Kaiser Permanente Rancho Cordova Medical Offices

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an unusual soft-tissue tumor with a propensity for subclinical extension and local recurrence. Surgical excision, even with tissue-sparing techniques, may cause significant deformity or disability because of the infiltrative nature of DFSP. In this study, we evaluate retrospective data obtained from 4 patients with locally advanced or recurrent DFSP who received neoadjuvant imatinib mesylate therapy before undergoing Mohs micrographic surgery. OBSERVATIONS: Patients treated with neoadjuvant imatinib therapy had an average tumor size reduction of 36.9%. This clinical response was paralleled by histopathologic changes, including decreased cellularity in 100% of the total area as well as significant hyalinization. Imatinib therapy for DFSP before Mohs micrographic surgery was associated with 100% local control at a maximum follow-up of 4 years. CONCLUSIONS: Neoadjuvant imatinib therapy is a well-tolerated, novel approach to DFSP that reduces tumor burden and facilitates resection. Larger prospective studies are needed to confirm and expand on these results.

Abstract Lack of constitutive data has impeded efforts to model the subsurface transport of organic‐liquid contaminants. To help fill this need, functional relationships between fluid saturations and capillary pressures were obtained using a unique fluid‐retention cell. The functional relationships between water saturations and NAPL‐water capillary pressures, and between total‐liquid saturations and air‐NAPL capillary presures in two‐ and three‐fluid phase systems were measured directly during monotonic drainage of a fine quartz sand and a nonswelling loam soil. Additionally, measurements were made between water saturations and air‐water capillary pressures for an air‐water fluid system in both porous media. The NAPLs investigated were Soltrol 170®, toluene, and trichloroethylene (TCE). Following the measurements, the two‐ and three‐fluid retention relations were compared to test the validity of extending two‐phase saturation‐pressure (S‐P) relations to three‐fluid systems. Good agreement was observed between the two‐ and three‐fluid data for Soltrol 170®, toluene, and TCE in both porous media. An S‐P scaling format for two‐ and three‐phase systems was also evaluated. Results indicate that a single multiphase retention function is suitable for describing two‐ and three‐phase S‐P relations in similar porous media; however, it is unclear whether the scaling factors can be predicted a priori from ratios of interfacial tensions.

OBJECTIVE: To compare survival among patients with head and neck cancer before and after implementing a weekly multidisciplinary clinic and case conference. METHODS: A retrospective cohort study with chart review was conducted of 3081 patients (1431 preimplementation, 1650 postimplementation) diagnosed with stage I-IVB tumors in the oral cavity, oropharynx, hypopharynx, nasopharynx, or larynx. Pre- and postimplementation differences in overall and disease-specific survival 1, 2, and 3 years after diagnosis were assessed with unadjusted Kaplan-Meier curves and multivariable Cox proportional hazard regression models adjusted for demographic characteristics, comorbidity burden, smoking status, tumor site and stage, p16 status for oropharyngeal squamous cell cancer, and initial treatment modality. RESULTS: Patients less commonly presented with oropharyngeal squamous cell cancer and advanced tumors (III-IVB) and received primary treatment with surgery alone or with adjuvant therapy preimplementation than postimplementation. Overall survival at 3 years was 77.1% and 79.9% (P = .07) and disease-specific survival was 84.9% and 87.5% (P = .05) among pre- and postimplementation patients, respectively. At 3 years, preimplementation patients had slightly poorer overall (hazard ratio, 1.20; 95% CI, 1.02-1.40) and disease-specific (hazard ratio, 1.26; 95% CI, 1.03-1.54) adjusted survival than postimplementation patients. In unadjusted and adjusted analyses, survival improvements were more pronounced among patients with advanced disease. DISCUSSION: A multidisciplinary clinic and case conference were associated with improved outcomes among patients with head and neck cancer, especially those with advanced tumors. IMPLICATIONS FOR PRACTICE: All patients with head and neck cancer should receive multidisciplinary team management, especially those with advanced tumors.

(Strep pyogenes). CT scans were also conducted to analyze his right lateral periorbital tissue. Subsequently, the patient was admitted to the ICU, where a wound vacuum-assisted closure (VAC) was placed on his right eye. Once the NPWT was complete, the patient was prescribed antibiotics and was able to improve the health within his right eye.

