Clinical Focus

  • Radiation Oncology

Academic Appointments

Professional Education

  • Residency: Stanford University Dept of Radiation Oncology (2016) CA
  • Internship: Stanford University Dept of General Surgery (2012) CA
  • Board Certification: American Board of Radiology, Radiation Oncology (2017)
  • Fellowship, Stanford University Radiation Oncology, Brachytherapy & SBRT (2017)
  • Residency, Stanford University & The University of Utah, Radiation Oncology (2016)
  • Residency: University of Utah Radiation Oncology Residency (2015) UT
  • Internship, Stanford University, General Surgery (2012)
  • Medical Education: Temple University School of Medicine (2011) PA
  • MD, Temple University School of Medicine (2011)

Clinical Trials

  • Stereotactic Body Radiation Therapy or Intensity-Modulated Radiation Therapy in Treating Patients With Stage IIA-B Prostate Cancer Not Recruiting

    This randomized phase III trial studies how well stereotactic body radiation therapy works compared to intensity-modulated radiation therapy in treating patients with stage IIA-B prostate cancer. Radiation therapy uses high energy x-rays to kill tumor cells and shrink tumors. Stereotactic body radiation therapy is a specialized radiation therapy that sends x-rays directly to the tumor using smaller doses over several days and may cause less damage to normal tissue. Stereotactic body radiation therapy may work better in treating patients with prostate cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

    View full details

All Publications

  • Environmentally sustainable brachytherapy care. Brachytherapy Lichter, K. E., Baniel, C. C., Anderson, J., Bhatia, R., Frick, M. A., Thiel, C. L., Gandhi, S., Sarria, G. R., Bagshaw, H. P., Petereit, D., Chino, J., Grover, S., Singer, L., Hsu, I., Mohamad, O. 2022

    View details for DOI 10.1016/j.brachy.2022.06.002

    View details for PubMedID 35794032

  • Assessment of Second Primary Cancer Risk Among Men Receiving Primary Radiotherapy vs Surgery for the Treatment of Prostate Cancer. JAMA network open Bagshaw, H. P., Arnow, K. D., Trickey, A. W., Leppert, J. T., Wren, S. M., Morris, A. M. 2022; 5 (7): e2223025


    Shared decision-making is an important part of the treatment selection process among patients with prostate cancer. Updated information is needed regarding the long-term incidence and risk of second primary cancer after radiotherapy vs nonradiotherapy treatments, which may help to inform discussions of risks and benefits for men diagnosed with prostate cancer.To assess the current incidence and risk of developing a second primary cancer after receipt of radiotherapy vs nonradiotherapy treatments for prostate cancer.This retrospective cohort study used the Veterans Affairs Corporate Data Warehouse to identify 154 514 male veterans 18 years and older who had localized prostate cancer (tumor stages T1-T3) diagnosed between January 1, 2000, and December 31, 2015, and no cancer history. A total of 10 628 patients were excluded because of (1) incomplete treatment information for the year after diagnosis, (2) receipt of both radiotherapy and a surgical procedure in the year after diagnosis, (3) receipt of radiotherapy more than 1 year after diagnosis, (4) occurrence of second primary cancer or death within 1 year or less after diagnosis, (5) prostate-specific antigen value greater than 99 ng/mL within 6 months before diagnosis, or (6) no recorded Veterans Health Administration service after diagnosis. The remaining 143 886 patients included in the study had a median (IQR) follow-up of 9 (6-13) years. Data were analyzed from May 1, 2021, to May 22, 2022.Diagnosis of a second primary cancer more than 1 year after prostate cancer diagnosis.Among 143 886 male veterans (median [IQR] age, 65 [60-71] years) with localized prostate cancer, 750 (0.5%) were American Indian or Alaska Native, 389 (0.3%) were Asian, 37 796 (26.3%) were Black or African American, 933 (0.6%) were Native Hawaiian or other Pacific Islander, 91 091 (63.3%) were White, and 12 927 (9.0%) were of unknown race; 7299 patients (5.1%) were Hispanic or Latino, 128 796 (89.5%) were not Hispanic or Latino, and 7791 (5.4%) were of unknown ethnicity. A total of 52 886 patients (36.8%) received primary radiotherapy, and 91 000 (63.2%) did not. A second primary cancer more than 1 year after prostate cancer diagnosis was present in 4257 patients (3.0%), comprising 1955 patients (3.7%) in the radiotherapy cohort and 2302 patients (2.5%) in the nonradiotherapy cohort. In the multivariable analyses, patients in the radiotherapy cohort had a higher risk of second primary cancer compared with those in the nonradiotherapy cohort at years 1 to 5 after diagnosis (hazard ratio [HR], 1.24; 95% CI, 1.13-1.37; P < .001), with higher adjusted HRs in the subsequent 15 years (years 5-10: 1.50 [95% CI, 1.36-1.65; P < .001]; years 10-15: 1.59 [95% CI, 1.37-1.84; P < .001]; years 15-20: 1.47 [95% CI, 1.08-2.01; P = .02).In this cohort study, patients with prostate cancer who received radiotherapy were more likely to develop a second primary cancer than patients who did not receive radiotherapy, with increased risk over time. Although the incidence and risk of developing a second primary cancer were low, it is important to discuss the risk with patients during shared decision-making about prostate cancer treatment options.

    View details for DOI 10.1001/jamanetworkopen.2022.23025

    View details for PubMedID 35900763

  • Environmental Outcomes Associated With Transition From In-Person to a Virtual Oncology Conference During the COVID-19 Pandemic. JAMA oncology Lichter, K. E., Drew, T., Demeulenaere, S., Wong, E., Mohamad, O., Yom, S. S., Bagshaw, H. P. 2022

    View details for DOI 10.1001/jamaoncol.2022.1925

    View details for PubMedID 35737362

  • IMRT and SBRT Treatment Planning Study for the First Clinical Biology-Guided Radiotherapy System. Technology in cancer research & treatment Pham, D., Simiele, E., Breitkreutz, D., Capaldi, D., Han, B., Surucu, M., Oderinde, S., Vitzthum, L., Gensheimer, M., Bagshaw, H., Chin, A., Xing, L., Chang, D. T., Kovalchuk, N. 2022; 21: 15330338221100231


    Purpose: The first clinical biology-guided radiation therapy (BgRT) system-RefleXionTM X1-was installed and commissioned for clinical use at our institution. This study aimed at evaluating the treatment plan quality and delivery efficiency for IMRT/SBRT cases without PET guidance. Methods: A total of 42 patient plans across 6 cancer sites (conventionally fractionated lung, head, and neck, anus, prostate, brain, and lung SBRT) planned with the EclipseTM treatment planning system (TPS) and treated with either a TrueBeam or Trilogy were selected for this retrospective study. For each Eclipse VMAT plan, 2 corresponding plans were generated on the X1 TPS with 10mm jaws (X1-10mm) and 20mm jaws (X1-20mm) using our institutional planning constraints. All clinically relevant metrics in this study, including PTV D95%, PTV D2%, Conformity Index (CI), R50, organs-at-risk (OAR) constraints, and beam-on time were analyzed and compared between 126 VMAT and RefleXion plans using paired t-tests. Results: All but 3 planning metrics were either equivalent or superior for the X1-10mm plans as compared to the Eclipse VMAT plans across all planning sites investigated. The Eclipse VMAT and X1-10mm plans generally achieved superior plan quality and sharper dose fall-off superior/inferior to targets as compared to the X1-20mm plans, however, the X1-20mm plans were still considered acceptable for treatment. On average, the required beam-on time increased by a factor of 1.6 across all sites for X1-10mm compared to X1-20mm plans. Conclusions: Clinically acceptable IMRT/SBRT treatment plans were generated with the X1 TPS for both the 10mm and 20mm jaw settings.

