Accurate three-dimensional dosimetry is essential in modern radiotherapy techniques such as volumetric-modulated arc therapy (VMAT) and intensity-modulated radiation therapy (IMRT). In this research work, the PRESAGE® dosimeter was used as quality assurance (QA) tool for VMAT planning for head and neck (H&N) cancer.

Computer tomography (CT) scans of an Image Radiation Oncology Core (IROC) H&N anthropomorphic phantom with both IROC standard insert and PRESAGE® insert were acquired separately. Both CT scans were imported into the Pinnacle (9.4 version) TPS for treatment planning, where the structures [planning target volume (PTV), organs at risk) and thermoluminescent detectors (TLDs) were manually contoured and used to optimise a VMAT plan. Treatment planning was done using VMAT (dual arc: 182°–178°, 178°–182°). Beam profile comparisons and gamma analysis were used to quantify agreement with film, PRESAGE® measurement and treatment planning system (TPS) calculated dose distribution.

The average ratio of TLD measured to calculated doses at the four PTV locations in the H&N phantom were between 0·95 to 0·99 for all three VMAT deliveries. Dose profiles were taken along the left–right, the anterior–posterior and superior–inferior axes, and good agreement was found between the PRESAGE® and Pinnacle profile. The mean value of gamma results for three VMAT deliveries in axial and sagittal planes were found to be 94·24 and 93·16% when compared with film and Pinnacle, respectively. The average values comparing the PRESAGE® results and dose values calculated on Pinnacle were observed to be 95·29 and 94·38% in the said planes, respectively, using a 5%/3 mm gamma criteria.

The PRESAGE® dose measurements and calculated dose of pinnacle show reasonable agreement in both axial and sagittal planes for complex dual arc VMAT treatment plans. In general, the PRESAGE® dosimeter is found to be a feasible QA tool of VMAT plan for H&N cancer treatment.

To design, construct and evaluate an anthropomorphic head and neck phantom for the dosimetric evaluation of 3D-conformal radiotherapy (3D-CRT) dose planning and delivery, for protocols developed by the Radiation Therapy Oncology Group (RTOG).

An anthropomorphic head and neck phantom was designed and fabricated using Perspex material with delineated planning target volumes (PTVs) and organs at risk (OARs) regions. The phantom was imaged, planned and irradiated conformally by a 3D-CRT plan. Dosimetry within the phantom was assessed using thermoluminescent dosimeters (TLDs). The reproducibility of phantoms and TLD readings were checked by three repeated identical irradiations. Subsequent three clinical 3D-CRT plans for nasopharyngeal patients have been verified using the phantom. Measured doses from each dosimeter were compared with those acquired from the treatment planning system (TPS).

Phantom's measured doses were reproducible with <3·5% standard deviation between the three TLDs’ repeated measurements. Verification of three head and neck 3D-CRT patients’ plans was implemented, and good agreement between measured values and those predicted by TPS was found. The percentage dose difference for TLD readings matched those corresponding to the calculated dose to within 4%.

The good agreement between predicted and measured dose shows that the phantom is a useful and efficient tool for 3D-CRT technique dosimetric verification.

A pilot study was undertaken to find significance of vascular endothelial growth factor (VEGF) and cancer antigen (CA 15.3) in breast cancer patients.

Total 70 patients with breast cancer were divided into triple negative breast cancer (TNBC) and non-TNBC depending on oestrogen receptors, progesterone receptors or HER-2/neu receptors status. Serum CA 15.3 and VEGF levels were evaluated with enzyme-linked immunosorbent assay at the time of diagnosis and were correlated with age, tumour size and stage of the disease in both the groups. Spearman's test was used to find the correlation.

