Karthick Raj Mani, Shantanu Sapru, K. J. Maria Das and Ayan Basu
Aim: To demonstrate a simple technique of cranio-spinal irradiation (CSI) in supine position using inter fraction moving field junctions to feather out any potential hot and cold spots.
Materials and Methods: Fifteen patients diagnosed with medulloblastoma were treated during the period February 2011 to June 2015 were included in this study. Out of fifteen patients in the study nine were male and 6 were female with a median age of 13.4 years (range 5-27 years). All the patients were positioned supine on CT simulation, immobilized using thermoplastic mask and aligned using room based laser system. Two parallel opposed lateral fields for the whole brain using an asymmetrical jaw with isocenter at C2 vertebral body. A posterior field also placed to cover the cervical and dorsal field using the same isocenter at C2. The second isocenter was placed at lumbar vertebral region to cover the remaining dorsal, lumbar and sacral region using an inter-fraction moving junction. Field-in-field and enhanced dynamic wedge used to homogeneous dose distribution when required.
Results and Discussion: In this study, we found that only two patients failed in the primary site, no radiation myelitis or recurrences in the filed junctions were reported in these fifteen patients with a median follow-up of 36.4 months. The automated sequence of treatment plans with moving junctions in the comfortable supine position negating the need for manual junction matching or junction shifts avoiding potential treatment errors and also facilitating delivery of anesthesia where necessary.
Karthick Raj Mani, Suresh Poudel and K J Maria Das
Purpose: To investigate the cardio-pulmonary doses between Deep Inspiration Breath Hold (DIBH) and Free Breathing (FB) technique in left sided breast irradiation.
Materials & Methods: DIBH CT and FB CT were acquired for 10 left sided breast patients who underwent whole breast irradiation with or without nodal irradiation. Three fields single isocenter technique were used for patients with node positive patients along with two tangential conformal fields whereas only two tangential fields were used in node negative patients. All the critical structures like lungs, heart, esophagus, thyroid, etc., were delineated in both DIBH and FB scan. Both DIBH and FB scans were fused with the Dicom origin as they were acquired with the same Dicom coordinates. Plans were created in the DIBH scan for a dose range between 50 Gy in 25 fractions. Critical structures doses were recorded from the Dose Volume Histogram for both the DIBH and FB data set for evaluation.
Results: The average mean heart dose in DIBH vs FB was 13.18 Gy vs 6.97 Gy, (p = 0.0063) significantly with DIBH as compared to FB technique. The relative reduction in average mean heart dose was 47.12%. The relative V5 reduced by 14.70% (i.e. 34.42% vs 19.72%, p = 0.0080), V10 reduced by 13.83% (i.e. 27.79 % vs 13.96%, p = 0.0073). V20 reduced by 13.19% (i.e. 24.54 % vs 11.35%, p = 0.0069), V30 reduced by 12.38% (i.e. 22.27 % vs 9.89 %, p = 0.0073) significantly with DIBH as compared to FB. The average mean left lung dose reduced marginally by 1.43 Gy (13.73 Gy vs 12.30 Gy, p = 0.4599) but insignificantly with DIBH as compared to FB. Other left lung parameters (V5, V10, V20 and V30) shows marginal decreases in DIBH plans compare to FB plans.
Conclusion: DIBH shows a substantial reduction of cardiac doses but slight and insignificant reduction of pulmonary doses as compared with FB technique. Using the simple DIBH technique, we can effectively reduce the cardiac morbidity and at the same time radiation induced lung pneumonitis is unlikely to increase.
Karthick Raj Mani, Saumen Basu, Md Anisuzzaman Bhuiyan, Sharif Ahmed, Mostafa Aziz Sumon, Kh Anamul Haque, Ashim Kumar Sengupta, Md Rashid Un Nabi and K. J. Maria Das
Objective: The purpose of this study is to demonstrate the synchronous bilateral breast irradiation radiotherapy technique using a single isocenter. Materials and Methods: Six patients of synchronous bilateral breast were treated with single isocenter technique from February 2011 to June 2016. All the patients underwent a CT-simulation using appropriate positioning device. Target volumes and critical structures like heart, lung, esophagus, thyroid, etc., were delineated slice by slice in the CT data. An isocenter was placed above the sternum on the skin and both medial tangential and lateral tangential of the breast / chest wall were created using asymmetrical jaws to avoid the beam divergence through the lung and heart. The field weighting were adjusted manually to obtain a homogenous dose distribution. The planning objectives were to deliver uniform doses around the target and keep the doses to the organ at risk within the permissible limit. The beam energy of 6 MV or combination of 6 MV and 15 MV photons were used in the tangential fields according to the tangential separation. Boluses were used for all the mastectomy patients to increase the doses on the chest wall. In addition to that enhanced dynamic wedge and field in field technique were also used to obtain a homogenous distribution around the target volume and reduce the hot spots. The isocenter was just kept on the skin, such that the beam junctions will be overlapped only on the air just above the sternum. Acute toxicity during the treatment and late toxicity were recorded during the patient’s follow-up. Results: During the radiotherapy treatment follow-up there were no acute skin reactions in the field junctions, but one patient had grade 1 esophagitis and two patients had grade 2 skin reactions in the chest wall. With a median follow-up of 38.5 months (range: 8 - 49 months), no patients had a local recurrence, but one patients with triple negative disease had a distant metastases in brain and died after 28 months. Conclusions: We were able to successfully treat the synchronous bilateral breast using single isocenter radiotherapy while keeping the lung and heart doses within the acceptable dose limits. During the treatment follow-up there were no symptoms of acute skin reactions in the field junction.