    View details for DOI 10.1177/15330338221100231

    View details for PubMedID 35579876

  • Medical Scribe Impact on Provider Efficiency in Outpatient Radiation Oncology Clinics Before and During the COVID-19 Pandemic. Telemedicine reports Devine, M., Wang, E., von Eyben, R., Bagshaw, H. P. 2022; 3 (1): 1-6


    Purpose/Objectives: Medical documentation has become increasingly challenging for providers, particularly with changes to telemedicine visit formats during the ongoing COVID-19 pandemic. Medical scribes may help mitigate this burden. Our objective was to determine how scribes affect provider efficiency during the COVID-19 pandemic. Materials/Methods: Providers completed a survey in February 2020 (S1, prepandemic) and 1 year into the COVID-19 pandemic in February 2021 (S2, during pandemic). S1 evaluated perceived impact of scribes on clerical work, medical documentation, and efficiency during office visits using the Likert scale. S2 also addressed scribe use during telemedicine visits. Provider time spent on documentation with or without a scribe was evaluated using a five-level ordinal scale. Provider response was assessed using descriptive frequency statistics. Fisher's exact test was used to compare categorical variables. Analysis was performed using SAS version 9.4 (SAS Institute, Inc., Cary, NC). All tests were two sided with an alpha level of 0.05. Results: Fifty-eight providers responded to the surveys: 36 (62%) for S1 and 22 (38%) for S2. Scribe use decreased perceived clerical work and facilitated chart review, and recording of physical examination findings, note documentation, and improved efficiency, both before and during the pandemic (p=0.5, p=0.7, p=0.8, p=0.8, p=0.9, respectively). Scribe use significantly decreased time to complete documentation prepandemic (p=0.002) and during the pandemic for both in-person (p≤0.0001) and telemedicine visits (p=0.0004). More providers took >60min to complete medical documentation without the use of a scribe prepandemic (72% vs. 30% with a scribe, p=0.006) and during the pandemic, after both in-person (40% vs. 0% with a scribe, p=0.002) and telemedicine visits (35% vs. 0% with a scribe, p=0.002). Conclusions: Scribe use decreases provider time spent on medical documentation and improves overall efficiency before and during the COVID-19 pandemic for both in-person and telemedicine visits. Integration of scribes into radiation oncology in-person and telemedicine clinics may improve provider satisfaction by reducing burden of documentation.

    View details for DOI 10.1089/tmr.2021.0035

    View details for PubMedID 35720450

  • Syndrome of inappropriate secretion of antidiuretic hormone following high dose rate brachytherapy for prostate cancer: a case report. BMC urology Ayoola, A., Sodji, Q. H., Chin, S., Panousis, P., Bagshaw, H. P., Buyyounouski, M. K. 2022; 22 (1): 32


    The syndrome of inappropriate secretion of antidiuretic hormone is a disorder characterized by the excess release of antidiuretic hormone and can result in hyponatremia. If managed inappropriately, severe hyponatremia can cause seizures, cerebral edema, and even death. There are various known causes of this inappropriate release of antidiuretic hormone, including malignancy, CNS disorders, and disturbances in the hypothalamic-pituitary-renal axis. However, reports of syndrome of inappropriate secretion of antidiuretic hormone after brachytherapy for prostate cancer are exceedingly rare.We report a case of symptomatic hyponatremia secondary to the inappropriate secretion of antidiuretic hormone after prostate high-dose rate brachytherapy under general anesthesia in a patient with adenocarcinoma of the prostate.In rare instances, inappropriate secretion of antidiuretic hormone can occur after high-dose rate brachytherapy for prostate cancer. The cause is likely multifactorial, involving pain or discomfort ensuing from the surgical procedure, the general anesthesia or intraoperative drugs administered. However, due to the potential severity of the side effects, timely diagnosis is crucial to ensure prompt, and effective management.

    View details for DOI 10.1186/s12894-022-00984-y

    View details for PubMedID 35272646

  • A personalized decision aid for prostate cancer shared decision making. BMC medical informatics and decision making Bagshaw, H. P., Martinez, A., Heidari, N., Scheinker, D., Pollack, A., Stoyanova, R., Horwitz, E., Morton, G., Kishan, A. U., Buyyounouski, M. K. 1800; 21 (1): 374


    BACKGROUND: A shared decision-making model is preferred for engaging prostate cancer patients in treatment decisions. However, the process of assessing an individual's preferences and values is challenging and not formalized. The purpose of this study is to develop an automated decision aid for patient-centric treatment decision-making using decision analysis, preference thresholds and value elicitations to maximize the compatibility between a patient's treatment expectations and outcome.METHODS: A template for patient-centric medical decision-making was constructed. The inputs included prostate cancer risk group, pre-treatment health state, treatment alternatives (primarily focused on radiation in this model), side effects (erectile dysfunction, urinary incontinence, nocturia and bowel incontinence), and treatment success (5-year freedom from biochemical failure). A linear additive value function was used to combine the values for each attribute (side effects, success and the alternatives) into a value for all prospects. The patient-reported toxicity probabilities were derived from phase II and III trials. The probabilities are conditioned on the starting state for each of the side effects. Toxicity matrices for erectile dysfunction, urinary incontinence, nocturia and bowel incontinence were created for the treatment alternatives. Toxicity probability thresholds were obtained by identifying the patient's maximum acceptable threshold for each of the side effects. Results are represented as a visual. R and Rstudio were used to perform analyses, and R Shiny for application creation.RESULTS: We developed a web-based decision aid. Based on preliminary use of the application, every treatment alternative could be the best choice for a decision maker with a particular set of preferences. This result implies that no treatment has determinist dominance over the remaining treatments and that a preference-based approach can help patients through their decision-making process, potentially affecting compliance with treatment, tolerance of side effects and satisfaction with the decision.CONCLUSIONS: We present a unique patient-centric prostate cancer treatment decision aid that systematically assesses and incorporates a patient's preferences and values to rank treatment options by likelihood of achieving the preferred outcome. This application enables the practice and study of personalized medicine. This model can be expanded to include additional inputs, such as genomics, as well as competing, concurrent or sequential therapies.

    View details for DOI 10.1186/s12911-021-01732-2

    View details for PubMedID 34972513

  • An Expert Review on the Combination of Relugolix with Definitive Radiation Therapy for Prostate Cancer. International journal of radiation oncology, biology, physics Roy, S., Zaorsky, N. G., Bagshaw, H. P., Berlin, A., Koontz, B., Nguyen, P., Chen, R., Dess, R. T., Jackson, W. C., Kishan, A. U., Stish, B., Nagar, H., Posadas, E., Tran, P. T., Solanki, A., Shore, N. D., Guo, G., Ponsky, L., Shoag, J. E., Morgans, A. K., Garcia, J. A., Showalter, T. N., Feng, F. Y., Spratt, D. E. 1800


    Androgen deprivation therapy (ADT) is an integral component in the management of prostate cancer across multiple disease states. Traditionally, luteinizing hormone-releasing hormone (LHRH) agonists constituted the backbone of ADT. However, gonadotropin-releasing hormone receptor hormone (GnRH) antagonists are also available, which offer faster testosterone suppression and reduced likelihood of ADT-related adverse effects compared to LHRH agonists, including the potential for fewer ADT-associated major cardiac events. Until recently, all forms of LHRH agonists and GnRH antagonist formulations are of parenteral administration. However, recently relugolix gained FDA approval as the first oral GnRH antagonist. Relugolix achieves faster and more complete testosterone suppression compared to an LHRH agonist. This translates to more rapid prostate-specific antigen response compared to LHRH agonists. After discontinuation of relugolix, testosterone recovers faster than after GnRH agonists or injectable GnRH antagonist therapy. Overall, these factors provide opportunities for more precisely defined ADT duration when combined with radiation therapy. The rapid onset and offset testosterone suppression with relugolix, however, may require physicians to rethink the mechanism and goals of ADT when prescribing. As an oral formulation, relugolix enables patients to avoid pain and injection site reactions, limit extra office visits for injections, and achieve a shorter duration of experiencing the side effects of castrate testosterone levels. This convenience and tolerability may enhance physicians' willingness to prescribe ADT and patients' feeling of control over their ADT course, but the potential advantages are accompanied by the risks of patients choosing to discontinue therapy to escape side effects of ADT. This article focuses on different aspects of what is known and unknown regarding the optimal use of ADT and radiation therapy, and how relugolix, due to its properties, fit into our current treatment paradigms for localized prostate cancer.

    View details for DOI 10.1016/j.ijrobp.2021.12.005

    View details for PubMedID 34923058

  • Toxicity After Stereotactic Body Radiation Therapy for Prostate Cancer in Patients With Inflammatory Bowel Disease: A Multi-institutional Matched Case-Control Series. Advances in radiation oncology Juarez, J. E., Romero, T., Mantz, C. A., Pepin, A., Aghdam, N., Suy, S., Steinberg, M. L., Levin-Epstein, R. G., Nickols, N. G., Kaplan, I. D., Meier, R. M., Pham, H. T., Linson, P. W., Hong, R. L., Buyyounouski, M. K., Bagshaw, H. P., Fuller, D. B., Katz, A. J., Loblaw, A., Collins, S. P., Kishan, A. U. 2021; 6 (6): 100759


