Here, we report the feasibility and long-term efficacy of a granulomatous slack skin disease (GSSD) treatment with combined high-energy photon and proton beams.

A GSSD patient with abdominal disease volume 25×15×2–4 cm deep was recommended for treatment at this institution. In addition to photons and electrons, high-energy protons delivered with advanced planning techniques and patient positioning were used. The patient was irradiated to a total dose of 40 Gy by using 20 Gy matched photon and electrons followed by 20 Gy equivalent protons delivered by using innovative range compensation and patient positioning.

The test patient tolerated the treatment well and is now a 10-year survivor of the disease.

Treatment of GSSD with protons is feasible. The range and narrow penumbra properties of the proton beam provided an ideal capability to match fields accurately to cover large volumes while also sparing underlying normal tissues.

It is common for head and neck patients to be affected by time trend errors as a result of weight loss during a course of radiation treatment. The objective of this planning study was to investigate the impact of weight loss on volumetric modulated arc therapy (VMAT) as well as intensity modulated radiation therapy (IMRT) for locally advanced head and neck cancer using automatic co-registration of the cone beam computed tomography.

A retrospective analysis of previously treated IMRT plans for ten patients with locally advanced head and neck cancer was done. A VMAT plan was also produced for all patients. We calculated the dose–volume histograms (DVH) indices for spinal cord planning at risk volumes (PRVs), the brainstem PRVs (SC+0·5 cm and BS+0·5 cm, respectively) as well as mean dose to the parotid glands.

The results show that the mean difference in dose to the SC+0·5 cm was 1·03% and 1·27% for the IMRT and VMAT plans, respectively. As for dose to the BS+0·5, the percentage difference was 0·63% for the IMRT plans and 0·61% for the VMAT plans. The analysis of the parotid gland doses shows that the percentage change in mean dose to left parotid was −8·0% whereas that of the right parotid was −6·4% for the IMRT treatment plans. In the VMAT plans, the percentages change for the left and the right parotid glands were −6·6 and −6·7% respectively.

This study shows a clinically significant impact of weight loss on DVH indices analysed in head and neck organs at risk. It highlights the importance of adaptive radiotherapy in head and neck patients if organ at risk sparing is to be maintained.

The use of metallic containing creams to prevent and treat radiodermatitis is controversial and lacking evidence base. We compare the dose effect of two metallic-based skin creams, which could be used for treating radiodermatitis, to a control.

Universal containers of silver sulfadiazine cream, zinc oxide cream and aqueous cream were examined using a computed tomography scanner to assess their electron densities relative to water. Second, each cream was exposed to 100 kV and 6 MV photons. The relative doses were measured using an X-ray chamber.

The relative electron density measured was similar for the silver sulfadiazine and aqueous creams. Zinc oxide was 40% higher. The relative dose measurements showed that silver sulfadiazine behaved in a similar way to aqueous cream; however, zinc oxide cream exhibited a dose difference of 11·0% in kV photons and −4·1% in MV photons.

Application of silver sulfadiazine appears unlikely to bring about significant changes in the dose distribution when compared with aqueous during MV or kV radiotherapy. While zinc oxide cream brought about more significant dose changes.

Simulation has been effective for changing attitudes towards team-based competencies in many areas, but its role in teaching interprofessional collaboration (IPC) in radiation medicine (RM) is unknown. This study reports on feasibility and IPC outcomes of a team-based simulation event; ‘Radiation Medicine Simulation in Learning Interprofessional Collaborative Experience’ (RM SLICE).

Radiation therapy (RTT), medical physics (MP) and radiation oncology (RO) trainees in a single academic department were eligible. Scheduled closure of a modern RM clinic allowed rotation of five high-fidelity cases in three 105-minute timeslots. A pre/post-survey design evaluated learner satisfaction and interprofessional perceptions. Scales included the Readiness for Interprofessional Learning Scale (RIPLS), UWE Entry Level Interprofessional Questionnaire (UWEIQ), Trainee Test of Team Dynamics and Collaborative Behaviours Scale (CBS).

