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The use of metallic containing creams to prevent and treat radiodermatitis is controversial and lacking evidence base. We compare the dose effect of two metallic-based skin creams, which could be used for treating radiodermatitis, to a control.
Universal containers of silver sulfadiazine cream, zinc oxide cream and aqueous cream were examined using a computed tomography scanner to assess their electron densities relative to water. Second, each cream was exposed to 100 kV and 6 MV photons. The relative doses were measured using an X-ray chamber.
The relative electron density measured was similar for the silver sulfadiazine and aqueous creams. Zinc oxide was 40% higher. The relative dose measurements showed that silver sulfadiazine behaved in a similar way to aqueous cream; however, zinc oxide cream exhibited a dose difference of 11·0% in kV photons and −4·1% in MV photons.
Application of silver sulfadiazine appears unlikely to bring about significant changes in the dose distribution when compared with aqueous during MV or kV radiotherapy. While zinc oxide cream brought about more significant dose changes.
Simulation has been effective for changing attitudes towards team-based competencies in many areas, but its role in teaching interprofessional collaboration (IPC) in radiation medicine (RM) is unknown. This study reports on feasibility and IPC outcomes of a team-based simulation event; ‘Radiation Medicine Simulation in Learning Interprofessional Collaborative Experience’ (RM SLICE).
Radiation therapy (RTT), medical physics (MP) and radiation oncology (RO) trainees in a single academic department were eligible. Scheduled closure of a modern RM clinic allowed rotation of five high-fidelity cases in three 105-minute timeslots. A pre/post-survey design evaluated learner satisfaction and interprofessional perceptions. Scales included the Readiness for Interprofessional Learning Scale (RIPLS), UWE Entry Level Interprofessional Questionnaire (UWEIQ), Trainee Test of Team Dynamics and Collaborative Behaviours Scale (CBS).
Twenty-one trainees participated; six ROs (28·57%), six MPs (28·57%) and nine RTTs (42·86%). All cases were conducted, resolved and debriefed within the allotted time. Twenty-one complete sets (100%) of evaluations were returned. Participants reported limited interaction with other professional groups before RM SLICE. Perceptions of team functioning and value of team interaction in ‘establishing or improving the care plan’ were high for all cases, averaging 8·1/10 and 8·9/10. Average CBS scores were 70·4, 71·9 and 69·5, for the three cases, scores increasing between the first and second case for 13/21 (61·9%) participants. RIPLS and UWEIQ scores reflected positive perceptions both pre- and post-event, averaging 83·5 and 85·2 (RIPLS) and 60·6 and 55·7 (UWEIQ), respectively. For all professions for both scales, the average change in score reflected improved IP perceptions, with agreement between scales for 15/20 (75·0%) participants. Overall, perception of IPC averaged 9·14/10, as did the importance of holding such an event annually.
Team-based simulation is feasible in RM and appears to facilitate interprofessional competency-building in high-acuity clinical situations, reflecting positive perceptions of IPC.
To quantify the effect of breathing motion on post-mastectomy radiotherapy with three-dimensional (3D) tangents and intensity-modulated radiotherapy (IMRT)
Materials and methods
Patients trained for breath-hold underwent routine free breathing (FB) computed tomography (CT) simulation for radiotherapy as well as additional CT scans with breath held at the end of normal inspiration (NI scan) and expiration (NE scan) for study. The FB scan was used to develop both tangents and IMRT plans. To simulate breathing, each plan was copied and applied on NI and NE scans. The respiratory parameters of the patients as well as the dosimetric data with both the plans were analysed.
Breathing motion resulted in mean fall in target coverage (V95) with IMRT by more than 5% when compared with tangents, and this effect significantly correlated with higher tidal volume. There was also a decrease in the mean target minimal dose by 20–25% with IMRT when compared with 10–12% with tangents, attributable to breathing motion. However, the cardiac dose crossed the limit (V25<10%) with breathing in the 3D tangents plan.
Dosimetric coverage of the chest wall is sensitive to breathing motion for the IMRT technique when compared with standard tangents, especially in patients with large tidal volume.
Peer-review programmes in radiation oncology are used to facilitate the process and evaluation of clinical decision-making. However, web-based peer-review methods are still uncommon. This study analysed an inter-centre, web-based peer-review case conference as a method of facilitating the decision-making process in radiation oncology.
A benchmark form was designed based on the American Society for Radiation Oncology targets for radiation oncology peer review. This was used for evaluating the contents of the peer-review case presentations on 40 cases, selected from three participating radiation oncology centres. A scoring system was used for comparison of data, and a survey was conducted to analyse the experiences of radiation oncology professionals who attended the web-based peer-review meetings in order to identify priorities for improvement.