    Purpose: To evaluate the safety of stereotactic body radiation therapy (SBRT) for prostate cancer in men with inflammatory bowel disease (IBD).Methods and Materials: We queried a consortium database for patients with IBD receiving SBRT for prostate cancer between 2006 and 2012. Identified patients were matched with patients without a history of IBD in a 3:1 fashion based on dose, fractionation, use of androgen deprivation therapy, and age distribution. Logistic regression was used to evaluate the association between having IBD and experiencing acute and late gastrointestinal (GI) and genitourinary (GU) toxicities as scored on the Common Terminology Criteria for Adverse Events scale. Time to late toxicity was evaluated using proportional hazard Cox models. Our study was limited by absence of data on prostate size, baseline International Prostate Symptom Score, and rectal dose-volume histogram parameters.Results: Thirty-nine patients with flare-free IBD at time of treatment (median follow-up 83.9 months) and 117 matched controls (median follow-up 88.7 months) were identified. A diagnosis of IBD was associated with increased odds of developing any late grade GI toxicity (odds ratio [OR] 6.11, P <.001) and GU toxicity (odds ratio 6.14, P < .001), but not odds of developing late grade ≥2 GI (P=.08) or GU toxicity (P=.069). Acute GI and GU toxicity, both overall and for grade ≥2 toxicities, were more frequent in men with IBD (P < .05). Time to late GI and GU toxicity of any grade was significantly shorter in patients with IBD (P < .001). Time to late grade ≥2 GU, but not grade ≥2 GI toxicity, was also shorter in patients with IBD (P=.044 for GU and P=.144 for GI).Conclusions: Patients with IBD who received SBRT for PCa had a higher likelihood of developing acute GI and GU toxicity, in addition to experiencing lower grade late toxicities that occurred earlier. However, patients with IBD did not have a higher likelihood for late grade ≥2 GI or GU toxicity after SBRT compared with the control cohort. Interpretation of this data are limited by the small sample size. Thus, men with IBD in remission should be properly counseled about these risks when considering SBRT.

    View details for DOI 10.1016/j.adro.2021.100759

    View details for PubMedID 34585025

  • Automated Contour Propagation of the Prostate From pCT to CBCT Images via Deep Unsupervised Learning Liang, X., Bibault, J. E., Leroy, T., Escande, A., Zhao, W., Chen, Y., Buyyounouski, M. K., Hancock, S. L., Bagshaw, H. P., Xing, L. ELSEVIER SCIENCE INC. 2021: E95
  • Development and Validation of an Interpretable Artificial Intelligence Model to Predict 10-Year Prostate Cancer Mortality CANCERS Bibault, J., Hancock, S., Buyyounouski, M. K., Bagshaw, H., Leppert, J. T., Liao, J. C., Xing, L. 2021; 13 (12)


    Prostate cancer treatment strategies are guided by risk-stratification. This stratification can be difficult in some patients with known comorbidities. New models are needed to guide strategies and determine which patients are at risk of prostate cancer mortality. This article presents a gradient-boosting model to predict the risk of prostate cancer mortality within 10 years after a cancer diagnosis, and to provide an interpretable prediction. This work uses prospective data from the PLCO Cancer Screening and selected patients who were diagnosed with prostate cancer. During follow-up, 8776 patients were diagnosed with prostate cancer. The dataset was randomly split into a training (n = 7021) and testing (n = 1755) dataset. Accuracy was 0.98 (±0.01), and the area under the receiver operating characteristic was 0.80 (±0.04). This model can be used to support informed decision-making in prostate cancer treatment. AI interpretability provides a novel understanding of the predictions to the users.

    View details for DOI 10.3390/cancers13123064

    View details for Web of Science ID 000666025900001

    View details for PubMedID 34205398

  • MR to Ultrasound Image Registration with Segmentation-Based Learning for HDR Prostate Brachytherapy Chen, Y., Xing, L., Yu, L., Liu, W., Fahimian, B., Niedermayr, T., Bagshaw, H., Buyyounouski, M., Han, B. WILEY. 2021
  • PSMA- and GRPR-targeted PET: Results from 50 Patients with Biochemically Recurrent Prostate Cancer. Journal of nuclear medicine : official publication, Society of Nuclear Medicine Baratto, L., Song, H., Duan, H., Hatami, N., Bagshaw, H., Buyyounouski, M., Hancock, S., Shah, S. A., Srinivas, S., Swift, P., Moradi, F., Davidzon, G. A., Iagaru, A. 2021


    Rationale: Novel radiopharmaceuticals for positron emission tomography (PET) are evaluated for the diagnosis of biochemically recurrent prostate cancer (BCR PC). Here, we compare the gastrin releasing peptide receptors (GRPR) - targeting 68Ga-RM2 with the prostate specific membrane antigen (PSMA) - targeting 68Ga-PSMA11 and 18F-DCFPyL. Methods: Fifty patients had both 68Ga-RM2 PET/MRI and 68Ga-PSMA11 PET/CT (n = 23) or 18F-DCFPyL PET/CT (n = 27) at an interval ranging from 1 to 60 days (mean±SD: 15.8±17.7). Maximum standardized uptake values (SUVmax) were collected for all lesions. Results: RM2 PET was positive in 35 and negative in 15 of the 50 patients. PSMA PET was positive in 37 and negative in 13 of the 50 patients. Both scans detected 70 lesions in 32 patients. Forty-three lesions in 18 patients were identified only on one scan: 68Ga-RM2 detected 7 more lesions in 4 patients, while PSMA detected 36 more lesions in 13 patients. Conclusion: 68Ga-RM2 remains a valuable radiopharmaceutical even when compared with the more widely used 68Ga-PSMA11/18F-DCFPyL in the evaluation of BCR PC. Larger studies are needed to verify that identifying patients for whom these two classes of radiopharmaceuticals are complementary may ultimately allow for personalized medicine.

    View details for DOI 10.2967/jnumed.120.259630

    View details for PubMedID 33674398

  • Automated Contour Propagation of the Prostate From pCT to CBCT Images Via Deep Unsupervised Learning. Medical physics Liang, X., Bibault, J., Leroy, T., Escande, A., Zhao, W., Chen, Y., Buyyounouski, M. K., Hancock, S. L., Bagshaw, H., Xing, L. 2021


    PURPOSE: To develop and evaluate a deep unsupervised learning (DUL) framework based on a regional deformable model for automated prostate contour propagation from planning computed tomography (pCT) to cone-beam CT (CBCT).METHODS: We introduce a DUL model to map the prostate contour from pCT to on-treatment CBCT. The DUL framework used a regional deformable model via narrow band mapping to augment the conventional strategy. 251 anonymized CBCT images from prostate cancer patients were retrospectively selected and divided into three sets: 180 were used for training, 12 for validation, and 59 for testing. The testing dataset was divided into two Groups. Group one contained 50 CBCT volumes, with one physician-generated prostate contour on CBCT image. Group two contained 9 CBCT images, each including prostate contours delineated by four independent physicians and a consensus contour generated using the STAPLE method. Results were compared between the proposed DUL and physician-generated contours through the Dice similarity coefficients (DSC), the Hausdorff distances, and the distances of the center-of-mass.RESULTS: The average DSCs between DUL-based prostate contours and reference contours for test data in Group one and Group two-consensus were 0.83 ± 0.04, and 0.85 ± 0.04, respectively. Correspondingly, the mean center-of-mass distances were 3.52 mm ± 1.15 mm, and 2.98 mm ± 1.42 mm, respectively.CONCLUSIONS: This novel DUL technique can automatically propagate the contour of the prostate from pCT to CBCT. The proposed method shows that highly accurate contour propagation for CBCT-guided adaptive radiotherapy is achievable via the deep learning technique.

    View details for DOI 10.1002/mp.14755

    View details for PubMedID 33544390

  • MR to ultrasound image registration with segmentation-based learning for HDR prostate brachytherapy. Medical physics Chen, Y. n., Xing, L. n., Yu, L. n., Liu, W. n., Fahimian, B. P., Niedermayr, T. n., Bagshaw, H. P., Buyyounouski, M. n., Han, B. n. 2021


    Propagation of contours from high-quality magnetic resonance (MR) images to treatment planning ultrasound (US) images with severe needle artifacts is a challenging task, which can greatly aid the organ contouring in high dose rate (HDR) prostate brachytherapy. In this study, a deep learning approach was developed to automatize this registration procedure for HDR brachytherapy practice.Because of the lack of training labels and difficulty of accurate registration from inferior image quality, a new segmentation-based registration framework was proposed for this multi-modality image registration problem. The framework consisted of two segmentation networks and a deformable registration network, based on the weakly-supervised registration strategy. Specifically, two 3D V-Nets were trained for the prostate segmentation on the MR and US images separately, to generate the weak supervision labels for the registration network training. Besides the image pair, the corresponding prostate probability maps from the segmentation were further fed to the registration network to predict the deformation matrix, and an augmentation method was designed to randomly scale the input and label probability maps during the registration network training. The overlap between the deformed and fixed prostate contours was analyzed to evaluate the registration accuracy. Three datasets were collected from our institution for the MR and US image segmentation networks, and the registration network learning, which contained 121, 104 and 63 patient cases, respectively.The mean Dice similarity coefficient (DSC) results of the two prostate segmentation networks are 0.86±0.05 and 0.90±0.03, for MR images and the US images after the needle insertion, respectively. The mean DSC, center-of-mass (COM) distance, Hausdorff distance (HD) and averaged symmetric surface distance (ASSD) results for the registration of manual prostate contours were 0.87±0.05, 1.70±0.89 mm, 7.21±2.07 mm, 1.61±0.64 mm, respectively. By providing the prostate probability map from the segmentation to the registration network, as well as applying the random map augmentation method, the evaluation results of the four metrics were all improved, such as an increase of DSC from 0.83±0.08 to 0.86±0.06 and from 0.86±0.06 to 0.87±0.05, respectively.A novel segmentation-based registration framework was proposed to automatically register prostate MR images to the treatment planning US images with metal artifacts, which not only largely saved the labor work on the data preparation, but also improved the registration accuracy. The evaluation results showed the potential of this approach in HDR prostate brachytherapy practice.

