RADIATION THERAPY COMMUNICATION: NASAL PASSAGE AND PARANASAL SINUS LYMPHOMA IN A PONY

An aged pony with extensive paranasal sinus and nasal passage B-cell lymphoma was treated with palliative radiation therapy. Sixteen gray were administered in two fractions, 7 days apart. A lateral field was used for the first fraction and a dorsal field for the second. Because of tumor being present in the left frontal sinus, gross tumor was knowingly excluded from the treated volume in the lateral field. The tumor regressed within 2 months and the pony remained free of clinical disease for 2.5 years. Acute, temporary blindness developed shortly after the second radiation fraction, but a direct causal relationship with the radiation therapy was not confirmed. The only radiation side effect was leukotrichia. Palliative treatment was successful in improving and prolonging the quality of life. These results suggest that localized equine B-cell lymphoma is radiosensitive, and that palliative radiation therapy is a reasonable consideration for large tumors, even when tumor volume prevents all gross tumor from being irradiated.     

RADIATION EXPOSURE DURING EQUINE RADIOGRAPHY

All personnel present in the X-ray examination room during equine radiography were monitored using low energy direct reading ionization chambers (pockets dosimeters) worn outside the lead apron at neck level. The individuals' task and dosimeter readings were recorded after each examination. Average doses ranged from 0 to 6 mrad per study. The greatest exposures were associated with radiography of the shoulder and averaged less than 4 mrad. The individual extending the horse's limb was at greatest risk although the individual holding the horse's halter and the one making the X-ray exposure received similar exposures.
A survey of the overhead tube assembly used for some of the X-ray examinations also was performed. Meter readings obtained indicated an asymetric dose distribution around the tube assembly, with the highest dose occurring on the side to which the exposure cord was attached.
Although the exposures observed were within acceptable limits for occupational workers, we have altered our protocol and no longer radiograph the equine shoulder unless the horse is anesthetized. Continued use of the pocket dosimeters and maintenance of a case record of radiation exposure appears to make the technologists more aware of radiation hazards.     

ANCILLARY EQUIPMENT TO INCREASE QUALITY AND REDUCE RADIATION EXPOSURE IN THE EQUINE NUCLEAR MEDICINE LABORATORY

The construction of ancillary equipment used to improve image quality and reduce personnel radiation exposure in the equine nuclear medicine laboratory is illustrated. The devices include a self supporting lead sheet for shielding the distal limb or limb pair, a hanging lead sheet for shielding the proximal limb, a lead square for shielding the urinary bladder or jugular catheter, a restraining board for acquiring a palmar view of the foot, a head support to stabilize the head for imaging and a head support for stabilizing the neck for imaging. The restraining board and head supports decrease patient motion, improve image quality, and decrease the number of repeat acquisitions so that the time to perform the complete study is shortened. The self supporting shielding device allows the handlers to increase their distance from the horse which enhances radiation safety.     

HEMANGIOMA OF THE DISTAL PHALANX IN A COLT

A yearling Thoroughbred colt was admitted to the University of Florida College of Veterinary Medicine with severe, progressive lameness of the left forelimb. A centrally located expansile lytic lesion involving approximately 40% of the distal phalanx with a large associated vascular channel was identified by radiography. Increased vascular phase pooling, increased soft tissue phase uptake, and a photopenic area on bone phase images corresponding to the lytic lesion within the left distal phalanx were identified by vascular, soft tissue, and bone phases of a three phase bone scan, respectively. Contrast medium accumulation and disappearance in dilated vessels within the lesion was apparent angiographically. The colt was euthanized and the histologic diagnosis was hemangioma of the distal phalanx with a pathologic fracture.     

RADIATION THERAPY COMMUNICATION—REIRRADIATION OF A NASAL TUMOR IN A BRACHYCEPHALIC DOG USING INTENSITY MODULATED RADIATION THERAPY

A 5‐year‐old spayed female Shih Tzu was referred for evaluation of a nasal transitional carcinoma. A total lifetime dose of 117 Gy was delivered to the intranasal mass in three courses over nearly 2 years using fractionated intensity modulated radiation therapy (IMRT) to spare normal tissues. Clinically significant late normal tissue side effects were limited to bilaterally diminished tear production. The patient died of metastatic disease progression 694 days after completion of radiation therapy course 1. This case demonstrates that retreatment with radiation therapy to high lifetime doses for recurrent local disease may be well tolerated with IMRT.     