The mean scores for the evaluations were 82·7, 84·5, 86·3 and 87·3% for cervical, prostate, breast and head and neck presentations, respectively. The survey showed that radiation oncology professionals were confident about the role of web-based peer-reviews in facilitating sharing of good practice, stimulating professionalism and promoting professional growth. The participants were satisfied with the quality of the audio and visual aspects of the web-based meeting.
The results of this study suggest that simple inter-centre web-based peer-review case conferences are a feasible technique for peer review in radiation oncology. Limitations such as data security and confidentiality can be overcome by the use of appropriate structure and technology. To drive the issues of quality and safety a step further, small radiotherapy departments may need to consider web-based peer-review case conference as part of their routine quality assurance practices.
To evaluate the inter-fraction variation in interstitial high-dose-rate (HDR) brachytherapy. To assess the positional displacement of catheters during the fractions and the resultant impact on dosimetry.
Although brachytherapy continues to be a key cornerstone of cancer care, it is clear that treatment innovations are needed to build on this success and ensure that brachytherapy continues to provide quality care for patients. The dosimetric advantages offered by HDR brachytherapy to the tumour volume rely on catheter positions being accurately reproduced for all fractions of treatment.
Materials and methods
A total of 66 patients treated over a period of 22 months were considered for this study. All the patients underwent computer tomography (CT) scan and three-dimensional treatment planning was carried out. Brachytherapy treatment was delivered by the HDR afterloading system. On completing the last fraction, CT scan was repeated and treatment re-planning was done. The variation in position of the implanted applicators and their impact on dosimetric parameters were analysed using both the plans.
For all breast-implant patients, the catheter displacement and D90 dose to clinical target volume were <3 mm and 3%, respectively. The displacement for carcinoma of the tongue, carcinoma of the buccal mucosa, carcinoma of the floor of mouth, carcinoma of the cervix, soft-tissue sarcoma and carcinoma of the lip were comparatively high.
Inter-fraction errors occur frequently in interstitial HDR brachytherapy. If no action is taken, it will result in a significant risk of geometrical miss and overdose to the organs at risk. It is not recommended to use a single plan to deliver all the fractions. Imaging is recommended before each fraction and decision on re-planning must be taken.
Cancer patients spend a lot of time receiving medical care. Our study investigates patients’ preferences regarding reducing the time involved in non-palliative radiotherapy care.
A total of 142 Dutch patients were included in our study. Using a contingent valuation survey, we measured the proportion of patients who preferred to reduce their patients’ time, splitting it into five different categories, and, for those who did, whether and how much they were willing to pay for this to happen.
About 50% of the patients preferred to reduce their time waiting for admission by 1 week and their travel time by half; 20 and 62% wanted to reduce their waiting time by half and their treatment time from 20 to 5 minutes, respectively; 36% preferred to be treated 7 instead of 5 days a week; and 20% of those wishing to reduce their patients’ time were willing to pay, and their mean willingness to pay (WTP) ranged from £0·32 to £18·1 per hour’s reduction of their time.
Half of the patients seem to assess their patients’ time as reasonable. The other half preferred to reduce it, but only about 20% of them were willing to pay for it to happen and their mean WTP was low.
The objective of this work was to investigate the accuracy of AAA dose calculation algorithm for RapidArc volumetric modulated technique (VMAT) in the presence of anatomical heterogeneities in the pelvic region.
Material and methods
An anthropomorphic phantom was used to simulate a prostate case, delineating planning target volumes (PTVs) and organs at risk. VMAT plans were optimised in eclipse (v10·0) treatment planning system (TPS). The dose distributions were calculated by the AAA dose calculation algorithm. A total of 49 thermoluminiscent dosimeters were inserted into the anthropomorphic phantom and dose measurements were compared with the predicted TPS doses.
The average dose variation was −1·5% for planning target volume corresponding to the prostate and −0·3% for planning target volume corresponding to the pelvic nodes, −0·2% for the rectum, +2·4% for the bladder, −2·0% for the femoral heads and +1·0% for the intestinal package.
AAA is a reliable dose calculation for the treatment with VMAT in the anatomy of the pelvis.
This study aimed to determine the potential role and guidelines for implementation of skill-based peer mentoring for radiotherapy planning education.