Twenty-one trainees participated; six ROs (28·57%), six MPs (28·57%) and nine RTTs (42·86%). All cases were conducted, resolved and debriefed within the allotted time. Twenty-one complete sets (100%) of evaluations were returned. Participants reported limited interaction with other professional groups before RM SLICE. Perceptions of team functioning and value of team interaction in ‘establishing or improving the care plan’ were high for all cases, averaging 8·1/10 and 8·9/10. Average CBS scores were 70·4, 71·9 and 69·5, for the three cases, scores increasing between the first and second case for 13/21 (61·9%) participants. RIPLS and UWEIQ scores reflected positive perceptions both pre- and post-event, averaging 83·5 and 85·2 (RIPLS) and 60·6 and 55·7 (UWEIQ), respectively. For all professions for both scales, the average change in score reflected improved IP perceptions, with agreement between scales for 15/20 (75·0%) participants. Overall, perception of IPC averaged 9·14/10, as did the importance of holding such an event annually.

Team-based simulation is feasible in RM and appears to facilitate interprofessional competency-building in high-acuity clinical situations, reflecting positive perceptions of IPC.

The aim of this study was to assess the feasibility of radiographer led verification of cone-beam computed tomography (CBCT) images for patients with solitary lung tumours treated with stereotactic body radiotherapy treatment (SBRT).

CBCT setup images of 20 patients from the first fraction of each patient were retrospectively registered by therapeutic radiographers. The displacements recorded were compared with the clinical oncologist’s original online match. The time taken by radiographers to verify the CBCT images was also recorded.

Overall agreement for all radiographers when compared with the clinical oncologist match was 91%. Interobserver variations between radiographers were X plane 0·87 (0·76–0·94); Y plane 0·74 (0·51–0·88); and Z plane 0·88 (0·78–0·95) intraclass correlation coefficient and 95% confidence interval. The average time taken for verification was 128 seconds.

Therapeutic radiographers are able to verify CBCT images for thorax SBRT with results comparable to the ‘gold standard’ clinical oncologists’ match, however additional training will be provided for online verification. The time taken was within acceptable limits.

The dosimetric benefits of Deep Inspiration Breath Hold (DIBH) in reducing cardiac dose are well documented, however reports on the patient’s personal experience with this technique are limited. The purpose of this research is to investigate DIBH from the patient’s perspective and to provide recommendations to further improve the patient experience.

A questionnaire was used to record the patient’s comprehension of DIBH instructions and preparation for treatment. Levels of comfort, confidence and technical challenge were also recorded and an open-format question allowed patients to provide suggestions to improve the DIBH experience.

The majority of patients do not find it difficult to hold their breath at the correct level during DIBH and confidence levels regarding ability to follow instructions are good. Comprehension of instructions, preparation to perform DIBH and treatment position comfort levels were universally graded positively.

The majority of patients reported a strong level of comprehension and preparation that allows them to confidently perform DIBH as planned. Establishment of a dedicated treatment team, consistent patient instructions, regular feedback and an opportunity to rehearse DIBH can help increase patient confidence and reduce anxiety.

Head and neck cancer patients receiving radiotherapy can experience a number of toxicities, including weight loss and malnutrition, which can impact upon the quality of treatment. The purpose of this retrospective cohort study is to evaluate weight loss and identify predictive factors for this patient group.

A total of 40 patients treated with radiotherapy since 2012 at the study centre were selected for analysis. Data were collected from patient records. The association between potential risk factors and weight loss was investigated.

Mean weight loss was 5 kg (6%). In all, 24 patients lost >5% starting body weight. Age, T-stage, N-stage, chemotherapy and starting body weight were individually associated with significant differences in weight loss. On multiple linear regression analysis age and nodal status were predictive.

Younger patients and those with nodal disease were most at risk of weight loss. Other studies have identified the same risk factors along with several other variables. The relative significance of each along with a number of other potential factors is yet to be fully understood. Further research is required to help identify patients most at risk of weight loss; and assess interventions aimed at preventing weight loss and malnutrition.

Bladder complications may be seen in up to 12% of patients treated with pelvic irradiation. To report the long-term efficacy of hyperbaric oxygen therapy (HBOT) on radiation-induced cystitis.