This is a report of the use, efficacy, and theoretic safety of negative-pressure wound therapy over ocular structures as a part of surgical treatment for necrotizing fasciitis. We treated a 65-year-old man with facial necrotizing fasciitis requiring serial debridement and closure of extensive periorbital and nasal wounds with skin grafts. Negative-pressure wound therapy was first used as a bridge to allow temporary closure and to encourage granulation tissue development. It was then used as a bolster dressing to stabilize skin grafts in the complex wound, not amenable to tie-over dressings. Excellent functional and cosmetic reconstruction of the periorbital and nasal regions was achieved. After treatment, the patient's corrected vision was 20/20. To our knowledge, the use of negative-pressure wound therapy directly over ocular structures has not been previously documented. In this case, it was safely used over the eyes with no sequelae to the patient's vision.

Wildfires have become a regular seasonal disaster across the Western region of the United States. Wildfires require a multifaceted disaster response. In addition to fire suppression, there are public health and medical needs for responders and the general population in the path of the fire, as well as a much larger population impacted by smoke. This paper describes key aspects of the health and medical response to wildfires in California, including facility evacuation and shelter medical support, with emphasis on the organization, coordination, and management of medical teams deployed to fire incident base camps. This provides 1 model of medical support and references resources to help other jurisdictions that must respond to the rising incidence of large wildland fires.

Rectangular Schlumberger arrays can be used for 2-dimensional lateral profiling of apparent<br>resistivity at a unique current electrode separation, hence single depth of penetration. Numerous<br>apparent resistivity measurements are collected moving the potential electrodes (fixed MN spacing)<br>within a rectangle of defined dimensions. The method provides a fast, cost-effective means for the<br>collection of dense resistivity data to provide high-resolution information on subsurface hydeogeologic<br>conditions.<br>Several rectangular Schlumberger resistivity arrays were employed at Los Alamos National<br>Laboratory (LANL) from 1989 through 1995 in an area adjacent to and downhill from an outfall pipe,<br>septic tank, septic drainfield, and sump. Six rectangular arrays with 2 AB spacings were used to<br>delineate lateral low resistivity anomalies that may be related to fractures that contain clay and/or<br>vadose zone water. Duplicate arrays collected over a three year time period exhibited very good data<br>repeatability.<br>The properties of tritium make it an excellent groundwater tracer. Because tritium was present<br>in discharged water from all of the anthropogenic sources in the vicinity it was used for this purpose.<br>One major low resistivity anomaly correlates with relatively high tritium concentrations in the tuff. This<br>was determined from borehole samples collected within and outside of the anomalous zone. The<br>anomaly is interpreted to be due to fractures that contain clay from the soil profile. The clay was<br>deposited in the fractures by aeolian processes and by surface water infiltration. The fractures likely<br>served as a shallow vadose zone groundwater pathway.

