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Brittany Butler
DOS 711
April 15, 2018

Article: Choosing wisely after publication of level I evidence in breast cancer radiotherapy.1
Summary: This article addresses the American Society for Radiation Oncology (ASTRO)
recommendations of hypofractionation breast treatment in women > 50 years of age and
evidence of omission of treatment being reasonable when > 70 years of age. The National
Comprehensive Cancer Network institution analyzed their response to these recommendations by
comparing treatment methods in 2006, 2008, 2011, and 2013. They then compared their results
to national trends. During those years, costs of hypofractionation and conventional in 3D and
intensity modulated radiation therapy (IMRT) treatment methods were estimated. Their
organization exceeded omission rates of radiation therapy treatment in women over >70 years of
age. One mention of future research in this article was that there are multiple trials of radiation
therapy treatment omission in younger ages. Intensity modulated radiation therapy use was also
addressed and was not used at their organization on women >50 with early stage, hormone
receptor positive, breast cancer. It was discussed as to why IMRT may be advantageous to
organizations from a money-making perspective. Overall, the data they provided demonstrated it
is possible to change rapidly in response to new guidelines with reasonable evidence based
decision making.
Future Research projects:
 Future research was mention in other organizations analyzing their response rates. One
could analyze their internship site adaption to recommendations and this would
contribute to data on trends of adaptation across the United States.
 Addressing addition scenarios was also noted as a limitation of this study. Future
research could include addressing treatments such as sequential boosts.
 This was not referred to by the author but one could retrospectively analyze their
organizations breast patients that received conventional fractionation that should have
received hypofractionated based on new guidelines.
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Article: Radiation therapy of synchronous bilateral breast carcinoma (SBBC) using multiple
techniques. 2
Summary: This article addressed multiple techniques in planning bilateral breast carcinoma.
The techniques included were 3D, IMRT and volumetric modulated arc therapy (VMAT)
planning. These plans were evaluated based on the dose volume histogram (DVH) and planning
target volume (PTV) doses. Conformity index and homogeneity were also reported. The benefit
of 3D treatment planning was low organs at risk (OAR) doses. Intensity modulated radiation
therapy had better dose distribution of the target and OARs. Volumetric modulated arc therapies
advantage was treatment efficiency. It was concluded that there are distinct limitations due to
the treatment planning system (TPS) and it was not possible to make a protocol or
recommendation off this study alone but instead aide in establishing future guidelines.
Future Research Projects:
 This article noted that they were limited by the version of the TPS software they were
using. Further research on newer version software may have different outcomes and
could be an area of further research.

Article: Quantitative analysis of respiration-induced motion of each liver segment with helical
computed tomography and 4-dimensional computed tomography.3
Summary: This article analyzed respiratory motion in various liver segments and establishing
correlations to defining the internal target volume (ITV) based on individual and segment
locations. A sample of 20 patients were studied with various primary cancers, all undergoing CT
simulation scanning of the whole liver. Phases were established in the TPS from the 4DCT
images at full inspiration (phase 0) and full expiration (phase 50) and directions in 3 dimensions.
Their results concluded that there was more motion to the lateral segments of the liver versus
medial segments.
Future Research Projects: This study explained some limitation of their study which could be
identified as future research.
 Their small sample size was noted in that with a larger the sample size, the smaller the
standard deviation and therefore a more confined ITV margin could be discovered.
Following the same parameters, more data at other facilities could be obtained for future
research.
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 The phases analyzed in this article was full inspiration and full expiration, there are other
phases of respiratory motion in between that could be researched.

Article: Optimizing volumetric arc radiotherapy for dental rehabilitation in oropharynx cancer –
A retrospective dosimetry review and feasibility planning study.4
Summary: Retrospectively, mandible and maxilla volumes were dosimetrically analyzed in
radically treated oropharynx patients with VMAT planning. It is noted that the anterior mandible
is a critical structure in terms of restorative dental surgery. Anterior mandible doses are higher
for patients with T stage and inclusion of level 1b, making it a critical structure in optimization.
High doses to these structures can limit potential surgery options. This study included 57
patients and 88% they retrospectively could reoptimize the mandible within accepted constraints,
reducing the median anterior dose by 5 Gy. Currently, oncologist do not measure dose to tooth
bearing areas of the bone, creating a disconnect in continuous care. This article concluded that
the dose should be monitored to this sub group of patients, and considered prospectively,
bridging a gap between specialties for better patient outcomes.
Future Research Projects:
 Mandible doses for larynx and hypopharynx cancers are also known to be higher and
could be studied.
 If this were to be done prospectively, doses to the cord could be analyzed for percentage
increase when considering anterior mandible optimization compared to retrospectively
excluding mandible in calculation.

Article: Cardiac dose reduction with deep inspiration breath hold for left-sided breast cancer
radiotherapy patients with and without regional nodal irradiation.5
Summary: Left sided breast or chest wall cancer treatments results in increased dose to the
heart, specifically the left anterior descending (LAD) coronary artery. Deep inspiration breath
hold (DIBH) has been developed to minimize dose to these structures. Threshold doses to the
heart and arteries have not been determined but less than 4 Gy mean heart dose has been
proposed in this article. This study mainly analyzed which patients would benefit most from the
DIBH technique and if there was a percentage difference in whole breast radiotherapy treated
patients and those receiving internal mammary chain (IMC), regional nodal irradiation in
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addition to whole breast using wide tangent technique. They concluded that the mean dose to the
heart and LAD was less with DIBH technique than wide tangent technique. It was stated that at
a minimum it should be used for whole breast/chest wall with nodal involvement but is justified
in using for all left sided radiation therapy breast patients.
Future Research Projects:
 There are other forms of nodal irradiation that could be examined and compared as well,
such as photon-electron techniques.
 There is no official cardiac structure thresholds and therefore further research would be
needed to determine.
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References

1. Niska JR, Keole SR, Pockaj BA, et al. Choosing wisely after publication of level I
evidence in breast cancer radiotherapy. Breast Cancer (Dove Med Press). 2018;10:31-37.
https://doi.org/10.1016/j.meddos.2017.08.003
2. Sung JK, Mi JL, Seon MY. Radiation therapy of synchronous bilateral breast carcinoma
(SBBC) using multiple techniques. Med Dosim. 2018;43(1):55-68.
https://doi.org/10.1016/j.meddos.2017.08.003
3. Tsai YL, Wu CJ, Shaw S, Yu PC, Nien HH, Lui LT. Quantitative analysis of respiration-
induced motion of each liver segment with helical computed tomography and 4-
dimensional computed tomography. Radial Oncol. 2018;13(1):59.
http://dx.doi.org/10.1186/s13014-018-1007-0
4. O’cathail SM, Karir N, Shah K. Optimizing volumetric arc radiotherapy for dental
rehabilitation in oropharynx cancer – A retrospective dosimetry review and feasibility
planning study. Oral Oncol. 2018;76:16-21.
https://doi.org/10.1016/j.oraloncology.2017.11.020
5. Yeung R, Conroy L, Long K, et al. Cardiac dose reduction with deep inspiration breath
hold for left-sided breast cancer radiotherapy patients with and without regional nodal
irradiation. Radiat Oncol. 2015;10:200. http://dx.doi.org/10.1186/s13014-015-0511-8