to fill out a survey regarding their contouring experience. These contours
were evaluated against a gold standard set of contours using a Dice coefficient method and a
penalty-based metric scoring system. The authors found inconsistency of contouring with all the
OARs, and the largest inconsistency with the esophagus. No predictive correlation was found
between RTOG guideline knowledge and positive scoring.
Future Research: The authors acknowledged that the use of multiple data sets allowed for
interdosimetrist inconsistency comparison, and some comparison of intradosimetrist variability.
Future research could use more data sets to examine intradosimetrist inconsistency to determine
intention versus accident among individual dosimetrists. For example, 10 data sets could be
provided to each of a set of 15+ dosimetrists, in order to determine potential patterns of
individual contouring inaccuracies.
Article 4
Summary: Park et al4 examined the dosimetric impact of jaw tracking in VMAT planning for
the liver, lung and pancreas. The authors examined 31 cases treated with jaw tracking and re-
planned these cases with fixed jaw plans to evaluate potential dosimetric differences. Areas
compared were the dosimetric verification of the treatment plans, the uniformity of the target
dose distributions, the partial volume doses in OARs, and the low-dose volume. The authors
found that dose uniformity was similar between the two types of planning. The jaw tracking
technique was found to significantly reduce the partial volume dose of the OARs examined. The
low dose volumes were also found to be smaller when utilizing the jaw tracking technique.
Future Research: The authors acknowledge that a limitation of this study was the uniformity
and small size of the PTV’s that were examined. Future research could examine the dosimetric
impact of the jaw tracking technique on larger PTV volumes, such as those treated in the head
and neck region.
Article 5
Summary: Coffey et al5 dosimetrically compared supine VMAT planning versus prone 3D
conformal planning for whole breast plus nodal irradiation. Doses to the ipsilateral lung and
heart were the focus of comparison, along with target coverage. Three patients with invasive
ductal carcinoma were simulated in both the supine and prone positions with the intention of
treating whole breast plus nodal involvement. These cases were planned using VMAT on the
supine CT scans and 3D conformal on the prone CT scans. The authors found that the supine
VMAT plans were able to achieve better target coverage but resulted in higher doses to the
ipsilateral lung and to the heart. The authors concluded that both techniques were able to
maintain constraints, but that the ideal technique was dependent on patient anatomy and
lumpectomy bed location.
Future Research: The authors acknowledge that the retrospective nature of this research was a
limitation to their study. They state that although each patient was simulated supine and prone,
the prone simulations were not always in the optimal position. Future research could
prospectively examine supine VMAT planning versus prone 3D conformal planning with a
larger pool of optimally simulated patients. Another potential angle would be to add in a
comparison of supine 3D conformal planning with heart blocking, in addition to the other two
techniques. It may be beneficial to do so because many departments still utilize this technique for
left sided breast patients with nodal involvement.
 References
1. Jones RT, Rezaeian NH, Desai NB, et al. Dosimetric comparison of rectal-sparing capabilities
of rectal balloon vs injectable spacer gel in stereotactic body radiation therapy for prostate
cancer: lessons learned from prospective trials. Med Dosim. 2017;42(4):341-347.
http://dx.doi.org/10.1016/j.meddos.2017.07.002
2. Pursley J, Damato AL, Czerminska MA, Margalit DN, Sher DJ, Tishler RB. A comparative
study of standard intensity-modulated radiotherapy and RapidArc planning techniques for
ipsilateral and bilateral head and neck irradiation. Med Dosim. 2016;42(1):31-36.
http://dx.doi.org/10.1016/j.meddos.2016.10.004
3. McCall R, MacLennan G, Taylor M, et al. Anatomical contouring variability in thoracic
organs at risk. Med Dosim. 2016;41(4):344-350. http://dx.doi.org/10.1016/j.meddos.2016.08.004
4. Park BD, Cho BC, Kim JH, Lee SW, Ahn SD, Kwak JW. Dosimetric impact of the jaw-
tracking technique in volumetric modulated arc therapy. J Nucl Med Radiat Ther. 2016;7:301.
http://dx.doi.org/10.4172/2155-9619.1000301
5. Coffey A, Renucci L, Hunzeker A, Lenards M. Whole breast nodal irradiation using supine
VMAT and prone 3D planning: A case study. Med Dosim. 2017;42(3):185-189.
http://dx.doi.org/10.1016/j.meddos.2017.02.007