Oral mucositis is common for patients undergoing chemoradiotherapy for squamous cell carcinoma of the head and neck (SCCHN). Despite the significant detrimental sequelae associated, there is no consensus on the optimum mouth care regimen. This prospective audit aims to record mucositis and dysphagia toxicity and the level of analgesia prescribed when recent products: MuGard™, Caphosol® and Episil® are compared with our standard departmental mouth care regimen.

Patients undergoing concurrent chemoradiotherapy for locally advanced SCCHN at University Hospital Birmingham, UK were prospectively audited weekly for 8 consecutive weeks starting from week 1 of chemoradiotherapy from June 2009 until January 2011. Patients received either standard oral care regimen of aspirin, glycerin and sucralfate, or, MuGard™, Caphosol® or Episil®. Grade of mucositis, dysphagia and analgesia score were prospectively recorded using the common toxicity criteria v3·0.

One hundred and four patients were included. There was no difference in the grade and duration of mucositis (p = 0·82), dysphagia (p = 0·99) or analgesia score (p = 0·61) for either MuGard™, Caphosol® or Episil® compared with standard oral care.

There is no evidence from this audit that Mugard™, Caphosol® or Episil® improves mucositis and dysphagia toxicity or the level of analgesia prescribed compared with our standard departmental mouth care regimen. Randomised trials comparing these approaches are required to detect any meaningful clinical benefit.

The Virtual Environment for Radiotherapy Training (VERT) is a high-fidelity simulation hardware and software resource that replicates the expensive and high-pressure clinical environment of a radiotherapy treatment machine. The simulation allows students to gain confidence with clinical techniques in a safe and unpressured academic environment before clinical placement. The aim of this study was to establish the current and future role of VERT and explore the potential for collaborative resource development and research.

An anonymous online survey was made available to all users of the software internationally (n=52). A mixture of fixed and open response questions gathered usage data and user feedback.

The study had a 90% response rate (n=47). Most participants (78·5%) used the resource 1 day/week or less; around 8,000 hours worldwide. It was clear that most participants used the simulation resource to help student to either gain understanding of concepts and techniques or to gain practice with techniques and practical skills. There was good support for collaborative resource development, deployment and evaluation to help VERT users to fully exploit its range of pedagogical uses.

This audit demonstrated high levels of engagement and enthusiasm for collaborative resource development and ongoing research among the radiotherapy simulation community. Adoption of an international Academic Community of Practice for collaborative simulation resource deployment and support may be of significant value and is worthy of further discussion and consideration.

An increasing number of external beam treatment modalities including intensity modulated radiation therapy, volumetric modulated arc therapy (VMAT) and stereotactic radiosurgery uses very small fields for treatment planning and delivery. However, there are major challenges in small photon field dosimetry, due to the partial occlusion of the direct photon beam source’s view from the measurement point, lack of lateral charged particle equilibrium, steep dose-rate gradient and volume averaging effect of the detector response and variation of the energy fluence in the lateral direction of the beam. Therefore, experimental measurements of dosimetric parameters such as percent depth doses (PDDs), beam profiles and relative output factors (ROFs) for small fields continue to be a challenge.

In this study, we used a homogeneous water phantom and the heterogeneous anthropomorphic stereotactic end-to-end verification (STEEV) head phantom for all dose measurements and calculations. PDDs, lateral dose profiles and ROFs were calculated in the Eclipse Treatment Planning System version 13·6 using the Acuros XB (AXB) and the analytical anisotropic algorithms (AAAs) in a homogenous water phantom. Monte Carlo (MC) simulations and measurements using the Exradin W1 Scintillator were also accomplished for four photon energies: 6 MV, 6FFF, 10 MV and 10FFF. Two VMAT treatment plans were generated for two different targets: one located in the brain and the other in the neck (close to the trachea) in the head phantom (CIRS, Norfolk, VA, USA). A Varian Truebeam linear accelerator (Varian, Palo Alto, CA, USA) was used for all treatment deliveries. Calculated results with AXB and AAA were compared with MC simulations and measurements.

The average difference of PDDs between W1 Exradin Scintillator measurements and MC simulations, AAA and AXB algorithm calculations were 1·2, 2·4 and 3·2%, respectively, for all field sizes and energies. AXB and AAA showed differences in ROF of about 0·3 and 2·9%, respectively, compared with W1 Exradin Scintillator measured values. For the target located in the brain in the head phantom, the average dose difference between W1 Exradin Scintillator and the MC simulations, AAA and AXB were 0·2, 3·2 and 2·7%, respectively, for all field sizes. Similarly, for the target located in the neck, the respective dose differences were 3·8, 5·7 and 3·5%.

