The management of breast cancer patients from diagnosis to treatment and beyond can be variable depending on factors including tumour extent and location, histology, genetics, health and wellbeing of the patient as well as personal patient preferences. The therapeutic radiographer’s role is not only vital to ensure safe and accurate radiotherapy delivery but also crucially, as the regular patient interface, they must be fully empowered to engage effectively with all aspects of the patient care pathway. They must be knowledgeable and up to date with evidence-based practices relating to the patient experience including surgery, chemotherapy, endocrine therapy and radiotherapy.

The aim of this paper is to outline the breast cancer management pathway, highlighting the potential side effects that occur as a result of breast radiotherapy treatment and concomitant treatment in order to inform therapeutic radiographers and best practice.

The treatment pathway for breast cancer patients varies greatly depending on a wide range of factors and is very much individualised for each patient. Each treatment modality has its advantages and disadvantages, and all come with a number of side effects that can affect a patient’s daily living. Toxicities can arise during radiotherapy treatment or months after treatment, and education regarding the management of these is essential for effective patient care. Many technological advances in radiotherapy treatment techniques and regimes have the potential to decrease radiation-induced side effects. Despite attempts to standardise clinical guidelines on the use of topical agents and dressings, historical opinions and ideas are still evident in clinical practice. The use of grading systems in radiotherapy tends to only record patients’ physical symptoms and not their holistic wellbeing and emotional needs.

Therapeutic radiographers must ensure that they remain equipped with the skills and knowledge to correctly manage and/or signpost services effectively. This overall outline of the management of patients with breast cancer is designed to help therapeutic radiographers reflect on the current practices and to inspire them, where evidence dictates, to seize opportunities, to explore improvement and to enhance best practice.

Inflammatory bowel disease (IBD) [i.e., Crohn’s disease (CD) and ulcerative colitis (UC)] has been considered a relative contraindication for radiation therapy (RT) to the abdomen or pelvis, potentially preventing patients with a diagnosis of IBD from receiving definitive therapy for their malignancy.

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) conventions, a PubMed/MEDLINE literature search was conducted using the keywords RT, brachytherapy, inflammatory bowel disease, Crohn’s disease, ulcerative colitis and toxicity.

A total of 1,206 publications were screened with an addition of 8 studies identified through hand searching. Nineteen studies met the inclusion criteria for quantitative analysis. The total population across all studies was 497 patients, 50·5% having UC, 37% having CD and an additional 12·5% having unspecified IBD. Primary gastrointestinal malignancy (55%) followed by prostate cancer (40%) composed the bulk of the population. Acute and late grade 3 or greater gastrointestinal specific toxicity ranged from 0–23% to 0–13% respectively for those patients with IBD treated with RT to the abdomen or pelvis. In the literature reviewed, RT does not appear to increase fistula or stricture formation or IBD flares; however, one study did note RT to be a statistically significant risk factor for subsequent IBD flare on multivariate analysis.

A review of reported acute and late toxicities suggests that patients with IBD should still be considered for definitive radiotherapy. Patient characteristics including IBD distribution relative to the irradiated field, inflammatory activity at the time of radiation, overall disease severity and disease phenotype in the case of CD (fistulising versus stricturing versus inflammatory only) should be considered on an individual basis when evaluating potential patients. When possible, advanced techniques with strict organ at risk dose constraints should be employed to limit toxicity in this patient population.

Neuroblastoma is the most common extracranial solid tumour of infancy and accounts for about 6–10% of paediatric cancers. It has a biologically and clinically heterogeneous behaviour that ranges from spontaneous regression to cases of highly aggressive metastatic disease that could be unresponsive to standard therapy. In recent years, there have been several investigations into the development of various diagnostic, predictive and prognostic biomarkers towards personalised and targeted management of the disease.

This paper reports on the review of current clinical and emerging biomarkers used in risk assessment, screening for early detection and diagnosis, prognostication and monitoring of the response of treatment of neuroblastoma in paediatric patients.

