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Introduction Methods Results Conclusion Paediatric cancers are rare, and most children requiring radiation therapy receive external beam radiation (EBRT). Although EBRT may offer organ preservation compared to surgery, it can be associated with significant late effects. Image‐guided brachytherapy is a highly specialised technique offering both organ preservation and dose conformity to minimise late toxicity.This is a retrospective mono‐institutional review of paediatric brachytherapy in one of the largest paediatric centres in Australia. Outcomes and toxicities are presented as well as brachytherapy versus proton plan comparison in four patients.A total of 14 patients were treated with adjuvant brachytherapy between 2012 and 2022. The predominant histology was rhabdomyosarcoma, and all patients had pelvic tumours. High‐dose rate (HDR) brachytherapy was given for 13 patients with one patient receiving low‐dose rate (LDR) brachytherapy. Only one grade three late toxicity was reported and two patients developed metastatic disease within one year of completion of treatment. The brachytherapy plan was superior to protons in two of four patients and equivocal in one patient.This is the first Australian publication of a paediatric brachytherapy series from a single institution. This retrospective series demonstrates the feasibility and safety of brachytherapy in paediatric pelvic tumours. The initial work presented here demonstrates the value of a comprehensive radiation plan review in selecting the optimal modality for an individual paediatric patient. [ABSTRACT FROM AUTHOR]

Introduction: Stereotactic ablative radiotherapy (SABR) is a standard of care treatment for medically inoperable early‐stage non‐small‐cell lung cancer (NSCLC). The CHISEL trial was a phase 3 randomised controlled trial that compared SABR to conventional radiation therapy (CRT). Using patient‐level data, we compared the cost‐effectiveness of SABR and CRT for early‐stage NSCLC. Methods: Data on treatment exposure, outcomes (recurrence, survival) and quality of life (QoL; EORTC QLQ‐C30) were sourced from the trial. Quality‐adjusted life years (QALYs) were estimated for the trial period using Australian utility weights for the EORTC QLQ‐C30‐derived QLU‐C10D. Costs related to simulation, planning, delivery, verification and post‐treatment monitoring were estimated by applying Australian Medicare Benefits Schedule fees. The costs of post‐progression therapy and grade ≥3 toxicity were estimated using trial data and relevant literature sources. Cost‐effectiveness was investigated as the incremental cost per QALY gained for SABR compared to CRT. Results: Complete QoL data were available for 21 patients: 14 in the SABR arm and 7 in the CRT arm. Mean QALYs discounted at 5% per annum were similar between arms: 12.68 months for SABR and 12.12 months for CRT. The mean costs of delivering SABR and CRT were $4763 and $6817, respectively. The costs of monitoring were similar in both arms, $4856 and $4853 for SABR and CRT. The mean costs of post‐progression therapy were $24,572 for SABR and $42,801 for CRT. The mean costs of grade ≥3 toxicity were $809 in the SABR arm and $132 in the CRT arm. Therefore, the total mean cost for SABR over the period of interest was lower for SABR than CRT. Given lower mean costs and numerically higher QALYs for SABR compared with CRT, an incremental cost‐effectiveness ratio was not calculated. Conclusion: Compared to CRT, SABR is a cost‐effective treatment for early‐stage NSCLC as the estimated upfront treatment cost and the cost of subsequent care are lower for SABR for comparable mean QALYs. Assessment of the lifetime QALYs and projections of cost estimation will provide a better indication of the long‐term cost‐effectiveness of SABR. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to describe the research productivity among RANZCR Radiation Oncology (RO) trainees. Methods: Publicly available data on RO fellows, who were awarded the RANZCR fellowship between July 2014 and June 2023, was extracted from the RANZCR Annual Reports. Fellows who had qualified overseas and did not undertake full RANZCR training were excluded. A PubMed search was performed for publications by each fellow in the 5 years prior, and 6 months, after the estimated completion of training. Research productivity was defined as the number of first‐author and any‐author publications per trainee. Results: In total, 168 eligible RO fellows were included in this study. 104 (62%) and 118 (70%) fellows had first‐author and any‐author publications during training, respectively. A total of 203 first‐author and 308 unique any‐author publications were identified, with mean first‐author and any‐author publications per trainee of 1.21 (SD = 2.37) and 2.02 (SD = 3.71), respectively. Trainee research was most commonly published in JMIRO (34% of first‐author and 27% of any‐author publications). There were significant differences in the number of first‐author publications by gender (P = 0.04) and training jurisdictions (P = 0.03). There were also differences in the number of any‐author publications by gender (P = 0.002) and training jurisdictions (P = 0.03). There was a significant increase in any‐author publications over the 9‐year study period (P = 0.005). Conclusion: This is the first study evaluating research productivity among RO fellows during training. We identified disparities in research productivity by gender and training jurisdictions. This offers opportunities to tailor efforts to better support a vibrant and productive research culture across the RO training program. [ABSTRACT FROM AUTHOR]

Introduction: This study compared the predictive ability of radiation‐induced cataract between maximum point dose of the lens (Lens Dmax) ≥7 Gy, mean lens dose (Lens Dmean) ≥7 Gy, Lens Dmax ≥10 Gy, and Lens Dmean ≥10 Gy. Methods: Patients aged 3–18 years received cranial irradiation or radiation therapy at head and neck area between January 2010 and December 2019 at our institute were included. Patients without baseline and/or follow‐up eye examination were excluded. Receiver operating characteristic (ROC) curves identified potential predictors and Cox regression analysed correlations between potential factors and cataract occurrence. Results: Sixty‐three patients (122 eyes) were analysed. Cataracts were detected in 14 eyes (11.5%). Median follow‐up time was 4 years (range 0.5–10 years), with cataract developing in a median of 2.5 years (range 0.3–7 years). Three patients (21.4%) developed grade ≥3 cataract. Lens Dmean ≥10 Gy was associated with cataract formation. Conclusion: Lens Dmean ≥10 Gy showed the highest ability for predicting radiation‐induced cataract in paediatric patients. Net reclassification improvement (NRI) suggested that changing lens dose constraint from Dmax <7 Gy to Dmean <10 Gy would miss 7% of cataract cases but avoid 28% of unnecessary restrictions. Adopting a mean lens dose <10 Gy was suggested as a constraint for lens dose. [ABSTRACT FROM AUTHOR]

