Despite the acknowledged value of providing prostate radiotherapy patients with sexual dysfunction (SD) information, there is little evidence related to patient perceptions of this or the extent to which information is provided to them. This study aimed to critically evaluate the quality and format of SD information given to patients before, during and after radical EBRT to treat prostate cancer.

Members of UK prostate cancer support groups were asked to complete an anonymous online survey tool seeking opinions of the SD information they were given before, during and after external beam radiotherapy (EBRT).

There were 56 responses to the survey with over 42% of respondents reporting that they had not received any SD information. Of those who did, 78·1% (25/32) received information before the start of EBRT. Physicians were the most involved in the provision of SD information, with nurses and therapeutic radiographers being underutilised. Responses were mostly negative, or neutral regarding the quality of SD information and the information received about impact on relationships, psychological and emotional health. Many participants wanted more information and support.

This study demonstrates that prostate cancer patients who have undergone radical EBRT have not received adequate information relating to potential sexual function side effects and the psychological and emotional effects of SD. This information should be included in verbal and written information provided at all stages of the radiotherapy pathway.

Carcinomatous meningitis with metastases to the spinal cord [intramedullary spinal cord (IMSC)] is very rare, and a quick intervention to management of these patients is important in preventing neurological deterioration.

We report a case of IMSC metastases from a stage IV non-small cell lung carcinoma in a 57-year-old man who presented with Brown-Sequard syndrome along with multiple brain metastases with associated carcinomatous meningitis and managed with urgent palliative external beam radiation therapy.

A quick, short course of palliative radiation therapy for inoperable patients with IMSC metastases provides improvement in neurological function in the management of these oncologic emergencies in patients with short survival times.

Radiotherapy treatment delivery is evaluated by a pre-treatment patient-specific quality assurance (PSQA) procedure to ensure the patient receives an accurate radiation dose. The current PSQA practice by using conventional phantoms requires more set-up time and cost of purchasing the tools. Therefore, this study aimed to investigate the efficiency of an electronic portal imaging device (EPID) of linear accelerator (LINAC) as a PSQA tool for volumetric-modulated arc therapy (VMAT) planning technique for nasopharyngeal carcinoma (NPC) treatment delivery.

A NPC VMAT plan on a Rando phantom was performed by following the Radiation Therapy Oncology Group (RTOG) 0615 protocol. The gamma passing rate of the EPID and PSQA phantom (ArcCHECK) were compared among the gamma criteria of 3%/3 mm, 2%/2 mm and 1%/1 mm, respectively.

Both EPID and ArcCHECK phantom had distinguishable gamma passing rates in 3%/3 mm and 2%/2 mm with a difference of 0·87% and 0·30%, respectively. Meanwhile, the EPID system had a lower gamma passing rate than the ArcCHECK phantom in 1%/1 mm (21·23% difference). Furthermore, the sensitivity of the EPID system was evaluated and had the largest deviation in gamma passing rate from the reference position in gamma criteria of 2%/2 mm (41·14%) compared to the 3%/3 mm (25·45%) and 1%/1 mm (31·78%), discretely. The best fit line of the linear regression model for EPID was steeper than the ArcCHECK phantom in 3%/3 mm and 2%/2 mm, and vice versa in gamma criteria of 1%/1 mm. This indicates that the EPID had a higher sensitivity than the ArcCHECK phantom in 3%/3 mm and 2%/2 mm but less sensitivity in 1%/1 mm.

The EPID system was efficient in performing the PSQA test of VMAT treatment in HUSM with the gamma criteria of 3%/3 mm and 2%/2 mm.

Buschke–Lowenstein tumour (BLT) is a rare verrucous lesion often associated with human papillomavirus infection. It is an indolent but locally aggressive lesion usually arising from the genitalia or anorectum, with a potential risk of recurrence and malignant transformation. The first line of management is surgical or laser excision. Topical agents cryotherapy, radiotherapy and chemo-immunomodulators are reserved for residual or recurrent cases and smaller lesions.

A 24-year-old female on antiretroviral therapy presented in our department with a large cauliflower-shaped growth involving the perineum, vulva and lower vagina. A biopsy of the lesion was suggestive of a BLT. Due to the extensive nature of the disease, surgery was deferred. The lesion was treated with definitive external beam radiation therapy (EBRT) using a 6-megavoltage photon beam on a Cobalt-60 unit.

