This volume of Arthurian Literature ranges from the reception of Geoffrey of Monmouth in Wales to the Camelot of T. H. White. Georgia Henley discusses Latin literary culture in medieval Wales, evaluating the intellectual and literary context in which Geoffrey of Monmouth's seminal Historia regum Britanniae was received. She makes the case for discarding the binary distinction of ‘Welsh vs Latin’ in favour of a view of medieval Wales as a multilingual culture in which Latin and Welsh existed side-by-side and the classical tradition had a significant influence on Welsh literature.

We are pleased to be able to publish a revised version of Prof. Erich Poppe's 2016 O'Donnell Lecture in Celtic Studies, in which he shines a bright comparative light (in terms of both plot and lexis) on Chrétien's Ivain, the Middle English Ywain and Gawain and the Middle Welsh Owein, otherwise known as Chwedyl Iarlles y Ffynnawn (The Tale of the Lady of the Well / Countess of the Spring). In his reading of these poems, Poppe effectively demonstrates Peter Clemoes’ axiom that to read ‘Medieval Welsh literature alongside that of Middle English’ is to recognize how great a debt English literature owes to the Celtic tradition for its Arthurian inspirations.

Christopher Berard returns to the subject of Edward III's abandoned Order of the Round Table to argue that, while Edward's ‘un-Arthurian’ tactics at Crécy made his association with the legendary king problematic, his victory at Poitiers and the capture of the flower of French knighthood – and of Jean II of France himself – rendered that association apt once more. Portraying himself as an Arthurian ‘King of Kings’ enabled Edward to negotiate a treaty with, and seek ransom for, the French king without undermining his own claim to that throne.

Ralph Hanna considers Ywain and Gawain and the Alliterative Morte Arthure in the cultural and political context of the turbulent history of the borders and of two great northern families, the Percys and the Nevilles. In spite of the popular image of the ‘uncouth / violent North’, he argues that northern romances diverge from the popular insular pattern of usurpation, exile and return, focusing instead on more domestic themes and on ‘the failure of mere martial prowess to offer meaningful achievement’. He sees Ywain and Gawain as a response to criticism of romance in texts such as Cursor mundi, stressing the importance of both time and ‘trowth’.

This book is intended primarily for trainees in clinical oncology, but members of other professions such as medical oncology, surgery, palliative care, nursing and radiography will also find it useful. The book started life as a set of lecture notes from the Cardiff Annual FRCR Part II course, but has since grown to include more topics than could possibly be covered during the three days of that course. Our approach in producing this volume has been to focus on practical suggestions appropriate to day-to-day decision making during the treatment of oncology patients. We are very grateful to our colleagues from Velindre and elsewhere, who are listed on page xi, for reviewing specific chapters and ensuring that the advice contained within is as widely applicable as possible.

The first seven chapters cover ‘generic’ topics which provide background information on cancer treatments. These are chemotherapy, biological and hormonal treatments, radiotherapy planning, research, emergencies and palliative care. The chapters which follow each focus on a tumour site or tumour type. In this latter group, the chapter layout is fairly consistent to help the reader navigate through the book. Thus, each chapter begins with background information on tumour types, anatomy, incidence, epidemiology, risk factors and aetiology. Next there are sections on pathology, routes of spread and, where appropriate, screening. These are followed by clinical sections on presentation, investigations, treatment and prognosis. Most of the chapters also discuss areas of current interest and clinical trials, reflecting the rapidly changing nature of clinical oncology where many areas of practice are open to debate. Where references are given, we have tried as much as possible to include those key publications which have influenced clinical practice. Towards the end of the book there is a series of ‘single best answer’ multiple choice questions, which will give the reader the opportunity to test their knowledge.

In a book of this length, it is not possible to provide as much of the subject as would be found, for example, in the larger multivolume oncology textbooks. Nevertheless, an attempt has been made to give an overview of clinical oncology practice at the present time, which we hope will be of interest and benefit to trainees.

