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Purpose: Artificial intelligence (AI) and machine learning present an opportunity to enhance clinical decision-making in radiation oncology. This study aims to evaluate the competency of ChatGPT, an AI language model, in interpreting clinical scenarios and assessing its oncology knowledge., Methods and Materials: A series of clinical cases were designed covering 12 disease sites. Questions were grouped into domains: epidemiology, staging and workup, clinical management, treatment planning, cancer biology, physics, and surveillance. Royal College-certified radiation oncologists (ROs) reviewed cases and provided solutions. ROs scored responses on 3 criteria: conciseness (focused answers), completeness (addressing all aspects of the question), and correctness (answer aligns with expert opinion) using a standardized rubric. Scores ranged from 0 to 5 for each criterion for a total possible score of 15., Results: Across 12 cases, 182 questions were answered with a total AI score of 2317/2730 (84 %). Scores by criteria were: completeness (79 %, range: 70-99 %), conciseness (92 %, range: 83-99 %), and correctness (81 %, range: 72-92 %). AI performed best in the domains of epidemiology (93 %) and cancer biology (93 %) and reasonably in staging and workup (89 %), physics (86 %) and surveillance (82 %). Weaker domains included treatment planning (78 %) and clinical management (81 %). Statistical differences were driven by variations in the completeness (p < 0.01) and correctness (p = 0.04) criteria, whereas conciseness scored universally high (p = 0.91). These trends were consistent across disease sites., Conclusions: ChatGPT showed potential as a tool in radiation oncology, demonstrating a high degree of accuracy in several oncologic domains. However, this study highlights limitations with incorrect and incomplete answers in complex cases., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [DAP reports a Clinician-Scientist Grant from the Ontario Institute for Cancer Research, royalties from Uptodate.com, and a consultant role with equity from Need Inc. TN declares a speaker fee with the Radiosurgery society and a consultant role with equity from Need Inc. CG declares consulting fees and stock options from Need inc. GSB declares an advisory board position with advanced accelerator applications, a director position with the Centre for Translation Cancer Research, and a research grant from Siemens. PCC declares he is an employee of Need Inc. AM declares honoraria from Sanofi. The other authors declare no competing interests.]., (Copyright © 2024. Published by Elsevier B.V.)