VEGF levels were found to be >400 pg/ml in 27 patients, 19 (54·33%) of them were TNBC and only 8 (22·87%) non-TNBC. Mean values of the VEGF were, 784·34 pg/ml in TNBC and 334·60 pg/ml non-TNBC patients, respectively. CA 15.3 level was found to be higher in non-TNBC group (60·72 U/ml) than in TNBC group (45·24 U/ml). In all patients significant correlation was found between serum CA 15.3 level and tumour size and stage of the disease. In non-TNBC patients significant correlation was seen between CA 15.3 values and stage of the disease, but VEGF had no correlation with any of the disease parameters. In TNBC patients, there was no correlation between CA 15.3 level and any of the disease parameters but VEGF showed a significant correlation with both tumour size and stage of the disease.

Expression profile of VEGF was high in TNBC than non-TNBC patients. VEGF serves to be a better biomarker as compared with CA 15.3 in TNBC patients.

Patient teaching in radiation therapy may include restrictions on applying skin products owing to concerns that the presence of such materials may increase skin dose. These restrictions may create unnecessarily complicated and conflicting self-care instructions.

To determine what thickness of skin product is necessary to produce a clinically meaningful dose increase to the skin, and provide recommendations for evidence-based patient instructions.

Dosimetric measurements and Monte Carlo simulations were used to calculate skin dose under 0–1·5 mm thicknesses of two common classes of skin product for a variety of treatment geometries. The thickness of product required to produce a clinically significant dose increase to the skin was determined.

The thickness of product required to create a clinically meaningful dose increase was >0·7 mm for 10 × 10 cm2 fields and >1·5 mm for 1 × 1 cm2 fields. A typical application of product would be only 0·3 mm.

It seems unrealistic to anticipate patients using sufficiently large quantities of skin product to be of clinical concern. We therefore recommend that there are no dosimetric reasons to restrict the use of these types of skin products during radiation therapy for common treatment scenarios.

Electronic portal imaging device (EPID) offers high-resolution digital image that can be compared with a predicted portal dose image. A very common method to quantitatively compare a measured and calculated dose distribution that is routinely used for quality assurance (QA) of volumetric-modulated arc therapy (VMAT) and intensity-modulated radiation therapy treatment plans is the evaluation of the gamma index. The purpose of this work was to evaluate the gamma passing rate (%GP), maximum gamma (γmax), average gamma (γave), maximum dose difference (DDmax) and the average dose difference (DDave) for various regions of interest using Varian’s implementation of three absolute dose gamma calculation techniques of improved, local, and combined improved and local.

We analyzed 232 portal dose images from 100 prostate cancer patients’ VMAT plans obtained using the Varian EPID on TrueBeam Linacs.

Our data show that the %GP, γmax and γave depend on the gamma calculation method and the acceptance criteria. Higher %GP values were obtained compared with both our current institutional action level and the American Association of Physicists in Medicine Task Group 119 recommendations.

The results of this study can be used to establish stricter action levels for pre-treatment QA of prostate VMAT plans. A stricter 3%/3 mm improved gamma criterion with a passing rate of 97% or the 2%/2 mm improved gamma criterion with a passing rate of 95% can be achieved without additional measurements or configurations.

To analyse interfraction setup using two different image guidance modalities for prostate and head-and-neck (H&N) cancer treatment.

Seventy-two prostate and 60 H&N cancer patients, imaged with kilovoltage cone beam computed tomography (KVCBCT) or megavoltage fan beam computed tomography (MVFBCT), were studied retrospectively. The daily displacements in mediolateral (ML), craniocaudal (CC) and anteroposterior (AP) dimensions were investigated. The setup errors were calculated to determine the clinical target volume to planning target volume (CTV-to-PTV) margins.

Based on 1,606 KVCBCT and 2,054 MVFBCT scans, average interfraction shifts in ML, CC and AP direction for H&N cases were 0·5 ± 1·5, −0·3 ± 2·0, 0·3 ± 1·7 mm using KVCBCT, 0·2 ± 1·9, −0·2 ± 2·4 and 0·0 ± 1·7 mm using MVFBCT. For prostate cases, average interfraction displacements were −0·3 ± 3·9, 0·2 ± 2·4, 0·4 ± 3·8 mm for MVFBCT and −0·2 ± 2·7, −0·6 ± 2·9, −0·5 ± 3·4 mm for KVCBCT. The calculated CTV-to-PTV margins, if determined by image-guided radiotherapy (IGRT) data, were 5·6 mm (H&N) and 7·8 mm (prostate) for MVFBCT, compared with 4·8 mm and 7·2 mm for KVCBCT. We observed no statistically significant difference in daily repositioning using KVCBCT and MVFBCT in early, middle and late stages of the treatment course.

