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The COVID-19 pandemic has required a rapid and evolving response in order to enable the continued delivery of radiotherapy, whilst effectively managing the risk of infection to patients and staff. In early March 2020, we were presented with the challenge of achieving safe delivery of care in clinical practice for a group of patients that are already at higher risk of morbidity from COVID-19 with only limited guidance.
This article outlines the adjustments made at The Christie at Oldham satellite centre in order to promote optimal care to our patients receiving radiotherapy, and to mitigate infection risk at the department for both patients and staff.
Materials and Methods:
We share insight into some of the evolving processes that our team have developed since March 2020 in promoting optimal care to patients receiving radiotherapy at The Christie at Oldham satellite centre. These include changes to the department floor, paper flow, supportive care and staffing.
Results and Conclusions:
As we continue to progress through this pandemic, we accept that there will be an ongoing journey of learning with adjustments to practice and evolving ‘new norm’, thereby ensuring we keep our patients and team safe and well. We also hoped that our experience would support radiotherapy-related practices in surges of the pandemic in other parts of the world or in case of the second wave.
This study attempts to investigate fiducial marker (FM) migration and calculate the prostate planning target volume (PTV) margin considering the setup errors after translation corrections alone (T) and translation plus rotational corrections (T+R) and anatomy variation with respect to the corrected fiducial position, analysed on cone beam computed tomography (CBCT) images.
Methods and materials:
CBCT images from 25 patients are analysed for FM movements, setup error and anatomy variation with respect to the seed match positions. Systematic and random components of setup error and prostate movements are used to calculate the PTV margin for CBCT-based FM localisation in two scenarios, translation corrections only and translation plus rotational correction. MTNW887825 soft tissue gold markers (Civco, Orange City, FL, USA) were used with the department-specific immobilisation system and rectal and bladder filling protocols.
The average directional inter-marker distance variation is −0·05 ± 0·90 mm. The systematic setup errors for T+R are 0·40, 0·63 and 0·80 mm in right–left (RL), anterior–posterior (AP) and superior–inferior (SI), respectively. The corresponding values for T only are 0·54, 0·69 and 0·90 mm. The systematic prostate movement from T+R corrected FM positions are 0·65, 1·27 and 1·32 mm in the RL, AP and SI directions.
Minimal FM movements are noted from the study. The PTV margins to incorporate the daily T+R corrected setup error and prostate deformation are found to be 2·5, 4·5 and 5·2 mm in the RL, AP and SI directions, respectively. The corresponding margins for T only corrected scenario are found to be 2·8, 4·8 and 5·7 mm.
Papillon treatment is a form of contact X-ray brachytherapy (CXB) which is used as an alternative to surgery for rectal cancer. This study aimed to audit patients who were referred for and treated with CXB over a 6-year period against guidelines derived from a critical review of the evidence base.
Materials and methods:
Patient demographics, tumour characteristics and outcome data were gathered for 31 patients referred for CXB. A critical review of the evidence identified consensus referral criteria and outcome data against which to audit patients.
Referral criteria were derived from six published studies. These applied to patients unfit for surgery or stoma-averse. All referred patients had a visible tumour or scar with a tumour size under 3 cm and sited less than 12 cm from the anal verge. Nodal status varied from N0 to N2, but there was no metastatic disease present. The audited cohort demonstrated demographic equivalence, while the initial clinical complete response and recurrence rates were also comparable.
This audit confirmed the validity of referral and treatment protocols and should guide future referrals until evidence from ongoing studies becomes available. These findings should contribute to the development of robust national guidelines.
The dosimetric impact of volumetric modulated arc therapy (VMAT) in lung cancer compared with 3D conformal radiotherapy (3DCRT) is well known. However, this improvement is often associated with an increase in low doses. The aim of this study is to quantify these results more accurately.
For each patient treated with 3DCRT, a second VMAT treatment plan was calculated. Usual dosimetric parameters such as target coverage or dose to the organs at risk were used to achieve the comparisons.
For planning target volume, homogeneity and conformity indices showed superiority of VMAT (respectively 0·07 and 0·87) compared to 3DCRT (0·11 and 0·57). For spinal cord planning organ at risk volume, the median maximum dose was 45·6 Gy in 3DCRT against 19·3 Gy in VMAT. Heart volume receiving at least 35 Gy (V35) decreased from 15·64% in 3DCRT to 8·28% in VMAT. Oesophagus V50 was higher in 3DCRT (25·45%) than in VMAT (14·03%). The mean lung dose was 17·9 Gy in 3DCRT versus 15·5 Gy in VMAT. Moreover, volumes receiving 5, 10 and 15 Gy were not significantly different between the two techniques when VMAT was performed with partial arcs.