Background and Purpose: Radiation therapy is used frequently for patients with prostate cancer. Dose escalation to intraprostatic lesions (IPLs) has been shown to improve oncologic outcomes, without increasing toxicity. Both multiparametric MRI (mpMRI) and PSMA PET can be used to identify IPLs., Materials and Methods: A systematic review was conducted to determine the ability of mpMRI, PSMA PET and their combination to detect IPLs prior to radical prostatectomy (RP) as correlated with the histology. Trials included patients that had mpMRI, PSMA PET, or both, prior to RP. The quality of the histopathological-radiological co-registration was assessed as high or low for each study. Recorded outcomes include sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). A meta-analysis was conducted using a bivariate model to determine the pooled sensitivity and specificity for each imaging modality. This systematic review was registered through PROSPERO (CRD42023389092)., Results: Altogether, 42 studies were included in the systematic review. Of these, 20 could be included in the meta-analysis. The pooled sensitivity (95 % CI), specificity (95 % CI) and AUROC for mpMRI (n = 13 studies) were 64.7 % (50.2 % - 76.9 %), 86.4 % (79.7 % - 91.1 %), and 0.852; the pooled outcomes for PSMA PET (n = 12) were 75.7 % (64.0 % - 84.5 %), 87.1 % (80.2 % - 91.9 %), and 0.889; for their combination (n = 5), the pooled outcomes were 70.3 % (64.1 % - 75.9 %), 81.9 % (71.9 % - 88.8 %), and 0.796. When reviewing studies with a high-quality histopathological-radiological co-registration, IPL delineation recommendations varied by study and the imaging modality used., Conclusion: All of mpMRI, PSMA PET or their combination were found to have very good diagnostic outcomes for detecting IPLs. Recommendations for delineating IPLs varied based on the imaging modalities used and between research groups. Consensus guidelines for IPL delineation would help with creating consistency for focal boost radiation treatments in future studies., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Glenn Bauman is Primary Investigator on the OICR funded trial ARGOS/CLIMBER that is examining the use of hybrid PSMA PET/MRI for dose escalation in high intermediate and high risk prostate cancer. Dr. Bauman also leads other clinical trials examining the use of PSMA PET/CT in the management of men with prostate cancer that are funded through Ontario Health-Cancer Care Ontario. All other authors declare that they have no know competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: Dominant cancer foci within the prostate are associated with sites of local recurrence post radiotherapy. In this systematic review we sought to address the question: "what is the clinical evidence to support differential boosting to an imaging defined GTV volume within the prostate when delivered by external beam or brachytherapy"., Materials and Methods: A systematic review was conducted to identify clinical series reporting the use of radiation boosts to imaging defined GTVs., Results: Thirteen papers describing 11 unique patient series and 833 patients in total were identified. Methods and details of GTV definition and treatment varied substantially between series. GTV boosts were on average 8 Gy (range 3-35 Gy) for external beam, or 150% for brachytherapy (range 130-155%) and GTV volumes were small (<10 ml). Reported toxicity rates were low and may reflect the modest boost doses, small volumes and conservative DVH constraints employed in most studies. Variability in patient populations, study methodologies and outcomes reporting precluded conclusions regarding efficacy., Conclusions: Despite a large cohort of patients treated differential boosts to imaging defined intra-prostatic targets, conclusions regarding optimal techniques and/or efficacy of this approach are elusive, and this approach cannot be considered standard of care. There is a need to build consensus and evidence. Ongoing prospective randomized trials are underway and will help to better define the role of differential prostate boosts based on imaging defined GTVs., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To compare lesional stereotactic radiosurgery to whole brain (WBRT) radiotherapy with simultaneous in-field boost for brain metastases in terms of overall survival., Methods: A retrospective review was performed on two institutional databases of 500 patients diagnosed with brain metastatic disease who received either stereotactic radiosurgery (SRS, n = 381) or whole brain with simultaneous in-field boost radiotherapy (SIB, n = 119), between 2002 and 2011. Propensity-score matching was utilized to obtain two groups with similar known prognostic factor characteristics. Kaplan-Meier and univariable/multivariable Cox modeling were conducted to assess the treatment impact on overall survival (OS)., Results: Propensity-score matching created a matched cohort of 178 patients (89 SRS/SIB) with similar baseline characteristics. Multivariable analysis demonstrated that presence/absence of systemic metastases, patient age, tumor volume, and presence/absence of active primary were found to be more predictive of OS than treatment assignment (p = 0.38). SIB was associated with reduced intracranial failure likely due to the WBRT component of the treatment (HR 0.36, p<0.001)., Conclusions: Adjusting for other predictive factors, treatment with either SRS or SIB did not result in any statistically significant difference in OS; however, observed intracranial failure was different due to the use of WBRT in the SIB cohort., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To report pooled overall survival and time to radiological intracranial progression results related to arc-based image-guided radiotherapy for dose-escalation of oligometastatic disease of the brain., Methods and Materials: Anonymized patient, tumor, and treatment data were pooled from the VU University medical center (VUmc) and the London Regional Cancer Program (LRCP) for patients treated with whole brain radiotherapy (20 Gy/5 VUmc, 30 Gy/10 LRCP) with simultaneous integrated boost (SIB) to individual intracranial lesions (40 Gy/5 VUmc, 35-60 Gy/10 LRCP) to perform survival/intracranial control outcome analyses., Results: A total of 120 patients were treated by both the LRCP (n=70) and VUmc (n=50) between 2005 and 2010. Median lesional dose BED3,10 for the entire cohort of patients were 147 and 72 Gy, respectively. Median follow-up for the entire cohort of patients was 4.7 months with median follow-up of 5.2 months for living patients. On multivariable analysis, primary lung cancer (HR 2.044), presence of systemic metastatic disease (HR 1.937), and lower baseline WHO performance status (HR 1.742) were significant (p<0.05) predictors of shorter overall survival. Cumulative brain metastases volume (HR 1.014, p=0.06) was of borderline significance on analysis of intracranial control., Conclusions: This pooled analysis has provided robust outcome data regarding the use of arc-based radiotherapy with SIB., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Radiosurgery has a long history in Canada. Since the treatment of the first patient at the McGill University Health Center in 1985, radiosurgery programs have been developed from coast to coast. These have included multidisciplinary teams of radiation oncologists, neurosurgeons, medical physicists, radiation technologists and other health professionals. In 2008, the CARO Board of Directors requested that a working group be formed to define the role of the radiation oncologist in the practice of radiosurgery. Taking into account evolving technology, changing clinical practice and current scope of practice literature, the working group made recommendations as to the role of the radiation oncologists. These recommendations were endorsed by the Canadian Association of Radiation Oncology board of directors in September 2009 and are present herein. It is recognized that patients benefit from a team approach to their care but it is recommended that qualified radiation oncologists be involved in radiosurgery delivery from patient consultation to follow-up. In addition, radiation oncologists should continue to be involved in the administrative aspects of radiosurgery programs, from equipment selection to ongoing quality assurance/quality improvement., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