Introduction: Radiotherapy plays a key role in the multidisciplinary management of oesophageal cancers across neoadjuvant, definitive and palliative settings. Improved precision in radiotherapy planning and delivery techniques have allowed treating disease with tighter margins reducing toxicity. In this study, we examine the appropriateness of current practice in defining the planning target volume (PTV). Methods: This is a single institutional retrospective study of patients who received radiotherapy for oesophageal cancers using volumetric modulated arc therapy (VMAT) during 2020. All cone‐beam computerised tomography (CBCT) scans were reviewed to assess whether PTV expansions appropriately accounted for tumour motion and interfractional variation. Results: Of the 27 patients, 2 (7%), 5 (19%) and 20 (74%) had cervical, thoracic and distal/gastro‐oesophageal junction (GOJ) disease, respectively. 16 (59%) had adenocarcinoma and 9 (33%) had squamous cell carcinoma. 9 of 20 distal/GOJ patients were planned and treated according to the institutional stomach filling protocol. 521/528 (98.7%) CBCTs demonstrated adequate target coverage. Cervical, thoracic and GOJ regions demonstrated adequate target coverage in 57/58, 96/97 and 368/373 CBCTs with median PTV expansions of 5, 7 and 7 mm, respectively. In four patients with GOJ disease, CBCT review identified five episodes where the target volume was insufficiently covered during the treatment course. Conclusion: In this single institutional retrospective study, for the vast majority of patients, our institutional practice of defining PTV margins achieved satisfactory target treatment. The interfractional variations observed in patients with GOJ tumours due to target motion and variable gastric volume, highlights the role of further refinements to motion management techniques in this cohort. [ABSTRACT FROM AUTHOR]

Normal tissue tolerance dose limits to the heart have been established to reduce the risk of radiation‐induced cardiac disease (RICD). Dose constraints have been developed based on either the mean dose delivered to the whole heart (MHD) or the dose delivered to a specific volume, for example, volume of heart receiving equal to or greater than 30 Gy (V30). There is increasing evidence that the impact of thoracic radiation on cardiac morbidity and mortality has been underestimated. Consequently, there is a need to reduce the dose delivered to the heart in radical radiotherapy treatment planning. The pathophysiology of RICD may relate to dose to specific cardiac substructures (CS) rather than the traditionally observed MHD for common toxicities. The MHD or V30 Gy threshold dose rarely represents the true dose delivered to individual CS. Studies have shown the dose to specific areas may be more strongly correlated with overall survival (OS). With advances in modern radiotherapy techniques, it is vital that we develop robust, evidence‐based dose limits for CS, to fully understand and reduce the risk of RICD, particularly in high‐risk populations with cardiac risk factors. The following review will summarise the existing evidence of dose limits to CS, explain how dose limits may vary according to different disease sites or radiation techniques and propose how radiotherapy plans can be optimised to reduce the dose to these CS in clinical practice. [ABSTRACT FROM AUTHOR]

Background: The suspension of breast cancer screening during the COVID‐19 pandemic altered patient diagnosis and management. This study investigates the impact of the COVID‐19 lockdowns, screening delays and reduced healthcare attendance on changes in tumour and treatment characteristics, particularly for biologically more aggressive breast cancers. Methods: This retrospective single‐hospital analysis utilized data from a prospective cancer database between July 2019 and June 2022. Patient, tumour and treatment factors were compared across pre‐pandemic, pandemic and post‐pandemic groups. Results: Symptomatic breast cancer increased from 42.3% in the pre‐, 53.1% in the pandemic and 57% in the post‐ respectively (P ≤ 0.05). Compared to the pre‐pandemic group (4.6%), an increase in stages 3 or 4 breast cancers in the pandemic (8.5%) and post‐pandemic (7.1%) was found. Increased node‐positivity in Ki67 > 20%, grade 3 or ER‐ tumours post‐pandemic (+5.4%, +14.8%, +33.4%, respectively) was identified. More neoadjuvant chemotherapy was found in both the pandemic (+4.3%) and post‐pandemic (+11.3%, P = 0.0261) groups. An increase in hypofractionated radiotherapy in the post‐pandemic group (+9.4%) was also identified. Conclusion: Our study identified a decrease in early‐stage cancers and an increase in node positivity, particularly for biologically more aggressive tumours. An increase in the number of patients receiving neoadjuvant chemotherapy or hypofractionated radiotherapy during the pandemic and post‐pandemic periods was also identified. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion Cranio‐spinal radiotherapy (CSI) is used to treat central nervous system malignancies in paediatric, adolescent/young adult (AYA), and adult patients. Its delivery in the paediatric/AYA population is particularly challenging across different age groups. This study aims to assess the setup variations and dosimetric impact of CSI in paediatric and AYA patients.This retrospective analysis included, 10 paediatric and AYA patients (aged 4–25) who underwent volumetric modulated arc therapy (VMAT) CSI between 2016 and 2022. Patient characteristics, diagnoses, prescribed CSI doses, and fractionation details were assessed. CT simulation and treatment planning followed standard protocols with setup errors were quantified by comparing daily treatment setup images with the planned position. The study evaluated the dosimetric impact on target volumes and organs at risk (OARs).The setup errors were identified, ranging from 0.5 to 6.2 mm in different directions, especially in the cranio‐caudal direction. Despite these variations, there was minimal impact observed on the coverage of clinical target volumes (CTV) and doses to OARs (<1% relative change).Ensuring precise setup in paediatric and AYA patients undergoing CSI is essential to maintain adequate CTV coverage. Although occasional substantial setup variations occurred during treatment, they had a limited impact on CTV coverage and OAR doses when infrequent. Appropriate planning target volume (PTV) margins can effectively compensate for occasional shifts. However, systematic errors could compromise treatment quality if undetected. Regular off‐line review of patient set‐up trends is recommended. [ABSTRACT FROM AUTHOR]