    View details for DOI 10.1002/mp.14901

    View details for PubMedID 33905566

  • Refining the Definition of Biochemical Failure in the Era of Stereotactic Body Radiation Therapy for Prostate Cancer: the Phoenix Definition and Beyond. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology Martin Ma, T., Roy, S., Wu, X., Mantz, C., Fuller, D., Miszczyk, L., Napieralska, A., Namysł-Kaletka, A., Bagshaw, H. P., Buyyounouski, M. K., Glicksman, R., Andrew Loblaw, D., Katz, A., Upadhyaya, S. K., Nickols, N., Steinberg, M. L., Philipson, R., Aghdam, N., Suy, S., Pepin, A., Collins, S. P., Boutros, P., Rettig, M. B., Calais, J., Wang, M., Zaorsky, N., Kishan, A. U. 2021


    The Phoenix definition for biochemical failure (BCF) after radiotherapy uses nadir PSA (nPSA)+2ng/mL to classify a BCF and was derived from conventionally fractionated radiotherapy, which produces significantly higher nPSAs than stereotactic body radiotherapy (SBRT). We investigated whether an alternative nPSA-based threshold could be used to define post-SBRT BCFs.PSA kinetics data on 2038 patients from 9 institutions were retrospectively analyzed for low- and intermediate-risk PCa patients treated with SBRT without ADT. We evaluated the performance of various nPSA-based definitions. We also investigated the relationship of relative PSA decline (rPSA, PSA18month/PSA6month) and timing of reaching nPSA+2 with BCF.Median follow-up was 71.9 months. BCF occurred in 6.9% of patients. Median nPSA was 0.16ng/mL. False positivity of nPSA+2 was 30.2%, compared to 40.9%, 57.8%, and 71.0% for nPSA+1.5, nPSA+1.0, and nPSA+0.5, respectively. Among patients with BCF, the median lead time gained from an earlier nPSA+threshold definition over the Phoenix definition was minimal. Patients with BCF had significantly lower rates of early PSA decline (mean rPSA 1.19 vs. 0.39, p<0.0001) and were significantly more likely to reach nPSA+2 ≥18 months (83.3% vs. 21.1%, p<0.0001). The proposed criterion (rPSA≥2.6 or nPSA+2≥18 months) had a sensitivity and specificity of 92.4% and 81.5%, respectively, for predicting BCF in patients meeting the Phoenix definition and decreased its false positivity to 6.4%.The Phoenix definition remains an excellent definition for BCF post-SBRT. Its high false positivity can be mitigated by applying additional criteria (rPSA≥2.6 or time to nPSA+2≥18 months).

    View details for DOI 10.1016/j.radonc.2021.11.005

    View details for PubMedID 34774650

  • Dose-Response with Stereotactic Body Radiotherapy for Prostate Cancer: A Multi-Institutional Analysis of Prostate-Specific Antigen Kinetics and Biochemical Control. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology Levin-Epstein, R. G., Jiang, N. Y., Wang, X., Upadhyaya, S. K., Collins, S. P., Suy, S., Aghdam, N., Mantz, C., Katz, A. J., Miszczyk, L., Napieralska, A., Namysl-Kaletka, A., Prionas, N., Bagshaw, H., Buyyounouski, M. K., Cao, M., Agazaryan, N., Dang, A., Yuan, Y., Kupelian, P. A., Zaorsky, N. G., Spratt, D. E., Mohamad, O., Feng, F. Y., Mahal, B. A., Boutros, P. C., Kishan, A. U., Juarez, J., Shabsovich, D., Jiang, T., Kahlon, S., Patel, A., Patel, J., Nickols, N. G., Steinberg, M. L., Fuller, D. B., Kishan, A. U. 2020


    BACKGROUND AND PURPOSE: The optimal dose for prostate stereotactic body radiotherapy (SBRT) is still unknown. This study evaluated the dose-response relationships for prostate-specific antigen (PSA) decay and biochemical recurrence (BCR) among 4 SBRT dose regimens.MATERIALS AND METHODS: In 1,908 men with low-risk (50.0%), favorable intermediate-risk (30.9%), and unfavorable intermediate-risk (19.1%) prostate cancer treated with prostate SBRT across 8 institutions from 2003-2018, we examined 4 regimens (35 Gy/5 fractions [35/5, n=265, 13.4%], 36.25 Gy/5 fractions [36.25/5, n=711, 37.3%], 40 Gy/5 fractions [40/5, n=684, 35.8%], and 38 Gy/4 fractions [38/4, n=257, 13.5%]). Between dose groups, we compared PSA decay slope, nadir PSA (nPSA), achievement of nPSA ≤0.2 and ≤0.5 ng/mL, and BCR-free survival (BCRFS).RESULTS: Median follow-up was 72.3 months. Median nPSA was 0.01 ng/mL for 38/4, and 0.17-0.20 ng/mL for 5-fraction regimens (p<0.0001). The 38/4 cohort demonstrated the steepest PSA decay slope and greater odds of nPSA ≤0.2 ng/mL (both p<0.0001 vs. all other regimens). BCR occurred in 6.25%, 6.75%, 3.95%, and 8.95% of men treated with 35/5, 36.25/5, 40/5, and 38/4, respectively (p=0.12), with the highest BCRFS after 40/5 (vs. 35/5 hazard ratio [HR] 0.49, p=0.026; vs. 36.25/5 HR 0.42, p=0.0005; vs. 38/4 HR 0.55, p=0.037) including the entirety of follow-up, but not for 5-year BCRFS (≥93% for all regimens, p≥0.21).CONCLUSION: Dose-escalation was associated with greater prostate ablation and PSA decay. Dose-escalation to 40/5, but not beyond, was associated with improved BCRFS. Biochemical control remains excellent, and prospective studies will provide clarity on the benefit of dose-escalation.

    View details for DOI 10.1016/j.radonc.2020.09.053

    View details for PubMedID 33035622

  • Prostate-specific antigen kinetics and biochemical control following stereotactic body radiation therapy, high dose rate brachytherapy, and low dose rate brachytherapy: A multi-institutional analysis of 3,502 patients. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology Levin-Epstein, R., Cook, R. R., Wong, J. K., Stock, R. G., Jeffrey Demanes, D., Collins, S. P., Aghdam, N., Suy, S., Mantz, C., Katz, A. J., Nickols, N. G., Miszczyk, L., Napieralska, A., Namysl-Kaletka, A., Prionas, N. D., Bagshaw, H., Buyyounouski, M. K., Cao, M., Mahal, B. A., Shabsovich, D., Dang, A., Yuan, Y., Rettig, M. B., Chang, A. J., Jackson, W. C., Spratt, D. E., Lehrer, E., Zaorsky, N. G., Kupelian, P. A., Steinberg, M. L., Horwitz, E. M., Jiang, N. Y., Kishan, A. U. 2020


    BACKGROUND AND PURPOSE: Stereotactic body radiation therapy (SBRT), low dose rate brachytherapy (LDR-BT) and high dose rate brachytherapy (HDR-BT) are ablative-intent radiotherapy options for prostate cancer (PCa). These vary considerably in dose delivery, which may impact post-treatment prostate-specific antigen (PSA) patterns and biochemical control. We compared PSA kinetics between SBRT, HDR-BT, and LDR-BT, and assessed their relationships to biochemical recurrence-free survival (BCRFS).METHODS AND MATERIALS: Retrospective PSA data were analyzed for 3,502 men with low-risk (n=2223; 63.5%), favorable intermediate-risk (n=869; 24.8%), and unfavorable intermediate-risk (n=410; 11.7%) PCa treated with SBRT (n=1716; 49.0%), HDR-BT (n=512; 14.6%), or LDR-BT (n=1274; 36.4%) without upfront androgen deprivation therapy at 10 institutions from 1990-2017. We compared nadir PSA (nPSA), time to nPSA, achievement of nPSA <0.2 ng/mL and <0.5 ng/mL, rates of nPSA <0.4 ng/mL at 4 years, and BCRFS.RESULTS: Median follow-up was 72 months. Median nPSA and nPSA <0.2 ng/mL were stratified by risk group (interaction p≤0.001). Median nPSA and time to nPSA were 0.2 ng/mL at 44 months after SBRT, 0.1-0.2 ng/mL at 37 months after HDR-BT, and 0.01-0.2 ng/mL at 51 months after LDR-BT (mean log nPSA p≤0.009 for LDR-BT vs. SBRT or HDR-BT for low/favorable intermediate-risk). There were no differences in nPSA <0.4 ng/mL at 4 years (p≥0.51). BCRFS was similar for all three modalities (p≥0.27). Continued PSA decay beyond 4 years was predictive of durable biochemical control.CONCLUSION: LDR-BT led to lower nPSAs with longer continued decay compared to SBRT and HDR-BT, but no differences in BCRFS.