All the dosimetric parameters were improved with VMAT compared to the 3DCRT without increasing low doses when using partial arcs.
Stereotactic body radiation therapy for lung tumours can expose patients to radiation pneumonitis (RP) (<6 months after irradiation) and lung fibrosis (beyond 6 months). The aim of this study was to describe post-irradiation radiographics appearances.
Materials and methods:
This retrospective study of 90 patients with a stage I non-small cell lung carcinoma reports a detailed description of the computed tomography (CT) or positron emission tomography/CT changes that can be observed after treatment, according to modified Kimura score for RP and Koenig’s classification for fibrosis. This evaluation was realised at 1 month and then every 3–4 months, with a median follow-up of 35 months.
The most common radiological RP pattern was diffuse consolidation. It appears in a mean time of 4 months and reaches its maximum at 9 months after radiotherapy. Seventy-three per cent of the RP evolved to fibrosis. Most of these findings were encompassed in the 35 Gy isodose.
Radiological parenchymal changes are frequent in the treatment region, which renders the tumour response monitoring by tumour size, particularly by response evaluation criteria in solid tumours, unsuitable.
Breast cancer patients referred for external beam radiotherapy and who have large and/or pendulous breasts can present positioning and immobilisation challenges. Deep infra-mammary and/or lateral wrap skin folds can occur that can lead to unwanted radiation-induced skin toxicity. The purpose of the study was to evaluate the immobilisation techniques adopted for this subgroup of patients in order to inform best practice.
A survey aimed to identify the current clinical practice in radiotherapy centres throughout the United Kingdom and Ireland was undertaken. The email survey was distributed with support of the Radiotherapy Services Managers group.
Twenty-six of the 74 radiotherapy centres responded to the survey. Responses demonstrated that supine positioning with or without additional immobilisation was preferable. Of the eight different immobilisation techniques identified, patients positioned supine on a breast board wearing a bra was the most common. Only two of the centres reported using a prone technique.
Immobilisation and reproducibility are key for successful external beam radiotherapy particularly when advanced treatment techniques are being employed. No single technique gained widespread acceptance as the optimum for the effective immobilisation of patients with large and/or pendulous breasts. Further evaluative research in the form of a multi-centre trial is warranted in order to clearly establish the most effective immobilisation methods/devices for this ever expanding, subgroup of cancer patients.
The purpose of this study is to investigate the feasibility of proton arc therapy (PAT) using the double-scattering MEVION-S250 proton system. The treatment planning and dose delivery parameters from PAT were compared with conventional treatment planning techniques.
Materials and methods:
PAT was simulated with multiple conformal and fixed-aperture beams (5–15) using the MEVION-S250-double-scattering proton system. Conformal apertures were simulated with the Eclipse-treatment-planning system: (a) using a static single aperture that provides the best average conformal circular or rectangular apertures to cover the tumour from different angular views (SPAT), and (b) dynamic conformal apertures of the tumour shape at each irradiation angle that can be obtained from a multi-leaf-collimator system (DPAT).
The DPAT and SPAT plans provided superior dose coverage and sparing of normal tissues in comparison with conventional plans (CPT). The entrance normal tissue and skin doses (<40%) were lowered significantly by delivering dose from different directions over a wider angular view compared to conventional plans that have large entrance dose from only two fields. While the mean and minimum doses from PAT and CPT were comparable, the maximum doses from arc plans were lower than the maximum doses in conventional plans. The SPAT and DPAT plans had comparable dose parameters for regularly shaped targets. The heterogeneity index (HI) was superior in PAT plans which improved with increasing number of beams in arc plans for the different treatment sites. The conformality index (CI) depends on the treatment site and complexity of the shape of the planning target volume where for brain, pancreatic and lung tumours, PAT plans conformality was comparable and sometimes superior to CPT; and HI and CI were generally better in DPAT compared to SPAT.
PAT plans have superior dose coverage and sparing of normal tissues compared to CPT plans using the MEVION double-scattering system as shown in this simulation study. Ideally, conformal proton arcs require beam shaping and dose delivery with the gantry moving; however, the MEVION double-scattering system lacks a multi-leaf collimator system and cannot deliver dose during gantry rotation. The single aperture conformal proton therapy technique is more time and cost effective compared with conventional techniques that are used currently with the MEVION proton therapy system because of the elimination of the need for patient-specific compensators. In present study, PAT was simulated with the MEVION double-scattering proton therapy system; however, it can be performed also with other proton therapy systems.
Concurrent chemoradiation is the definitive treatment for advanced cervical cancer. Pelvic radiation is known to damage the adjacent normal tissues thereby causing acute toxicities. The modern conformal radiation techniques like three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy are known to reduce the toxicities and improve clinical outcomes.