In the absence of IGRT, the CTV-to-PTV margin determined using IGRT data, may be varied for different imaging modalities for prostate and H&N irradiation.

The success of radiation therapy for cancer patients is dependent on the ability to deliver a total tumouricidal radiation dose capable of eradicating all cancer cells within the clinical target volume, however, the radiation dose tolerance of the surrounding healthy tissues becomes the main dose-limiting factor. The normal tissue adverse effects following radiotherapy are common and significantly impact the quality of life of patients. The likelihood of developing these adverse effects following radiotherapy cannot be predicted based only on the radiation treatment parameters. However, there is evidence to suggest that some common genetic variants are associated with radiotherapy response and the risk of developing adverse effects. Radiation genomics is a field that has evolved in recent years investigating the association between patient genomic data and the response to radiation therapy. This field aims to identify genetic markers that are linked to individual radiosensitivity with the potential to predict the risk of developing adverse effects due to radiotherapy using patient genomic information. It also aims to determine the relative radioresponse of patients using their genetic information for the potential prediction of patient radiation treatment response.

This paper reports on a review of recent studies in the field of radiation genomics investigating the association between genomic data and patients response to radiation therapy, including the investigation of the role of genetic variants on an individual’s predisposition to enhanced radiotherapy radiosensitivity or radioresponse.

The potential for early prediction of treatment response and patient outcome is critical in cancer patients to make decisions regarding continuation, escalation, discontinuation, and/or change in treatment options to maximise patient survival while minimising adverse effects and maintaining patients’ quality of life.

To compare the image-based three-dimensional treatment planning using AcurosTM BV and AAPM TG-43 algorithm for intracavitary brachytherapy of carcinoma cervix.

Twenty-seven patients with cancer cervix, stage IIB or IIIB with vaginal involvement limited to the upper third of the vagina was included into the study. Intracavitary treatments with the patient in this study done with computed tomography and magnetic resonance imaging compatible ring applicator. Groupe European de Curietherapie and European Society for Therapeutic Radiology and Oncology recommended doses to target volumes and organs at risk compared using dose volume histogram.

The mean value of Point ‘A’ dose was compared between AcurosTM BV and TG-43, which indicates 0·13% difference. The differences in the mean dose to gross tumour volume for various volumes are V100% 0·28%, V150% 1·22% and V200% 1·03%; all volumes showed small difference but statistical significant (p<0·05). The mean dose of high-risk clinical target volume (HRCTV) D90 using AcurosTM BV was 8·47 Gy, which was 1·63% less compared with TG-43. The mean point A dose using AcurosTM BV is 1·04 times the dose to D90 of mean HRCTV. The same difference was observed in comparison with TG43. D2cc and D0·1cc of the bladder, rectum and sigmoid showed a statistically significant difference (p<0·05) in comparison with TG-43.

The differences in dosimetric parameters between the AcurosTM BV and TG-43 proved to be statistically significant. The difference is very small, and they are clinically insignificant.

To investigate whether a radiographer-led radiotherapy pathway can provide an efficient service for patients requiring treatment for symptomatic skeletal metastases.

A retrospective review of 425 courses of palliative radiotherapy was conducted. Data was analysed assessing diagnosis, dose/fractionation, time from referral to treatment, gender, age, inpatient/outpatient status and referring clinic location for radiographer- and clinical oncologist-led cohorts.