    View details for DOI 10.1016/j.radonc.2020.07.014

    View details for PubMedID 32663537

  • Continuing Medical Student Education During the Coronavirus Disease 2019 (COVID-19) Pandemic: Development of a Virtual Radiation Oncology Clerkship. Advances in radiation oncology Pollom, E. L., Sandhu, N., Frank, J., Miller, J. A., Obeid, J., Kastelowitz, N., Panjwani, N., Soltys, S. G., Bagshaw, H. P., Donaldson, S. S., Horst, K., Beadle, B. M., Chang, D. T., Gibbs, I. 2020; 5 (4): 732–36


    Purpose: Our institution cancelled all in-person clerkships owing to the coronavirus disease 2019 pandemic. In response, we designed a virtual radiation oncology medical student clerkship.Methods and Materials: We convened an advisory panel to design a virtual clerkship curriculum. We implemented clerkship activities using a cloud-based learning management system, video web conferencing systems, and a telemedicine portal. Students completed assessments pre- and postclerkship to provide data to improve future versions of the clerkship.Results: The virtual clerkship spans 2 weeks and is graded pass or fail. Students attend interactive didactic sessions during the first week and participate in virtual clinic and give talks to the department during the second week. Didactic sessions include lectures, case-based discussions, treatment planning seminars, and material adapted from the Radiation Oncology Education Collaborative Study Group curriculum. Students also attend virtual departmental quality assurance rounds, cancer center seminars, and multidisciplinary tumor boards. The enrollment cap was met during the first virtual clerkship period (April 27 through May 8, 2020), with a total of 12 students enrolling.Conclusions: Our virtual clerkship can increase student exposure and engagement in radiation oncology. Data on clerkship outcomes are forthcoming.

    View details for DOI 10.1016/j.adro.2020.05.006

    View details for PubMedID 32775783

  • Deep learning applications in automatic needle segmentation in ultrasound-guided prostate brachytherapy. Medical physics Wang, F., Xing, L., Bagshaw, H., Buyyounouski, M., Han, B. 2020


    PURPOSE: High-Dose-Rate (HDR) brachytherapy is one of the most effective ways to treat the prostate cancer, which is the second most common cancer in men worldwide. This treatment delivers highly conformal dose through the transperineal needle implants and is guided by a real time ultrasound (US) imaging system. Currently, the brachytherapy needles in the US images are manually segmented by physicists during the treatment, which is time-consuming and error-prone. In this study, we propose a set of deep learning based algorithms to accurately segment the brachytherapy needles and locate the needle tips from the US images.METHODS: Two deep neural networks are developed to address this problem. First, a modified deep U-Net is used to segment the pixels belonging to the brachytherapy needles from the US images. Second, an additional VGG-16 based deep convolutional network is combined with the segmentation network to predict the locations of the needle tips. The networks are trained and evaluated on a clinical US images dataset with labeled needle trajectories collected in our hospital (Institutional Review Board approval (IRB 41755)).RESULTS: The evaluation results show that our method can accurately extract the trajectories of the needles with a resolution of 0.668 mm and 0.319 mm in x and y direction respectively. 95.4% of the x direction and 99.2% of the y direction have error ≤ 2 mm. Moreover, The position resolutions of the tips are 0.721 mm, 0.369 mm and 1.877 mm in x, y and z directions respectively, while 94.2%, 98.3% and 67.5% of the data have error ≤ 2 mm.CONCLUSIONS: This paper proposed a neural network based algorithm to segment the brachytherapy needles from the US images and locate the needle tip. It can be used in the HDR brachytherapy to help improve the efficiency and quality of the treatments.

    View details for DOI 10.1002/mp.14328

    View details for PubMedID 32542758

  • A Deep Learning Framework for Prostate Localization in Cone Beam CT Guided Radiotherapy. Medical physics Liang, X. n., Zhao, W. n., Hristov, D. H., Buyyounouski, M. K., Hancock, S. L., Bagshaw, H. n., Zhang, Q. n., Xie, Y. n., Xing, L. n. 2020


    To develop a deep learning-based model for prostate planning target volume (PTV) localization on cone-beam CT (CBCT) to improve the workflow of CBCT-guided patient setup.A two-step task-based residual network (T2 RN) is proposed to automatically identify inherent landmarks in prostate PTV. The input to the T2 RN is the pre-treatment CBCT images of the patient, and the output is the deep learning-identified landmarks in the PTV. To ensure robust PTV localization, the T2 RN model is trained by using over thousand sets of CT images with labeled landmarks, each of the CTs corresponds to a different scenario of patient position and/or anatomy distribution generated by synthetically changing the planning CT (pCT) image. The changes, including translation, rotation, and deformation, represent vast possible clinical situations of anatomy variations during a course of radiation therapy (RT). The trained patient-specific T2 RN model is tested by using 240 CBCTs from six patients. The testing CBCTs consists of 120 original CBCTs and 120 synthetic CBCTs. The synthetic CBCTs are generated by applying rotation/translation transformations to each of the original CBCT.The systematic/random setup errors between the model prediction and the reference are found to be less than 0.25/2.46 mm and 0.14/1.41° in translation and rotation dimensions, respectively. Pearson's correlation coefficient between model prediction and the reference is higher than 0.94 in translation and rotation dimensions. The Bland-Altman plots show good agreement between the two techniques.A novel T2 RN deep learning technique is established to localize the prostate PTV for RT patient setup. Our results show that highly accurate marker-less prostate setup is achievable by leveraging the state-of-the-art deep learning strategy.

    View details for DOI 10.1002/mp.14355

    View details for PubMedID 32583418

  • Executive Summary of the American Radium Society Appropriate Use Criteria for Radiation Treatment of Node-Negative Muscle Invasive Bladder Cancer. International journal of radiation oncology, biology, physics Dinh, T. T., Mitin, T. n., Bagshaw, H. P., Hoffman, K. E., Hwang, C. n., Karnes, R. J., Kishan, A. U., Liauw, S. L., Lloyd, S. n., Potters, L. n., Showalter, T. N., Taira, A. V., Vapiwala, N. n., Zaorsky, N. G., D'Amico, A. V., Nguyen, P. L., Davis, B. J. 2020


    /Objectives:Definitive radiotherapy (RT), with or without concurrent chemotherapy, is an alternative to radical cystectomy for patients with localized, muscle-invasive bladder cancer (MIBC) who are either not surgical candidates or prefer organ preservation. We aim to synthesize an evidence-based guideline regarding the appropriate use of RT.We performed a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) literature review using the PubMed and Embase databases. Based upon the literature review, critical management topics were identified and reformulated into consensus questions. An expert panel was assembled to address key areas of both consensus and controversy using the modified Delphi framework.A total of 761 articles were screened, of which 61 were published between 1975 to 2019 and included for full review. There were seven well-designed studies, 20 good quality studies, 28 quality studies with design limitations, and six references not suited as primary evidence. Adjuvant radiotherapy after cystectomy was not included due to lack of high-quality data or clinical utilization. An expert panel consisting of 14 radiation oncologists, one medical oncologist, and one urologist was assembled. We identified four clinical variants of MIBC: surgically fit patients who wish to pursue organ preservation, patients surgically unfit for cystectomy, patients medically unfit for cisplatin-based chemotherapy, and borderline cystectomy candidates based on age with unilateral hydronephrosis and normal renal function. We identified key areas of controversy, including use of definitive radiotherapy for patients with negative prognostic factors, appropriate radiotherapy dose, fractionation, fields and technique when used, and chemotherapy sequencing and choice of agent.There is limited level-one evidence to guide appropriate treatment of MIBC. Studies vary significantly with regards to patient selection, chemotherapy utilization, and radiotherapy technique. A consensus guideline on the appropriateness of RT for MIBC may aid practicing oncologists in bridging the gap between data and clinical practice.