Cardiac risk mitigation is a major priority in improving outcomes for cancer survivors as advances in cancer screening and treatments continue to decrease cancer mortality. More than half of adult cancer patients will be treated with radiotherapy (RT); therefore it is crucial to develop a framework for how to assess and predict radiation‐induced cardiac disease (RICD). Historically, RICD was modelled solely using whole heart metrics such as mean heart dose. However, data over the past decade has identified cardiac substructures which outperform whole heart metrics in predicting for significant cardiac events. Additionally, non‐RT factors such as pre‐existing cardiovascular risk factors and toxicity from other therapies contribute to risk of future cardiac events. In this review, we aim to discuss the current evidence and knowledge gaps in predicting RICD and provide a roadmap for the development of comprehensive models based on three interrelated components, (1) baseline CV risk assessment, (2) cardiac substructure radiation dosimetry linked with cardiac‐specific outcomes and (3) novel biomarker development. [ABSTRACT FROM AUTHOR]

Summary Increased survivorship, improvements in cancer treatments, and the potential for cardiac side effects from cancer treatments have resulted in increased collaboration between oncologists and cardiologists and the development of cardio‐oncology clinics. This collaboration is important given its role in ensuring greater patient satisfaction, aiding teams of clinicians in making complex treatment decision, and ensuring cardiac complications are diagnosed at an early stage. The particularities of implementing this collaboration in the field of radiation oncology and how this setting is different from other areas of cardio‐oncology have not been well detailed in the literature. This paper will discuss what is currently understood about the need for and role of cardio‐oncology and what a cardio‐oncology services involves, with a particular emphasis on patient and clinician needs in the field of radiation oncology. The literature and recent guidelines do advocate for a detailed baseline assessment of cancer patients undergoing radiotherapy, especially patients with treatment or patient risk factors that increase their risk of cancer‐therapy related cardiotoxicity. Advancements in cardiac imaging techniques will be discussed as these may help to diagnose cardiac side effects of certain cancer treatments, including radiotherapy, at an early stage. A multi‐disciplinary and collaborative approach is well received by patients and such an approach, guided by the aim of maintaining a patient's cancer treatment wherever possible, should be the cornerstone of cardio‐oncology clinics regardless of the patient's treatment regime. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusions Communication and collaboration are integral in radiation oncology practice. A recently published qualitative study identified several deficiencies in skills development for Australian/New Zealand trainees. We aim to validate these findings to guide curriculum development.A quantitative survey was developed through an iterative process, using themes identified in the previous qualitative investigation. This survey was distributed to radiation oncologists and trainees across Australia and New Zealand via email. Data collection and management utilised the REDCap system. Question types varied to maximise richness of data, including ranking, likert‐scales and free‐text questions. Results are primarily reported descriptively.Totally 35 participants submitted completed survey responses with broad representation across geography, gender and clinician seniority. To learn communication, participants reported strong preferences towards informal observation (60% agreement) and self‐reflection (49% agreement), and against online learning (77% disagreement) methodologies. Nearly 35% acknowledge poor communication at least weekly, with time pressure being a major barrier (63% agreement). Clinical uncertainty and existing patient/family assumptions (both 74% agreement) contribute to difficulties in breaking bad news, with online learning being the only negatively perceived training modality (23% agreement). No participants reported any formal training/mentoring in multi‐disciplinary team (MDT) engagement. Conflict was commonly witnessed/experienced (97%) and 26% of participants avoid MDTs due to difficulties experienced.This study validates the themes previously identified. We identified a strong preference for informal learning methodologies and against online modules, discordant to published literature. Effective collaboration within MDTs is identified as a particular area of need. We recommend future curriculum modification considers these results to maximise efficacy. [ABSTRACT FROM AUTHOR]

Background: The use of Computed Tomography (CT) imaging data to create 3D printable patient‐specific devices for radiation oncology purposes is already well established in the literature and has shown to have superior conformity than conventional methods. Using non‐ionizing radiation imaging techniques such as photogrammetry or laser scanners in‐lieu of a CT scanner presents many desirable benefits including reduced imaging dose and fabrication of the device can be completed prior to simulation. With recent advancements in smartphone‐based technology, photographic and LiDAR‐based technologies are more readily available than ever before and to a high level of quality. As a result, these non‐ionizing radiation imaging methods are now able to generate patient‐specific devices that can be acceptable for clinical use. Purpose: In this work, we aim to determine if smartphones can be used by radiation oncologists or other radiation oncology staff to generate bolus or brachytherapy surface moulds instead of conventional CT with equivalent or comparable accuracy. Methods: This work involved two separate studies: a phantom and participant study. For the phantom study, a RANDO anthropomorphic phantom (limited to the nose region) was used to generate 3D models based on three different imaging techniques: conventional CT, photogrammetry & LiDAR which were both acquired on a smartphone. Virtual boli were designed in Blender and 3D printed from PLA plastic material. The conformity of each printed boli was assessed by measuring the air gap volume and approximate thickness between the phantom & bolus acquired together on a CT. For the participant study, photographs, and a LiDAR scan of four volunteers were captured using an iPhone 13 Pro™ to assess their feasibility for generating human models. Each virtual 3D model was visually assessed to identify any issues in their reconstruction. The LiDAR models were registered to the photogrammetry models where a distance to agreement analysis was performed to assess their level of similarity. Additionally, a 3D virtual bolus was designed and printed using ABS material from all models to assess their conformity onto the participants skin surface using a verbal feedback method. Results: The photogrammetry derived bolus showed comparable conformity to the CT derived bolus while the LiDAR derived bolus showed poorer conformity as shown by their respective air gap volume and thickness measurements. The reconstruction quality of both the photogrammetry and LiDAR models of the volunteers was inadequate in regions of facial hair and occlusion, which may lead to clinically unacceptable patient‐specific device that are created from these areas. All participants found the photogrammetry 3D printed bolus to conform to their nose region with minimal room to move while three of the four participants found the LiDAR was acceptable and could be positioned comfortably over their entire nose. Conclusions: Smartphone‐based photogrammetry and LiDAR software show great potential for future use in generating 3D reference models for radiation oncology purposes. Further investigations into whether they can be used to fabricate clinically acceptable patient‐specific devices on a larger and more diverse cohort of participants and anatomical locations is required for a thorough validation of their clinical usefulness. [ABSTRACT FROM AUTHOR]