After four weekly mentoring sessions, both Year 3 mentors (n=9) and Year 2 mentees (n=9) were invited to complete a short online questionnaire relating to the impact of the initiative. The tool contained a mixture of Likert-style questions concerning student enjoyment and perceived usefulness of the initiative as well as more qualitative open questions that gathered perceptions of the peer mentoring process, implementation methods and potential future scope.
Several key discussion themes related to benefits to each stakeholder group, challenges arising, improvements and potential future directions. There were high levels of enjoyment and perceived value of the mentoring from both sides with 100% of the 18 respondents enjoying the experience. The informal format encouraged further learning, while mentors reported acquisition of valuable skills and gains in knowledge.
Peer mentoring has a valuable and enjoyable role to play in radiotherapy planning training and helps consolidate theoretical understanding for experienced students. An informal approach allows for students to adopt the most appropriate mentoring model for their needs while providing them with a free space to engender additional discussion.
This single-case feasibility study presents an undergraduate radiotherapy student’s experiences of remote access to University treatment planning software in place of on-site practical learning. With clinical sites increasingly utilising telemedicine there is interest in educational applications of this technology.
Materials and methods
This was an unplanned study with the student initiating remote access; additional tutor support was provided as requested. Subsequent discussion between the tutor and student formed the basis for the presented findings.
A second-year student planned five assessment cases from home, supported by regular on-campus tutorials. The student saved a 2-hour journey per practical and gained additional planning practice time. Unit performance was 10% less than a previous Unit, but student satisfaction with the format was high.
Educational remote access to treatment planning software is logistically feasible, although strict guidelines and formal tutor support is vital. Remote access can alleviate pressure on facilities and improve student time efficiency. Controlled and supported provision of remote access to planning software could enhance on-site practical teaching sessions for more mature independent learners. Further cohort-wide studies could clarify advantages, disadvantages and possible role of remote access for radiotherapy planning education.
To analyse the preliminary results of CyberKnife stereotactic radiotherapy (SBRT) boost in primary head and neck cancer patients among Indian population.
Methods and materials
A total of nine patients of primary head and neck cancer were treated with CyberKnife SBRT boost after intensity-modulated radiation therapy (IMRT). The median phase 1 IMRT dose was 54 Gy/27 fractions. Histological types included squamous cell carcinoma (n=7) and adenoid cystic carcinoma (n=2). Response was evaluated using positron emission tomography/computed tomography and detailed clinical examination.
As a preliminary analysis with median follow up of 8 months (range: 6–19 months), phase 2 median tumour volume of 16·3 cc and a median dose of 5 Gy per fraction, eight patients had loco-regionally stable disease and one had distant metastasis. With objective assessment five patients had complete response. Treatment was well tolerated with no grade 3 or more acute toxicities directly related to CyberKnife boost.
CyberKnife SBRT boost is an attractive option for primary head and neck cancers especially where disease is in close proximity to critical structures hindering radical dose delivery. Future prospective analysis and optimum assessment of total biological effective dose (BED) in a properly selected case might actually benefit the use of CyberKnife SBRT boost.
In this work, dosimetric properties of the PTW Octavius detector in and out of the irradiation field have been evaluated. The 2D array of ion chambers has the potential to simplify the linear accelerator QA and pre-treatment verification.
Materials and methods
The evaluation was performed using customised written codes in Matlab and SPSS software for statistical analysis.
Experiments indicate that the reproducibility and stability of the measurements were excellent; the detector showed the same signal with a maximum deviation of <0·5% in the short and long term. Comparisons of the ion chamber with the detector showed the same results with a maximum deviation of ~0·1%. As the detector response is linear with the dose, it can be used for the measurement at regions of high-dose gradient effectively. Logarithmic regression y=0·127 ln(x)+0·729 for detector signal and field size changes yielded a coefficient of determination of 0·997. The dose value decreases with increase in source-to-surface distance, which was modelled using a binomial regression with a coefficient of determination of 0·998 that agrees with the ionisation chamber measurement within 1%.
On the basis of the measurements and comparisons performed, this system is a reliable and accurate dosimeter for quality assurance in radiotherapy.
The Calypso 4D Localization System gives the possibility to track the tumour during treatment, with no additional ionising radiation delivered. To monitor the patient continuously an array is positioned above the patient during the treatment. We intend to study, for various gantry angles, the attenuation effect of the array for 6- and 10 MV and flattening filter free (FFF) 6- and FFF 10 MV photon beams.