Radiotherapy resulted in a significant response without any acute toxicity, following which, topical podophyllin application was advised for the residual perianal lesion. The patient is disease free after 9 months of follow-up.

A multidisciplinary approach is important to treat the BLT. Lesions not amenable to surgery or local therapies can be treated with EBRT with reasonable control and acceptable toxicities.

The study aimed to compare the dosimetric performance of Acuros® XB (AXB) and anisotropic analytical algorithm (AAA) for lung SBRT plans using Monte Carlo (MC) simulations.

We compared the dose calculation algorithms AAA and either of the dose reporting modes of AXB (dose to medium (AXB-Dm) or dose to water (AXB-Dw)) algorithms implemented in Eclipse® (Varian Medical Systems, Palo Alto, CA) Treatment planning system (TPS) with MC. PRIMO code was used for the MC simulations. The TPS-calculated dose profiles obtained with a multi-slab heterogeneity phantom were compared to MC. A lung phantom with a tumour was used to validate TPS algorithms using different beam delivery techniques. 2D gamma values obtained from Gafchromic film measurements in the tumour isocentre plane were compared with TPS algorithms and MC. Ten VMAT SBRT plans generated in TPS with each algorithm were recalculated with a PRIMO MC system for identical beam parameters for the clinical plan validation. A dose–volume histogram (DVH) based plan comparison and a 3D global gamma analysis were performed.

AXB demonstrated better agreement with MC and film measurements in the lung phantom validation, with good agreement in PDD, profiles and gamma analysis. AAA showed an overestimated PDD, a significant difference in dose profiles and a lower gamma pass rate near the field borders. With AAA, there was a dose overestimation at the periphery of the tumour. For clinical plan validation, AXB demonstrated higher agreement with MC than AAA.

AXB provided better agreement with MC than AAA in the phantom and clinical plan evaluations.

The radiotherapy techniques are evolving. Besides optimal tumour coverage, considering organs at risk (OAR) is pertinent to radiation oncologists. In mid-lower esophageal cancer (MLEC) radiotherapy, heart is the main OAR. Studies on excess absolute risk (EAR) of cardiovascular disease (CVD) in MLEC radiotherapy are limited in the main literature. Therefore, this study was conducted to estimate the EAR of CVD in patients with MLEC treated with the intensity-modulated radiation therapy (IMRT) technique.

Family history of heart disease and smoking increased the EAR of CVD significantly compared to the cholesterol and high-sensitivity C-reactive protein. The 10-year EAR of the high-risk group was more than four times of the low-risk group at all ages. In the low-risk group, EAR of CVD after radiotherapy of esophageal cancer can increase by up to 9·1%, while in the high-risk group, EAR increased by 34·89%.

Adding the baseline CVD risk factors improved the estimation of EAR of heart disease after MLEC radiotherapy with the IMRT technique.

To limit the entrance dose to normal tissue and achieve the appropriate treatment time (TT) by using three different virtual structures with directional blocks for left-sided post-mastectomy radiation therapy (PMRT) with regional nodal irradiation (RNI).

Ten breast cancer patients who received PMRT by helical tomotherapy were enrolled. Three virtual structures were created for each patient: Organ-based, L-shaped (LB) and C-shaped (CB). The dose to the target and organ at risk (OARs), TT, the volume which received dose 5 Gy (V5Gy), integral dose (ID) and block structure contouring workload (BSCW) of the three virtual block techniques were evaluated. The performance scores were used to explore the suitable technique.

The CB plans showed a significantly better V5Gy, ID and contralateral breast-sparing. However, the CB plans revealed the longest TT and BSCW (p < 0·001). Contrary to the LB, the LB plans showed a significantly reduced TT and BSCW and provided the balance of plan efficiency with the highest score.

The LB technique is considered to be the suitable technique for left-sided PMRT with RNI and provided the advantage of TT, V5Gy, ID and BSCW while maintaining acceptable criteria for the target and OARs.

To assess the accuracy of the Varian PerfectPitch six-degree-of-freedom (6DOF) robotic couch by using a Varian SRS QA phantom.

