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To evaluate and develop an image-guided radiotherapy (IGRT) protocol for the effective treatment of prostate and pelvic lymph nodes.
Methods and materials
This study comprised of nine patients receiving radiotherapy for node negative prostate cancer, who had a pair of planar kV images taken for 37 treatment fractions. The positioning accuracy for both implanted fiducial markers and pelvic bony anatomy (surrogate for pelvic node position) was calculated using random and systematic errors. Appropriate margins were also determined. All patients followed a strict bladder and bowel protocol before computed tomography planning and treatment.
In total, 292 sets of images were used for fiducial marker and pelvic bone registration. A discrepancy of >5 mm between the fiducial markers and the anatomical pelvic bone was seen in 4% of treatment sessions. The maximum displacement observed between the fiducial match and the bone match was 7, 10 and 4 mm in the A/P (anterior/posterior), S/I (superior/inferior) and R/L (right/left) directions, respectively.
The margins used in combination with an online IGRT strategy ensure both the fiducial match and the bone match correlate within 5 mm thus allows good coverage of both prostate and nodal target volumes. It is essential that this is combined with a strict bladder and rectal preparation protocol to ensure accuracy and reproducibility.
The aims of this project were to identify the national range of breast boost radiotherapy doses and variations in treatment practice; determine the factors that potentially cause variations; and examine whether differences between regions are based on clinical evidence or access to technical and financial resources by surveying Therapeutic Radiographers across the United Kingdom to determine current radiotherapy boost practice.
A cross-sectional study design was selected. An electronic questionnaire using the website Survey Monkey® tool was utilised to collect categorical data from practicing Therapeutic Radiographers within the United Kingdom.
Participants were invited to participate from radiotherapy departments across the four countries of the United Kingdom (England, Scotland, Wales and Northern Ireland). There are 52 radiotherapy departments across 12 regions of the United Kingdom.
In total, 34 Therapeutic Radiographers participated. Their responses were grouped according to their region of practice. Results indicated that there are ten different dose schedules offered to patients nationally for the treatment of breast boost, with 77% of respondents using electrons to deliver boost radiotherapy.
There is no general consensus among Therapeutic Radiographers about whether factors such as age, tumour size, tumour grade or the presence of negative or positive margins, influence the therapeutic doses prescribed for different patients. This may be attributed to the absence of clinical research evidence to support evidence-based practice.
We evaluated water-equivalent slabs as an alternative to a bolus to reduce radiation dose to the underlying lungs during electron scar boost irradiation in breast cancer patients with a thin chest wall undergoing post-mastectomy radiation therapy.
Materials and methods
Percent depth doses (PDDs) and attenuation factors were obtained for 6 MeV (the lowest electron energy in most clinics) with solid water slabs (1–10 mm by 1 mm increments) placed on top of electron cones. Scatter dose to contralateral breast caused by the solid water slabs was measured on a human-like phantom using two selective scar boost patient setups.
The PDD plots showed that the solid water slabs had similar dosimetric effects to the bolus with lower skin dose to ipsilateral breast for the same thickness. Slab attenuation and scatter dose to the contralateral breast were increased by ~220% and by a factor of 3 with a 5 mm slab, respectively.
Our results demonstrate the feasibility of using water-equivalent slabs to reduce lung dose for electron scar boost treatment in mastectomy patients with a thin chest wall. However, the increases in treatment time and scatter dose to the contralateral breast are the disadvantages of this approach.
The effective source to surface distance (SSDeff) for different combinations of energy/applicator size of the electron beam produced by the light intraoperative accelerator, a mobile dedicated intraoperative radiotherapy accelerator, has been calculated in this study.
Both ionometric dosimetry and Monte Carlo (MC) simulation were followed to obtain the SSDeff for different combinations of electron energy/applicator size. Simulations were performed using Monte Carlo Nuclear Particles (MCNP) MC code. Measurements were performed by Advance Markus chamber and inside a polymethyl methacrylate slab phantom. Inverse square law method was employed to determine the SSDeff from acquired dosimetry data.