A 73-year-old man presented for Mohs micrographic surgery with a biopsy-confirmed basal cell carcinoma on his right ear and requested the additional examination of a skin lesion on his left ear. The examination showed a 7-mm, thin, crusted papule on the midhelix (Fig 1), and a shave biopsy was performed to evaluate for basal and squamous cell carcinoma. Pathology showed a tumor composed predominantly of spindle-shaped cells with pleomorphic nuclei and multiple mitoses, with positivity to CD10 immunoperoxidase, transected at the base (Figs 2 and 3 [hematoxylin-eosin, original magnifications ×100 and ×200, respectively]).Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3View Large Image Figure ViewerDownload Hi-res image Download (PPT) Question 1: What is the most likely diagnosis?A.Desmoplastic melanomaB.Atypical fibroxanthomaC.Morpheic basal cell carcinomaD.Clear cell sarcomaE.Squamous cell carcinoma Answers:A.Desmoplastic melanoma – Incorrect. Histology for this would show strands of elongated, spindle-shaped cells surrounded by mature collagen bundles. The cells resemble fibroblasts, some with hyperchromatic and bizarre nuclei, and are typically CD10−.1Weedon D. 3rd ed. Weedon's Skin Pathology. Churchill Livingstone Elsevier, 2010: 682-690Google ScholarB.Atypical fibroxanthoma – Correct. Pathology showed that this tumor was composed predominantly of spindle-shaped cells with pleomorphic nuclei and multiple mitoses, characteristic of atypical fibroxanthoma. This is a rare, malignant, cutaneous neoplasm that exists along a clinicopathologic spectrum with pleomorphic dermal sarcoma (also known as undifferentiated pleomorphic sarcoma). Although these tumors share many similarities, the recognition of distinguishing characteristics may predict differences in clinical behavior and outcomes. A pleomorphic dermal sarcoma is often larger than an atypical fibroxanthoma and is more likely to recur or metastasize. An atypical fibroxanthoma, by definition, is confined to the dermis, whereas a pleomorphic dermal sarcoma involves the subcutis, fascia, lymphatics, or vascular structures.2Kolb L. Schmieder G.J. Atypical fibroxanthoma.in: StatPearls [Internet]. StatPearls Publishing, 2021https://www.ncbi.nlm.nih.gov/books/NBK459342/Date accessed: August 3, 2021Google Scholar,3Chapman L.W. Yu S.S. Arron S.T. Atypical fibroxanthoma.Semin Cutan Med Surg. 2019; 38: E65-E66https://doi.org/10.12788/j.sder.2019.008Crossref PubMed Scopus (4) Google Scholar Because the lesion was transected at the base, pleomorphic dermal sarcoma cannot be ruled out with this biopsy alone.C.Morpheic basal cell carcinoma – Incorrect. Histology for this would show narrow 50 elongated strands and small islands of basophilic tumor cells embedded in a dense, fibrous stroma.1Weedon D. 3rd ed. Weedon's Skin Pathology. Churchill Livingstone Elsevier, 2010: 682-690Google ScholarD.Clear cell sarcoma – Incorrect. These tumors (“melanomas of soft parts”) are composed of nests and strands of oval or elongated cells separated by collagenous septa, with copious pale or granular amphophilic cytoplasm.1Weedon D. 3rd ed. Weedon's Skin Pathology. Churchill Livingstone Elsevier, 2010: 682-690Google ScholarE.Squamous cell carcinoma – Incorrect. Histopathology for this tumor would show nests of squamous epithelial cells, with abundant eosinophilic cytoplasm and large vesicular nuclei, arising from the epidermis and extending into the dermis.1Weedon D. 3rd ed. Weedon's Skin Pathology. Churchill Livingstone Elsevier, 2010: 682-690Google Scholar Question 2: What is the appropriate next step?A.ReassuranceB.CryotherapyC.Repeat shave biopsyD.Mohs micrographic surgeryE.Topical imiquimod Answers:A.Reassurance – Incorrect. Reassurance is not appropriate for atypical fibroxanthoma or pleomorphic dermal sarcoma.B.Cryotherapy – Incorrect. Cryotherapy is not effective for either entity on the differential diagnosis.C.Repeat shave biopsy – Incorrect. Although this may confirm the diagnosis, both entities on the differential diagnosis would undergo Mohs micrographic surgery. A repeat biopsy would only delay the treatment without any benefit.D.Mohs micrographic surgery – Correct. The lesion was transected at the base, precluding the preoperative differentiation of atypical fibroxanthoma from pleomorphic dermal sarcoma. The treatment of choice for both is Mohs micrographic surgery.2Kolb L. Schmieder G.J. Atypical fibroxanthoma.in: StatPearls [Internet]. StatPearls Publishing, 2021https://www.ncbi.nlm.nih.gov/books/NBK459342/Date accessed: August 3, 2021Google Scholar,3Chapman L.W. Yu S.S. Arron S.T. Atypical fibroxanthoma.Semin Cutan Med Surg. 2019; 38: E65-E66https://doi.org/10.12788/j.sder.2019.008Crossref PubMed Scopus (4) Google ScholarE.Topical imiquimod – Incorrect. This is not effective for either entity on the differential diagnosis. Question 3: Mohs micrographic surgery was performed, and intraoperative frozen sections revealed that the tumor was confined to the dermis. Which of the following is true?A.Recurrence rates are as high as 90%B.Metastases are commonC.When metastases occur, they are usually to the parotid gland, lymph nodes, or subcutaneous tissueD.The patient should be screened every 4 monthsE.Atypical fibroxanthoma stains negative for p53, S100A6, vimentin, and procollagen 1 Answers:A.Recurrence rates are as high as 90% – Incorrect. Following Mohs micrographic surgery, recurrence rates for atypical fibroxanthoma are 0% to 6.9%.B.Metastases are common – Incorrect. Metastases are rare but usually occur 1 to 2 years after the initial diagnosis of atypical fibroxanthoma.C.When metastases occur, they are usually to the parotid gland, lymph nodes, or subcutaneous tissue – Correct.D.The patient should be screened every 4 months – Incorrect. Patients with histories of atypical fibroxanthoma should be screened annually and counseled to limit ultraviolet exposure.E.Atypical fibroxanthoma stains negative for p53, S100A6, vimentin, and procollagen 1 – Incorrect. Atypical fibroxanthoma is considered a diagnosis of exclusion histologically, in part because it stains positive for several nonspecific stains, including CD10, p53, S100A6, vimentin, and procollagen 1.2Kolb L. Schmieder G.J. Atypical fibroxanthoma.in: StatPearls [Internet]. StatPearls Publishing, 2021https://www.ncbi.nlm.nih.gov/books/NBK459342/Date accessed: August 3, 2021Google Scholar None disclosed