We followed 70 patients diagnosed with radiation cystitis submitted to HBOT in our institution from 2007 to 2013. All patients answered a questionnaire documenting symptom severity pre-HBOT and at the end of the follow-up period using the Late Effects of Normal Tissues – Subjective, Objective, Management, Analytical (LENT-SOMA) scale. Our treatment protocol consisted of multiple sessions (median of 40) of 100% oxygen delivery in a multiplace hyperbaric chamber at 2·4 atm for 80 minutes.

With a median follow-up of 55·5 (4–85) months, the success rate after the follow-up period in terms of haematuria resolution or improvement was 91·4%. The mean score of each subjective variable of LENT-SOMA scale (dysuria, frequency, haematuria, incontinence) were significantly lower after the follow-up period (p<0·05) with the exception of decreased stream (p=0·14). The sum of all subjective scores of LENT-SOMA scale was also significantly lower after the follow-up period (p<0·05). No serious complications were observed.

Our results highlight the safety and long-term benefits of HBOT on haemorrhagic radiation cystitis and other distressful bladder symptoms.

This study aims to develop an expedited radiotherapy (RT) process and evaluate its time savings in women requiring whole breast RT.

An inter-professional RT team streamlined the computed tomography (CT) simulation and treatment pathway for a ‘QuickStart’ process. Target delineation was performed by an advanced practice radiation therapist and approved by the radiation oncologist (RO) for planning. Automated breast planning software was used for treatment planning and standard quality checks were performed. To assess time savings, the initial 25 QuickStart patients were matched with women who underwent whole breast simulation on the same day (±3 days), treated using the conventional process.

A total of 73 post-lumpectomy women were treated through the QuickStart process; the median consent-to-RT was 2 days (range: 0–13) and the mean CT simulation-to-RT treatment was 2 hours and 42 minutes (SD 0:30). In the subgroup analysis, QuickStart patients saved an average of 11 days from CT simulation-to-RT and had shorter median wait-times for both surgery/chemotherapy-to-RT (60 versus 38 days; p=0·002) and consultation-to-RT (7 versus 20 days; p<0·001).

Through inter-professional team efforts and the application of automated planning software, we have achieved a process that significantly decreases patient wait-times while maintaining the quality of whole breast RT.

To quantify the effect of breathing motion on post-mastectomy radiotherapy with three-dimensional (3D) tangents and intensity-modulated radiotherapy (IMRT)

Patients trained for breath-hold underwent routine free breathing (FB) computed tomography (CT) simulation for radiotherapy as well as additional CT scans with breath held at the end of normal inspiration (NI scan) and expiration (NE scan) for study. The FB scan was used to develop both tangents and IMRT plans. To simulate breathing, each plan was copied and applied on NI and NE scans. The respiratory parameters of the patients as well as the dosimetric data with both the plans were analysed.

Breathing motion resulted in mean fall in target coverage (V95) with IMRT by more than 5% when compared with tangents, and this effect significantly correlated with higher tidal volume. There was also a decrease in the mean target minimal dose by 20–25% with IMRT when compared with 10–12% with tangents, attributable to breathing motion. However, the cardiac dose crossed the limit (V25<10%) with breathing in the 3D tangents plan.

Dosimetric coverage of the chest wall is sensitive to breathing motion for the IMRT technique when compared with standard tangents, especially in patients with large tidal volume.

To develop a regime of care for patients with head and neck cancers undergoing intensity-modulated radiotherapy (IMRT), with the support of a health advisor (HA) and temporary access to the mouth care product Caphosol™.

A HA was temporarily employed to assess, monitor and refer patients as appropriate and ensure patients received and utilised supplies of Caphosol™. A retrospective audit was undertaken to provide a gap analysis of current service. The data were used to develop a pro forma for documenting assessments and monitoring lifestyle factors for IMRT patients. Assessments referrals and compliance, plus hospital admissions owing to treatment-related issues, were documented during the baseline audit and the temporary HA service and provision of Caphosol™.

The presence of a HA facilitated 100% compliance with appropriate assessments, referrals and adherence to treatment. The data suggests that the additional provision of Caphosol™ may have reduced levels of mucositis and associated pain.

