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Proton radiotherapy for breast cancer

Introduction Numerous planning studies demonstrate superior dosimetry for proton radiotherapy compared with photon-based radiotherapy for breast cancers of all stages, even compared with intensity-modulated radiotherapy. Protons can reduce dose to the heart by a factor of two to three compared with well-designed photon-based three-dimensional conformal plans, and target coverage is improved with protons. An ongoing randomized clinical trial is comparing proton therapy to photon therapy to…

Intensity-modulated proton therapy patient treatments

Introduction Intensity-modulated proton therapy (IMPT) can begin only after a number of other processes have been completed, including simulation and treatment planning. For both proton and photon treatments, radiation oncology has evolved to the point in which the treatment parameters, defined in the treatment planning process, are included in the radiation oncology electronic medical record (EMR) to be uploaded to the delivery system for each treatment…

Physics quality assurance

Introduction This chapter describes the physics quality assurance (QA) program for the proton pencil beam scanning (PBS) gantry of the Hitachi ProBeat machine (Hitachi America, Ltd., Tarrytown, NY) at the Proton Therapy Center University of Texas MD Anderson Cancer Center (UT MDACC PTC), which has been in clinical use since May 2008. This QA program has two components, namely machine QA and patient treatment field–specific QA.…

Principles of intensity-modulated proton therapy treatment planning

Intensity-modulated proton therapy is effective for complex targets Proton beam therapy (PBT), with its characteristic Bragg peak, holds the promise of further reducing toxicity. Several techniques exist for the administration of PBT, including passive scatter proton therapy (PSPT) and intensity-modulated proton therapy (IMPT). Although PSPT decreases dose distally, we also face a clinical challenge with dose-escalated radiotherapy using PSPT for tumors in very complicated anatomy. Because…

Immobilization and simulation

Introduction Intensity-modulated proton therapy (IMPT) using pencil beam scanning (PBS) technology is advancing rapidly for delivering precise and more conformal doses to target volumes while sparing surrounding normal and critical tissues. To fully use the advantages of IMPT, immobilization and simulation is a critical step, similar to intensity-modulated radiation therapy (IMRT) and volumetric-modulated therapy (VMAT) using photons. The goal is to have small intra- and interfraction…

Clinical commissioning of pencil beam scanning for intensity-modulated proton therapy

Introduction In radiation oncology, “clinical commissioning,” or simply “commissioning,” refers to the process that takes place after a machine has passed acceptance tests but before the first patient can be treated. Commissioning tasks for proton therapy include but are not limited to the following: (1) calibrating the computed tomography (CT) scanner for proton therapy; (2) acquiring beam data and establishing and validating the beam model in…

Principles of proton beam therapy

Introduction The potential of physical characteristics of protons for cancer treatments was first recognized by Wilson in 1946. During the following four decades or so, proton accelerators at various physics laboratories around the world were adapted for clinical purposes. Examples of such facilities include the University of California Berkeley; the Harvard Cyclotron Laboratory in Cambridge, Massachusetts; Uppsala University, Sweden; Dubna, Russia; and Chiba, Japan. Physics laboratory-based…

Principles of radiobiology

Introduction Radiotherapy is used as one of the major treatment modalities for patients with malignant diseases at different disease stages. Currently, the most common radiation choice for the majority of cancers is photon (x-ray)-based intensity-modulated external beam radiotherapy. Notably, recent advances in technology and basic and clinical research have facilitated the safe delivery of more effective and noninvasive radiotherapy for malignant diseases using charged particles, including…

Protocols for Imaging Studies in the Oncologic Patient

Well–thought-out protocols for imaging are critical to ensure that the resultant images have the best possible chance to answer the clinical question. In the case of oncologic patients, this usually hinges on whether disease is stable, has regressed, or has progressed and whether there are new sites of disease. Beyond these fundamental questions, our patients may have unexpected findings, as well as complications from therapy. The…