Purpose: A study was performed using two commercially available 2D detector array systems for IMRT patient specific QA by resetting all beam angels to gantry angle at zero degree and leaving all beam angles as planned to investigate and verify the dose delivery accuracy, limitation of the devices in the QA procedures. Method and Materials: Calibration was established at 0 degree beam angle, with the beam normal to the array plane. This study utilized one complicated head and neck IMRT plan with 9 fields (18 spitted fields). The Varian Eclipse treatment planning system (TPS) with Anisotropic Analytical Algorithm and Varian 21Ex LINAC were used for this study. The 2D array systems tested were MapCHECK with MapPhan from Sun Nuclear Corporation, and Im'RT MatriXX from IBA. Two QA phantoms were constructed by (1) MapPhan with MapCHECK and (2) solid water with MatriXX. The summed dose measured was compared to calculated one using two phantoms. Results: At gantry zero degree, 99.7% pass rate for MapPhan with MapCHECK was achieved using 3% and 3 mm DTA criteria in absolute mode and 99.2% for MatriXX. At true planned angle, 93.4% pass rate for MapPhan with MapCHECK and 93.0% for MatriXX. Conclusions: Although all arrays performed reasonably well in the composite dose for real gantry angles, it may indicate the loss of QA information in the composite. Since with the beam normal to the detector plane of 2D array, all measurement points carry the same information weight. Whereas delivery angles between normal and parallel, measurement carries varying amounts of weight for each point samples or not sampled depending on field size and beam angles. The application of a 2D array to real gantry angle IMRT QA requires careful considerations.

Pemphigus vulgaris (PV) is an autoimmune disorder affecting the skin and mucous membranes. The condition may be confused with a number of disorders, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and erythema multiforme (EM), all of which are life-threatening. Immunohistological and histochemical analyses remain the optimal methods for differentiating these diseases. There is still insufficient evidence regarding the true incidence rate of ocular disease in PV as well as its distinct clinical types. This report sets to review the case of a 62-year-old male with atypical ocular pemphigus vulgaris and review the literature.

2062 Background: Meningioma is the most common primary brain tumor in the United States, but there is limited data on clinical outcomes. Methods: We performed descriptive and survival analysis of meningioma cases diagnosed 2001-2010 from the Kaiser Permanente Northern California Cancer Registry, which began inclusion of benign brain tumors in 2001. Datasets provided variables on gender, age at diagnosis, race, and vital status. Chart review extracted additional information on mortality, histology, imaging, tumor size, tumor site, and treatment. We used Kaplan Meier method to calculate overall survival (OS) and disease-free survival (DFS) and log-rank test to compare survival rates by variables. Cox proportional hazard models were used to analyze variables relative to endpoints. Results: 1968 cases in 1792 patients with meningioma were analyzed. 55% of cases had histological confirmation. 5- and 10-year OS and DFS for all groups were 76% & 61% and 89% & 82%. Disease progression and recurrence presented in 10% of cases at 10 years, resulting in 4% disease-specific mortality (DSM). Statistically significant prognostic factors of worse DFS were age >= 80, WHO grade 2-3, tumor size >= 18 mm, peritumoral edema on imaging, Simpson grades (SG) 4 or 5, and no surgery. Factors associated with significantly worse OS included age >= 60, male gender, tumor size >= 42 mm, peritumoral edema, SG 4 or 5, no histology and no treatment (NT). SG 1-3 groups provided statistically the highest OS and DFS. There was no significant difference in DFS or OS for definitive RT versus surgery and adjuvant RT groups. Definitive RT showed significantly better OS than NT (HR=0.46, 95% CI: 0.21-0.98). Cases with progression or recurrence had 51% DSM with 65% of deaths associated with lack of salvage therapy. Salvage RT provided better OS benefit compared to other salvage groups (HR=0.35, 95% CI: 0.14-0.91). Conclusions: We demonstrated favorable long-term outcome for meningiomas and confirmed the prognostic benefit of Simpson grading. We have identified additional adverse factors affecting outcome. While surgery remains standard, definitive RT demonstrates comparable outcome to cases not amenable to gross total resection. Salvage RT is effective, providing a survival benefit.