Introduction: The main mission of the Australian and New Zealand Children's Haematology and Oncology Group (ANZCHOG) is to develop and facilitate local access to the world's leading evidence‐based clinical trials for all paediatric cancers, including brain tumours, as soon as practically possible. Diffuse intrinsic pontine gliomas (DIPGs) — a subset of a larger group of tumours now termed diffuse midline glioma, H3K27‐altered (DMG) — are paediatric brain cancers with less than 10% survival at two years. In the absence of any proven curative therapies, significant recent advancements have been made in pre‐clinical and clinical research, leading many to seek integration of novel therapies early into standard practice. Despite these innovative therapeutic approaches, DIPG remains an incurable disease for which novel surgical, imaging, diagnostic, radiation and systemic therapy approaches are needed. Main recommendations: All patients with DIPG should be discussed in multidisciplinary neuro‐oncology meetings (including pathologists, neuroradiologists, radiation oncologists, neurosurgeons, medical oncologists) at diagnosis and at relapse or progression.Radiation therapy to the involved field remains the local and international standard of care treatment.Proton therapy does not yield a superior survival outcome compared with photon therapy and patients should undergo radiation therapy with the available modality (photon or proton) at their treatment centre.Patients may receive concurrent chemotherapy or radiation‐sensitising agents as part of a clinical trial.Biopsy should be offered to facilitate consideration of experimental therapies and eligibility for clinical trial participation.After radiation therapy, each patient should be managed individually with either observation or considered for enrolment on a clinical trial, if eligible, after full discussion with the family.Re‐irradiation can be considered for progressive disease. Changes in management as a result of the guideline: Every child diagnosed with DIPG should be offered enrolment on a clinical trial where available. Access to investigational drugs without biological rationale outside the clinical trial setting is not supported. In case of potentially actionable target identification with molecular profiling and absence of a suitable clinical trial, rational targeted therapies can be considered through compassionate access programs. [ABSTRACT FROM AUTHOR]

The intrinsic stochasticity of patients' response to treatment is a major consideration for clinical decision‐making in radiation therapy. Markov models are powerful tools to capture this stochasticity and render effective treatment decisions. This paper provides an overview of the Markov models for clinical decision analysis in radiation oncology. A comprehensive literature search was conducted within MEDLINE using PubMed, following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Only studies published from 2000 to 2023 were considered. Selected publications were summarized in two categories: (i) studies that compare two (or more) fixed treatment policies using Monte Carlo simulation and (ii) studies that seek an optimal treatment policy through Markov Decision Processes (MDPs). Relevant to the scope of this study, 61 publications were selected for detailed review. The majority of these publications (n = 56) focused on comparative analysis of two or more fixed treatment policies using Monte Carlo simulation. Classifications based on cancer site, utility measures and the type of sensitivity analysis are presented. Five publications considered MDPs with the aim of computing an optimal treatment policy; a detailed statement of the analysis and results is provided for each work. As an extension of Markov model‐based simulation analysis, MDP offers a flexible framework to identify an optimal treatment policy among a possibly large set of treatment policies. However, the applications of MDPs to oncological decision‐making have been understudied, and the full capacity of this framework to render complex optimal treatment decisions warrants further consideration. [ABSTRACT FROM AUTHOR]

Background: Efficient and accurate delineation of organs at risk (OARs) is a critical procedure for treatment planning and dose evaluation. Deep learning‐based auto‐segmentation of OARs has shown promising results and is increasingly being used in radiation therapy. However, existing deep learning‐based auto‐segmentation approaches face two challenges in clinical practice: generalizability and human‐AI interaction. A generalizable and promptable auto‐segmentation model, which segments OARs of multiple disease sites simultaneously and supports on‐the‐fly human‐AI interaction, can significantly enhance the efficiency of radiation therapy treatment planning. Purpose: Meta's segment anything model (SAM) was proposed as a generalizable and promptable model for next‐generation natural image segmentation. We further evaluated the performance of SAM in radiotherapy segmentation. Methods: Computed tomography (CT) images of clinical cases from four disease sites at our institute were collected: prostate, lung, gastrointestinal, and head & neck. For each case, we selected the OARs important in radiotherapy treatment planning. We then compared both the Dice coefficients and Jaccard indices derived from three distinct methods: manual delineation (ground truth), automatic segmentation using SAM's 'segment anything' mode, and automatic segmentation using SAM's 'box prompt' mode that implements manual interaction via live prompts during segmentation. Results: Our results indicate that SAM's segment anything mode can achieve clinically acceptable segmentation results in most OARs with Dice scores higher than 0.7. SAM's box prompt mode further improves Dice scores by 0.1∼0.5. Similar results were observed for Jaccard indices. The results show that SAM performs better for prostate and lung, but worse for gastrointestinal and head & neck. When considering the size of organs and the distinctiveness of their boundaries, SAM shows better performance for large organs with distinct boundaries, such as lung and liver, and worse for smaller organs with less distinct boundaries, like parotid and cochlea. Conclusions: Our results demonstrate SAM's robust generalizability with consistent accuracy in automatic segmentation for radiotherapy. Furthermore, the advanced box‐prompt method enables the users to augment auto‐segmentation interactively and dynamically, leading to patient‐specific auto‐segmentation in radiation therapy. SAM's generalizability across different disease sites and different modalities makes it feasible to develop a generic auto‐segmentation model in radiotherapy. [ABSTRACT FROM AUTHOR]