To retrospectively evaluate the frequency and severity of acute toxicities encountered during concurrent chemoradiation of locally advanced cancer cervix treated with 3D-CRT.
The medical case records of 174 cervical cancer patients treated between November 2015 and November 2018 were studied. One hundred and thirteen histologically proven locally advanced cancer cervix patients (Stage IIB–IIIB) treated with concurrent 3D conformal chemoradiation between were included in the study. Patients received 46 Gy in 23 fractions with concurrent weekly cisplatin (40 mg/m2) on days 1, 8, 15 and 22 of radiation. The study endpoints were treatment-related toxicities which were graded according to CTCAE version 5.0.
One hundred and thirteen patients were analysed for the study. Gastrointestinal toxicity was the predominant toxicity observed followed by haematological toxicity. 31·7% patients reported grade 1–2 diarrhoea and 39·7% reported grade 1–2 leucopenia. None of the patients reported grade 3 or higher toxicities. Treatment interruptions were noted due to these toxicities.
Concurrent chemoradiation is the definitive treatment for locally advanced carcinoma cervix with acceptable toxicities. Proper management measures should be undertaken for these toxicities to avoid treatment interruptions and ensure better treatment compliance.
To determine the frequency, factors and reasons of patient non-adherence to radiotherapy (RT) in a tertiary cancer centre.
Inadvertent treatment interruptions often lead to prolongation of planned treatment time. In the case of RT with a curative intent, prolongation of planned treatment has been associated with inferior clinical outcomes. Delay or prolongation of treatment is associated with a relative risk of local recurrence by up to 2% per day for specific malignancies. Thus, it is critical to understand key factors that influence non-adherence to RT.
Methods and Materials:
A retrospective observation audit was conducted comprising patients treated with radical, adjuvant or palliative RT at our centre from January 2018 to December 2018. Non-adherence was defined as premature permanent termination of planned treatment by the patient without recommendation or consultation from the treating clinician. All data were collected and analysed (retrospectively) with the help of Statistical Package for the Social Sciences (SPSS) version 22.
A total of 1,548 patients were included in the study of which 105 (6·7%) were non-adherent to planned RT. Of the total 105 patients, 44 (42%) were elderly (60 years and above). Treatment non-adherence was predominant in males (male:female = 1·85:1). More than 90% of non-adherent patients had stage III and IV cancer. A total of 77 patients (74%) out of 105 were more than 50 km away from our centre. A total of 66 (63%) out of 105 patients had completed more than 2 weeks of radiation (40% of planned RT) and then defaulted for radiation due to acute toxicities.
Treatment adherence is a major factor in determining successful outcomes among cancer patients treated with RT. This study reveals several factors that contribute to non-adherence to treatment.
Breast cancer patients experience skin reactions during radiotherapy. Radiation-induced skin reactions can result in treatment delivery being interrupted. The aim of this paper is to evaluate the skincare management of patients receiving radiotherapy for breast cancer in order to inform best practice.
A literature search was undertaken using USearch and HONNI in support of the first-hand evidence gained from the supervised on-treatment review of patients receiving radiotherapy for breast cancer.
There is evidence to suggest that the skincare advice given to patients varies widely between departments in the UK with many not following nationally recommended guidelines. Studies demonstrate that there are ways to reduce skin reactions and that there are a range of effective management strategies being adopted. Prophylactic skincare has been explored to improve the resilience of the skin prior to commencing radiotherapy.
Further investigation is required in order to clearly establish the optimum national skincare management for breast cancer patients. More studies are required to test the effectiveness and viability of prophylactic measures. Skincare guidance needs to be robustly developed and effectively promoted by therapeutic radiographers for radiotherapy patients to benefit from reduced, radiation-induced, skin reactions.
Lung cancer has a high mortality rate mainly due to the lack of early detection or outward signs and symptoms, thereby often progressing to advanced stages (e.g., stage IV) before it is diagnosed. However, if lung cancers can be diagnosed at an early stage and also if clinicians can prospectively identify patients likely to respond to specific treatments, then there is a very high potential to increase patients’ survival. In recent years, several investigations have been conducted to identify cancer biomarkers for lung cancer risk assessment, early detection and diagnosis, the likelihood of identifying the group of patients who will benefit from a particular treatment and monitoring patient response to treatment.
Materials and Methods:
This paper reports on the review of 19 current clinical and emerging biomarkers used in risk assessment, screening for early detection and diagnosis and monitoring the response of treatment of non-small-cell lung cancers.