    View details for DOI 10.1016/j.ijrobp.2020.10.031

    View details for PubMedID 33127490

  • Virtual Radiation Oncology Clerkship During the COVID-19 Pandemic and Beyond. International journal of radiation oncology, biology, physics Sandhu, N., Frank, J., von Eyben, R., Miller, J., Obeid, J., Kastelowitz, N., Panjwani, N., Soltys, S., Bagshaw, H. P., Donaldson, S. S., Horst, K., Beadle, B. M., Chang, D. T., Gibbs, I. C., Pollom, E. 2020; 108 (2): 444–51


    PURPOSE: We evaluated the impact of a virtual radiation oncology clerkship.METHODS AND MATERIALS: We developed a 2-week virtual radiation oncology clerkship that launched on April 27, 2020. Clerkship components included a virtual clinic with radiation oncology faculty and residents, didactic lectures, student talks, and supplemental sessions such as tumor boards and chart rounds. Medical students completed pre- and post-clerkship self-assessments. Faculty and resident participants also completed surveys on their experience with virtual lectures and clinics. Pre- and post-clerkship results were compared using a 2-sided paired t test. An analysis of variance model was used to analyze the clerkship components.RESULTS: Twenty-six medical students, including 4 visiting students, enrolled over 2 clerkship periods (4 weeks). All students completed the pre- and post-clerkship self-assessments and agreed that the clerkship improved their understanding of radiation oncology. Compared with 3 (11.5%) students who agreed that they understood the daily responsibilities of a radiation oncologist before the clerkship, 22 (84.6%) students agreed and 3 (11.5%) strongly agreed that they understood the daily responsibilities of a radiation oncologist after the clerkship (P < .0001). Although 15 students (57.7%) reported an increased interest in radiation oncology because of the clerkship, the mean level of interest in radiation oncology as a career remained the same, with pre- and post-clerkship scores of 3.0 (±0.9) and 3.0 (±1.1) on a 5-point scale, respectively (P = .7). Students found virtual clinic and didactic lectures to be the most valuable components of the clerkship. Most respondents agreed (30.8%) or strongly agreed (65.4%) to recommend the clerkship to their classmates.CONCLUSIONS: Our virtual clerkship was effective in increasing medical student interest in and knowledge about radiation oncology. These data will help optimize a new paradigm of virtual radiation oncology education for medical students during COVID-19 and beyond.

    View details for DOI 10.1016/j.ijrobp.2020.06.050

    View details for PubMedID 32890529

  • Automatic intraprostatic lesion segmentation in multiparametric magnetic resonance images with proposed multiple branch Unet. Medical physics Chen, Y. n., Xing, L. n., Yu, L. n., Bagshaw, H. P., Buyyounouski, M. K., Han, B. n. 2020


    Contouring intraprostatic lesions is a prerequisite for dose-escalating these lesions in radiotherapy to improve the local cancer control. In this study, a deep learning-based approach was developed for automatic intraprostatic lesion segmentation in multiparametric magnetic resonance imaging (mpMRI) images contributing to the clinical practice.mpMRI images from 136 patient cases were collected from our institution, and all these cases contained suspicious lesions with Prostate Imaging Reporting and Data System (PI-RADS) score ≥ 4. The contours of the lesion and prostate were manually created on axial T2-weighted (T2W), apparent diffusion coefficient (ADC) and high b-value diffusion-weighted imaging (DWI) images to provide the ground truth data. Then a multiple branch UNet (MB-UNet) was proposed for the segmentation of indistinct target in multi-modality MRI images. An encoder module was designed with three branches for the three MRI modalities separately, to fully extract the high-level features provided by different MRI modalities; an input module was added by using three sub-branches for three consecutive image slices, to consider the contour consistency among different image slices; deep supervision strategy was also integrated into the network to speed up the convergency of the network and improve the performance. The probability maps of the background, normal prostate and lesion were output by the network to generate the segmentation of the lesion, and the performance was evaluated using the Dice similarity coefficient (DSC) as the main metric.A total of 162 lesions were contoured on 652 image slices, with 119 lesions in the peripheral zone, 38 in the transition zone, 4 in the central zone and 1 in the anterior fibromuscular stroma. All prostates were also contoured on 1,264 image slices. As for the segmentation of lesions in the testing set, MB-UNet achieved a per case DSC of 0.6333, specificity of 0.9993, sensitivity of 0.7056; and global DSC of 0.7205, specificity of 0.9993, sensitivity of 0.7409. All the three deep learning strategies adopted in this study contributed to the performance promotion of the MB-UNet. And missing the DWI modality would degrade the segmentation performance more markedly compared with the other two modalities.A deep learning-based approach with proposed MB-UNet was developed to automatically segment suspicious lesions in mpMRI images. This study makes it feasible to adopt boosting intraprostatic lesions in clinical practice to achieve better outcomes.

    View details for DOI 10.1002/mp.14517

    View details for PubMedID 33012016

  • Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease. Global spine journal Azad, T. D., Varshneya, K., Herrick, D. B., Pendharkar, A. V., Ho, A. L., Stienen, M., Zygourakis, C., Bagshaw, H. P., Veeravagu, A., Ratliff, J. K., Desai, A. 2019: 2192568219889363


    This was an epidemiological study using national administrative data from the MarketScan database.To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease.We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into "Early RT" if they received RT within 4 weeks of surgery and as "Late RT" if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes.A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications (P = .574).When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.

    View details for DOI 10.1177/2192568219889363

    View details for PubMedID 32875859

  • Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease GLOBAL SPINE JOURNAL Azad, T. D., Varshneya, K., Herrick, D. B., Pendharkar, A., Ho, A. L., Stienen, M., Zygourakis, C., Bagshaw, H. P., Veeravagu, A., Ratliff, J. K., Desai, A. 2019
  • Incorporating imaging information from deep neural network layers into image guided radiation therapy (IGRT). Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology Zhao, W., Han, B., Yang, Y., Buyyounouski, M., Hancock, S. L., Bagshaw, H., Xing, L. 2019; 140: 167–74


    BACKGROUND AND PURPOSE: To investigate a novel markerless prostate localization strategy using a pre-trained deep learning model to interpret routine projection kilovoltage (kV) X-ray images in image-guided radiation therapy (IGRT).MATERIALS AND METHODS: We developed a personalized region-based convolutional neural network to localize the prostate treatment target without implanted fiducials. To train the deep neural network (DNN), we used the patient's planning computed tomography (pCT) images with pre-delineated prostate target to generate a large amount of synthetic kV projection X-ray images in the geometry of onboard imager (OBI) system. The DNN model was evaluated by retrospectively studying 10 patients who underwent prostate IGRT. Three out of the ten patients who had implanted fiducials and the fiducials' positions in the OBI images acquired for treatment setup were examined to show the potential of the proposed method for prostate IGRT. Statistical analysis using Lin's concordance correlation coefficient was calculated to assess the results along with the difference between the digitally reconstructed radiographs (DRR) derived and DNN predicted locations of the prostate.RESULTS: Differences between the predicted target positions using DNN and their actual positions are (mean ± standard deviation) 1.58 ± 0.43 mm, 1.64 ± 0.43 mm, and 1.67 ± 0.36 mm in anterior-posterior, lateral, and oblique directions, respectively. Prostate position identified on the OBI kV images is also found to be consistent with that derived from the implanted fiducials.CONCLUSIONS: Highly accurate, markerless prostate localization based on deep learning is achievable. The proposed method is useful for daily patient positioning and real-time target tracking during prostate radiotherapy.

    View details for DOI 10.1016/j.radonc.2019.06.027

    View details for PubMedID 31302347

  • Multi-institutional Analysis of Prostate-Specific Antigen Kinetics Following Stereotactic Body Radiotherapy (SBRT). International journal of radiation oncology, biology, physics Jiang, N. Y., Dang, A. T., Yuan, Y., Chu, F., Shabsovich, D., King, C. R., Collins, S. P., Aghdam, N., Suy, S., Mantz, C. A., Miszczyk, L., Napieralska, A., Namysl-Kaletka, A., Bagshaw, H., Prionas, N., Buyyounouski, M. K., Jackson, W. C., Spratt, D. E., Nickols, N. G., Steinberg, M. L., Kupelian, P. A., Kishan, A. U. 2019


    PURPOSE: Understanding prostate-specific antigen (PSA) kinetics after radiotherapy plays a large role in the management of prostate cancer (PCa) patients. This is particularly true regarding establishing expectations regarding PSA nadir (nPSA) and PSA bounces, which can be disconcerting. As increasingly more patients are being treated with stereotactic body radiotherapy (SBRT) for low- and intermediate-risk PCa, it is imperative to understand the PSA response to SBRT.METHODS&MATERIALS: PSA data from five institutions were retrospectively analyzed for localized PCa patients treated definitively with SBRT alone from 2004 to 2016. Patients received 35-40 Gy in five fractions per institutional standards. Patients who had less than 12 months of PSA data or received androgen deprivation therapy were excluded from this study. Linear and logistic multivariable analysis were performed to identify predictors of nPSA, bounce, and biochemical recurrence, and joint latent class models (JLCM) were developed to identify significant predictors of time to biochemical failure.RESULTS: 1062 patients were included in this study. Median follow-up was 66 months (interquartile range (IQR) 36.4 - 89.9 months). Biochemical failure per the Phoenix criteria occurred in 4% of patients. Median nPSA was 0.2 ng/ml, median time to nPSA was 40 months, 84% of patients had a nPSA <0.5 ng/ml, and 54% of patients had a nPSA <0.2 ng/ml. On multivariable analysis, nPSA was a significant predictor of biochemical failure. Benign PSA bounce was noted in 26% of patients. The median magnitude of PSA bounce was 0.52 ng/ml (IQR 0.3 - 1.0 ng/ml). Median time to PSA bounce was 18.1 months (IQR 12.0 - 31.1 months). On multivariable analysis, age and radiation dose were significantly associated with a lower incidence of bounce. JLCM modeling found that nPSA and radiation dose were significantly associated with longer time to biochemical failure.CONCLUSIONS: In this multi-institutional cohort of patients with long-term follow-up, we found that SBRT led to low nPSAs. In turn, lower nPSAs are associated with reduced incidence of, and longer time to, biochemical failure. Benign PSA bounces occurred in a quarter of patients, as late as several years after treatment. Further studies are needed to directly compare the PSA response of patients who receive SBRT versus other treatment modalities.