Introduction

Ovarian cancer is the fifth most common cancer in women and the second most common gynaecological cancer, but the most common cause of death from gynaecological malignancy in the Western world. Epithelial ovarian cancer, fallopian tube cancer and peritoneal cancer share similar characteristics and behaviour and are treated in the same way. Ovarian cancer has been named a ‘silent killer’ because of its lack of symptoms during early stages. Around 90% of ovarian cancers arise from the epithelium. Two-thirds of patients present with stage III or IV disease, with increasing abdominal symptoms including ascites. Treatment typically depends on a combination of surgery and chemotherapy. In recent years there has been interest in the role of biological treatments, particularly the angiogenesis inhibitor, bevacizumab. Over the past 40 years there has been a modest increase in the survival from ovarian cancer in the UK, attributable primarily to the use of platinum-based chemotherapy, and around 40% of patients are expected to survive for 5 years or more.

Types of tumour affecting the ovary

The WHO classification of tumours of the ovary defines broad categories of ovarian tumours (WHO classification, 2003):

1. • surface epithelial–stromal tumours;

2. • sex cord–stromal tumours;

3. • germ cell tumours;

4. • tumours of the rete ovarii;

5. • miscellaneous tumours;

6. • lymphomas and haematopoietic tumours;

7. • secondary tumours.

Surface epithelial–stromal tumours are classified as benign, borderline or malignant. The subtypes are serous, mucinous, endometrioid, malignant mixed müllerian tumour (carcinosarcoma), clear cell, transitional cell, squamous cell, mixed and undifferentiated or unclassified.

Sex cord–stromal tumours are classified as granulosa tumours (including granulosa cell tumours and theca-fibroma tumours), sertoli cell tumours, sex-cord tumours of mixed or unclassified cell types, gynandroblastoma and steroid cell tumours.

Germ cell tumours are classified as primitive germ cell tumours (including dysgerminoma, yolk sac tumour and embryonal carcinoma), biphasic or triphasic teratomas (including immature teratoma and mature teratoma), and monodermal teratoma (composed of a single type of tissue and includes struma ovarii, which is composed of thyroid cells).

Incidence and epidemiology

The annual incidence of ovarian cancer in the UK is 17 per 100,000 women, ranging from 14 per 100,000 in Northern Ireland to 20 per 100,000 in Wales. Approximately 7000 cases are reported per year in the UK.

Introduction

It is important to understand the basic techniques of radiotherapy planning because these will help when developing complex plans. These techniques, which are taught at the First FRCR level (Royal College of Radiologists), are used by the treatment centre's Physics Department for checking the validity of calculations before they are applied to patients, and anyone interpreting plans will need to be familiar with them to know whether it is worth adjusting treatment plans during review. Advanced radiotherapy techniques will be discussed in Chapter 6.

There are several useful reviews of radiotherapy physics in the literature. One by Shiu and Mellenberg (2001) includes sections on isodose planning. Another, by Purdy (2000), provides a perspective on future directions in 3D treatment planning. Radiotherapy is a rapidly developing field and it is important to ensure that new methods satisfy safety and effectiveness requirements before being adopted as routine treatments.

This chapter will deal with the general principles of developing isodose plans that are suitable for treatment and will use specific examples to highlight particular points. It will focus mainly on external beam radiotherapy with megavoltage photons; there will be shorter sections on the use of electrons and brachytherapy. Some aspects of radiotherapy planning using lower energy (kilovoltage) photons will be discussed in Chapter 36. The use of unsealed radiation sources for prostate, thyroid and childhood cancers are discussed in Chapters 22, 38 and 40, respectively.

Treatment planning overview

Radiotherapy planning can be divided into stages as follows.

1. • Patient preparation, position and immobilisation.

2. • Localisation method (e.g. orthogonal films, CT scanning, and image co-registration).

3. • Definition of target volumes and organs at risk.

4. • Radiotherapy technique, including beam arrangements, beam energy, size and shape, weighting, wedges and production of isodose plan.

5. • Prescription, including number of phases, dose, energy and fractionation.

6. • Verification (i.e. checking the geometrical set-up of the treatment). This can take place before treatment in the simulator or CT simulator, and/or during treatment using portal imaging.

Quality assurance (QA) is essential and it is of paramount importance for each member of the planning team to be familiar with the overall process.

Patient position and immobilisation

For radiotherapy to be effective it must be delivered accurately, and it is important to understand the methods of immobilisation and the inevitable uncertainties in the delivery of treatment.