To examine patient satisfaction with a Clinical Specialist Radiation Therapist (CSRT) in a palliative radiotherapy clinical environment.

A one-point dissemination design captured satisfaction scores from patients who did (n=19) and did not (n=14) receive palliative care from the CSRT. The ‘Patient Satisfaction Questionnaire’ included six common questions and four additional questions for patients seen by a CSRT. T-tests compared results from common questions and mean values, standard deviations were also calculated.

For questions ‘I was told everything that I want to know about my condition’ and ‘I felt that the problem that I came with was sorted out properly’, those who received care from the CSRT scored significantly (p<0·05) higher than those that did not (p=0·033, 0·037). For CSRT-specific questions, 89% of participants felt the experience with the CSRT was excellent, 78% strongly agreed/agreed having a CSRT on the care team was important, and 89% of participants strongly agreed/agreed having a CSRT on the care team was important to patients’ understanding of treatment.

Patients receiving care from the CSRT had better understanding of treatment and an excellent experience with the CSRT. This interaction provided more opportunities to address patient questions/concerns, thus alleviating patient anxiety, increasing satisfaction with care, and demonstrating how new roles can develop new models of care within the current healthcare system.

Achieving daily consistent bladder volume is acknowledged as challenging for patients undergoing radiotherapy to the cervix or endometrium. We investigated if use of an ultrasound bladder volume scanner (BioCon-700) improves bladder reproducibility when used during an active volume correction protocol.

During our method-comparison study, prospectively recruited patients (n=20) followed a fluid-loading protocol to achieve acceptable bladder volume. Bladder ultrasound was performed daily to verify planned volume, with patients actively correcting volumes outside a planned range up to a maximum of three times. Using the Bland–Altman method, we compared mean ultrasound readings (USMean) with mean cone-beam computed tomography (CBCT) volumes (CBCTMean). We also conducted staff focus groups exploring issues encountered during implementation of bladder scanning.

Comparing USMean with CBCTMean produced a mean of the differences −10±49·92 mL (1 SD), demonstrating that bladder volume scanning is equivalent to our standard measure for the stated confidence levels. The cohort mean bladder volume decrease from week 1 to 5 was only 8·4%. Mean USMean was 323 mL, mean CBCTMean was 313 mL. Staff experience with the scanner overall was positive.

The BioCon-700 is suitable for the purpose of daily pre-treatment volume verification, facilitating daily assessment and modification of bladder volume, resulting in reproducible treatment volumes.

Craniospinal irradiation (CSI) has become an important and challenging radiation technique for radiation oncologists. Helical tomotherapy (HT) seems to have dosimetric advantage for CSI compared with other radiation modalities. The purpose of this study was to compare dosimetric data between two different HT plans; simultaneous integrated boost (SIB) and sequential boost (Sq).

Twelve previously treated CSI contoured datasets by SIB technique were replanned. Dosimetric comparative parameters of targets were conformity index (CI) and homogeneity index (HI). For organ at risk (OARs), the mean dose of parallel organs, D2% of serial organs and whole body integral dose (ID) were also investigated.

SIB plan significantly provided more conformed dose to CSI and tumour boost while resulting in a similar CI in spinal boost region compared with Sq plan. The HI showed no differences between two plans. Radiation exposure to serial organs and ID were also significantly lower in SIB plan.

CSI treatment using HT, SIB technique was feasible and had more target coverage while minimising the radiation dose to healthy tissues.

During left-sided breast radiotherapy, the heart is often exposed to radiation dose. Shielding can be utilised to reduce heart exposure, but compromises the dose delivered to the breast tissue and, in a proportion of patients, to the tumour bed. Deep inspiration breath hold (DIBH) can be used as a technique to move the heart away from the treatment area and thus reduce heart dose. This study examines the efficacy of the Elekta Active Breathing Coordinator (ABC), a DIBH method, in reducing heart dose.

In total, 12 patients receiving radiotherapy to the left breast were planned for treatment with both a free-breathing (FB) and an ABC scan. The dose volume histogram data for the plans was analysed with respect to heart V13, V5 Gy, mean heart dose and ipsilateral lung V18 Gy. Tumour bed D98%, threshold lung volume in breath hold (BH) and the maximum BH time for each patient was also measured. Patients then received their radiotherapy treatment using the ABC plan and the systematic error in the craniocaudal, lateral and vertical axes was assessed using orthogonal imaging.

The median heart V13 Gy for FB and DIBH patients was 3% (range, 0·85–11·28) and 0% (range, 0–1·56), respectively, with a mean heart dose of 2·62 Gy (range, 1·21–4·93) in FB and 1·51 Gy (range, 1·17–2·22) in ABC. The median lung V18 Gy was 8·7% (3·08–14·87) in FB plans and 9% (4·88–12·82) in ABC plans. The mean systematic set-up errors in all three planes were within the departmental set-up tolerance of 5 mm for both techniques. Median FB tumour bed D98% was 97·4% (92·8–99·5) and 97·5% (97·3–98·5) for ABC.

