Comment on the recent results of Hopewell, Morris and Dixon-Brown on radiation myelitis produced by irradiation of very short segments of rat spinal cord

Safety of a simple asymmetric jaw technique in the treatment of head and neck cancer

We reviewed our experience treating head and neck malignancies junctioning over the spinal cord using asymmetric collimation. The mean dose delivered to the cord was 43.28 Gy above to the junction, 40.36 Gy below it. With a median follow-up of 20 months, none of our 32 patients developed radiation myelitis.

Series model volume effects in a population of non-identical patients: how low is low?

Working with several mechanisms of critical local tissue damage, formulae are analytically derived that describe normal tissue complication probabilities (ntcps) for series-type radiotherapy complications arising in heterogeneous patient populations. Using the formulae, values are calculated for deltaD50(10)-the increase in dose leading to a 50% series-type complication rate (D50) when irradiated organ volume is reduced tenfold. From the structure of the ntcp formulae derived, it follows that dose-levels leading to clinically relevant serious complication rates (less than 5%) will change less with irradiated volume than will D50. Calculated values of deltaD50(10) for the heterogeneous series model are low-generally less than 6 Gy; such values are much lower than those calculated for the non-heterogeneous series model (27-37 Gy). These results suggest that if the dose-limiting toxicity of a radiotherapy treatment is a series-type complication with a local damage mechanism similar to any of those studied in this work, then even very substantial improvements in technique-leading to large reductions in highly dosed normal tissue volumes-would be unlikely to allow a useful degree of escalation of the dose delivered to the tumour, unless highly dosed normal tissue volumes can be reduced below the length-scale of a functional subunit.

A mathematical model of the volume effect which postulates cell migration from unirradiated tissues

PURPOSE

In order to simulate the large variation in tolerance doses for very small treatment volumes, we introduce a model which assumes the presence of cells which have migrated from unirradiated tissues.

METHODS AND MATERIALS

In order to represent serial architecture, the new model adds a new parameter to the familiar expression for serial architecture. Data derived from the model is fitted to the dose-response data developed by Hopewell et al. (Hopewell, J.W., Morris, A.D. and Dixon-Brown, A. The influence of field size on the late tolerance of the rat spinal cord to single doses of X rays. Br. J. Radiol. 60: 1099-1108, 1987) using white matter necrosis of rat spinal cord.

RESULTS

The new model with a cell-migration term more accurately describes the large differences in threshold doses for a very small treatment volume than a model without a cell-migration term.

CONCLUSION

Although these results do not prove that cell migration is the mechanism behind the volume effect for very small volume, they do suggest that the probability of normal tissue complication is more accurately predicted by the new model.

A practical evaluation of five dose-volume histogram reduction algorithms

A unifying approach to cumulative dose-volume histogram (CDVH) reduction analysis is presented, utilising two weighted linear interpolation models (VWD, DWV), two weighted probability models (VWP, DWP) and a novel integral probability model (IPM). As a test of their predictive value these algorithms were applied to CDVH data generated from lung doses, measured by TLD arrays in a female anthropomorphic phantom. Three arbitrary configurations of breast size and location of "target volume" within the breast were "treated", using an appropriate electron field (Varian Clinac 1800) or double-plane iridium-192 implant. Calculated effective doses from each of the reduction algorithms showed the iridium implant to be dosimetrically the most favourable in two the three configurations. Likewise, complication probabilities, based on a logistic dose-volume response function showed lung complication probabilities to be lower for the interstitial technique in the same situations. All algorithms tested showed reasonable consistency, with the exception of the VWD. The rationale and value of comparative rather than absolute dose-volume histogram analyses are discussed.

Dose-volume correlation in radiation-related late small-bowel complications: a clinical study

The effects of the volume of irradiated small bowel on late small-bowel tolerance was studied, taking into account the equivalent total dose and type of pre-irradiation surgical procedure. A method was developed to estimate small-bowel volumes in the high-dose region of the radiation treatment using CT-scans in the treatment position. Using this method small-bowel volumes were measured for three-field and AP-PA pelvic treatments (165 cm3 and 400 cm3, respectively), extended AP-PA pelvic treatment (790 cm3), AP-PA treatment of para-aortic nodes (550 cm3) and AP-PA treatment of para-aortic and iliac nodes (1000 cm3). In a retrospective study of 111 patients irradiated after surgery for rectal or recto-sigmoid cancer to a dose of 45-50 Gy in 5 weeks, extended AP-PA pelvic treatment (n = 27) resulted in a high incidence of severe small-bowel complications (37%), whereas for limited (three-field) pelvic treatment (n = 84) the complication rate was 6%. These complication data together with data from the literature on postoperative radiation-related small-bowel complications were analysed using the maximum likelihood method to fit the data to the logistic form of the dose-response relation, taking the volume effect into account by a power law. The analysis indicated that the incidence of radiation-related small-bowel complications was higher after rectal surgery than after other types of surgery, which might be explained by the development of more adhesions. For both types of surgery a volume exponent of the power-law of 0.26 +/- 0.05 was established. This means that if the small-bowel volume is increased by a factor of 2, the total dose has to be reduced by 17% for the same incidence of small-bowel complications.

The biological effect of inhomogeneous dose distributions in fractionated radiotherapy

The linear quadratic (LQ) model is applied to an organ receiving a fractionated course of radiotherapy with an inhomogeneous dose distribution. It is shown that the gradient in the extrapolated response dose (ERD) will be steeper than the gradient in the physical dose. This effect will be greatest for an organ with a small alpha/beta ratio treated with large dose fractions. Clinical implications are discussed with an emphasis on radiation myelitis.