Tumour markers can significantly improve diagnosis; however, the invasive, unpleasant and inconvenient nature of current tissue biopsies limits their applications, especially in paediatric patients. Therefore, the development of a non-invasive, reliable high accurate and personalised diagnostic tool capable of early detection and rapid response is the most promising step towards advanced cancer management from tumour diagnosis, therapy to patient monitoring and represents an important step towards the promise of precision, personalised and targeted medicine. Liquid biopsy assay with wide ranges of clinical applications is emerging to hold incredible potential for advancing cancer treatment and has greater promise for diagnostic purposes, identification and tracking of tumour-specific alterations during the course of the disease and to guide therapeutic decisions.

To investigate the central electrode artefact effect of different ion chambers in the verification phantom using the dose calculation algorithms Analytical Anisotropic Algorithm (AAA) and Acuros XB.

The dosimetric study was conducted using an in-house fabricated polymethyl methacrylate head phantom. The treatment planning system (TPS)-calculated doses in the phantom with detectors were compared against the dummy detector fillets using AAA and Acuros XB algorithm. The planned and measured doses were compared for the study.

The mean percentage variation in volumetric-modulated arc therapy plans using Acuros XB and the measurement in the head phantom are statistically significant (p-value = 0.001) for FC65 and CC13 chambers. In small volume chambers (A14SL and CC01), the measured and TPS-calculated dose shows a good agreement.

The study confirmed the CT set of the phantom with detectors (FC65 and CC13) give more artefacts/heterogeneity caused a significant variation in dose calculation using Acuros XB. Therefore, the study suggests a method of using phantom CT set with the dummy detector for mean dose calculation for the Acuros XB algorithm.

Total Skin Electron Therapy (TSET) is a specialised radiotherapy technique to treat cutaneous T-cell lymphomas. The purpose of this article is to review different in-vivo dosimetry techniques and to identify further research direction in TSET

Studies focused on in-vivo dosimetry in TSET were included. Studies based on absolute dosimetry in TSET were excluded and no restriction was applied regarding the type of treatment technique and the type of dosimeter.

From the review of articles, we have found that obesity index and patient position during treatment plays a major role in underdose or overdose in TSET. Many studies favour individualised boost dose to patients. The analysis showed that thermoluminescent dosimeters are the most widely used dosimeters in TSET, and time-consuming is the only drawback in the use of dosimetry.

Study showed that the practice of using in-vivo dosimetry would be better way to treat TSET by ensuring accuracy of dose delivery to the patients. Further, only limited studies are available for dosimetry with radiochromic films. With this observation, we have started exploring the use of radiochromic film in our TSET dosimetry, and the results can be analysed to standardise the technique in future.

An image-guided radiotherapy capable linear accelerator was installed at our hospital which is equipped with an X-ray volumetric imaging (XVI) system. The aim of this study was to describe the results of acceptance tests which were carried out on the XVI facility to verify the manufacturer’s specification.

The commissioning test had six elements: system safety, geometric accuracy, image quality, registration and correction accuracy, X-ray tube and generator performance, and quality assurance (QA) procedures.

We had satisfactory results for all the tests. The system passed the safety testes, and the agreement of isocentres was found to be within the tolerance limit. Imaging quality was acceptable. Registration and correction accuracy was tasted with indigenously developed phantom and positioned accurately at isocentre. X-ray tube and generator test results showed that the tube was performing properly.

The described tests represent that the performance of the system is maintained at acceptable levels.

The aim of this paper is to investigate the effectiveness of physical exercise in managing fatigue during radiotherapy for prostate cancer patients. It explores the impact of various physical exercise regimes and their role in the prevention and management of fatigue to help inform best practice.

A literature search was conducted on OVID Medline database with a follow-up search on google scholar to include relevant references found during the initial search. Relevant systematic reviews and randomised controlled trials (RCTs) arising from this search were reviewed.

There is evidence to support the notion that physical exercise in all its forms is an effective and safe intervention for fatigue management for prostate cancer patients undergoing radiotherapy. Although widely studied, there is limited evidence of fatigue management strategies being clearly implemented into current radiotherapy practice for patients with prostate cancer. This information is essential to enable therapeutic radiographers to educate prostate cancer patients regarding effective exercise strategies and ensure that fatigue is managed optimally.