The future holds promise for personalised and targeted medicine from prevention, diagnosis to treatment, which take into account individual patient’s variability, though it depends on the development of effective biomarkers interrogating the key aberrant pathways and potentially targetable with molecular targeted or immunologic therapies. Lung cancer biomarkers have the potential to guide clinical decision-making since they can potentially detect the disease early, measure the risk of developing the disease and the risk of progression, provide accurate information of patient response to a specific treatment and are capable of informing clinicians about the likely outcome of a cancer diagnosis independent of the treatment received. Moreover, lung cancer biomarkers are increasingly linked to specific molecular pathway deregulations and/or cancer pathogenesis and can be used to justify the application of certain therapeutic or interventional strategies.
To evaluate the quality of rectal hydrogel spacer (HS) insertions from literature in patients undergoing radical radiotherapy for prostate cancer. The secondary aim is to assess the benefit of HSs in patients with risk factors more likely to have rectal complications, such as non-conventional radiotherapy dose fractionations and high-risk disease.
Method and materials:
A literature search of peer-reviewed electronic articles was carried out using Boolean connectors and Medical Subject Headings in the databases. Databases searched included ScienceDirect, Medline and Cinahl. The articles were assessed using relevant critical appraisal skills programme tools.
From the 26 studies used, HS showed a clinically significant relative reduction in rectal planning dose volumes for both high- and low-risk prostate cancer patients in a range of radiotherapy treatment modalities including volumetric modulated arc therapy, intensity-modulated radiotherapy, intensity-modulated proton therapy, stereotactic ablative body radiotherapy and brachytherapy. Spacer placements were successfully inserted in 99% of patients. However, rectal wall infiltration occurrence was 6% and ≥2 cm unsymmetrical placements in 2%.
A spacer scoring system based on the HS symmetry has provided evidence of the quality of the position inserted, which was visually aided by T2-wieghted MRIs. Despite optimal HS placements ranging from 62 to 72%, HS had a clinically significant reduction of ≥25% in planned rectal V70 dose in 97% of patients.
The aim of this study was to compare volumetric modulated arc therapy (VMAT) with dynamic intensity-modulated radiation therapy (dIMRT) and step-and-shoot IMRT (ssIMRT) for different treatment sites.
Materials and methods:
Twelve patients were selected for the planning comparison study. This included three head and neck, three brain, three rectal and three cervical cancer patients. Total dose of 50 Gy was given for all the plans. Plans were done for Elekta synergy with Monaco treatment planning system. All plans were generated with 6 MV photons beam. Plan evaluation was based on the ability to meet the dose volume histogram, dose homogeneity index, conformity index and radiation delivery time, and monitor unit needs to deliver the prescribed dose.
The VMAT and dIMRT plans achieved the better conformity (CI98% = 0·965 ± 0·023) and (CI98% = 0·939 ± 0·01), respectively, while ssIMRT plans were slightly inferior (CI98% = 0·901 ± 0·038). The inhomogeneity in the planning target volume (PTV) was highest with ssIMRT with HI equal to 0·097 ± 0·015 when compared to VMAT with HI equal to 0·092 ± 0·0369 and 0·095 ± 0·023 with dIMRT. The integral dose is found to be inferior with VMAT 105·31 ± 53·6 (Gy L) when compared with dIMRT 110·75 ± 52·9 (Gy L) and ssIMRT 115 38 ± 55·1(Gy L). All the techniques respected the planning objective for all organs at risk. The delivery time per fraction for VMAT was much lower than dIMRT and ssIMRT.
Our results indicate that dIMRT and VMAT provide better sparing of normal tissue, homogeneity and conformity than ssIMRT with reduced treatment delivery time.
Prostate cancer is one of the most common solid malignancies and has a high morbidity rate. The uncertainty of the prostate location compromises the overall treatment plan optimisation. To account for the location uncertainty, the radiation oncologist needs to expand the margin of the planning target volume (PTV), which may increase the radiation toxicity to organs in proximity.
Materials and methods:
In this study, we investigated the quality of treatment plans for a patient with different ring sizes (2 and 3 cm). A small ring-shaped structure circumferentially around the PTV helps in defining the location of PTV. Prostate and pelvic node plans were analysed with dose prescription to 99% of PTV.
Additional ring-shaped structures led to more conformal dose coverage for target with reduced radiation side effects to nearby organ at risk (OAR). Expected treatment time was slightly higher for 2 cm ring compared to 3 cm ring. In case of prostate, expected duration was 4% higher, while for node plan, expected duration for 2 cm ring was 16% higher compared to 3 cm ring plan.
It was observed that using a smaller size ring can lead to improved dose sparing to OAR with same target coverage as with larger dimension ring. The composite plans do not show any clinically significant difference in dose to OARs.