With increasing the applicator diameter at a given energy, SSDeff is also increased. The same result is obtained with increasing the electron beam energy for a given applicator size. The results of MC-based SSDeff for 10 cm diameter reference applicator at different energies were in a good accordance with those obtained by ionometric dosimetry. The maximum and mean differences between the results were 1·1 and 0·6%, respectively.
The results of this study showed that SSDeff of intraoperative electron beam is highly dependent on the applicator size and is a mild function of electron beam energy. These facts are in accordance with those reported for conventional electron beam. The good agreement between the results of MC simulation and ionometric dosimetry confirms the application of MCNP code in modelling of intraoperative electron beam and obtaining the intended parameters.
To report of long-term results and toxicity profiles using image-guided brachytherapy (IGBT) combined with whole pelvic radiation therapy (WPRT) for cervical carcinoma.
Materials and Methods
In total, 52 patients with locally advanced cervical carcinoma were enrolled into the study. WPRT was used to treat the clinical target volume (CTV) with a dose of 45–50·4 Gy in 23–28 fractions. IGBT using computed tomography was performed at the dose of 6·5–7 Gy×4 fractions to the minimum dose covering 90% of target volume (D90) of high-risk clinical target volume (HR-CTV).
The mean cumulative dose in equivalent doses of 2 Gy for the D90 of HR-CTV, dose at 2% at refereed volume (D2cc) of bladder, D2cc of rectum and D2cc of sigmoid colon were 92·4, 87·9, 69·6, and 72 Gy, respectively. At the median follow-up time of 61 months, the 5-year local control, disease-free survival, and overall survival rates were 96·2, 75 and 84·6% respectively. Two patients (3·8%) developed grade 3–4 gastrointestinal and two patients (3·8%) developed grade 3–4 genitourinal toxicities.
The combination of WPRT plus IGBT showed very promising long-term results with excellent local control and toxicity profiles.
To measure dosimetric characteristics for linear accelerator-based electron beams, which are applied through locally manufactured acrylic tubes for intraoral radiotherapy and to calculate the secondary cancer risk for organs at risk.
Materials and methods
Six different acrylic tubes were exposed to a 6-MeV electron beam; they had tips with three angles (0°, 15° and 30°) and two diameters (2·5 and 3·0 cm). Gafchromic EBT2 film was horizontally and vertically inserted in a solid water phantom to measure the dose profiles and percentage depth doses (PDDs). The measured data from radio-photoluminescence glass dosimeters placed on the neck and both eyes were used to estimate the lifetime attributable risk of secondary cancer resulting from intraoral radiotherapy for tongue cancer.
A total of 12 dose profiles were obtained from six different acrylic applicators at 0·5 and 1·28 cm depths. Circular shapes were obtained from 0° applicators, and oval shapes were obtained from 15° and 30° applicators. Absorbed doses at a 0·5 cm depth were higher than those at a 1·28 cm depth. PDD shapes for the six acrylic applicators were similar to those of a normal 6 MeV electron beam. Larger-diameter applicators showed higher PDD than smaller-diameter applicators with the same tip angle. According to our secondary cancer risk estimation, if 100,000 patients received intraoral radiotherapy at 30 years and lived until 80 years, 122 female and 22 male patients would develop secondary thyroid cancer, while 13 female and 18 male patients would develop secondary ocular melanoma or retinoblastoma.
Dosimetric characteristics for linear accelerator-based intraoperative radiotherapy treatment beam were confirmed. In addition, we found that 0·1% of tongue cancer patients would get secondary malignancies for both eyes and thyroid from this treatment.
We aimed to assess the impact of advanced multileaf collimator (MLC) models and flattening filter-free (3F) beam in volumetric-modulated arc therapy (VMAT)-based craniospinal irradiation (CSI).
CT scans of five medulloblastoma patients who previously received CSI at our hospital were used for the present study. Patients were planned for a prescription dose of 35 Gy to craniospinal axis. A three-dimensional conformal radiotherapy (3DCRT) plan and a VMAT plan using 1 cm MLC leaf width were generated as the gold standard (reference arm). Test VMAT plans were generated using Agility MLC model (MLC leaf width 5 mm) for various combinations of flattened beam (F) and 3F beam for treating the brain and spine planning target volume (PTV). Organs at risks (OARs) were analysed for dose 5, 50, 75 and 90% volumes, mean dose and maximum dose.
