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Felicia Chu
University of Wisconsin La-Crosse DOS 711
4/6/19
Identifying Gaps in Literature and Future Research

Article 1: Real-time Online Matching in High Dose-per-Fraction Treatments: Do Radiation

Therapists Perform as Well as Physicians?¹

Summary:

High dose treatments require physician presence at the machine for image matching, but
waiting can disrupt workflow and increase patient time on the table. This study examines
whether patient position matching performed by radiation therapists (RTT) is as accurate as
matching performed by physicians. Data was collected for 16 RTTs and 5 physicians on KV
bone and CBCT matches, and then the Wilcoxon rank sum test was used to determine statistical
difference between RTT and physician shifts. Resulting differences in shifts between physicians
and RTTs was not statistically different, indicating that RTTs match as accurately as physicians.
Having therapists perform the match at the machine, and then having physicians review images
offline afterwards would be more efficient.

Future Study:

A research gap exists in that these findings only apply to KV and CBCT imaging. How
can workflow be improved for treatments requiring other image specifications? A future study
suggested in the article investigates accuracy for a different imaging modality called ExacTrac,
used for cranial stereotactic radiosurgery (SRS). Data can compare physician shifts against
therapist shifts for ExacTrac. Comparable matches, which is predicted, can eliminate the need for
physician presence on the machine and improve workflow for those cases as well.
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Article 2: Tumor Control and Toxicity after SBRT for Ultracentral, Central, and Paramediastinal
Lung Tumors²

Summary:

Stereotactic body radiation therapy (SBRT) is the standard of care for medically
inoperable early stage non small cell lung cancer (NSCLC), and has been proven effective for
peripheral lung tumor treatment. However, centrally located tumors are prone to pulmonary
toxicity and radiation injury because of their proximity to critical mediastinal structures. This
study analyzes toxicity results for central lung tumors treated with SBRT, rates and patterns of
tumor control, and overall survival retrospectively. Results show that SBRT for central lung
tumors have similar control and outcomes compared to SBRT for peripheral lesions, but also
increased toxicity. This risk calls for patient counseling and shared decision making to determine
treatment approach.

Future Study:

If patients chose to proceed with stereotactic body irradiation for a central lung mass,
what factors will provide the best outcome and mitigate damage? A lack of consensus remains in
the optimal treatment approach and fractionation schedules for centrally located tumors. There is
still a limited amount of information regarding what SBRT treatment schedules offer the best
control. A future study can determine how various dose schedules impact control rate and
toxicity.

Article 3: Hypofractionated radiation therapy for durable palliative treatment of bleeding,

fungating breast cancers³

Summary:

Fungating breast cancers are challenging to treat. Patients present with severe symptoms
including bleeding, discharge, and pain, and additionally, cosmesis-related psychosocial distress.
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This study investigates the role of hypofractionated palliative radiation therapy in improving
quality of life for patients with extensive breast cancer. Studies were conducted on randomized
breast cancer patients with whole brain metastases, comparing 2 regimens of hypofractionation
versus conventional fractionation to the whole brain. Hypofractionated treatment showed similar
results in terms of local control, acute toxicity, and cosmesis, establishing the use of
hypofractionated whole brain radiation therapy as the standard after breast conserving surgery.

Future Study:

Although hypofractionated palliative radiation therapy is effective for controlling whole

brain metastases in patients with fungating breast cancer, there is still unclarity in control over its
role in breast lesions. The article calls for further studies to test the efficacy of hypofractionated
schedules for treatments of patients with fungating disease, both in terms of biological effective
dose and psychosocially. Do shorter treatment regiments improve quality of life for these
patients? What is appropriate dose fractionation to achieve optimal results?

Article 4: Risk of dry eye syndrome in patients treated with whole-brain radiotherapy⁴

Summary:

With patients living longer due to advances in therapy, there has been a rise of dry eye
syndrome as a late toxicity in whole brain radiotherapy (WBRT). Lacrimal gland dose
constraints are usually not considered in WBRT. This article investigates average dose to the
lacrimal gland in WBRT and determines whether this dose is clinically significant. A
retrospective review was carried out on 70 plans, delivering 30 Gy in 10 fractions. Lacrimal
glands were contoured and sample t-tests compared max dose per treatment plan to mean dose to
both lacrimal glands. Results showed that correlations were significant, calling for a need to
contour lacrimal glands and set dose constraints to reduce late onset of dry eye in WBRT.

Future Study:
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Contributors acknowledge that data relies on total dose and constraints alone to determine
dry eye onset, without consideration to outside factors such as beta blockers, antihistamines, and
systemic medications that are dehydrating. A future study can evaluate lacrimal gland toxicity on
clinical follow up with lacrimal gland avoidance for whole brain irradiation, and tally
development of dry eye syndrome with medical variables eliminated from the sample size. As
pointed out in the article, a future study can also determine optimal dose constraints on the
lacrimal gland to reduce toxicities.

Article 5: Whole-brain Irradiation Field Design: A Comparison of Parotid Dose⁵

Summary:

Little is known about the risk of parotid gland irradiation in whole brain radiotherapy
(WBRT), despite being well documented for patients receiving higher fractionation treatments
for head and neck cancer. Dose to salivary glands can decrease saliva production and cause
xerostomia. This article determines whether a whole brain irradiation field inferior border to C1
or C2 produces better results for the patient in terms of parotid sparing and limiting acute side
effects.​ ​A retrospective study was conducted on nineteen WBRT patients treated to C1 and 26
patients treated to C2 using the same dose fractionation and Radiation Therapy Oncology Group
(RTOG) parotid dose constraints. A statistical χ2 test and Student t-test analysis compared mean
parotid dose against the RTOG 0615 standard of V20 < 20 cc and V30 < 50% of parotid volume.
Results show that parotid dose constraints are better met with a C1 border. Treating to C1 is
therefore preferable to C2 for limiting parotid toxicity.

Future Study:

A question still remains as to whether sparing the parotid with C1 irradiation fields will
limit onset of xerostomia for patients receiving whole brain irradiation. A future study can
investigate onset, if any, and severity of xerostomia in patients treated to a C1 border.
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References
1. Levin D, Grinfeld G, Greenberg V, et al. Real-time Online Matching in High
Dose-per-Fraction Treatments: Do Radiation Therapists Perform as Well as Physicians?
Practical Radiation Oncology.​ 2019;9(2). doi:10.1016/j.prro.2018.10.002.
2. Nguyen KNB, Hause DJ, Novak J, Monjazeb AM, Daly ME. Tumor Control and
Toxicity after SBRT for Ultracentral, Central, and Paramediastinal Lung Tumors.
Practical Radiation Oncology.​ 2019;9(2). doi:10.1016/j.prro.2018.11.005.
3. Grewal AS, Freedman GM, Jones JA, Taunk NK. Hypofractionated radiation therapy for
durable palliative treatment of bleeding, fungating breast cancers. ​Practical Radiation
Oncology​. 2019;9(2):73-76. doi:10.1016/j.prro.2018.11.003.
4. Nanda T, Wu C-C, Campbell AA, et al. Risk of dry eye syndrome in patients treated with
whole-brain radiotherapy. ​Medical Dosimetry​. 2017;42(4):357-362.
doi:10.1016/j.meddos.2017.07.007.
5. Wu C-C, Wuu Y-R, Jani A, et al. Whole-brain Irradiation Field Design: A Comparison of
Parotid Dose. ​Medical Dosimetry.​ 2017;42(2):145-149.
doi:10.1016/j.meddos.2017.02.006.