The stereotactic radiosurgery (SRS) phantom has five tungsten carbide BBs each with 7·5 mm in diameter arranged with the known geometry. Optical surface images and cone beam CT (CBCT) images of the phantom were taken at different pitch, roll and rotation angles. The pitch, roll, and rotation angles were varied from −3 to 3 degrees by inputs from the linac console. A total of 39 Vision RT images with different rotation angle combinations were collected, and the Vision RT software was used to determine the rotation angles and translational shifts from those images. Eight CBCT images at most allowed rotational angles were analysed by in-house software. The software took the coordinates of the voxel of the maximum CT number inside a 7·5-mm sphere surrounding one BB to be the measured position of this BB. Expected BB positions at different rotation angles were determined by multiplying measured BB positions at zero pitch and roll values by a rotation matrix. Applying the rotation matrix to 5 BB positions yielded 15 equations. A linear least square method was used for regression analysis to approximate the solutions of those equations.

Of the eight calculations from CBCT images, the maximum rotation angle differences (degree) were 0·10 for pitch, 0·15 for roll and 0·09 for yaw. The maximum translation differences were 0·3 mm in the left–right direction, 0·5 mm in the anterior–posterior direction and 0·4 mm in the superior–inferior direction.

The uncertainties of the 6-DOF couch were examined with the methods of optical surface imaging and CBCT imaging of the SRS QA phantom. The rotational errors were less than 0·2 degree, and the isocentre shifts were less than 0·8 mm.

In this study, the relation between radiation pneumonitis (RP) and a wide spectrum of clinical, radiographic and treatment-related factors was investigated. As scoring of low-grade RP can be subjective, RP grade ≥3 (RP ≥ G3) was chosen as a more objective and clinically significant endpoint for this study.

105 consecutive patients with locally advanced non-small cell lung cancer underwent conventionally fractionated radio-(chemo-)therapy to a median dose of 64 Gy. A retrospective analysis of 25 clinical (gender, race, pulmonary function, diabetes, statin use, smoking history), radiographic (emphysema, interstitial lung disease) and radiotherapy dose- and technique-related factors was performed to identify predictors of RP ≥ G3. Following testing of all variables for statistical association with RP using univariate analysis (UVA), a forward selection algorithm was implemented for building a multivariate predictive model (MVA) with limited sample size.

Median follow-up of surviving patients was 33 months (9–132 months). RP ≥ G3 was diagnosed in 10/105 (9·5%) patients. Median survival was 28·5 months. On UVA, predictors for RP ≥ G3 were diabetes, lower lobe location, planning target volume, volumetric modulated arc therapy (VMAT), lung V5 Gy (%), lung Vspared5 Gy (mL), lung V20 Gy (%) and heart V5 Gy (% and mL). On MVA, VMAT was the only significant predictor for RP ≥ G3 (p = 0·042). Lung V5 Gy and lung V20 Gy were borderline significant for RP ≥ G3. Patients with RP ≥ 3 had a median survival of 10 months compared to 29·5 months with RP < G3 (p = 0·02).

In this study, VMAT was the only factor that was significantly correlated with RP ≥ G3. Avoiding RP ≥ G3 is important as a toxicity per se and as a risk factor for poor survival. To reduce RP, caution needs to be taken to reduce low-dose lung volumes in addition to other well-established dose constraints.

Brachytherapy is an effective local treatment for early-stage head and neck cancers. Mold irradiation is a method in which the source is placed in the oral cavity in sites where the soft tissue is thin and an irradiation source cannot be implanted. However, dose calculations based on TG-43 may be subject to uncertainty due to the heterogeneity of tissues and materials used for the irradiation of head and neck cancers.

In this study, we investigated the basic physical properties of different materials and densities in the molds, retrospectively analysed patient plans and verified the doses of intraoral mold irradiation using a dose verification system with MC simulations specifically designed for brachytherapy, which was constructed independently.

Dose–volume histograms were obtained with a treatment planning system (TG-43) and MC simulation and revealed a non-negligible difference in coverage of high-risk clinical target volume (HR-CTV) and organ at risk (OAR) between calculations using computed tomography values and those with density changes. The underdose was 10·6%, 3·7% and 5·6% for HR-CTV, gross tumour volume and OAR, respectively, relative to the treatment plan. The calculations based on the differences in the elemental composition and density changes in TG-43, a water-based calculation algorithm, resulted in clinically significant dose differences. The validation method was used only for the cases of complex small source therapy.

The findings of this study can be applied to more complex cases with steeper density gradients, such as mold irradiation.