Further research is required into the optimum physical exercise prescription to reduce radiation-induced fatigue, and standardised best practice guidelines should be developed nationally. A future move toward patient education into physical exercise and wellbeing should be a central component of the therapeutic radiographer role with specialist advice offered by review radiographers, empowering patients to become more physically active during treatment. Therapeutic radiographers have a unique opportunity to educate and promote physical exercise through a holistic wellbeing approach that aims to mitigate fatigue and improve quality of life.

The aim of this study was to evaluate planning target volume (PTV) margins for two different locations using an electronic portal imaging device (EPID) to ensure that the correct radiation dose is delivered to the tumour when using intensity-modulated radiation therapy (IMRT).

Setup data were collected from 40 patients treated with IMRT for head and neck cancer (HN) (20 patients) and prostate cancer (20 patients). Setup errors from 720 registration images were analysed to evaluate systematic and random errors. Thereafter, optimal PTV margins were calculated based on International Commission on Radiation Units and Measurements 62 (ICRU), Stroom and Parker formulas compared with the Van Herk’s recipe.

To calculate the margins around the PTV, several different formulas have been used. Setup margins ranged between 2–4·3, 2·2–4·6 and 2·1–4·7 mm in X, Y and Z directions, respectively, for HN cases. Similarly, for the prostate site, setup margins ranged between 3·7–8·3, 3·2–6·8 and 3·3–8·2 mm in X, Y and Z directions.

To ensure better coverage of target volume, we adopted a PTV margin of 5 mm for HN PTVs and 10 mm for prostate PTVs in our department.

The coronavirus disease (COVID-19) pandemic is bound to put tremendous pressure on the existing healthcare system. This aim of this technical note is to help in triaging patients with brain tumours who are sent for radiotherapy during this pandemic and to provide safe and evidence-based care.

Published data for this review were identified by systematically searching PubMed database from November 2007 onwards with the following Medical Subject Heading (Mesh) terms ‘Brain tumours’, ‘COVID-19’, ‘coronavirus’, ‘SARS-nCoV-2’, ‘Radiotherapy’, ‘Guidelines’ ‘hypofractionation’ using Boolean search algorithm. Articles in English language were reviewed.

We tried to apply the as low as reasonable achievable (ALARA) principle in triaging and management of patients for radiotherapy. We identified protocols which have hypofractionated regimens (reducing patient visits to hospital, time spent in treatment console) with similar outcomes when compared to conventional fractionated regimens and not overburdening the healthcare facility. We also identified the tumours for which we could safely avoid or delay the initiation of radiotherapy.

Treatment decisions made during the COVID-19 pandemic rely on the safety first/do no harm principle and evidence-based prioritisation of cases for triage. This article is a tool to aid in triaging and prioritising brain tumour patient management. This is for consideration during the pandemic only and certainly not as a strategy for permanent practice change.

Merkel cell carcinoma (MCC) is an aggressive cutaneous neuroendocrine tumour. Although surgical resection is a treatment choice, it often occurs in the head and neck and occurs mainly in the elderly, making surgery impossible. Radical radiation therapy may be an alternative to surgery in these patients. In addition, radiation treatment may be performed even after recurrence after surgery.

An 82-year-old MCC patient had cT2N0M0, stage IIA MCC on the left cheek that metastasised to lymph node 2 months after surgery. She was treated with radiation monotherapy with a hypofractionation schedule (39 Gy at 3 Gy per fraction).

The patient achieved complete remission after radiotherapy without severe toxicities.

This technical note describes a quantitative assessment of the production of radioactive materials during a year-long clinical operation of a Mevion S250i Hyperscan proton therapy system. The production of accumulated radioactive materials plays an important role in determining radiation safety in and around the proton therapy facilities.

We have conducted a weekly room survey, every week for a year, during normal clinical operation.

We estimated the accumulated activity from secondary neutron activation on aluminium structures at 3 m away from isocentre in the beamline to be less than 300 μCi.

Supine orientation is the standard treatment position for radiation therapy for head and neck cancer. Some patients, however, cannot tolerate this due to pooling of secretions and airway concerns, and theoretically, treatment would be better tolerated in a prone position. Here, we described the first prone treatment setup and delivery for a patient with head and neck cancer.

A 68-year-old male patient with inoperable locally advanced, T4aN0M0, squamous cell carcinoma of the maxillary sinus was simulated, planned, and treated in prone position due to sinus congestion.