THE ROLE OF PROTECTIVE LEAD CLOTHING IN REDUCING RADIATION EXPOSURE RATES TO PERSONNEL DURING EQUINE BONE SCINTIGRAPHY

Bone scintigraphy is often used in horses because of its sensitivity and noninvasive nature. A 99mTc labeled radiopharmaceutical is injected at a dose of between 5.7 and 7.3GBq. Images are acquired immediately postinjection and 2-4h post. People are often in the room with the horse during the acquisition process. Objectives of this study were to (a) document the radiation exposure rates at different distances from various sites of the horse at varying times post injection and (b) study the usefulness of wearing lead aprons to reduce exposure rates to personnel. Radiation exposure rates were measured in at three distances (at skin surface and at 30 and 100 cm from the skin) from three sites (shoulder, thorax, and pelvis) in 19 horses. Exposure rates were measured with and without shielding by a 0.5-mm lead equivalent apron during both the pool and delayed phases. A 0.5mm equivalent lead apron significantly decreases radiation exposure (P<0.05) at these three distances from the three sites during both image acquisition phases. Mean dose reduction factors from the lead apron range from 3.6 to 5.7.     

DEFINITIVE RADIATION THERAPY FOR INFILTRATIVE THYROID CARCINOMA IN DOGS

The medical records of eight dogs with histopathologically confirmed infiltrative thyroid carcinoma treated with external beam radiation were reviewed and a retrospective analysis of survival and local tumor control were performed. The dogs received a definitive radiotherapy protocol of 46.8-48 Gray. All dogs had a reduction in tumor size to a clinically undetectable level on follow up examinations. Kaplan-Meier analysis indicated a median survival time of 24.5 months. Pulmonary metastasis was detected in three dogs and one of these dogs had concurrent bone metastasis. One dog had bone metastasis alone. Two dogs were alive at the censor. This study suggests that fractionated, definitive radiation therapy using multiple, moderate doses of radiation is an effective treatment for local control of invasive thyroid carcinoma in dogs.     

USE OF PORTAL RADIOGRAPHY TO INCREASE ACCURACY OF DOSE DELIVERY IN RADIATION THERAPY

Port films were acquired for all radiation therapy patients (n = 132) treated over a thirteen month period to 1] assist in initial treatment field set-up on Day 1, 2] for quality assurance with a second port film taken on Day 7 of radiation therapy, and 3] as a means to document the radiation treatment field as a part of the patients permanent medical record. Port films were used for both patients treated with a definitive course of radiation (n = 97 patients), and those treated palliatively (n = 35 patients). The portal radiographs were valuable in terms of the initial set-up, and to correct for any positioning or other errors at the time of the one week recheck. Changes were made, based on the initial port film on Day 1, in 53% and 57% of treatment fields for palliative and definitive radiation patients, respectively. The changes made in both definitively and palliatively irradiated patients were usually in field position, an increase in field size to include all of the tumor, or a decrease in field size to spare normal tissue. Fewer changes were necessary based on the Day 7 recheck port films, but these day-7 rechecks are recommended for quality control. Based on the high frequency of changes introduced because of the initial port film findings, it is recommended that port films be incorporated on a routine basis in veterinary radiation therapy.     

USE OF A PETROLEUM-BASED BOLUS FOR PHOTON RADIATION THERAPY OF DISTAL EXTREMITIES IN DOGS

While skin sparing is an advantage of megavoltage beams, in certain clinical situations the planning target volume includes the skin surface and a skin sparing effect is not desirable. A tissue equivalent material, termed build up bolus, is used in these situations to provide adequate absorbed dose at the surface of the skin. However, an irregular patient contour can lead to air gaps between the build up bolus and the skin surface, which may result in variability in radiation dose across the target volume. The shape of the canine distal hind extremity is irregular, and commercially available bolus materials do not conform well to this region. The purpose of this study was to assess the dose homogeneity achieved using a petroleum-based bolus material, in combination with a commercially available sheet bolus, for radiation treatment of the canine tarsus. Repeated setups were performed to mimic daily treatment setups in the clinic setting, and computed tomographic scans were performed after each setup. Dose distribution achieved with a cobalt therapy machine and a 6 MV linear accelerator was assessed using three-dimensional treatment planning software. The dose to the clinical target volume fell within 95% and 107% of the prescribed dose for both treatment machines, which is considered clinically acceptable by the authors. This petroleum-based bolus is equivalent to water in its photon attenuation, conforms well to an irregular patient contour, and retains its shape after positioning. Applications to other anatomical sites could be considered.     