We compare the accuracy of the off-axis Winston–Lutz (WL) test in two versions of ExacTracTM: version 6.0 (ETv6) and Dynamic (ETD) in the same linac (TrueBeam STx®).

An upgraded of the ExacTracTM system was done in our institution. It was designed as an off-axis WL test before the update for comparison purposes. A head 3D-printed phantom based on a patient’s computed tomography images was used. Nine metallic fiducials were inserted and distributed on the phantom. Each target (fiducial) was designed an off-axis WL test with eight different gantry/collimator/table combinations. The phantom was placed using two different ETv6 and ETD in the same linac, and cone-beam computed tomography and electronic portal imaging device (EPID) images were acquired. The 2D deviation between the centre of the fiducial and the radiation field was found and compared with the original digital reconstructed radiography (DRR) by the profiles.

The phantom allows the definition of a procedure to determine off-axis deviations in radiosurgery treatments. The displacements calculated from the WL test showed acceptable values for both versions taking into account 3D displacement tolerances of 1 mm. These values were reached with rigorous quality assurance (QA) linac tests performed routinely that include mechanical, MV/kV and image-guided radiotherapy (IGRT) tests. However, ETD indicated more accurate values for all the targets no matter the distance to the isocentre (3D displacements < 0·5 mm).

In terms of the IGRT correction without set-up displacements, ETD is up to twice as accurate as the ETv6, showing 3D displacements up to 0·5 mm in all targets.

Secondary oesophageal carcinoma from a breast primary is an infrequent phenomenon. Given the rarity of this presentation, there is a general lack of consensus on management guidelines.

Herein, we report a case of a 65-year-old female presented with dysphagia, 14 years post-surgery for breast cancer. She was diagnosed with oesophageal metastases and was treated with combination of systemic chemotherapy, hormonal therapy and local radiotherapy. Our patient tolerated the treatment well and achieved a significant symptomatic improvement post-radiotherapy. We also performed a review of literature on oesophageal metastases from breast primary, aiming to improve the diagnostic accuracy and treatment efficacy in this rare presentation.

We conclude that patients who present with persistent dysphagia post-breast cancer treatment should undergo an endoscopic ultrasound (EUS)-guided fine-needle biopsy (FNB) to rule out oesophageal metastasis. We suggest systemic chemotherapy with hormonal therapy and radiotherapy for local control as a management of choice in this condition. Even though prognosis is difficult to predict in these patients, this combined modality of treatment seems to achieve better overall survival.

Stereotactic ablative radiotherapy (SABR) is susceptible to challenges for tumours affected by intrafraction organ motion. This study aims to investigate the effect of breathing characteristics and plan complexity on the interplay effect.

A patient-specific interplay effect evaluation was performed using in-house software with an alpha version of the treatment planning verification software Verisoft (PTW-Freiburg, Germany) on VMAT plans. The OCTAVIUS 4D phantom was used to acquire the static dose distribution, and the simulation approach was utilised to generate the moving dose distribution. The influence of plan complexity, PTV size, number of breaths, and motion amplitudes on the interplay effect were examined. The dose distribution of two extreme phases—end-inhale and end-exhale—was considered using the gamma criteria of 2%/2 mm for the interplay effect evaluation.

A strong correlation was found between the motion amplitude (p < 0.001) and the NBs (p < 0.001) with the gamma-passing rate. No correlation was found between the gamma-passing rate and the PTV size or plan complexity.

The simulation tool allowed the analysis of a large number of breathing traces, demonstrating how free-breathing patients, suspected of high interplay, could be selected for other motion management solutions. The simulated cases showed strong interplay effects for long breathing periods with extended motion amplitudes in a small group of patients.

In image-guided radiotherapy (IGRT), the imaging conditions of computed tomography (CT) may impact the positioning uncertainty, but verification methods are currently unavailable. This study aimed to propose a validation method for the imaging conditions of helical CT for IGRT. Predicting the impact of image distortion on image guidance may reduce uncertainty in radiotherapy planning.

Image guidance was performed on the reference images of four Duracon balls by changing the imaging conditions and the positions on the CT images by helical scanning. The predictors of image guidance error and those of the contour mismatch between the reference and cone-beam CT (CBCT) images were analysed.

The image guidance error exceeded 1 mm when the contour centre of the ball was shifted by more than 1 mm. The mismatch between the contours of the reference and CBCT images occurred with the imaging conditions wherein the first slice of the ball was distorted.