Abstract Xeroderma pigmentosum (XP) is a multigenic, recessively inherited precancerous disorder occurring in approximately 4 per million live births in the United States with higher rates in Japan, the Middle East, and regions of Latin America. Eight separate genetic subgroups, known as complementation groups, each due to a mutation in a separate gene and associated with a defect in a separate protein encoded by that gene are known at present, but the biology may be considerably more complex, with other genes not yet identified and other defective genes and proteins simultaneously involved. The seven known “classical” complementation groups, identified as XP-A to XP-G, are associated with defective nucleotide excision type DNA repair(NER) of adducts induced into the DNA of sun exposed cells by ultraviolet radiation in sunlight, whereas the eighth complementation group, designated the “variant” group, XP-V, is associated with defective DNA synthesis bypassing such adducts in a process known as “trans-lesion synthesis” (TLS); some of these patients have been shown to have a defective DNA polymerase, pol eta, which is primarily responsible for this TLS in normal human cells. Depending on the severity of the disease and the degree of sun protection, XP patients have historically been known to be markedly susceptible to skin and other cancers in sun-exposed areas, with hundreds or even thousands of such cancers developing early in life, often in early childhood. EXPERIMENTAL DESIGN AND METHODS: Over ten years ago we began to apply topical 5 fluorouracil (5-FU), 2 to 8 percent, once or twice per day for two to three weeks every three to six months, as tolerated, topically to sun exposed areas of children with XP, identified clinically and/or by cellular functional assays testing fibroblasts removed from these subjects and grown in culture. Topical 5-FU is known to sensitize normal immunity, producing focal inflammation at sites of developing skin cancers; such skin cancers, or their precursors, actinic keratoses, then tend not to arise at these sites. Some XP patients do not experience focal inflammation but are protected from development of skin cancer by a second mechanism. More recently we have alternatively applied imiquimod (IQ), 2 to 5 percent, topically to these same sites. IQ acts as an immune response modifier in a manner analogous to that of topical 5-FU. Fourteen patients have now been treated for over 5 years. RESULTS: Over 5 to nine years, the 14 patients have developed a total of 88 skin cancers, all non-melanoma skin cancers and all removed at early stages with minimal morbidity, even though DNA repair related, “unscheduled DNA synthesis” (UDS) was as low as two percent. Thousands of skin cancers were expected in this group without this intervention. Skin inflammation was also reduced. CONCLUSION: Skin cancer may be effectively prevented in XP patients using topical immune response modifiers such as topical 5-FU or IQ. Citation Format: W Clark Lambert, Randal Anderson, Muriel W. Lambert. Prevention of skin cancer in xeroderma pigmentosum: A long-term study of fourteen patients. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1787. doi:10.1158/1538-7445.AM2014-1787

e18048 Background: Outcomes for patients with head and neck cancer (HNC) are affected by tumor specific features, as well as demographic characteristics and health-related comorbidities. We previously found that women have a higher risk of HNC death compared with risk of death from other causes using a General Competing Event (GCE) model. With a larger, more recent and well-annotated cohort of patients with HNC from Kaiser Permanente Northern California, we applied the GCE model to investigate sex and racial disparities in all-cause, HNC-specific, and non-HNC mortality. Methods: We identified patients with mucosal HNC treated in the curative setting between 2013-2017 on sociodemographic and clinical factors. Using GCE models adjusted for age, smoking status, Charlson comorbidity index, primary tumor site, and tumor stage, we examined if gender and race/ethnicity were associated with a higher relative hazard of HNC-specific mortality over non-HNC mortality (relative hazard ratio (RHR), ‘gcerisk’ package in R). Follow-up was measured from HNC diagnosis date to death or end of study (12/31/2022) whichever occurred earliest. Results: In our cohort of 1616 patients (mean age at diagnosis: 64.2 years), 25.7% were female. The majority were White (70.5%), followed by Asian (12.3%), Hispanic (8.0%), Black (4.8%), and other/unknown (4.3%). Women were less likely to smoke and had more oral cavity cancer and less p16+ oropharyngeal cancer than men. Patients of non-white (vs. white) race were younger, lived in more deprived neighborhoods, had less smoking and alcohol use, had more nasopharyngeal carcinoma and less p16+ oropharyngeal cancer. Over a median follow-up of 6.5 years, 274 patients died of HNC, and 279 patients died of other causes. Greater HNC-specific mortality was associated with female gender (RHR ratio 1.63; 95% confidence interval [CI] 1.10-2.41) and non-White race (RHR ratio 1.40; 95% CI 0.95-2.08). Conclusions: We observed worse HNC-specific mortality among female and nonwhite patients, which may be related to underlying disease biology and socioeconomic factors. This highlights the importance of examining both HNC-specific and non-HNC mortality to identify cancer health disparities. Mortality outcomes associated with gender and race among 1616 patients with head and neck cancer (HNC) treated in the curative setting. Variable All-Cause Mortality HR a (95% CI) Cancer Specific Mortality HR a (95% CI) Non-Cancer Mortality HR a (95% CI) Cancer Specific vs. Non-Cancer Mortality RHR* a (95% CI) Female vs. Male 1.07 (0.88, 1.29) 1.37 (1.04, 1.79) 0.84 (0.63, 1.12) 1.63 ( 1.10, 2.41 ) Non-White vs. White 0.94 (0.77, 1.14) 1.11 (0.85, 1.46) 0.79 (0.60, 1.05) 1.40 (0.95, 2.08) HR = Hazard ratio. *RHR = Relative hazard ratio for HNC-specific mortality vs. non-HNC mortality. a Adjusted for age, smoking status, Charlson comorbidity index, primary tumor site, tumor stage.