ASSESSMENT OF THE ACCURACY AND PRECISION OF A PATIENT IMMOBILIZATION DEVICE FOR RADIATION THERAPY IN CANINE HEAD AND NECK TUMORS

The positioning accuracy and precision of a head and neck immobilization device for radiation therapy of tumors in the canine skull was evaluated. Nineteen dogs with a spontaneous tumor of the head were enrolled including 12 with an intracranial mass and seven with an intranasal or maxillary tumor. Three hundred thirty-three pairs of orthogonal digital portal radiographs were analyzed to assess patient displacement in the cranial–caudal, lateral, and dorso-ventral directions. The mean systematic displacement was 0.8, 1, and 0.9 mm. The mean random displacement was 1.9, 1.6, and 1.5 mm. These values resulted in an overall displacement of 2.1 mm in the cranial–caudal direction, 1.8 mm in the lateral direction, and 1.7 mm in the dorsal–ventral direction. The mean displacement value of the three dimensional (3D) vector was 2.4 mm with a standard deviation of 2.1. Ninety-five percent of all vectors were <6.4 mm. This study quantifies the precision and accuracy of this particular positioning device. Knowing the limitations and setup variability of the system being used to set patients up for daily radiotherapy is paramount to planning and delivering appropriate radiation doses, especially as more complex treatment methods are used.     

SURVIVAL TIMES FOR CANINE INTRANASAL SARCOMAS TREATED WITH RADIATION THERAPY: 86 CASES (1996–2011)

Sarcomas comprise approximately one‐third of canine intranasal tumors, however few veterinary studies have described survival times of dogs with histologic subtypes of sarcomas separately from other intranasal tumors. One objective of this study was to describe median survival times for dogs treated with radiation therapy for intranasal sarcomas. A second objective was to compare survival times for dogs treated with three radiation therapy protocols: daily‐fractionated radiation therapy; Monday, Wednesday, and Friday fractionated radiation therapy; and palliative radiation therapy. Medical records were retrospectively reviewed for dogs that had been treated with radiation therapy for confirmed intranasal sarcoma. A total of 86 dogs met inclusion criteria. Overall median survival time for included dogs was 444 days. Median survival time for dogs with chondrosarcoma (n = 42) was 463 days, fibrosarcoma (n = 12) 379 days, osteosarcoma (n = 6) 624 days, and undifferentiated sarcoma (n = 22) 344 days. Dogs treated with daily‐fractionated radiation therapy protocols; Monday, Wednesday and Friday fractionated radiation therapy protocols; and palliative radiation therapy protocols had median survival times of 641, 347, and 305 days, respectively. A significant difference in survival time was found for dogs receiving curative intent radiation therapy vs. palliative radiation therapy (P = 0.032). A significant difference in survival time was also found for dogs receiving daily‐fractionated radiation therapy vs. Monday, Wednesday and Friday fractionated radiation therapy (P = 0.0134). Findings from this study support the use of curative intent radiation therapy for dogs with intranasal sarcoma. Future prospective, randomized trials are needed for confirmation of treatment benefits.     

COMBINATION OF RADIATION THERAPY AND FIROCOXIB FOR THE TREATMENT OF CANINE NASAL CARCINOMA

Carcinomas represent two‐thirds of canine nasosinal neoplasms. Although radiation therapy (RT) is the standard of care, the incidence of local recurrence following treatment is high. Cyclooxygenase‐isoform‐2 (COX‐2) is expressed in 71–95% of canine nasal carcinomas and has been implicated in tumor growth and angiogenesis. Accordingly, COX‐2 inhibition seems rational to improve outcome. Dogs with histologically confirmed, previously untreated nasal carcinomas were randomized to receive the combination of a selective COX‐2 inhibitor (firocoxib) and palliative RT (Group 1) or RT and placebo (Group 2). Patients were regularly monitored with blood tests, urinalysis, and computed tomography. Pet owners were asked to complete monthly a quality‐of‐life questionnaire. Twenty‐four dogs were prospectively enrolled. According to Adams modified system, there were five stage 1, five stage 2, three stage 3, and 11 stage 4 tumors. Two dogs had metastases to regional lymph nodes. Median progression‐free interval and overall survival were 228 and 335 days in Group 1 (n = 12) and 234 and 244 days in Group 2 (n = 12). These differences were not statistically significant. The involvement of regional lymph nodes was significantly associated with progression‐free interval and overall survival (P = 0.004). Quality of life was significantly improved in Group 1 (P = 0.008). In particular, a significant difference was observed for activity and appetite. Although not providing a significant enhancement of progression‐free interval and overall survival, firocoxib in combination with RT is safe and improved life quality in dogs with nasal carcinomas.     