Prone position was well tolerated by the patient, who then did not require daily anaesthesia for airway secretion management. The prone dosimetry demonstrated good target coverage and normal tissue sparing. His treatment setup was found to be reproducible throughout the course of therapy.

We successfully demonstrated the feasibility of prone treatment position for patients with head and neck cancer who are unable to tolerate supine position due to unmanageable secretions. Consideration should be given to prone treatment when designing both radiation therapy protocols and individual treatment plans.

Radiation-induced malignancies are a rare phenomenon. Post-radiation sarcoma accounts for 0·5–5·5% of all sarcomas. Adjuvant radiotherapy (RT) after surgery plays a significant role in the treatment of breast cancer. Sarcomas of the breast, chest wall, sternum, axilla or supraclavicular region have been reported as a rare complication of RT for breast cancer. Osteosarcoma (OS) of the sternal bone is a rarely reported entity. OS of the sternum secondary to therapeutic ionising radiation is an even rarer diagnosis, and no such cases have been reported in India as per our literature search. Here we report such a case of post-radiation sarcoma after breast cancer treatment—OS presenting in the sternum and both the second ribs in a young lady.

Our patient developed a sarcoma within a previously irradiated field. The latent period was 7·5 years. She initially suffered from a breast carcinoma for which she underwent radical surgery in the form of modified radical mastectomy. She also received 50 Gy RT dose to the chest wall and axilla. She subsequently developed an OS of chest wall in the high-dose region of RT. Another key factor is the high possibility of familial/hereditary cancer inheritance syndrome like Li-Fraumeni in our patient. Though she was never tested for p53 mutations, her young age at first diagnosis (26 years), extremely strong positive family history and spectra of cancers affecting her first-degree blood relatives (brain tumours, leukaemia) strongly hint at the possibility of such a cancer syndrome. Retrospectively, the question certainly arises, given her young age and family history, whether this patient was a right candidate for RT even once as compared to the fact that she received radiation twice.

Standard external beam radiotherapy is a treatment option for patients with localised prostate cancer and is used in patients with low-, intermediate- and high-risk disease with androgen deprivation according to the risk of the disease. In the last few years, hypofractionated radiotherapy has been demonstrated to be as safe as standard radiotherapy if given over a shorter time than standard radiotherapy with larger doses per fraction. External radiotherapy for localised prostate cancer typically delivers 37–42 fractions of 1·8–2·0 Gy per fraction given 5 days per week over 7·5–8·5 weeks. Hypofractionated radiotherapy delivers 20–28 fractions of 2·5–2·6 Gy per fraction given 5 days per week over 4–5·6 weeks.

A retrospective analysis of assessment of 30 patients was undertaken from 2016 to 2018. The aim of this study was to evaluate the 2-year outcomes of 30 patients with prostate cancer treated with hypofractionated radiotherapy 70 Gy in 28 fractions.

Biochemical failure with hypofractionated radiotherapy was found in a total of 20% of patients. In the classification by risk groups, there were no biochemical failures in low-risk patients; in the low intermediate course, 3·3% of patients; in the high intermediate group, 3·3% patients; and in the high-risk group, the largest documented biochemical failure was in 13·3% of patients. For acute urinary toxicity, grade I was 56·6%; grade II, 6·6%. For acute rectal toxicity, grade I was 46·6%; grade II, 3·3%.

This is one of the first studies of hypofractionated radiotherapy in prostate cancer in Latin America, and the results of this study demonstrated that the outcomes were similar to the standard regimen in all risk groups.

Optic nerve glioma (OPG) is a rare tumour of children and adolescents. The treatment is challenging as it may jeopardise the visual outcome. We are reporting a case of bilateral OPG, treated with intensity-modulated radiotherapy in our department.

An 18-year-old female presented with a gradually deteriorating vision in both eyes. A detailed clinical and ophthalmological examination was carried out. Her MRI of orbit and brain were suggestive of bilateral optic nerve glioma. She was treated with intensity-modulated radiotherapy to a total dose of 54Gy in 30 fractions over 6 weeks.

She well tolerated the treatment. Post radiotherapy at 8 weeks, she had stabilization of vision on clinical assessment.

Radiotherapy using IMRT can be successfully used to treat OPG, and it checks tumour growth and prevents further deterioration.