    View details for DOI 10.1016/j.ijrobp.2019.06.2539

    View details for PubMedID 31276777

  • Evaluating Prostate-Specific Antigen (PSA) Nadir and Bounce After Stereotactic Body Radiotherapy (SBRT) in a Multi-Institutional Cohort Jiang, N., Dang, A., Yuan, Y., Chu, F., King, C., Collins, S., Aghdam, N., Suy, S., Miszczyk, L., Mantz, C., Bagshaw, H., Buyyounouski, M., Steinberg, M., Kupelian, P., Kishan, A. ELSEVIER SCIENCE INC. 2019: E17
  • Long-term Outcomes of Stereotactic Body Radiotherapy for Low-Risk and Intermediate-Risk Prostate Cancer JAMA NETWORK OPEN Kishan, A. U., Dang, A., Katz, A. J., Mantz, C. A., Collins, S. P., Aghdam, N., Chu, F., Kaplan, I. D., Appelbaum, L., Fuller, D. B., Meier, R. M., Loblaw, D., Cheung, P., Pham, H. T., Shaverdian, N., Jiang, N., Yuan, Y., Bagshaw, H., Prionas, N., Buyyounouski, M. K., Spratt, D. E., Linson, P. W., Hong, R. L., Nickols, N. G., Steinberg, M. L., Kupelian, P. A., King, C. R. 2019; 2 (2)
  • Long-term Outcomes of Stereotactic Body Radiotherapy for Low-Risk and Intermediate-Risk Prostate Cancer. JAMA network open Kishan, A. U., Dang, A., Katz, A. J., Mantz, C. A., Collins, S. P., Aghdam, N., Chu, F., Kaplan, I. D., Appelbaum, L., Fuller, D. B., Meier, R. M., Loblaw, D. A., Cheung, P., Pham, H. T., Shaverdian, N., Jiang, N., Yuan, Y., Bagshaw, H., Prionas, N., Buyyounouski, M. K., Spratt, D. E., Linson, P. W., Hong, R. L., Nickols, N. G., Steinberg, M. L., Kupelian, P. A., King, C. R. 2019; 2 (2): e188006


    Importance: Stereotactic body radiotherapy harnesses improvements in technology to allow the completion of a course of external beam radiotherapy treatment for prostate cancer in the span of 4 to 5 treatment sessions. Although mounting short-term data support this approach, long-term outcomes have been sparsely reported.Objective: To assess long-term outcomes after stereotactic body radiotherapy for low-risk and intermediate-risk prostate cancer.Design, Setting, and Participants: This cohort study analyzed individual patient data from 2142 men enrolled in 10 single-institution phase 2 trials and 2 multi-institutional phase 2 trials of stereotactic body radiotherapy for low-risk and intermediate-risk prostate cancer between January 1, 2000, and December 31, 2012. Statistical analysis was performed based on follow-up from January 1, 2013, to May 1, 2018.Main Outcomes and Measures: The cumulative incidence of biochemical recurrence was estimated using a competing risk framework. Physician-scored genitourinary and gastrointestinal toxic event outcomes were defined per each individual study, generally by Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events scoring systems. After central review, cumulative incidences of late grade 3 or higher toxic events were estimated using a Kaplan-Meier method.Results: A total of 2142 men (mean [SD] age, 67.9 [9.5] years) were eligible for analysis, of whom 1185 (55.3%) had low-risk disease, 692 (32.3%) had favorable intermediate-risk disease, and 265 (12.4%) had unfavorable intermediate-risk disease. The median follow-up period was 6.9 years (interquartile range, 4.9-8.1 years). Seven-year cumulative rates of biochemical recurrence were 4.5% (95% CI, 3.2%-5.8%) for low-risk disease, 8.6% (95% CI, 6.2%-11.0%) for favorable intermediate-risk disease, 14.9% (95% CI, 9.5%-20.2%) for unfavorable intermediate-risk disease, and 10.2% (95% CI, 8.0%-12.5%) for all intermediate-risk disease. The crude incidence of acute grade 3 or higher genitourinary toxic events was 0.60% (n=13) and of gastrointestinal toxic events was 0.09% (n=2), and the 7-year cumulative incidence of late grade 3 or higher genitourinary toxic events was 2.4% (95% CI, 1.8%-3.2%) and of late grade 3 or higher gastrointestinal toxic events was 0.4% (95% CI, 0.2%-0.8%).Conclusions and Relevance: In this study, stereotactic body radiotherapy for low-risk and intermediate-risk disease was associated with low rates of severe toxic events and high rates of biochemical control. These data suggest that stereotactic body radiotherapy is an appropriate definitive treatment modality for low-risk and intermediate-risk prostate cancer.

    View details for PubMedID 30735235

  • Long-term outcomes of stereotactic body radiotherapy for low- and intermediate-risk prostate adenocarcinoma: A multi-institutional consortium study. Kishan, A., Katz, A. J., Mantz, C., Chu, F., Appelbaum, L., Loblaw, A., Cheung, P., Kaplan, I. D., Fuller, D. B., Pham, H. T., Meier, R., Buyyounouski, M. K., Shaverdian, N., Dang, A., Yuan, Y., Bagshaw, H., Prionas, N., Kupelian, P., Steinberg, M. L., King, C. R. AMER SOC CLINICAL ONCOLOGY. 2018
  • Sinoatrial node dysfunction after stereotactic ablative radiation therapy in the chest Qian, Y., Dudley, S., Kumar, K., Chaudhuri, A., Chin, A., Harris, J., Prionas, N., Nwachukwu, C., Bagshaw, H., Pollom, E. L., Ben Durkee, Shultz, D., Gensheimer, M. F., Diehn, M., Loo, B. W. AMER SOC CLINICAL ONCOLOGY. 2017
  • Adjuvant radiotherapy for atypical meningiomas. Journal of neurosurgery Bagshaw, H. P., Burt, L. M., Jensen, R. L., Suneja, G., Palmer, C. A., Couldwell, W. T., Shrieve, D. C. 2016: 1-7


    OBJECTIVE The aim of this paper was to evaluate outcomes in patients with atypical meningiomas (AMs) treated with surgery alone compared with surgery and radiotherapy at initial diagnosis, or at the time of first recurrence. METHODS Patients with pathologically confirmed AMs treated at the University of Utah from 1991 to 2014 were retrospectively reviewed. Local control (LC), overall survival (OS), Karnofsky Performance Status (KPS), and toxicity were assessed. Outcomes for patients receiving adjuvant radiotherapy were compared with those for patients treated with surgery alone. Kaplan-Meier and the log-rank test for significance were used for LC and OS analyses. RESULTS Fifty-nine patients with 63 tumors were reviewed. Fifty-two patients were alive at the time of analysis with a median follow-up of 42 months. LC for all tumors was 57% with a median time to local failure (TTLF) of 48 months. The median TTLF following surgery and radiotherapy was 180 months, compared with 46 months following surgery alone (p = 0.02). Excluding Simpson Grade IV (subtotal) resections, there remained an LC benefit with the addition of radiotherapy for Simpson Grade I, II, and III resected tumors (median TTLF 180 months after surgery and radiotherapy compared with 46 months with surgery alone [p = 0.002]). Patients treated at first recurrence following any initial therapy (either surgery alone or surgery and adjuvant radiotherapy) had a median TTLF of 26 months compared with 48 months for tumors treated at first diagnosis (p = 0.007). There were 2 Grade 3 toxicities and 1 Grade 4 toxicity associated with radiotherapy. CONCLUSIONS Adjuvant radiotherapy improves LC for AMs. The addition of adjuvant radiotherapy following even a Simpson Grade I, II, or III resection was found to confer an LC benefit. Recurrent disease is difficult to control, underscoring the importance of aggressive initial treatment.