POTENTIAL FOR INTENSITY-MODULATED RADIATION THERAPY TO PERMIT DOSE ESCALATION FOR CANINE NASAL CANCER

We evaluated the impact of inverse planned intensity-modulated radiation therapy (IMRT) on the dose-volume histograms (DVHs) and on the normal tissue complication probabilities (NTCPs) of brain and eyes in dogs with nasal tumors. Nine dogs with large, caudally located nasal tumors were planned using conventional techniques and inverse planned IMRT for a total prescribed dose of 52.5 Gy in 3.5 Gy fractions. The equivalent uniform dose for brain and eyes was calculated to estimate the normal tissue complication probability (NTCP) of these organs. The NTCP values as well as the DVHs were used to compare the treatment plans. The dose distribution in IMRT plans was more conformal than in conventional plans. The average dose delivered to one-third of the brain was 10 Gy lower with the IMRT plan compared with conventional planning. The mean partial brain volume receiving 43.6 Gy or more was reduced by 25.6% with IMRT. As a consequence, the NTCPs were also significantly lower in the IMRT plans. The mean NTCP of brain was two times lower and at least one eye could be saved in all patients planed with IMRT. Another possibility with IMRT is dose escalation in the target to improve tumor control while keeping the NTCPs at the same level as for conventional planning. Veterinary     

HYPOTHYROIDISM IN A DOG AFTER SURGERY AND RADIATION THERAPY FOR A FUNCTIONAL THYROID ADENOCARCINOMA

Hypothyroidism was diagnosed in a dog which had undergone unilateral thyroid lobectomy and external beam irradiation (48 Gy in 3 Gy fractions) for a functional cystic thyroid adenocarcinoma. Hypothyroidism became biochemically apparent within 4 months of completion of radiation therapy, and clinically apparent within 7 months. Clinical signs resolved after thyroid hormone supplementation. The potential for alterations in thyroid function should be considered in any animal undergoing radiation therapy in which the thyroid gland is included in the radiation field. This potential may be greater if surgery and radiation are combined.     

OSTEORADIONECROSIS AND RADIATION INDUCED BONE TUMORS FOLLOWING ORTHOVOLTAGE RADIATION THERAPY IN DOGS

Osteoradionecrosis and radiation-induced bone tumors are rare complications of radiation therapy. Little information regarding these complications is available in veterinary medicine. We characterized these complications and investigated risk factors in 119 dogs (122 sites) that received definitive orthovoltage radiation therapy to appendicular sites. Long-term survival was expected in all dogs. The complications of interest were osteoradionecrosis and secondary bone tumor, evaluated radiographically, histopathologically, or both. Complication rates were estimated using the Kaplan–Meier product-limit method, and Fisher's exact test or chi-square test was used to compare the complication rate. The median survival time was 1405 days, with median follow-up duration of 657 days. There were 10 radiation-induced bone tumors and five radiation-induced fractures, with two dogs developing both, for an overall complication rate of 11%. The latent period ranged from 1.2 to 6.4 years for osteoradionecrosis and from 2.6 to 8.7 years for radiation-induced bone tumor. Complications were significantly higher in the humerus ( P <0.0001), and in dogs younger than 7 years ( P =0.014). Similar assessment of complications in dogs irradiated with megavoltage photons or electrons are needed.     

DOSIMETRIC IMPACT OF DAILY SETUP VARIATIONS DURING TREATMENT OF CANINE NASAL TUMORS USING INTENSITY-MODULATED RADIATION THERAPY

Intensity-modulated radiation therapy (IMRT) can be employed to yield precise dose distributions that tightly conform to targets and reduce high doses to normal structures by generating steep dose gradients. Because of these sharp gradients, daily setup variations may have an adverse effect on clinical outcome such that an adjacent normal structure may be overdosed and/or the target may be underdosed. This study provides a detailed analysis of the impact of daily setup variations on optimized IMRT canine nasal tumor treatment plans when variations are not accounted for due to the lack of image guidance. Setup histories of ten patients with nasal tumors previously treated using helical tomotherapy were replanned retrospectively to study the impact of daily setup variations on IMRT dose distributions. Daily setup shifts were applied to IMRT plans on a fraction-by-fraction basis. Using mattress immobilization and laser alignment, mean setup error magnitude in any single dimension was at least 2.5 mm (0–10.0 mm). With inclusions of all three translational coordinates, mean composite offset vector was 5.9±3.3 mm. Due to variations, a loss of equivalent uniform dose for target volumes of up to 5.6% was noted which corresponded to a potential loss in tumor control probability of 39.5%. Overdosing of eyes and brain was noted by increases in mean normalized total dose and highest normalized dose given to 2% of the volume. Findings suggest that successful implementation of canine nasal IMRT requires daily image guidance to ensure accurate delivery of precise IMRT distributions when non-rigid immobilization techniques are utilized. Unrecognized geographical misses may result in tumor recurrence and/or radiation toxicities to the eyes and brain.     