It is recommended that a HA role be established within radiotherapy departments to facilitate lifestyle assessments, referrals and compliance with positive behaviour changes (e.g., stopping smoking). The use of Caphosol™ as a routine part of mouth care regime for IMRT patients also warrants further investigation.

There is no consensus on how long the initiation of radiotherapy (RT) can be delayed after surgery without a negative impact on survival.

We conducted a retrospective study of 278 patients with stage 0–II breast cancer, all of whom were treated with surgery and RT, with those at stages I–II also receiving chemotherapy. Patients were followed-up for 5 years after diagnosis to assess disease-free and overall survival.The independent variable was the delay in the initiation of RT, assessed by two criteria: time since the last treatment, considered acceptable if ≤6 weeks, and time since surgery, considered acceptable if ≤7 months, these cut-offs being used to categorise patients into two groups according to the length of delay.

No statistically significant differences were observed in the probability of disease-free survival (p=0·412) or overall survival (p=0·890). The appearance of recurrence was 5–59 months, with an average of 38·50 (14·31).

Delaying the initiation of RT for more than 6 weeks after last treatment does not seem to have a negative impact on disease-free or overall survival.

Peer-review programmes in radiation oncology are used to facilitate the process and evaluation of clinical decision-making. However, web-based peer-review methods are still uncommon. This study analysed an inter-centre, web-based peer-review case conference as a method of facilitating the decision-making process in radiation oncology.

A benchmark form was designed based on the American Society for Radiation Oncology targets for radiation oncology peer review. This was used for evaluating the contents of the peer-review case presentations on 40 cases, selected from three participating radiation oncology centres. A scoring system was used for comparison of data, and a survey was conducted to analyse the experiences of radiation oncology professionals who attended the web-based peer-review meetings in order to identify priorities for improvement.

The mean scores for the evaluations were 82·7, 84·5, 86·3 and 87·3% for cervical, prostate, breast and head and neck presentations, respectively. The survey showed that radiation oncology professionals were confident about the role of web-based peer-reviews in facilitating sharing of good practice, stimulating professionalism and promoting professional growth. The participants were satisfied with the quality of the audio and visual aspects of the web-based meeting.

The results of this study suggest that simple inter-centre web-based peer-review case conferences are a feasible technique for peer review in radiation oncology. Limitations such as data security and confidentiality can be overcome by the use of appropriate structure and technology. To drive the issues of quality and safety a step further, small radiotherapy departments may need to consider web-based peer-review case conference as part of their routine quality assurance practices.

This study evaluated the impact of a daily and weekly image-guided radiotherapy protocols in reducing setup errors and setting of appropriate margins in head and neck cancer patients.

Interfraction and systematic shifts for the hypothetical day 1–3 plus weekly imaging were extrapolated from daily imaging data from 31 patients (964 cone beam computed tomography (CBCT) scans). In addition, residual setup errors were calculated by taking the average shifts in each direction for each patient based on the first three shifts and were presumed to represent systematic setup error. The clinical target volume (CTV) to planning target volume (PTV) margins were calculated using van Herk formula and analysed for each protocol.

The mean interfraction shifts for daily imaging were 0·8, 0·3 and 0·5 mm in the S-I (superior-inferior), L-R (left-right) and A-P (anterior-posterior) direction, respectively. On the other hand the mean shifts for day 1–3 plus weekly imaging were 0·9, 1·8 and 0·5 mm in the S-I, L-R and A-P direction, respectively. The mean day 1–3 residual shifts were 1·5, 2·1 and 0·7 mm in the S-I, L-R and A-P direction, respectively. No significant difference was found in the mean setup error for the daily and hypothetical day 1–3 plus weekly protocol. However, the calculated CTV to PTV margins for the daily interfraction imaging data were 1·6, 3·8 and 1·4 mm in the S-I, L-R and A-P directions, respectively. Hypothetical day 1–3 plus weekly resulted in CTV–PTV margins of 5, 4·2 and 5 mm in the S-I, L-R and A-P direction.

The results of this study show that a daily CBCT protocol reduces setup errors and allows setup margin reduction in head and neck radiotherapy compared to a weekly imaging protocol.