Christina Ong

Research Literature Gap Activity

April 15, 2018
Article #1: Hypofractionated IMRT Breast Treatment with Simultaneous Versus Sequential
Boost Techniques
This aim of this study is to compare simultaneous integrated boost (SIB) and sequential boost
(SB) techniques in hypofractionated intensity modulated radiation therapy (IMRT) breast
treatment. A retrospective study of 23 previously treated patients with conventional fractionation
with SIB IMRT technique was chosen. The same CT datasets, planning target volumes (PTV),
and organs at risk (OAR) were used for this study. The dose prescription was entered
accordingly. For SIB technique, the dose prescription was 40 Gy in 15 fractions (2.67
Gy/fraction) for PTV1 (whole breast including tumor bed) and 48 Gy in 15 fractions (3.2
Gy/fraction) for PTV2 (tumor bed only) in 5 fractions per week schedule. For SB technique, the
dose prescription was 40 Gy in 15 fractions (2.67 Gy/fraction) for PTV1 and 50 Gy in 20
fractions (2.5 Gy/fraction) for PTV2 in 5 fractions per week schedule. Dose volume histogram
(DVH), conformity index (CI), and homogeneity index (HI) were calculated and evaluated based
on ICRU 83. The planning objectives were met in in all cases with both SIB and SB techniques.
With SIB technique, nevertheless, normal tissue sparing was better than SB and course of
treatment was shortened by 1 week. Further research studies may include more breast patients
treated with hypofractionated SIB IMRT as limited literature is available on this topic.
Article #2: Treatment Planning Study of Volumetric Modulated Arc Therapy and Three-
Dimensional Field-in-Field Techniques for Left Chest-Wall Cancers with Regional Lymph
Nodes
The objective of this study is to examine any dosimetric advantages of volumetric modulated arc
therapy (VMAT) over conventional four-field technique using three-dimensional conformal
field-in-field (FinF) in treatment planning of left chest-wall cancers with regional lymph nodes.
Twenty-two left-sided chest-wall patients with positive supraclavicular/axillary nodes were
randomly selected for this study. Dose volume histogram (DVH), homogeneity index (HI),
conformity index (CI), and equivalent uniform dose (EUD) for planning target volume (PTV)
and organs at risk (OAR) were evaluated for both VMAT and three-dimensional conformal FinF
plans in Eclipse. The results indicated that three-dimensional conformal FinF technique was able
to meet PTV coverage in all except two cases and VMAT met PTV coverage in all including the
two unmet cases in three-dimensional conformal FinF plans. Other findings from this study were
VMAT demonstrating a decrease in volume of the left lung receiving 20 Gy (V20) but an increase
in volumes of the right lung and right breast receiving 5 Gy (V5). Hence, due to the insignificant
benefits of VMAT and limited number of patients on this study and past literature, three-
dimensional conformal FinF technique is still recommended as the standard technique for chest-
wall treatments. Further research studies may include more patients to signify advantages of
VMAT over three-dimensional conformal FinF technique for chest-wall patients with regional
lymph nodes.
Article #3: The Role of a Prone Setup in Breast Radiation Therapy
The purpose of this research literature is to review prone setup in breast radiation therapy
investigated in several prospective trials by New York University (NYU). The development of
prone setup for breast patients starting in the early 1990s at Memorial Sloan-Kettering Cancer
Center (MSKCC), University of Southern California (USC), and then more recently at NYU
were discussed. From the data collected over the years, the advantages of prone setup in breast
patients were shown to drastically reduce dose to the heart, lungs, and the contralateral breast,
resulting in less acute toxicity and better cosmesis. The disadvantages/challenges/limitations of
prone setup in breast setup included decrease of regional nodes coverage, possibility of incorrect
patient positioning, and complaint of neck and back pain in maintaining the position.
Additionally, as mentioned in this journal article, most of the past literature studied breast
patients treated prone with three-dimensional conformal radiotherapy in standard fractionation
regimen. Thus further research studies may include breast patients treated prone with
concomitant boost radiotherapy as demonstrated in a Phase I-II trial performed at NYU in 2002
and currently in RTOG 1005.
Article #4: Treatment of Malignant Lymphoma in 100 Patients with Chemotherapy, Total Body
Irradiation, and Marrow Transplantation
The aim of this study is to analyze the effects of chemotherapy, total body irradiation, and
marrow transplantation in the treatment of malignant lymphoma. One hundred patients with
malignant lymphoma were treated and followed for 1 to 15 years at a single institution. Out of
the 100 patients, 28 patients were alive at the time of the study report. The results showed that
the use of high-dose chemoradiotherapy and bone marrow transplantation was the optimal
treatment with long-term survival rate for patients who were young, transplanted in early relapse
or second remission, and had not received previous chest radiation therapy. Nonetheless, further
research studies may include larger numbers of patients across multiple institutions using a
prospective randomized trial to confirm the outcome and its validity on patient disease histology
and stage and bone marrow source (syngeneic, autologous, or allogeneic).
*This journal article was published in 1987. There may already be further research studies since
then. For the purpose of this assignment, the research literature gap was noted based on the
content of this journal article.
Article #5: Palliative Radiotherapy for Thoracic Spine Metastases: Dosimetric Advantage of
Three-Dimensional Conformal Plans
The objective of this study is to assess any dosimetric advantages of three-dimensional
conformal radiation therapy (3DCRT) over conventional two-dimensional (2D) plans in
treatment planning of palliative radiotherapy for thoracic spine metastases. Ten patients with
mid-to-low thoracic spine metastases were selected for comparison. In 3DCRT plans, one
posteroanterior (PA) field and two posterior oblique fields were used; whereas, in 2D plans, a
single PA field or opposed anteroposterior (AP)/PA fields were utilized in Eclipse with 6 or 15
MV photon beams and heterogeneity corrections. Cumulative (3DCRT with one PA field with
two posterior oblique fields; 2D with a single PA field; 2D with AP/PA fields) dose volume
histograms (DVH) were generated for each of the 10 patients and applied for comparison.
Results presented reduction of dose to organs at risk (OAR), specifically the heart, and more
homogenous dose to planning target volumes (PTV) in 3DCRT plans against 2D plans. Further
research studies may include optimal beam arrangements in 3DCRT for patients with spine
metastases to maximize its ability to constraint dose to OAR as limited data exists in this area.
 References
1. Moorthy S, Elhateer H, Majumdar SKD, et al. Hypofractionated IMRT breast treatment
with simultaneous versus sequential boost techniques. J Nucl Med Radiat Ther.
2012;3(3). http://dx.doi.org/10.4172/2155-9619.1000130
2. Xu H, Hatcher G. Treatment planning study of volumetric modulated arc therapy and
three dimensional field-in-field techniques for left chest-wall cancers with regional lymph
nodes. Rep Pract Oncol Radiother. 2016;21(6):517-524.
https://dx.doi.org/10.1016/j.rpor.2016.07.005
3. Huppert N, Jozsef G, DeWyngaert K, et al. The role of a prone setup in breast radiation
therapy. Front Oncol. 2011;1(31). http://dx.doi.org/10.3389/fonc.2011.00031
4. Appelbaum FR, Sullivan KM, Buckner CD, et al. Treatment of malignant lymphoma in
100 patients with chemotherapy, total body irradiation, and marrow transplantation. J
Clin Oncol. 1987;5(9):1340-1347.
5. Yeo SG. Palliative radiotherapy for thoracic spine metastases: Dosimetric advantage of
three-dimensional conformal plans. Oncol Lett. 2015;10(1): 497-501. http://dx.doi.org/
10.3892/ol.2015.3205