Materials and methods
Measurements were performed using an ion chamber placed in a slab phantom positioned at the linac isocenter for 6 MV, 10 MV, FFF 6 MV and FFF 10 MV photon beams. Measurements were performed with and without array above the phantom for 0°, 10°, 20°, 40° and 50° beam angle for a True Beam STx linac, for 5×5 and 10×10 and 15×15 cm2 field size beams to evaluate the attenuation of the array. A VMAT treatment plan was measured using an ArcCheck with and without the array in the beam path.
Results and discussion
Attenuation measured values were up to 3%. Attenuation values were between 1 and 2% with the exception of the 30°–50° gantry angles which were up to 3.3%. The ratio values calculated in the ArcCheck for relative dose and absolute dose 10 were both 1·00.
Attenuation of the treatment beam by the Calypso array is within acceptable limits.
Orbital metastases lead to many distressful symptoms.
A case-report of a 44-year-old woman with a melanoma metastasis in the orbital cavity, is reported. A patient presented with headache, proptosis and diplopia. The stereotactic radiotherapy of 19.5 Gy in three fractions using CyberKnife was performed. Follow-up examination 7 months later revealed satisfactory local control of the tumour, alleviation of orbital symptoms with no negative impact on visual function.
Stereotactic radiotherapy seems to be a safe and effective treatment of orbital metastases from melanoma.
Histiocystic sarcoma is a rare, but aggressive tumour that often involves extranodal sites. Histiocystic sarcoma is recognised by the World Health Organization as one of six subtypes of dendritic cell neoplasms. Diagnosis is difficult due to overlapping immunohistochemistry with other dendritic cell neoplasms. The optimal roles for chemotherapy, radiotherapy and surgery in the treatment of histiocytic sarcoma remain unknown.
We report a case of a patient with histiocytic sarcoma diagnosed after excisional biopsy and immunohistochemistry testing.
The patient underwent external beam radiation therapy (EBRT). After 18 Gray (Gy), the 8 cm lesion had regressed to ~5 cm in diameter. The treatments were continued to a total dose of 45 Gy with the lesion regressing to less than a centimeter by the end of treatment. Local control was maintained but the patient died of acute myelogenous leukemia 5 months after her treatment.
This case suggests that histicytic sarcomas can be controlled locally with EBRT.
To explore possible predictors of early vaginal stenosis among patients with locally advanced cervix cancer on pelvic chemoradiation.
Patients and methods
A total of 232 patients with locally advanced cervix cancer, who received pelvic radiotherapy at our institute from November 2011 to October 2013, were prospectively studied. Possible predictors chosen were age, tumour stage, initial vaginal involvement, concomitant chemotherapy and development of vaginitis of Radio Therapy Oncology Group grade 2 or more during radiotherapy. Multiple logistic regression was carried out to assess predictors and the relative risk of predictors was calculated.
Initial vaginal involvement and addition of concomitant chemotherapy are predictors of early vaginal stenosis in locally advanced cervix cancer patients on pelvic chemoradiation. Relative risk for early vaginal stenosis with vaginal involvement at presentation was 16·31, whereas that for concomitant chemotherapy was 9·95.
Among patients with locally advanced cervix cancer receiving pelvic chemoradiation, two factors, namely, initial vaginal involvement and concomitant chemotherapy are predictive of early vaginal stenosis. Patients with these factors should be assessed at regular intervals for early vaginal stenosis during pelvic chemoradiation to assess the optimal timing of intracavitary brachytherapy. This is particularly of importance in the absence of facilities for interstitial brachytherapy to ensure appropriate target coverage.
Increasingly we are using a combination of surgery, chemotherapy and radiotherapy for treatment of gynaecological malignancies. Most studies in literature are concentrated on the concept of survival. There is minimal data examining the impact of these treatments on quality of life. Survival being a surrogate marker is an arbitrary end point and is of arguable significance if quality of life is not maintained. Long-term side effects of radiotherapy are debilitating and severely affect quality of life. Pelvic insufficiency fractures (PIF) are a known long-term side effect of radiotherapy. Intensity-modulated radiotherapy (IMRT) is being routinely used in the treatment of prostate and head and neck cancer. We postulated that use of IMRT in gynaecological cancers reduces the incidence of PIF.
Patients and methods
We retrospectively reviewed 10 cases of PIF treated on standard treatment. We recalculated dose volume histograms based on IMRT protocols for patients with PIF.
We found that none of the patients received any radiation at the fracture site and the total radiation received to the sacrum was lower compared with the standard treatment protocols.
We conclude that the feasibility of IMRT in gynaecological cancers should be further evaluated and might be an useful tool in reducing the number of PIF.