All 3DCRT plans and VMAT plans were aimed to cover 95% of PTV by at least 95% prescription dose. VMAT demonstrated lesser dose spillage than 3DCRT to body volume minus PTV (NTID: non tumor integral dose) for a dose threshold above 7·5 Gy. For the low-dose range (1–7 Gy), variation between the dose coverage between all VMAT plans (for either spine or brain PTV) was <1%. Intra-VMAT plan dose variation for all OAR’s for all tested parameters was <1 Gy. Average monitor unit (MU) difference among different VMAT plans ranged between 1·52 and 2·13 when normalised to 3DCRT MU. For VMAT plans, flat beam with 1 cm MLC showed the highest MU, whereas Agility MLC with 3F beam had the least MU values for intra-VMAT plans. No statistical significance variation (p) was observed in between reference arm and test arm plans except for mean dose and V107% for PTV spine. When compared between reference arm 3DCRT and test arm VMAT plans. For OAR’s, no statistical difference was observed between reference and test arm VMAT plans.
Reference arm plans and test arm plans exhibit no statistically significant difference. However, as compared with 3DCRT, VMAT plans are more conformal and produce lesser dose to OAR at the cost of higher delivered MU. 3F beams or finer width MLC’s (width <5 mm) have no advantage over the conventional 1 cm MLC and flat beam except that 3F beams have a shorter beam delivery time. This study demonstrate a significantly lesser spillage dose to NTID/body that of the reported literature, which is attributed to limited rotational arc length used for VMAT plans.
Advances in treatment over recent years have increased the long-term survival of young, female cancer patients; unfortunately these treatments bring a significant risk of ovarian failure and infertility. This literature review aimed to determine the optimal technique for ovarian preservation in pre-menopausal women receiving pelvic radiotherapy (IMRT). The traditional method comprises surgical transposition; IMRT and other emerging techniques may offer alternative non-invasive means of sparing ovaries and minimising dose.
A critical review of the evidence pertaining to pelvic radiotherapy and ovarian sparing was performed. Evidence was subjected to critical appraisal using the Critical Appraisal Skills Programme tool and thematic analysis of the findings identified key issues.
Surgical transposition appears to be a successful method of preserving ovarian function depending on the position of the ovaries outside of the radiation field, the age of the patient and the total dose received by the ovaries. There is limited modern evidence concerning its usage in relation to emerging techniques and technology. The use of IMRT is certainly widespread in the treatment of female pelvic cancers, however, there is no evidence supporting its use for reduction of ovarian dose. Several other studies have attempted to demonstrate new techniques to preserve ovarian function, but no functional outcome measures have reinforced their results.
Ovarian transposition has a proven track record for preservation of ovarian function, but the potential value of IMRT as a viable alternative to date remains unexplored. New work should be encouraged to determine the potential value of IMRT as a non-surgical alternative.
Increasing usage of magnetic resonance imaging (MRI) in radiotherapy (RT) and the advent of MRI-based image-guided radiotherapy (IGRT) suggests a need for additional training within the RT profession. This critical review aimed to identify potential gaps in knowledge by evaluating the current skill base in MRI among therapeutic radiographers as evidenced by published research.
Papers related to MRI usage were retrieved. Topic areas included outlining, planning and IGRT; diagnosis, follow-up and staging-related papers were excluded. After selection and further text analysis, papers were grouped by tumour site and year of publication.
The literature search and filtering resulted in a total of 123 papers, of which 66 were related to ‘outlining’, 37 to ‘planning’ and 20 to ‘IGRT’. The main sites of existing MRI expertise in RT were brain, central nervous system, prostate, and head and neck tumours. Expertise was clearly related to regions where MRI offered improved soft-tissue contrast. MRI studies within RT have been published from 2007 onwards at a steadily increasing rate.
Current use of MRI in RT is mainly restricted to sites where MRI offers a considerable imaging advantage over computed tomography. Given the changing use of MRI for image guidance, emerging therapeutic radiographers will require training in MRI interpretation across a wider range of anatomical regions.