Pulmonary Embolic Disease and Cardiac Masses and Tumors

Pulmonary Embolism Pulmonary embolism (PE) and deep vein thrombosis (DVT) are common problems in patients with cancer owing to local and humoral effects of the tumor as well as to the effects of therapy. The diagnosis of venous thromboembolic disease is challenging because of nonspecific clinical signs, symptoms, and laboratory evaluations. Computed tomography (CT) angiography has taken a central role in the diagnosis of PE. CT…

Complications in the Oncologic Patient: Abdomen and Pelvis

Introduction Treatment of cancer requires a multimodality approach, with most patients receiving chemotherapy, radiation, surgery, or a combination. It is important to understand the sequelae, complications, and imaging findings of each of the therapies to guide management of the oncologic patient. Preexisting conditions can also predispose a patient to such complications. The efficacy of chemotherapy has allowed many patients with previously unresectable disease to proceed to…

Complications in the Oncologic Patient: Chest

Introduction With advances in cancer therapy, iatrogenic diseases of the chest are increasingly encountered. They are predominated by those affecting the lungs, which are an important cause of patient morbidity and mortality. In the cancer patient, iatrogenic pulmonary disease could be as a result of chemotherapy, radiation therapy (RT), or stem cell transplantation (SCT). Recognizing these patterns of disease is important because the radiologist may be…

Interventional Imaging in the Oncologic Patient

Introduction The use of image-guided procedures has recently experienced tremendous growth in the setting of oncologic applications. There are several reasons for this increased use. Advances in diagnosis and therapy have led to increased survival benefit in this patient population. Earlier detection translates into more and more patients now presenting with their primary or metastatic disease still confined to a single organ. Therefore, these patients have…

Soft Tissue Sarcomas

Introduction Soft tissue sarcomas are rare mesenchymal tumors that originate from the mesoderm, with the notable exceptions of those arising from primitive neuroectodermal tissue and those with unknown cell derivation, such as Ewing sarcoma or synovial sarcoma. Because more than 50 clinically and molecularly distinct sarcoma subtypes exist, there is tremendous clinical variation that leads to marked heterogeneity in their respective clinical behavior, prognosis, metastatic risk,…

Melanoma

Introduction Cutaneous melanoma is an aggressive neoplasm that is the most common cause of death from cutaneous malignancies. Of additional concern, the incidence of melanoma has continue to rise over the past few decades. Primary melanoma most commonly arises in the skin. However, melanoma can arise less commonly in other sites such as the orbit and mucosa. This chapter focuses on imaging for cutaneous melanoma. The…

Imaging in Thyroid Cancer

Introduction Although thyroid cancer represents only approximately 2% of all malignancies worldwide, it is currently one of the most rapidly increasing malignancies in the Western world. Thyroid nodules can be palpated in 2% to 6% of patients and can be detected on imaging in approximately 50% of the general population. Approximately 5% of these nodules represent cancer. With newly available imaging modalities, more and more asymptomatic…

Cancer of Unknown Primary

Introduction Cancer of unknown primary (CUP) is a designation given to discordant group of metastatic carcinomas for which the primary site of origin cannot be identified, despite a thorough diagnostic workup that includes a thorough medical history, complete physical examination to include breast, pelvic, and rectal evaluations, complete blood count and biochemical analysis, urinalysis, serum prostate-specific antigen (PSA) in males, and histopathologic review of tissue specimens…

Bone Metastases

Introduction Bone metastases are common in patients with advanced malignancies. Autopsy series have shown an incidence of bone metastases of approximately 70% in breast and prostate cancer and 35% in lung cancer. Osseous metastases can profoundly influence quality of life and prognosis. Early and accurate detection is important for therapeutic planning, and many imaging modalities can be used for this purpose. X-ray–based technologies such as radiography…

Peritoneal Cavity a­nd Gastrointestinal Tract

Introduction To understand metastatic disease in the abdomen and pelvis, one must appreciate the remarkable complexity of the peritoneum. By definition, the serosal peritoneum is a membrane that covers the lining of the abdominal and pelvic cavity and reflects over the viscera to form ligaments, mesenteries, and omenta. These reflections structurally support the organs and are conduits for the blood vessels, lymphatics, and nerves. The network…