In this study, we compared dosimetric parameters such as PDD, beam profile and ROFs in water phantom and isocenter point dose measurements in an anthropomorphic head phantom representing a patient. We observed that measurements using the W1 Exradin scintillator agreed well with MC simulations and can be used efficiently for dosimetric parameters such as PDDs and dose profiles and patient-specific quality assurance measurements for small fields. In both homogenous and heterogeneous media, the AXB algorithm dose prediction agrees well with MC and measurements and was found to be superior to the AAA algorithm.

We review augmented (AR) and virtual reality (VR) applications in radiotherapy as found in the scientific literature and highlight future developments enabled by the use of small mass-produced devices and portability of techniques developed in other fields to radiotherapy.

The application of AR and VR within radiotherapy is still in its infancy, with the notable exception of training and teaching applications. The relatively high cost of equipment needed to generate a realistic 3D effect seems one factor that has slowed down its use, but also the sheer amount of image data is relatively recent, were radiotherapy professionals are only beginning to explore how to use this to its full potential. This increased availability of 3D data in radiotherapy will drive the application of AR and VR in radiotherapy to efficiently recognise and extract key features in the data to act on in clinical decision making.

The development of small mass-produced tablet devices coming on the market will allow the user to interact with computer-generated information more easily, facilitating the application of AR and VR. The increased connectivity enabling virtual presence of remote multidisciplinary team meetings heralds significant changes to how radiotherapy professionals will work, to the benefit of our patients.

To observe the impact of internal mammary node irradiation (IMNI) on disease-free survival (DFS) and overall survival (OS) in postmastectomy women with breast cancer.

Between 1978 and 1996, 153 women with stage II–III breast cancer were treated with postmastectomy radiation therapy (RT) with IMNI. Their clinical, pathological and treatment characteristics were matched with 166 patients without IMNI. The RT dose was 35 Gy to the chest wall and 40 Gy to the supraclavicular fossa and IMN in 15 fractions over 3 weeks with photons. All patients were planned with two-dimensional technique. Adjuvant chemotherapy was administered to 41% and endocrine therapy to 52% of the patients. Symptomatic patients were further assessed for late pulmonary and late cardiac effects.

The median follow-up period was 203 months (range, 182–224), and the median age was 44 years (range 20–73 years). The IMNI group had significantly more right-sided and inner/central quadrant tumours. Other characteristics were comparable between both the groups. DFS at 15 years with and without IMNI was 64 and 49%, respectively (p=0·0001). On multivariate analysis, IMNI was an independent, positive predictor of DFS [hazard ratio (HR), 2·89; p=0·0001]. Benefit of IMNI on DFS was more apparent in inner/central tumours [HR, 1·48; 95% confidence interval (CI), 1·02–2·88], N2–N3 patients (HR, 1·44; 95% CI, 1·09–2·10) and in those who received chemotherapy (HR, 1·70; 95% CI, 1·07–2·71). OS at 15 years with and without IMNI was 68 and 54%, respectively (p=0·0001). Late pulmonary toxicity was 1·5 versus 1% with and without IMNI, respectively. Late cardiac toxicity was 2·6 versus 1·8% with and without IMNI, respectively.

IMNI significantly improved DFS and OS in postmastectomy breast cancer patients. Benefit of IMNI was seen in patients with central/inner tumours and N2–N3 disease. Late cardiopulmonary toxicities were comparable between the two groups.

The burden of lifestyle-associated disease is increasing with a preventative approach to health becoming more of a focus. Within the oncology setting, the importance of supporting patients with positive lifestyle changes post treatment is included within the recently developed recovery package and the contribution of therapeutic radiographers will be significant in the implementation of this.

A 23-question survey tool was distributed via the online platform Survey Monkey. The questionnaire was promoted online through the Society and College of Radiographers (SCoR). All members of the SCoR had access to the questionnaire to allow for assessment of health improvement provision nationally. Quantitative and qualitative data were acquired and analysed using the statistical package for the social sciences, descriptive statistics and thematic analysis.

Therapy radiographers recognise importance of health promotion. Highest levels of provision were observed with smoking cessation and lowest levels of provision observed on the topic of exercise. Key barriers identified were staff responsibility and lack of knowledge and training of therapy radiographers.