ABC represents a good method of reducing radiation dose to the heart while not compromising on dose to the tumour bed, and it has a clear advantage over FB radiotherapy in reducing the risk of cardiac toxicity. It is tolerated well by patients and does not produce any difficulties in patient positioning.

This study was conducted for establishing inherent uncertainty in the shift determination by X-ray volumetric imaging (XVI) and calculating margins due to this inherent uncertainty using van Herk formula.

The study was performed on the XVI which was cone-beam computed tomography integrated with the Elekta AxesseTM linear accelerator machine having six degree of freedom enabled HexaPOD couch. Penta-Guide phantom was used for inherent translational and rotational shift determination by repeated imaging. The process was repeated 20 times a day without moving the phantom for 30 consecutive working days. The measured shifts were used for margins calculation using van Herk formula.

The mean standard deviations were calculated as 0·05, 0·05, 0·06 mm in the three translational (x, y and z) and 0·05°, 0·05°, 0·05° in the three rotational axes (about x, y, z). Paired sample t-test was performed between the mean values of translational shifts (x, y, z) and rotational shifts. The systematic errors were found to be 0·03, 0·04 and 0·03 mm while the random errors were 0·05, 0·06 and 0·06 mm in the lateral, cranio-caudal and anterio-posterior directions, respectively. For the rotational shifts, the systematic errors were 0·02, 0·03 and 0·03 and the random errors were 0·06, 0·05 and 0·05 in the pitch, roll and yaw directions, respectively.

Our study concluded that there was an inherent uncertainty associated with the XVI tools, on the basis of these six-dimensional shifts, margins were calculated and recorded as a baseline for the quality assurance (QA) programme for XVI imaging tools by checking its reproducibility once in a year or after any major maintenance in hardware or upgradation in software. Although the shift determined was of the order of submillimetre order, still that shift had great significance for the image quality control of the XVI tools. Every departments practicing quality radiotherapy with such imaging tools should establish their own baseline value of inherent shifts and margins during the commissioning and must use an important QA protocol for the tools.

To develop an auto-generated patient discharge summary for all patients being treated in the Radiation Therapy Department.

A patient discharge summary was developed using auto-generated data for all patients being treated in the Radiation Therapy Department. This ensures information relevant to the care of the patient is communicated effectively during transitions of care following radiation treatment, and provides a record of the treatment site(s), dose delivered, start/completion dates and contact information for Radiation Oncologists. The eScribe feature in MosaiQTM is utilised to auto-generate the patient discharge summary in less than one minute, and then printed and given to patients on the last day of treatment. This was piloted with palliative radiotherapy patients (n=22), who also completed a telephone survey.

Results revealed patients had passed this document onto other healthcare providers and appreciated having a record of their treatments. Feedback was obtained from radiation therapy staff and the Patient and Family Advisory Committee. Subsequently, the language of the patient discharge summary was simplified and a disclaimer was added, indicating the document is not a complete radiation therapy treatment record. This initiative was then rolled out to all radiotherapy patients.

Overall, the patient discharge summary allows for a quick, automated and standardised approach for transfer of information during care transitions without significant impact to the Radiation Therapy Departmental workflow.

To determine which concomitant boost technique is dosimetrically superior in the treatment of breast cancer; volumetric-modulated arc therapy (VMAT) or fixed field intensity-modulated radiotherapy (ff-IMRT).

In total, 30 breast patients were re-planned with both VMAT and fixed field concomitant boost intensity-modulated radiotherapy techniques. A hybrid technique was used delivering 80% of the dose through tangential beams and 20% through an integrated boost. A two-tailed t-test sample for means was used to compare the dosimetric differences between the techniques.

Maximum dose was statistically lower for VMAT; 103·2 versus 103·7% for ff-IMRT along with statistically lower V2 Gy doses to the contralateral lung (0·7 versus 1·6%) and heart for both left- (19·0%/22·6%), and right- (5·5%/8·8%) sided patients, respectively. ff-IMRT boasted significantly lower ipsilateral lung V20, V18 and V10 Gy (7·9/8·6/13·1 versus 8·1/8·8/13·4%) than VMAT, respectively. No differences were found with minimum coverage, mean dose and V5 Gy to all organs at risk (OARs).

VMAT and ff-IMRT techniques demonstrate excellent target coverage and OAR sparing facilitated by the hybrid planning technique and deep inspiration breath hold. There is no obvious dosimetrically superior option between the two techniques. Reduced treatment times with VMAT make it more desirable to implement clinically.