OBJECTIVE: Substance use disorders (SUDs) commonly co-occur with posttraumatic stress disorder (PTSD). Understanding PTSD clinics that serve higher percentages of patients with PTSD/SUD is crucial for improving SUD care in clinics with lower percentages of such patients. This study examined the differences between Veterans Affairs (VA) PTSD treatment sites with higher percentages ("High%") and lower percentages ("Low%") of patients with PTSD/SUD as well as exploring the roles of the PTSD/SUD specialists. METHODS: The study collected quantitative and qualitative data from 18 clinic directors and 21 specialists from 33 VA PTSD specialty outpatient clinics from 2014 to 2016. The clinics were chosen from the top and bottom quartiles based on two criteria: (1) the percentage of patients with PTSD/SUD and (2) the percentage of patients with PTSD/SUD who completed at least three SUD visits within the first month of their SUD treatment. The interviews sought to identify distinguishing characteristics between the High% and Low% clinics in terms of treatment access and practices for patients with PTSD/SUD. RESULTS: More of the High% clinics reported providing evidence-based, patient-centered, and integrated/concurrent PTSD/SUD treatment and had staff members with more up-to-date knowledge and skills than the Low% clinics. We also found the roles of the PTSD/SUD specialists were demanding and confusing, leading to high turnover rates. CONCLUSIONS: The two groups of PTSD clinics differed in three key factors: Resources, knowledge and skills of staff members, and local policies. Future research should focus on addressing resource limitations, knowledge gaps, and local policy disparities in Low% clinics. By emulating the practices of High% clinics, VA PTSD clinics can improve SUD care for patients with PTSD/SUD.

Purpose: A series of practical phantoms were constructed to investigate the accuracy of photon dose calculations performed by the Anisotropic Analytical Algorithm (AAA) in homogeneous and inhomogeneous media. Method and Materials: A total of seven heterogeneous and homogeneous phantoms with solid water (SW) and cork, SW with MapCHECK or MatriXX were constructed to investigate the difference between dose calculated by AAA in Eclipse treatment planning system (TPS) and measured dose using Varian 23 IX LINAC. Ion Chamber was used for point dose measurements and film, MapCHECK, MatriXX were used for 2D dose measurements. A detailed analysis of data computed by the AAA algorithm was carried out and data were compared against measurements. To better appraise the performance of AAA, data obtained from the pencil beam convolution (PBC) algorithm implemented in Eclipse were also added in the comparison. Results: AAA calculation has showed better than PBC in agreement with measurement from both ion chamber and 2D dosimeters. As planar dose evaluation, MapCHECK yielded a pass rate ranging from 88.5% to 95.5% for AAA, and 69.7% to 81.9% for PBC based on 1% difference and 1mm distance to agreement for different phantoms. The film dose distribution showed as well that AAA calculation is better than PBC in agreement with measurements. Generally, the better agreement of AAA than PBC calculation with measurement is more obvious in heterogeneous than homogeneous phantoms. Conclusions: Eclipse TPS dose calculation AAA showed better agreement with dose measurement in both heterogeneous (more significant) and homogeneous phantom than PBC using three different types of 2D dosimetry system and ion chamber. The design of measurements and construction of phantoms represent a simple, efficient, and accurate means for verifying dose calculation algorithms in TPS.