Patients aged ≥70 years were more likely to be planned by radiographers (n = 162/57, p < 0·001). Patients were more likely to be treated with 8 Gy in single fraction than with 20 Gy in five fractions (n = 279/136, p = 0·012). The median referral to treatment time in 8-Gy single-fraction prescriptions was 3 days for radiographer-led versus 7 days for clinical oncologist-led cohorts. In all patients and in 20 Gy in five-fraction prescriptions, it was 4 versus 8 days. A comparison of all prescriptions (p < 0·001), 8 Gy in single-fraction (p < 0·001) and 20 Gy in five-fraction prescriptions (p = 0·001) showed radiographer-led procedures as enabling faster access to treatment in each category.

A radiographer-led service can facilitate faster access to treatment than a clinical oncologist-led pathway for an appropriately selected patient caseload.

Accupuncture-like transcutaneous electrical nerve stimulation (ALTENS) therapy has been shown in prospective studies to be effective in the treatment of radiation-induced xerostomia. Those studies treated patients within 27 months from end of radiation with ALTENS delivered in the clinic using a Codetron unit. However, that unit is no longer produced and there is limited data on success of ALTENS when delivered at home.

A 50-year old man with xerostomia, 8 years post-radiation for T4N1 squamous cell carcinoma of the tonsillar fossa, was given ALTENS with a currently commercially available unit from Girish Surgical. He used the unit at home, 20 minutes daily for 8 weeks.

After 8 weeks of ALTENS therapy the patient saw a reduction in the Self-Reported University of Michigan Xerostomia-Related Quality of Life Scale from 20 to 1.

This case report demonstrates (1) the Girish Surgical unit is effective, (2) self-administration of ALTENS in patients who cannot come to clinic regularly may be practical and (3) ALTENS can still offer durable benefit to patients even 8 years after chemoradiation therapy.

To review the incidence of clinically significant pulmonary toxicity following total body irradiation (TBI) as a part of the conditioning regimen for acute lymphoblastic leukaemia (ALL) patients undergoing bone marrow transplantation (BMT) at The Ottawa Hospital Cancer Centre.

This is a retrospective review of ALL patients who received TBI in The Ottawa Hospital Bone Marrow Transplant Program (TOH-BMT) as part of their conditioning regimen from 1991 to 2011 inclusive. The patients were treated using a locally developed translating-couch irradiation technique. We have analysed all available data for the first 100 days following TBI to determine the incidence of radiation-induced pulmonary toxicities.

Of the total 622 patients undergoing TBI during the specified period, 88 had ALL. Median age at BMT was 30 years and the conditioning regimens varied. A total of 74 (84%) patients received 12 Gy/6 F/BID of TBI. A total of 55 (63%) patients have died, 32 (36%) within the 1st year after BMT. In the 1st year, pulmonary events were reported for 24 (27%) patients, and the follow-up notes were unavailable for seven (8%). Pulmonary toxicities were reported as the cause of death for six patients, five (6%) within the 1st year. It is estimated that the total number of deaths in the 1st year possibly attributed to radiation-induced lung injury was four (4·5%). Eight (9%) patients had symptoms suggestive of non-lethal grade 2–3 radiation-induced pneumonitis.

TBI continues to be an important component of the conditioning regimen for ALL patients undergoing BMT, and the incidence of radiation-induced pulmonary injury, using our technique and lung dose, is comparable to the published literature.

Head and neck cancer patients face many demanding events, such as radiation therapy, which can cause anxiety and uncertainty. Studies report that relevant information decreases emotional distress and inadequate communication can lead to increased fear and anxiety. There is a lack of research that describes what radiographers do when they meet the patients. The aim is to explain what radiographers’ do that may lead to less anxiety and uncertainty for head and neck cancer patients.

This study was conducted via qualitative interviews and took on a phenomenological, hermeneutic approach. Eleven head and neck cancer patients were interviewed 1-month post radiation therapy.

Successful meetings are characterised by the radiographer smiling, being pleasant, referring to the patient by their name, informing the patient thoroughly, asking open questions and answering questions.

Head and neck cancer patients feel vulnerable and need the radiographer to create a safe atmosphere when they undergo treatment. Then radiographers reduce uncertainty, provide emotional support, reduce loneliness, provide information and create alliances.

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.