Mismatch can be predicted by the coefficient of variation of the radii in the first and centre slices of the ball. Moreover, the image guidance error can be predicted by the contour centre shift of the ball.

In modulated radiotherapy treatments with the jaw tracking technique (JTT), the collimator jaws can dynamically follow the multileaf collimator apertures and reduce radiation leakage. This reduction protects normal tissue from unwanted doses. Previous research has highlighted the importance of defining which patients will benefit most from JTT. Besides, some authors have expressed their concerns about possible increases in monitor units (MUs). Treatments of patients with peripheral targets and isocentre located in the patient’s midline are of particular interest. The current work assessed the effect of JTT on these cases.

JTT plans for thirty-two patients were compared to plans with the static jaws technique. The volumes of normal tissue receiving 5 Gy (V5), 10 Gy (V10) and 20 Gy (V20), mean dose (Dmean), target coverage parameters D95, D2% and Paddick’s conformity index (PCI) were compared. MUs were also registered for comparisons. The decrease in the jaws opening with JTT was correlated to the decrease in dose values in normal tissue.

Small decreases were observed in D95 and in D2% values, without statistical significance. A 5% average decrease in PCI values was noticed as well as significant decreases in V5, V10 and Dmean values, 9% on average. A 3% decrease in V20 was also observed. The number of MUs decreased by 2%. A significant correlation was found between the reduction of the secondary collimation opening areas and the dose delivered to normal tissue.

JTT technique improved normal tissue protection in volumetric modulated arc therapy treatments for the patients included in the present study.

This retrospective cohort study tries to determine if there is a correlation between the effectiveness of low-dose radiotherapy (LDRT) in treating painful inflammatory or degenerative musculoskeletal disorders (MSDs) and the applied radiotherapy energy.

Between September 2019 and January 2020, a total of 91 patients with either painful inflammatory or degenerative MSDs were treated with LDRT. The inclusion criteria were patients older than 40 years with either painful inflammatory disorders such as epicondylitis humeri, plantar fasciitis or degenerative osteoarticular disorders of the wrist or ankle joints. All patients were treated with a single dose of 0·5 Gy and a total dose of 6·0 Gy (2 to 3 fractions weekly). Patients were divided into two groups. Orthovolt group was treated with 200 Kv, 15 mA and 1 mm copper filtration with different tubes according to the site to treatment using direct fields. The second group included patients treated with Linac machines with opposing fields using energies between 6 and 18 MV. The pain was evaluated before and on the last day of treatment and 4–6 months later using the Numerical Rating Scale.

91 patients compatible with the inclusion criteria were identified with a median of 60 years. The median duration of symptoms was 6 months. 46% of patients were males, and 54% were females. The Orthovolt group included 49% of the patients and the Megavoltage group 51%. Most of the patients (98%) were previously treated with other methods such as local corticosteroid injection, painkillers or physiotherapy. At the end of the treatment, 60% of the patient’s showed subjective pain relief and only 6% had a complete response. The follow-up conducted 4 to 6 months after the treatment showed that 65% of patients had a complete response and 8% had an improvement. The comparison between both studied groups shows that the used energy does not affect the response either at the end of the treatment or at the second control. The relationship between the aetiology and the early and late responses shows no difference in the early response but a better late response in patients suffering from inflammatory diseases with a p-value of 0·015. The response according to the treated location shows that patients with osteoarthritis of the ankle joint have a worse response in comparison to other examined joints and plantar fasciitis.

LDRT is an effective analgesic treatment option for both inflammatory and degenerative MSDs. There is no difference in response according to the used energy, and most of the patients show late responses 4 to 6 months after the treatment.

The dose calculation plays a crucial role in many aspects of contemporary clinical radiotherapy treatment planning process. It therefore goes without saying that the accuracy of the dose calculation is of very high importance. The gold standard for absorbed dose calculation is the Monte-Carlo algorithm.

This first of two papers gives an overview of the main openly available and supported codes that have been widely used for radiotherapy simulations.

The paper aims to provide an overview of Monte-Carlo in the field of radiotherapy and point the reader in the right direction of work that could help them get started or develop their existing understanding and use of Monte-Carlo algorithms in their practice.

It also serves as a useful companion to a curated collection of papers on Monte-Carlo that have been published in this journal.