The purpose of this study was to assess a variety of potential IMRT class solutions as compared to a helical tomotherapy (HT) class solution for localized prostate cancer. Target and critical structures were contoured on 10 prostate cancer patient CT datasets. HT treatment plans were compared to four different IMRT approaches by paired t-tests. HT prostate planning generally provided treatment plans with excellent target homogeneity and favorable critical structure sparing when compared to conventional IMRT.

Background and Purpose: The potential benefits and limitations of different radiation techniques (stereotactic arc therapy (SRS/T), intensity modulated radiotherapy (IMRT), helical tomotherapy (HT), Cyberknife and intensity-modulated multiple arc therapy (AMOA)) have been assessed using comparative treatment planning methods on twelve patients presenting with 'benign' brain tumours., Materials and Methods: Plans for five acoustic neurinomas, five meningiomas and two pituitary adenomas were computed to generate dose distributions for all modalities using a common CT dataset to delineate planning target volume and organs at risk., Results: HT, AMOA and IMRT resulted superior to SRS/T and Cyberknife for target coverage. For the first group V(95%) ranged from 98% to 100%, minimum dose ranged from 91% to 96% and standard deviation from 0.84% to 1.67%. For organs at risk all techniques respected planning objectives with a tendency of Cyberknife and SRS/T to better spare the brain stem and the healthy brain tissue (e.g., V(20Gy) of 2.0% and 2.3%, respectively, compared to 3.1-5.0% for the other techniques). AMOA is in general preferable to IMRT for all OARs. Conformity index (CI(95)) was better for HT and Cyberknife (both 1.8) and less for AMOA and IMRT (3.9 and 3.0, respectively)., Conclusion: All techniques provided good OAR sparing and primarily differed in target coverage indices. For the class of tumours investigated in this report, HT, AMOA and IMRT had better target coverage with HT providing the best combination of indeces. Between AMOA and IMRT, target coverage was comparable and, considering organs at risk, AMOA was slightly preferable.

Background and Purpose: Lung cancer treatment can be one of the most challenging fields in radiotherapy. The aim of the present study was to compare different modalities of radiation delivery based on a balanced scoring scheme for target coverage and normal tissue avoidance., Patients and Methods: Treatment plans were developed for 15 patients with stage III inoperable non-small cell lung cancer using 3D conformal technique and intensity-modulated radiotherapy (IMRT). Elective nodal irradiation was included for all cases to create the most challenging scenarios with large target volumes. A 2 cm margin was used around the gross tumour volume (GTV) to generate PTV2 and 1cm margin around elective nodes for PTV1 resulting in PTV1 volumes larger than 1000 cm(3) in 13 of the 15 patients. 3D conformal and IMRT plans were generated on a commercial treatment planning system (TheraPlan Plus, Nucletron) with various combinations of beam energies and gantry angles. A 'dose quality factor' (DQF) was introduced to correlate the plan quality with patient specific parameters., Results: A good correlation was found between the quality of the plans and the overlap between PTV1 and lungs. The patient feature factor (PFF), which is a product of several pertinent characteristics, was introduced to facilitate the choice of a particular technique for a particular patient., Conclusions: This approach may allow the evaluation of different treatment options prior to actual planning, subject to validation in larger prospective data sets.