    View details for DOI 10.3171/2016.5.JNS152809

    View details for PubMedID 27611201

  • Vulvar Recurrences After Intensity-modulated Radiation Therapy for Squamous Cell Carcinoma of the Anus. American journal of clinical oncology Bagshaw, H. P., Sause, W. T., Gawlick, U., Kim, H. T., Whisenant, J., Cannon, G. M. 2016: -?


    The objective is to determine localregional control (LRC), distant metastasis free survival, disease-free survival, overall survival (OS), and toxicity for patients with squamous cell carcinoma of the anus treated with definitive chemotherapy and intensity-modulated radiation therapy (IMRT).We conducted a retrospective review of patients treated using IMRT for squamous cell carcinoma of the anus at our institution since 2005. Patients with local recurrences were identified and reviewed. The Kaplan-Meier curves were used for LRC and OS.From 2005 to 2014, 52 patients were treated with IMRT-based chemoradiation for squamous cell carcinoma of the anus. Median dose to the primary tumor was 54 Gy. LRC, distant metastasis free survival, OS, and disease-free survival were 92.3%, 88.5%, 86.5%, and 84.6%, respectively, with a median follow-up of 20 months. Two local failures occurred at the anal primary site and 2 in the vulva. Despite subsequent palliative radiotherapy and chemotherapy, neither patient with a vulvar recurrence achieved disease control.In a cohort of patients treated with IMRT-based chemoradiation, 2 vulvar recurrences were identified within the avoided external genitalia despite limited recurrence rates within the cohort overall. This experience suggests that for patients with a locally advanced primary tumor and bulky bilateral inguinal or pelvic disease, the in-transit vulvar dermal lymphatics may be at risk for subclinical involvement and subsequent recurrence. If substantiated by a similar pattern of recurrence at other institutions, the external genitalia may need to be reclassified from an avoidance structure to a clinical treatment volume in patients with locally advanced anal cancer.

    View details for PubMedID 27438690

  • Local Control of Melanoma Brain Metastases Treated with Stereotactic Radiosurgery Journal of Radiosurgery & SBRT Bagshaw, H. P., Ly, D., Suneja, G., Jensen, R. L., Shrieve, D. C. 2016; 4 (3): 181-190
  • Palladium interstitial implant in combination with external beam radiotherapy and chemotherapy for the definitive treatment of a female urethral carcinoma. Gynecologic oncology reports Bagshaw, H. P., Williams, N. L., Huang, Y. J., Tward, J. D., Gaffney, D. K. 2015; 13: 40-43


    Primary urethral cancer is a rare diagnosis, especially in females. This report presents the utilization of a palladium interstitial implant and a review of the retrospective data published on the management of female urethral cancer. Excellent local control and survival has been obtained with the use of a palladium interstitial implant in combination with external beam radiotherapy and concurrent chemotherapy. This modality represents a novel and effective way to treat primary urethral cancer in females.

    View details for DOI 10.1016/j.gore.2015.06.001

    View details for PubMedID 26425719

  • Local control after stereotactic radiosurgery for brain metastases in patients with melanoma with and without BRAF mutation and treatment JOURNAL OF NEUROSURGERY Ly, D., Bagshaw, H. P., Anker, C. J., Tward, J. D., Grossmann, K. F., Jensen, R. L., Shrieve, D. C. 2015; 123 (2): 395-401


    BRAF inhibitors improve progression-free and overall survival in patients with metastatic melanoma. Brain metastases are common, and stereotactic radiosurgery (SRS) has been used, resulting in excellent local control. Because BRAF inhibitors are associated with intracranial responses, the authors hypothesized that BRAF inhibitors would improve local control in patients with melanoma who are receiving SRS for brain metastases.The authors retrospectively identified patients with metastatic melanoma who had been tested for BRAF mutation and treated with SRS for brain metastases. Patients with previous resection, multiple brain metastases, or multiple courses of SRS were eligible. SRS was delivered in a single fraction to a median dose of 2000 cGy. Patients with a BRAF mutation were treated with a BRAF inhibitor on the basis of physician preference.The authors identified 52 patients who were treated in 82 treatment sessions for 185 brain metastases and 13 tumor beds. At a median follow-up of 10.5 months, the 1-year local control rate was 69.2%. At 1 year, the local control rate for brain metastases in patients with BRAF mutation with BRAF treatment was 85.0%, and the local control rate for brain metastases in those without BRAF treatment was 51.5% (p = 0.0077). The rates of distant brain failure, freedom from whole-brain radiation, and overall survival were not different on the basis of BRAF mutation status or inhibitor therapy. The number of new intratumoral hemorrhages after SRS was increased significantly in patients with BRAF treatment.Treatment with BRAF inhibitors was associated with improved local control after SRS in patients with melanoma and brain metastases. An increased number of intratumoral hemorrhages was associated with BRAF inhibitor therapy.

    View details for DOI 10.3171/2014.9.JNS141425

    View details for Web of Science ID 000362200800015

    View details for PubMedID 25768829

  • Patterns of Care With Brachytherapy for Cervical Cancer INTERNATIONAL JOURNAL OF GYNECOLOGICAL CANCER Bagshaw, H. P., Pappas, L. M., Kepka, D. L., Tward, J. D., Gaffney, D. K. 2014; 24 (9): 1659-1664


    Concurrent chemotherapy with external beam radiotherapy (EBRT) and brachytherapy (BT) is critical to the curative treatment of locally advanced cervical cancer. Patterns of care and the use of EBRT and BT for locally advanced cervical cancer in the United States were analyzed with an emphasis on regional variation across the United States.A retrospective analysis was performed using the Surveillance, Epidemiology, and End Results Program database from 1988 to 2010 to identify women with locally advanced cervical carcinoma treated with definitive radiotherapy.Twelve thousand three hundred women were identified who met the inclusion criteria. From 1988 to 2010, percent use of EBRT and BT decreased from 68% to 45%; specifically, between 1988 and 2000, there was a decrease of 12% (P = 0.0003), and between 2000 and 2010, there was another decrease of 11% (P < 0.0001). When examined individually, 15 of the 16 registries displayed a decline in use of EBRT and BT with a significant decrease in 11 of the registries. No registry displayed an increased use of EBRT and BT, but the use of EBRT alone increased from 1988 to 2000 by 8% (P = 0.0055) and from 2000 to 2010 by 6% (P = 0.0095).Combination of EBRT and BT for locally advanced cervical cancer continues to decline, despite guidelines indicating the appropriateness of BT. This decline was seen for most regions across the United States, with a concomitant rise in the use of EBRT. EBRT alone is an inferior therapy and must be used in conjunction with BT to realize maximal patient benefit.

    View details for DOI 10.1097/IGC.0000000000000276

    View details for Web of Science ID 000344611800023

    View details for PubMedID 25251463

  • Does family history of prostate cancer affect outcomes following radiotherapy? Radiotherapy and oncology Bagshaw, H., Ruth, K., Horwitz, E. M., Chen, D. Y., Buyyounouski, M. K. 2014; 110 (2): 229-234


    To examine family history (FH) as a prognostic factor following radiotherapy (RT).Between 1989 and 2007, 1711 men with clinically localized prostate cancer and complete family history who had received RT (median RT dose=74Gy) without androgen deprivation therapy were analyzed. FH was defined as any prostate cancer in a first degree relative. For the biochemical failure (BF) outcome, this sample size has 85% power to detect a hazard ratio of 1.56 for positive versus negative FH.With a median follow-up of 71 months, there was no significant difference in the distribution of Gleason score (GS) or prostate specific antigen (PSA) based on FH. A positive FH was not an independent predictor of BF, distant metastasis (DM), prostate cancer specific mortality (PCSM), or overall mortality (OM) in Cox proportional multivariable analysis. On further analysis in a Cox proportional multivariable analysis, men with two or more first degree relatives with prostate cancer had a significantly higher likelihood of BF and DM than those with no FH, although there was no difference in PCSM or OM. Men with a positive FH (23%) were more likely to be younger, have a lower PSA, and non-palpable disease. There was no interaction between a positive FH and neither race nor treatment era (pre-PSA vs. PSA era).A positive FH is not a prognostic factor following RT and should not alter standard treatment recommendations. Patients with two or more first degree relatives with prostate cancer had a higher likelihood of BF and DM, but there was no effect on survival. There was no interaction between a positive FH and African American race or treatment era. A positive FH was however, associated with more favorable PSA values and T-stage that may be the result of earlier screening.

    View details for DOI 10.1016/j.radonc.2013.11.014

    View details for PubMedID 24560758

  • Radiation Therapy in Male Breast Cancer Oncology & Hematology Review Bagshaw, H. P., Cloyd, J. M., Poppe, M. M., Wapnir, I. L. 2014; 10: 61-65