Health improvement is part of the role of the therapy radiographer and is delivered within UK radiotherapy departments; however, there is scope to increase delivery with the identification and overcoming of barriers to provision.

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.

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.

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.

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.

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.

This study is a dosimetric and acute toxicity comparison of endometrial cancer patients treated with either Axxent (Xoft, Inc., San José, CA, USA) electronic and interstitial brachytherapy versus interstitial high dose rate brachytherapy (HDRBT).

Between 2015 and 2017, 94 patients with postoperative endometrial cancer were treated in our centre with the Axxent electronic brachytherapy (eBT) system. The V150 and V200 are evaluated prospectively for each plan. The mean age of patients was 65.9 years (age range 33–84 years), with different tumour staging. Of the 94 patients, 37 received exclusive adjuvant brachytherapy (25 Gy in five sessions); the remaining patients received external beam radiotherapy (EBRT) with a regimen of 23 sessions of 2 Gy each to the entire pelvis, followed by eBT (15 Gy in three sessions). Additionally, the absorbed doses received by the organs at risk (OAR), urinary bladder, rectum and sigmoid colon were compared with HDRBT plans, evaluating D2cc, V50% and V35%. Median follow-up was done for each of the 94 patients to assess the toxicity of the treatment: vaginal mucosa toxicity, rectal and urinary toxicity; and results are presented for acute toxicity, toxicity at 1 month after the end of treatment and follow-up after 12 months for a portion of patients according to the Radiation Therapy Oncology Group (RTOG) toxicity criteria.

The doses in OAR for eBT plans were lower than that for HDRBT plans, both Ir-192 and Co-60 plans, whose doses were similar. The dose in bladder with eBT was 63.8% of the prescribed dose for D2cc versus 70.1% for HDRBT Ir-192, for V50% was 7.2% versus 12.7% and for V35% was 15.2% versus 28.2%. In rectum the D2cc was 61.2% versus 68.4%, for V50% was 7.9% versus 14.3% and for V35% was 16.7% versus 32%. Results demonstrated lower doses to OAR in all eBT plans. Acute toxicity in eBT was very low in cases of mucositis, with only one case of toxicity greater than grade 1, rectal toxicity and urinary toxicity; results at 1 month are equally good, toxicity symptoms disappeared and no relapses have occurred to date.

The results of treatment with the Axxent eBT unit for 94 patients are very good, as no recurrence has been observed and the toxicity of the treatment is very low. The increase in V150 and V200 has not produced an increase in vaginal mucosa toxicity, and the doses in the OAR are lower than in the plans implemented for HDRBT with Ir-192 or Co-60. eBT is a good alternative to treat endometrial cancer in centres without conventional HDR availability. To date, there are limited published studies reporting on outcomes from patients treated with eBT.

The purpose of this study was to evaluate the dosimetric impact of multileaf collimator (MLC) positional errors on dynamic intensity-modulated radiotherapy (IMRT) treatments through planning simulation. Secondly the sensitivity of IMRT MatriXX device for detecting the MLC leaf positional errors was also evaluated.

In this study five dynamic IMRT plans, each for brain and head–neck (HN), were retrospectively included. An in-house software was used to introduce random errors (uniform distribution between −2·0 and +2·0 mm) and systematic errors [±0·5, ±0·75, ±1·0 and ±2·0 mm (+: open MLC error and −: close MLC error)]. The error-introduced MLC files were imported into the treatment planning system and new dose distributions were calculated. Furthermore, the dose–volume histogram files of all plans were exported to in-house software for equivalent uniform dose (EUD), tumour control probability and normal tissue complication probability calculations. The error-introduced plans were also delivered on LINAC, and the planar fluences were measured by IMRT MatriXX. Further, 3%/3 mm and 2%/2 mm γ-criteria were used for analysis.

In planning simulation study, the impact of random errors was negligible and ΔEUD was <0·5±0·7%, for both brain and HN. The impact of systematic errors was substantial, and on average, the maximum change in EUD for systematic errors (close 2 mm) was −10·7±3·1% for brain and −15·5±2·6% for HN.

It can be concluded that the acceptable systematic error was 0·4 mm for brain and 0·3 mm for HN. Furthermore, IMRT MatriXX device was able to detect the MLC errors ≥2 mm in HN and >3 mm errors in brain with 2%/2 mm γ-criteria.