Introduction: For liver stereotactic body radiation therapy (SBRT), the placement of fiducial markers or retained ethiodized oil by transarterial chemoembolisation (TACE) provides a landmark for consistent target localisation. TACE and fiducial markers are invasive procedures that harbour additional risks. We hypothesise that liver SBRT can be accurately delivered without the use of these invasive surrogate markers. Methods: We retrospectively identified 50 consecutive patients who underwent liver SBRT with respiratory motion management to a single lesion which exhibited retained ethiodized oil per prior TACE delivery. For each SBRT fraction, two manual rigid image registrations were performed by the treating physician. One using the liver contour as a surrogate for the target and second aligning only to the radio‐opaque retained ethiodized oil of the treated lesion. The magnitude of the displacement vector between the two registration methods was used to assess the accuracy of target localisation if ethiodized oil was not present. Results: For the 50 patients, a total of 244 analysable cone‐beam CTs (CBCTs) were included (six CBCTs excluded due to poor ethiodized oil visualisation). Respiratory motion management techniques consisted of active breathing control for 13 and abdominal compression for 37 patients. Forty‐two patients had peripheral lesions and eight had central lesions (<2 cm from left and right portal veins). The average target localisation offset between the two registration methods (i.e. liver contour vs. retained ethiodized oil alignment) for patients with a single peripheral or central liver lesion was 5.8 and 5.3 mm, respectively. Conclusions: Across all patients, the average change in target position exceeded 5 mm for image registration methods based on the liver contour alone versus the retained ethiodized oil region. This suggests that margins greater than 5 mm may be required for respiratory motion‐managed liver SBRT treatments in patients who do not undergo prior TACE or fiducial placement. [ABSTRACT FROM AUTHOR]

Introduction: The magnetic resonance linear accelerator (MRL) combines both magnetic resonance imaging and a linear accelerator, allowing for daily treatment adaptation. This study aimed to assess the impact of radiologist‐delivered training in magnetic resonance (MR) contouring of relevant structures within the male pelvis. Methods: Two radiation oncologists, two radiation oncology registrars and seven radiation therapists completed contouring on 10 male pelvis MR datasets both pre‐ and post‐training. A 2‐hour MR anatomy training session was delivered by a radiologist, who also provided the 'gold standard' contours. The pre‐ and post‐training contours were compared against the gold standard with Dice similarity coefficient (DSC) and Hausdorff distances calculated; and the pre‐ and post‐confidence scores and timing were compared. Results: The improvement in DSC were significant in prostate, rectum and seminal vesicles, with a post‐training median DSC of 0.87 ± 0.06, 0.92 ± 0.04 and 0.80 ± 0.14, respectively. The median Hausdorff improved with a median of 1.46 ± 0.78 mm, 0.52 ± 0.32 mm and 1.11 ± 0.86 mm for prostate, rectum and seminal vesicles, respectively. Bladder concordance was high both pre‐ and post‐training. Urethra contours improved post‐training, however, remained difficult to contour with a median post‐DSC of 0.51 ± 0.24. Overall, confidence scoring improved (P < 0.001) and timing decreased by an average of 4.4 ± 16.4 min post‐training. Conclusion: Radiologist‐delivered training improved concordance of male pelvis contouring on MR datasets. Further work is required in the identification of urethra on MRs. These findings are of importance in the MRL adaptive workflow. [ABSTRACT FROM AUTHOR]

This document provides guidelines for the safe practice of stereotactic body radiation therapy (SBRT) or stereotactic ablative radiation therapy (SABR). The guidelines aim to ensure appropriate care for patients receiving these treatments, which involve high-precision, image-guided dose delivery to well-defined targets with steep dose gradients. The document outlines recommendations for departmental staffing, equipment, planning, treatment, and quality assurance measures. It also emphasizes the importance of multidisciplinary expertise and ongoing training for the safe and accurate delivery of SBRT/SABR. The guidelines do not replace clinical judgment or decisions made by the treating team and are not meant to be used for litigious purposes. [Extracted from the article]

Primary aortic angiosarcomas (PAA) are rare angiosarcomas, frequently diagnosed in advanced stages due to initial misdiagnosis. This case describes a 66‐year‐old woman, initially presenting with a distal thoracic aorta thrombus and symptomatic bilateral popliteal emboli. Despite initial management and therapeutic anticoagulation, she experienced progressive lower limb claudication and 12 months following initial presentation she re‐presented with an obstructing distal thoracic aorta mass and metastatic disease. Histopathology confirmed metastatic epithelioid angiosarcoma. Despite urgent palliative radiotherapy, she died 6 weeks after diagnosis from complications of tumour thromboembolism. Suspicion for PAA should be raised in the case of thrombus in atypical segments (e.g. thoracic aorta) or progressive course despite anticoagulation. Multimodal imaging including MRI and FDG‐PET is useful to distinguish from benign aetiologies. [ABSTRACT FROM AUTHOR]

Canine primary pulmonary carcinomas (PCCs) are commonly treated with surgery with overall median survival times (MST) around a year; however, due to extent of disease, prognosis, or client preference, alternative treatments have been considered. Stereotactic body radiation therapy (SBRT) has been utilized in human cancer patients for local control of lung tumours as a surgical alternative. Twenty‐one PCCs in 19 dogs that received SBRT for local control were retrospectively evaluated. Dogs were staged according to the canine lung carcinoma stage classification (CLCSC) system with three as Stage 1, five as Stage 2, three as Stage 3, and eight as Stage 4. Overall MST was 343 days with 38% of patients alive at 1 year. Stage did not significantly impact survival time (p =.72). Five (26%) dogs had lymphadenopathy and MST was not significantly different from dogs without lymphadenopathy (343 vs. 353 days; p =.54). Five out of 18 evaluable dogs (28%) experienced acute lung VRTOG effects and 2 of 12 dogs (17%) experienced late lung VRTOG effects. Median lung dose, V5, V20, and D30 to the lung did not correlate significantly with the development of adverse radiation events. Twelve dogs had follow‐up imaging and the best response included a complete response (17%), partial response (42%), and stable disease (42%). Progressive disease was noted in seven dogs a median of 229 days after SBRT. SBRT was documented to be a safe and effective alternative to surgery and may have survival advantages for Stage 3 or 4 dogs according to the CLCSC. [ABSTRACT FROM AUTHOR]