Peer review of treatment plans has been used to improve planning consistency, decrease the need for replanning and improve quality of care through the safe delivery of high-quality radiotherapy plans. This narrative review summarises the clinical benefits and addresses the implementation of peer review of treatment plans in undergraduate medical dosimetry and radiation therapy training.
There are encouraging results of peer review for advanced treatment planning techniques such as Stereotactic Body Radiation Therapy techniques in clinical practice. Peer review can be used as a tool to improve students’ knowledge of organ-at-risk contouring, treatment plan critique and quality assurance. These desirable treatment planning skills can be easily transferred to clinical settings. Moreover, there are several potential pedagogical benefits such as improvement in student engagement, better communication skills and provision of synchronous and asynchronous feedback that can positively impact student success and future employment. However, there are several challenges in facilitating its implementation in university settings.
Embedding skills in peer review of treatment plans at undergraduate teaching level can be a powerful tool to impart clinical treatment planning knowledge. This narrative review provides a basis on which to develop an exploratory study of structured peer review activities in a training environment.
This article describes a collaborative project that aimed to develop a patient-centred curriculum in radiotherapy. In the wake of the Francis report in 2013 and a call for compassion to be a central tenet of health programmes, the project was a timely opportunity to enhance the radiotherapy curriculum.
Collaboration between university staff and patients and carers using the service improvement model Plan-Do-Study-Act was the method employed for the curriculum project. Two key discussion forums helped shape the curriculum plan, with module and course evaluation continuing to inform developments.
The key outcome of the project is that it has shaped the 'care' theme evident in the current undergraduate programme. Co-production methods resulted in the development of a range of shared classroom activities that focus on experiences, care values and communication strategies. The new curriculum has evaluated positively and the impact of learning is demonstrated both in the classroom and clinical setting. The project team have also influenced recruitment processes and patient and carer involvement in programme approval is embedded.
Working together, with patients and carers is an ideal method to enhance the curriculum and reflect the requirements in practice of current health and social care professions. Further developments in student assessment are planned.
This study was conducted for comparison of techniques between volumetric modulated arc therapy (VMAT), forward-planning intensity-modulated radiotherapy (FIMRT) and conventional technique for left-sided breast radiotherapy after conservative surgery.
In all, 20 postoperative left breast carcinoma patients were included in this study. In all plans the planning target volume (PTV) was the breast tissue with appropriate margin as per our institutional protocol. The contouring was done on a Monaco Sim (V5.00.02) contouring workstation. All patient were planned using partial arc VMAT in Monaco treatment planning system (TPS) (V5.00.02) and treated on Elekta Synergy linear accelerator. The 3D conformal radiotherapy (3DCRT) and FIMRT planning were done in CMS XIO (V5.00.01.1) TPS. The 3DCRT planning consisted of conventional medial and tangential wedge portals with multileaf collimator field shaping conforming to the target volume. For all the plans generated the following metrics were scored: V105%, V100%, V95%, mean dose (for PTV), V5%, V20%, D2cc and mean dose (for organs at risk).
The mean PTV volume for 20 patients was 1,074·6±405·1 cc. The highest PTV dose coverage was observed in the 3DCRT technique with 94·1±1·8% of the breast PTV receiving 95% of the prescription dose (V95%). However, it was also observed that this technique resulted in 21·3±10% of the PTV receiving more than 105% of the prescription dose (V105%), which was highest among the three techniques. In contrast, VMAT yielded lowest V95% of 93·0±1·8 and 3·3±5·5% of V105%.
This study concluded equivalent result between FIMRT and VMAT. However, VMAT was found to be the choice of radiotherapy technique as it produces lesser dose distribution to heart compared with any other technique.
Desmoid tumour is a rare neoplasm occurring intra- and extra-abdominally.
In this study, a lower extremity desmoid tumour located close to the ovaries was irradiated with tomotherapy after surgery in a 16-year-old female patient. 30 fractions defined for delivery of 54 Gy were administered to the patient.
The planning target volume and organs at risk doses were evaluated and the ovary doses were discussed for fertility.
The patient tolerated the radiotherapy well. During radiotherapy, only grade 1 skin toxicity occurred.