RADIATION THERAPY FOR INCOMPLETELY RESECTED CANINE MAST CELL TUMORS

The records of 56 dogs treated with megavoltage radiation for mast cell neoplasia were reviewed to determine the efficacy of this treatment modality. Total radiation dose ranged from 45 to 57 Gray (Gy), dose per fraction ranged from 3.0 to 4.0 Gy, and radiation treatment time ranged from 14–28 days. Median disease free interval (95% CI) was 32.7 (19–70) months. Median disease free interval for dogs older than 7.5 years was 15 (lower limit 7) months as compared to 62 (lower limit 20) for dogs younger than 7.5 years of age (p = 0.006). Median disease free interval for dogs with measurable disease was 12 (lower limit 5) months as compared to 54 (32–70) months for dogs with microscopic disease (p = 0.006). Radiation treatment time was also significantly related to disease free interval. Median disease free interval for dogs treated longer than 22 days was 12 (7–19) months as compared to greater than 50 (lower limit 20) months for dogs treated in 22 or fewer days (p < 0.001). This appeared to be due to more recurrences in dogs treated with 3-per-week fractionation and suggests that tumor proliferation in the interfraction interval may be important. Sex, tumor location, histologic grade, WHO clinical stage, number of radiation fractions, total radiation dose, and dose-per-fraction, as well as the following "yes/no" variables: steroids given, surgery prior to radiation, lymph nodes irradiated, and development of another mast cell tumor did not appear to influence median disease free interval or survival. Data presented herein support megavoltage radiation as an effective treatment for canine mast cell neoplasia, and suggest that disease free interval in dogs treated with daily fractions may be longer than that achieved with alternating day fractions.     

A NOVEL,REMOVABLE, CERROBEND,BEAM‐BLOCKING DEVICE FOR RADIATION THERAPY OF THE CANINE HEAD AND NECK: PILOT STUDY

Radiation therapy of the head and neck can result in mucositis and other acute affects in the oral cavity. This prospective pilot study evaluated a novel, intraoral, beam‐blocking device for use during imaging and therapeutic procedures. The beam‐blocking device was made from a metal alloy inserted into a coated frozen dessert mold (Popsicle® Mold, Cost Plus World Market, Oakland, CA). The device was designed so that it could be inserted into an outer shell, which in turn allowed it to be placed or removed depending on the need due to beam configuration. A Farmer type ionization chamber and virtual water phantom were used to assess effects of field size on transmission. Six large breed cadaver dogs, donated by the owner after death, were recruited for the study. Delivered dose at the dorsal and ventral surfaces of the device, with and without the alloy block in place, were measured using radiochromic film. It was determined that transmission was field size dependent with larger field sizes leading to decreased attenuation of the beam, likely secondary to scatter. The mean and median transmission on the ventral surface without the beam‐blocking device was 0.94 [range 0.94–0.96]. The mean and median transmission with the beam‐blocking device was 0.52 [range 0.50–0.57]. The mean and median increase in dose due to backscatter on the dorsal surface of the beam‐blocking device was 0.04 [range 0.02–0.04]. Findings indicated that this novel device can help attenuate radiation dose ventral to the block in dogs, with minimal backscatter.     

PET/CT FOLLOWING INTENSITY-MODULATED RADIATION THERAPY FOR PRIMARY LUNG TUMOR IN A DOG

A primary lung tumor in a dog treated with intensity-modulated radiation therapy was imaged approximately 6 weeks and 1-year posttreatment with combined positron emission tomography (PET) and computed tomography, utilizing the radiotracers 18F-fluorodeoxyglucose and 18F-fluorothymidine. These two tracers allowed discrimination of tumor from inflammation, and demonstrated spread of tumor along airways over time after treatment. Fusion of functional imaging with anatomic imaging is a useful tool, particularly in the field of oncology, with the potential for PET markers that delineate tumor from normal or reactive tissue, and potential or actual response to therapy.