Introduction: Correlations between radiation dose/volume measures and small bowel (SB) toxicity are inconsistent in the medical literature. We assessed the impact of inter‐provider variation in bowel bag contouring technique on estimates of radiation dose received by the SB during pelvic radiotherapy. Methods: Ten radiation oncologists contoured rectum, bladder and bowel bags on treatment planning computed tomography (CT) scans of two patients receiving adjuvant radiation for endometrial cancer. A radiation plan was generated for each patient and used to determine the radiation dose/volume for each organ. Kappa statistics were applied to assess the inter‐provider contouring agreement, and Levene test evaluated the homogeneity of variance for radiation dose/volume metrics, including the V45Gy (cm3). Results: The bowel bag showed greater variation in radiation dose/volume estimates compared to the bladder and rectum. The V45Gy ranged from 163 to 384 cm3 for data set A and 109 to 409 cm3 for dataset B. Kappa values were 0.82/0.83, 0.92/0.92 and 0.94/0.86 for the bowel bag, rectum, and bladder on data sets A/B, demonstrating lower inter‐provider agreement for bowel bag compared with bladder and rectum. Conclusion: Inter‐provider contouring variability is more significant for the bowel bag than the rectum and bladder, with an associated greater variability in dose and volume estimates during radiation planning. [ABSTRACT FROM AUTHOR]

Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active‐cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full‐text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active‐cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B‐cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non‐Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good‐excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active‐cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962). [ABSTRACT FROM AUTHOR]

In cancer radiotherapy (RT), each step can be digitalized, from CT simulation, planning, dose verification, and image guidance to treatment delivery. Therefore, RT may be the most digitized discipline in the field of internal medicine. Then, questions arise. What potential development opportunities does the development of network transmission technologies, such as blockchain and 5G, provide to promote the progress of tumor RT? What will the future of smart RT (SART) look like? The purpose of this article is to introduce briefly the main characteristics of blockchain and 5G transmission technologies and share ideas to imagine the "tomorrow" of smart RT, hoping to provide a more accurate, safe, and comfortable RT experience for patients in the future. [ABSTRACT FROM AUTHOR]

Background: Although most patients with cancer are treated with local therapy (LT), the proportion of late‐phase clinical trials investigating local therapeutic interventions is unknown. The purpose of this study was to determine the proportion, characteristics, and trends of phase 3 cancer clinical trials assessing the therapeutic value of LT over time. Methods: This was a cross‐sectional analysis of interventional randomized controlled trials in oncology published from 2002 through 2020 and registered on ClinicalTrials.gov. Trends and characteristics of LT trials were compared to all other trials. Results: Of 1877 trials screened, 794 trials enrolling 584,347 patients met inclusion criteria. A total of 27 trials (3%) included a primary randomization assessing LT compared with 767 trials (97%) investigating systemic therapy or supportive care. Annual increase in the number of LT trials (slope [m] = 0.28; 95% confidence interval [CI], 0.15–0.39; p <.001) was outpaced by the increase of trials testing systemic therapy or supportive care (m = 7.57; 95% CI, 6.03–9.11; p <.001). LT trials were more often sponsored by cooperative groups (22 of 27 [81%] vs. 211 of 767 [28%]; p <.001) and less often sponsored by industry (5 of 27 [19%] vs. 609 of 767 [79%]; p <.001). LT trials were more likely to use overall survival as primary end point compared to other trials (13 of 27 [48%] vs. 199 of 767 [26%]; p =.01). Conclusions: In contemporary late‐phase oncology research, LT trials are increasingly under‐represented, under‐funded, and evaluate more challenging end points compared to other modalities. These findings strongly argue for greater resource allocation and funding mechanisms for LT clinical trials. Plain language summary: Most people who have cancer receive treatments directed at the site of their cancer, such as surgery or radiation.We do not know, however, how many trials test surgery or radiation compared to drug treatments (that go all over the body).We reviewed trials testing the most researched strategies (phase 3) completed between 2002 and 2020.Only 27 trials tested local treatments like surgery or radiation compared to 767 trials testing other treatments.Our study has important implications for funding research and understanding cancer research priorities. In this comprehensive study, the authors aimed to evaluate the representation of LT in 794 phase 3 randomized trials registered on ClinicalTrials.gov and published between 2002 and 2020. Study results showed that only 27 trials (3.4%) tested LT, compared with 767 trials (96.6%) that investigated other modalities such as systemic therapy or supportive care. [ABSTRACT FROM AUTHOR]

As three‐dimensional (3D) printing becomes increasingly common in radiation oncology, proper implementation, usage, and ongoing quality assurance (QA) are essential. While there have been many reports on various clinical investigations and several review articles, there is a lack of literature on the general considerations of implementing 3D printing in radiation oncology departments, including comprehensive process establishment and proper ongoing QA. This review aims to guide radiation oncology departments in effectively using 3D printing technology for routine clinical applications and future developments. We attempt to provide recommendations on 3D printing equipment, software, workflow, and QA, based on existing literature and our experience. Specifically, we focus on three main applications: patient‐specific bolus, high‐dose‐rate (HDR) surface brachytherapy applicators, and phantoms. Additionally, cost considerations are briefly discussed. This review focuses on point‐of‐care (POC) printing in house, and briefly touches on outsourcing printing via mail‐order services. [ABSTRACT FROM AUTHOR]