A novel radiotherapy outlining application uses a small number of user-assigned points across orthogonal planes to generate a mesh which is then edited across multiple slices using innovative three-dimensional (3D) sculpting tools. This paper presents the results of a bladder outlining study that compared times and volumes for the new tool with those of a conventional manual outlining tool.

All students undertaking their first University radiotherapy planning module were invited to participate. Following training, they performed a timed outlining of the same male bladder dataset and provided feedback on their preferred method.

Comparison of times from the resulting ten datasets demonstrated that the 3D segmentation tool was significantly faster than conventional software with a mean time of 11·9 minutes compared with 19·2 minutes (p=0·03). The users expressed a preference for the new tool (eight users) over the conventional outlining software (two users).

A minimal point 3D volumetric manual outlining tool utilising orthogonal computed tomography planes demonstrated significant time saving for bladder segmentation compared with axial-based outlining within a group of novice outliners. Future work aims to establish the role of the 3D multi-slice sculpting tools in editing of auto-segmentation derived contour sets.

Volumetric-modulated arc therapy (VMAT) has emerged as one of the most favourable techniques for radiotherapy treatment in recent years because of its conformal dose distribution to the planning target volume (PTV), lower doses to adjacent normal organs at risk (OARs) and faster and easier dose delivery. A typical conventional VMAT protocol for low-intermediate risk prostate cancer uses a flattened 6 MV photon beam to deliver 78 Gy in 39 fractions, however, a recent Radiation Therapy Oncology Group study investigated prostate cancer radiotherapy with a hypofractionated dose scheme of 36·25 Gy in 5 fractions. One advantage of flattening filter-free (FFF) beams in radiotherapy is the higher doses in the central region on the dose profile and much higher dose delivery rates.

This paper reports the investigation of preclinical studies for implementing FFF beams in hypofractionated VMAT for prostate cancer radiotherapy. All treatment planning were accomplished using Varian EclipseTM treatment planning system version 11 and delivered on Varian Truebeam linear accelerators. The studies compared the biological-effective dose–volume histograms and dose–volume histograms of PTV and OARs for 20 patients using conventional and hypofractionated dose schemes. The study also evaluated the 6 and 10 MV FFF by comparing 6 and 10 MV VMAT plans with the FFF beams. The treatment time was investigated using plans with 6 MV beams and doses of 2, 4, 5, 6, 7·25 Gy/fraction and plans with 10 MV FFF with a dose of 7·25 Gy/fraction. We also investigated an angular monitor unit (MU) quantity (MU/deg) and its threshold value for RapidArcTM plans, beyond which FFF beams can be considered superior to flattened beams in terms of treatment time increased caused by higher dose per fraction.

The results show that the hypofractionated plans resulted in greater biological equivalent doses to PTV and lower doses to OARs. The 10 MV FFF plans have statistically lower mean doses to all the OARs, whereas PTV homogeneity index remains the same compared with other beam energies. The mean body integral dose for the 20 patients is 8·7% lower using 10 MV FFF compared with 6 MV FFF mainly because of the higher energy and less required MUs with the 10 MV FFF beam. The hypofractionated scheme with 10 MV FFF plan has the same treatment time as that of the 6 MV plan at 2 Gy/fraction, as the higher dose delivery rates at 10 MV FFF can compensate for the higher prescribed dose per fraction without the need of extra treatment time.

In this study, we observed that the 10 MV FFF beam is better for hypofractionated prostate cancer VMAT plan delivery. The threshold value of MU/deg is found to be 2·083 MU/deg based on our machine configurations.

The control of patient position, posture and respiratory movements during radiotherapy is important for effective and specific treatment of malignancy. We have developed an infrared (IR) interactive patient position guidance and acquisition control system for clinical use, comprising IR cameras, IR markers and dedicated software.

We evaluated the system with ten healthy volunteers and ten experienced operators. IR markers were placed on the body surface. Their positions were calculated using vectors of three translational and three rotational parameters, and the intrafractional error for each marker was acquired with and without respiratory motion. The inclusion of multiple positioning markers allowed for real-time visualisation of the patient posture, with feedback on misalignment and required postural adjustments.

The positioning time was 73 seconds (with a minimum period of 39 seconds), which was significantly shorter than for conventional line alignment. A comparison of positioning reproducibility between conventional line alignment and this system was <3·5 mm and was not patient dependent or operator dependent. An intrafractional error of displacement of up to 10·0 mm was found in the right iliac crest.

This IR interactive system was shown to be high utility and suitable for monitoring patient position, posture and respiratory movements during radiotherapy.

Deep inspiration breath hold (DIBH) is a method of motion management used in stereotactic ablative body radiotherapy (SABR) for lung tumours. An external gating block marker can be used as a tumour motion surrogate, however, inter-fraction gross target volume (GTV) displacement within DIBH occurs. This study measured this displacement during a reproducible breath hold regime. In addition, factors such as position of the gating block marker were analysed.