Background and Purpose: The purpose was to develop a systematic review that would address the following question: what is the role of radiopharmaceuticals in the palliation of metastatic bone pain in adults with uncomplicated, multifocal painful bone metastases whose pain is not controlled with conventional analgesic regimens? The outcomes of interest are pain response, analgesic consumption, overall survival, adverse effects and quality of life., Materials and Methods: A systematic review of the English published literature was undertaken to provide evidence relevant to the above outcomes., Results: Six randomized phase III trials, two randomized phase II trials and one randomized crossover trial of strontium-89 were reviewed. A randomized phase III trial comparing strontium-89 plus cisplatin with strontium-89 plus placebo reported a significantly higher proportion of patients experiencing pain relief for a significantly longer duration with strontium-89 plus cisplatin. A randomized phase III trial comparing adjuvant strontium-89 with placebo following radiotherapy reported a higher proportion of pain-free patients with strontium-89. Patients who received strontium-89 also experienced fewer new sites of bone pain. A second, but underpowered study failed to confirm these results. In one randomized trial of strontium-89 versus radiotherapy (hemibody or local), patients treated with strontium-89 developed fewer new sites of pain. In a second trial comparing strontium-89 versus local radiotherapy, median overall survival was improved with radiotherapy, while pain response and time-to-progression were similar in the two groups. One randomized phase III trial reported no difference in pain relief between strontium-89 and placebo. Three randomized phase III trials and two randomized phase II trials investigating samarium-153 were reviewed. In a randomized phase III trial of three different doses of samarium-153, the pain responses were similar for all three doses. In a randomized phase III trial of two different doses of samarium-153 versus placebo, the complete pain response rate was significantly higher with the higher dose of samarium-153 compared with placebo. In a randomized phase III trial comparing samarium-153 with placebo, significant differences favouring samarium-153 were reported for pain and opiate use. In addition, one randomized phase III trial, two randomized phase II trials, one randomized crossover trial and 13 phase II or phase I trials of rhenium, one phase I trial of tin-117 m and one phase II trial of phosphorus-32 were reviewed. The majority of patients treated in trials of radiopharmaceuticals where histology was specified had metastatic breast cancer (approximately 5-10% of patients reported), metastatic hormone-refractory prostate cancer (80-90% of patients reported) or metastatic lung cancer (5-10% of patients reported). Information on histologic subtype was not available for a significant proportion of patients treated on trials (30-40% of patients reported)., Conclusions: Use of single-agent radiopharmaceuticals (strontium-89 and samarium-153) should be considered as a possible option for the palliation of multiple sites of bone pain from metastatic cancer where pain control with conventional analgesic regimens is unsatisfactory and where activity on a bone scan of the painful lesions is demonstrated. Ongoing clinical research should seek to establish the benefit of newer radiopharmaceuticals and radiopharmaceuticals in combination with other systemic therapies.

Helical tomotherapy (HT) combines a rotating intensity modulated fan beam with integrated CT imaging for high precision radiotherapy. HT plans for 12 patients with small brain tumours were compared with five other radiotherapy techniques. Proton techniques gave overall the best results, while HT was shown to produce better target dose uniformity (average SD=1.3%) and kept irradiation of organs at risk as good as other photon methods.

Background and Purpose: The purpose was to develop a systematic review that would address the following questions: (a) when single-modality treatment external-beam radiotherapy is selected as the modality of choice, what is the role of three-dimensional (3D) conformal radiotherapy in treating clinically localized (T1, T2/NO, NX/MO) prostate cancer? The outcomes of interest are biochemical freedom from failure (bNED) rates, clinical recurrence-free survival, disease-specific survival and acute and late toxicity; (b) what is the appropriate dose and fractionation prescription in this clinical setting?, Materials and Methods: A systematic review of the English published literature was undertaken to provide evidence relevant to the above outcomes., Results: One randomized controlled trial comparing conventional radiotherapy to conformal therapy with dose escalation reported bNED rates. Three additional randomized controlled trials reported acute or chronic late outcome assessments. Additionally, phase II studies of dose escalation in sequential patient cohorts and non-randomized comparative assessments of dose-response and bNED rates in controlled analyses were reviewed. There is convincing evidence from randomized trials that the use of conformal therapy reduces acute and late treatment-related morbidity. There is preliminary evidence suggesting that when external-beam therapy alone is used to treat patients, conformal therapy with dose-escalation is more efficacious than doses of 70Gy. The increased efficacy appears to be predominantly seen in the subset of patients with intermediate-risk disease (PSA 10-20). There is conflicting evidence of the efficacy of dose-escalation in patients with low initial PSA (<10) and in patients with initial PSA greater than 20. Conformal radiotherapy at a dose of 78Gy appears to be relatively safe with no increase in acute or late effects compared with conventional treatment (up to 70Gy) so long as appropriate technological principles are considered., Conclusions: Patients who have external-beam radiotherapy should be treated using a 3D conformal technique. Patients with intermediate-risk disease (PSA 10-20) who are treated with external-beam radiotherapy alone should be offered doses of 75-78Gy in 180-200cGy fractions.