Procedural anxiety is a concern for a number of patients undergoing radiation therapy. While procedural anxiety is often treated pharmacologically, there is a clinical need for effective alternative strategies for patients who are contraindicated from medication use, and those who prefer not to take unnecessary medications. Objectives: The primary objective was to assess the efficacy of nonpharmacological interventions delivered to adults with cancer, in the radiation oncology department, just prior to, or during radiation therapy, in reducing levels of self‐reported procedural anxiety. The secondary objectives were to assess the efficacy of these interventions in reducing physiological symptoms of procedural anxiety and anxiety‐related treatment disruptions. Design: Systematic review. Data Sources: Electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and Cochrane Central Register of Controlled Trials) were searched from inception up until February 2022. Inclusion Criteria: Population: Adult patients with cancer undergoing external beam radiation therapy. Intervention: Nonpharmacological interventions delivered within the radiation therapy department. Comparison: standard care controls, or standard care plus an alternative intervention. Outcomes: level of self‐reported procedural anxiety (primary), physiological symptoms of anxiety (secondary) and measures of anxiety‐related treatment disruptions (secondary). Data Extraction and Analysis: Two reviewers independently extracted data. A meta‐analysis was originally planned but deemed not feasible as the studies could not be confidently pooled for meta‐analysis, due to the variability in the interventions, study designs and the generally low number of studies. Therefore, a narrative synthesis is presented. Results: Screening of 2363 records identified nine studies that met inclusion criteria: six studies of music interventions, two of video‐based patient education and one of aromatherapy. Overall, three studies received a global rating of strong methodological quality and low risk of bias. Three studies reported a significant effect of the intervention on reducing the primary outcome of self‐reported procedural anxiety: two music interventions (both strong methodological quality), and one video‐based patient education (moderate methodological quality). One of the studies (a music intervention) also reported a significant reduction in the secondary outcome of physiological symptoms of procedural anxiety (systolic blood pressure). Conclusions: The evidence for nonpharmacological interventions delivered to adults with cancer just prior to, or during radiation therapy, in reducing levels of self‐reported procedural anxiety is limited, with very few well‐designed studies. There is a need for interventions for procedural anxiety during radiation therapy to be evaluated through rigorous randomised controlled trials. [ABSTRACT FROM AUTHOR]

Background: Both nonoperative and operative treatments for spinal metastasis are expensive interventions. Patients' expected 3‐month survival is believed to be a key factor to determine the most suitable treatment. However, to the best of our knowledge, no previous study lends support to the hypothesis. We sought to determine the cost‐effectiveness of operative and nonoperative interventions, stratified by patients' predicted probability of 3‐month survival. Methods: A Markov model with four defined health states was used to estimate the quality‐adjusted life years (QALYs) and costs for operative intervention with postoperative radiotherapy and radiotherapy alone (palliative low‐dose external beam radiotherapy) of spine metastases. Transition probabilities for the model, including the risks of mortality and functional deterioration, were obtained from secondary and our institutional data. Willingness to pay thresholds were prespecified at $100,000 and $150,000. The analyses were censored after 5‐year simulation from a health system perspective and discounted outcomes at 3% per year. Sensitivity analyses were conducted to test the robustness of the study design. Results: The incremental cost‐effectiveness ratios were $140,907 per QALY for patients with a 3‐month survival probability >50%, $3,178,510 per QALY for patients with a 3‐month survival probability <50%, and $168,385 per QALY for patients with independent ambulatory and 3‐month survival probability >50%. Conclusions: This study emphasizes the need to choose patients carefully and estimate preoperative survival for those with spinal metastases. In addition to reaffirming previous research regarding the influence of ambulatory status on cost‐effectiveness, our study goes a step further by highlighting that operative intervention with postoperative radiotherapy could be more cost‐effective than radiotherapy alone for patients with a better survival outlook. Accurate survival prediction tools and larger future studies could offer more detailed insights for clinical decisions. [ABSTRACT FROM AUTHOR]

Background: We report the results of an international multi‐institutional cohort of oligometastatic (OMD) head and neck cancer (HNC) patients treated with SBRT. Methods: Patients with OMD HNC (≤5 metastases) treated with SBRT between 2008 and 2016 at six institutions were included. Treated metastasis control (TMC), progression‐free survival (PFS), and overall survival (OS) were analyzed by multivariable analysis (MVA). Results: Forty‐two patients with 84 HNC oligometastases were analyzed. The TMC rate at 1 and 2 years were 80% and 66%, with a median time to recurrence of 10.1 months. The median PFS and OS were 4.7 and 23.3 months. MVA identified a PTV point maximum (BED)10 > 100 Gy as a predictor of improved TMC (HR = 0.31, p = 0.034), and a cumulative PTV > 48 cc as having worse PFS (HR = 2.99, p < 0.001). Conclusion: Favorable TMC and OS was observed in OMD HNCs treated with SBRT. [ABSTRACT FROM AUTHOR]

Introduction: More than 20% of patients undergoing radiation therapy for head and neck cancer report anxiety specifically related to the immobilisation mask, a tight‐fighting mask patients are required to wear for the duration of each treatment session. However, limited research has investigated this from the patient perspective. The aim of this study was to better understand patient experiences of mask anxiety during head and neck cancer radiation therapy and to explore patient attitudes toward potential strategies that may reduce mask anxiety during this treatment. Methods: Five patients with head and neck cancer, who had self‐reported mask anxiety during radiation therapy, participated in semi‐structured, qualitative interviews exploring their experiences of anxiety and suggestions for reducing anxiety. A codebook thematic analysis was conducted. Results: Six main themes were identified: (1) triggers of anxiety; (2) adjusting to radiation therapy; (3) education about the mask; (4) coping; (5) motivation and (6) improving the patient experience. Conclusion: Findings from these interviews provide valuable insight into how and when healthcare providers may be able to assist patients to manage mask anxiety. Recommendations include increased communication from health care providers; delivery of visual information to improve patient preparedness; exposure/opportunities to interact with the masks prior to treatment commencing and increased control of music/soundtrack selection. However, a limitation of this study is the small sample size and further research is warranted. [ABSTRACT FROM AUTHOR]