A total of 121 cone beam computed tomography scans (CBCTs) from 22 patients who received DIBH SABR were retrospectively evaluated and the magnitude of inter-fraction GTV displacement was calculated for each fraction. This data was analysed to assess if any correlation existed between tumour displacement and variation in the gating block marker position on the patient, the amplitude of breath hold (BH) at computed tomography (CT), the amplitude of BH at treatment and the tumour location.

The measured tumour displacement was applied to the original planning CT to evaluate the dosimetric effect on surrounding organs at risk (OARs) using cumulative dose volume histograms (DVHs).

BH amplitude was reproducible within 0·13±0·1 cm (mean±standard deviation). The magnitude of tumour displacement within BH ranged from 0 to 1·52 cm (0·41±0·28 cm). Displacement in the superior-inferior, anterior-posterior and left-right planes were 0·31±0·26 cm, 0·16±0·18 cm and 0·07±0·12 cm, respectively. No statistically significant correlation was detected between tumour displacement within DIBH and the factors investigated. The range of variation in OAR dose was −7·0 to +3·6 Gy with one statistically significant increase in OAR dose observed (oesophagus mean dose increasing by 0·16 Gy).

Reproducible BH was achievable across a range of patients. Inter-fraction GTV displacement measured 0·41±0·28 cm. Due to this low level of motion, the correction of soft tissue moves did not adversely affect OAR dose.

In radiotherapy (RT) bolus material is used to increase skin dose and eliminate the ‘skin-sparing’ effect. Bolus fabrication is limited to the expertise of the practitioner and is time and resource intensive for both patients and staff to construct bolus. In addition, prefabricated bolus does not always conform to irregular surfaces resulting in variations to dose distribution at the skin surface. The purpose of this paper is to ascertain whether it is feasible to improve bolus conformity within radiation therapy by using a 3D printer to fabricate bolus.

A literature review was conducted that utilised Boolean terminology and included keywords; (‘3d’ OR ‘3-dimensional’ OR ‘three dimensional’) ‘bolus’ OR ‘boli’ conform*, (‘Radiation therapy’ OR ‘radiotherapy’) Printing.

Several key papers were identified and critically evaluated based of the title of the feasibility of improving bolus conformity with the used of 3D printing. Several fabrication material devices were explored.

The literature advocates that fused deposition modelling fabrication device clear polylactic acid material to be an adequate product to construct 3D printed bolus and conform to irregular surfaces. 3D bolus would prove advantageous for volumetric arc therapy/intensity modulated radiation therapy techniques as literature has shown the presence of air gaps, small field sizes and large beam obliquity can result in a >10% dose reduction at skin surface.

Stereotactic-fractionated radiotherapy and radiosurgery (RS) for benign and malignant intracranial lesions relies on a very high degree of accuracy in dose alignment due to the ablative dose delivered, and therefore requires a high-precision image guidance modality. The aim of this review is to investigate the localisation and verification accuracy performance of ExacTrac (ET) and Novalis Tx System.

A systematic review of the database Science Direct was carried out using search terms ‘stereotactic radiotherapy (SRT)’ and ‘ET’. All articles before 2000 were excluded. Only articles that involved intracranial lesions, with the exception of one article, were included in the final review.

Results from gold standard Hidden Target Tests and patient data show that patient position can be reproduced within 1·0 mm with the use of ET imaging. In addition, the 6 degrees of freedom algorithm function of ET allows for better translational accuracy as well optimal positioning when rotations are corrected for. Studies showed excellent correlation (p<0·01) between bony ET images and cone beam computed tomography (CBCT) soft tissue registration, evidencing the safe reliance of bony anatomy for image guidance via ET. Shifts were found to be comparable between CBCT and ET.

There is the need for regular calibration to prevent systematic errors and potential geographic miss. However, due to ET’s additional benefits, including reduced concomitant dose and faster imaging time, ET is the superior image guidance modality for RS/SRT in the treatment of intracranial lesions.

The aim of this study was to compare the dosimetric parameters and effects of simultaneous integrated boost (SIB) and traditional sequential electron boost, after helical tomotherapy, because of the lack of studies in this field in the current literature.

Computed tomographic data of 14 patients who received SIB in 2012–2015 were collected from Hong Kong Sanatorium & Hospital. New tomotherapy with SIB plans and tomotherapy with sequential boost plans were generated for each patient, and results were compared.

Conformation number, mean dose, dose received by 95% volume (both sides), ipsilateral lung volume receiving 20 Gy (V20) and skin dose (right side) were found to be significantly better for SIB (p<0·05), however coverage index and gross target volume dose showed no significant difference, and heart dose was significantly higher for SIB on the right side.

Tomotherapy with SIB may be able to offer less organ at risk dose (except for the heart), while maintaining the ability to deliver adequate dose coverage.