Introduction: Whether supraclavicular lymph node (SCLN) metastasis in patients with oesophageal cancer belongs to regional disease is controversial, leading to heterogeneity in clinical treatment decisions. This study aimed to determine the optimal treatment for lower thoracic oesophageal cancer (LTOC) with SCLN metastasis. Methods: Patients with LTOC registered in the Surveillance, Epidemiology, and End Results database during 2010–2015 were identified. Selected patients were grouped according to disease spread as those with locoregional disease, with SCLN metastasis or with distant metastasis, as well as according to treatment modality (neoadjuvant chemoradiotherapy followed by surgery (nCRT+S group), upfront surgery ± adjuvant therapy (upfront S group) and definitive chemoradiotherapy (dCRT group)). The Cox regression analysis and inverse probability of treatment weighting (IPTW) were used to identify the optimal treatment modality for different groups. Results: Of 11,767 LTOC patients identified from the database, the 5‐year overall survival (OS) rates for patients with the locoregional disease (n = 7,541), SCLN metastasis (n = 120) and distant metastasis (n = 4,106) were 28.3%, 10.0% and 3.0%, respectively (P < 0.001). Among patients with SCLN metastasis, median OS in the nCRT+S, upfront S and dCRT groups were 25, 14 and 8 months, respectively (P < 0.001). After IPTW, the nCRT+S group was still associated with better median OS compared with other groups. The multivariate analysis identified treatment modality as an independent prognostic factor for OS. Conclusions: Neoadjuvant chemoradiotherapy followed by oesophagectomy may be the optimal treatment modality for LTOC with SCLN metastasis. The findings of this study need to be validated in large prospective studies. [ABSTRACT FROM AUTHOR]

Introduction: Total body irradiation (TBI) practices vary considerably amongst centres, and the risk of treatment related toxicities remains unclear. We report lung doses for 142 TBI patients who underwent either standing TBI with lung shield blocks or lying TBI without blocks. Methods: Lung doses were calculated for 142 TBI patients treated between June 2016 and June 2021. Patients were planned using Eclipse (Varian Medical Systems) using AAA_15.6.06 for photon dose calculations and EMC_15.6.06 for electron chest wall boost fields. Mean and maximum lung doses were calculated. Results: Thirty‐seven patients (26.2%) were treated standing using lung shielding blocks with 104 (73.8%) treated lying down. Lowest relative mean lung doses were achieved using lung shielding blocks in standing TBI, reducing the mean lung doses to 75.2% of prescription (9.9 Gy), ±4.1% (range 68.6–84.1%) for a prescribed dose of 13.2 Gy in 11 fractions, including contributions from electron chest wall boost fields, compared to 12 Gy in 6 fraction lying TBI receiving 101.6% mean lung dose (12.2 Gy) ±2.4% (range 95.2–109.5%) (P ≪ 0.05). Patients treated lying down with 2 Gy single fraction received the highest relative mean lung dose on average, with 108.4% (2.2 Gy) ±2.6% of prescription (range 103.2–114.4%). Conclusion: Lung doses have been reported for 142 TBI patients using the lying and standing techniques described herein. Lung shielding blocks significantly reduced mean lung doses despite the addition of electron boost fields to the chest wall. [ABSTRACT FROM AUTHOR]

Introduction: The Australian Faculty of Radiation Oncology Genitourinary Group (FROGG) developed prostate bed clinical target volume (CTV) contouring guidelines which were subsequently used to develop the National EviQ guidelines for adjuvant and salvage post‐prostatectomy radiotherapy (PPRT). These guidelines were based mainly upon consensus agreement. With the advent of prostate‐specific membrane antigen (PSMA) positron emission tomography (PET), sites of recurrence can now be detected with low prostate‐specific antigen (PSA) levels following radical prostatectomy. We evaluated sites of recurrence in patients treated with FROGG/EviQ CTVs to inform upcoming modifications of these guidelines. Methods: At our institution, we use the FROGG/EviQ guidelines for PPRT. From 2015, patients with PSA failure following PPRT have been re‐staged using PSMA PET imaging. We identified patients with PET‐avid local, nodal, and distant recurrences, fusing them with original treatment plans to determine whether recurrences were within or outside the prostate bed CTV. Regional nodal failures were reviewed to determine if they were within current elective node contouring guidelines. Results: Ninety‐four patients had positive PSMA PET following PPRT. Nine (9.6%) recurrences were local, seven being local‐only. One local recurrence (1.1%) was just superior to the contoured prostate bed CTV, located within the vas deferens. Seventy‐three (77.7%) patients had a component of node failure, with 56 (59.6%) having node‐only failure. Sites of nodal relapses were covered by standard contouring guidelines 60.3% of the time. Conclusion: The low recurrence rate outside of current prostate bed CTV contouring guidelines is consistent with other studies using contemporary contouring, and validates the efficacy of the current FROGG/EviQ prostate bed CTV definition. [ABSTRACT FROM AUTHOR]

Introduction: We evaluated long‐term outcomes for octogenarians with localised prostate cancer treated using dose‐escalated image‐guided intensity‐modulated radiation therapy (IMRT) at our institution. Methods: The charts of octogenarians treated for localised prostate cancer were retrospectively reviewed. Overall survival (OS), prostate cancer‐specific survival (PCaSS), toxicity rates and changes from baseline were collected. Results: The median follow‐up was 97 months. Of 107 eligible patients, 27.1% had intermediate‐risk and 72.9% had high‐risk localised prostate cancer. Median dose was 78Gy, and 97.2% received ADT. OS was 91.4% and 67.2% at 5 and 10 years. PCaSS was 98.0% and 88.7% at 5 and 10 years. In all, 39 (36.4%) of patients died, with the cause of death known in 30: in 26.7% of these patients, prostate cancer was the cause of death. Grade ≥ 2 late GI and GU toxicity was 0.9% and 24.3% respectively. In all, 11.2% and 22.4% of patients reported worsening of GI or GU function from baseline, and 13.1% and 21.5% reported improvement in GI and GU function compared to baseline. Conclusion: Selected octogenarian patients with localised prostate cancer appear to benefit from radiation therapy and ADT. Despite excellent long‐term PCaSS, 26.7% of patients died of prostate cancer. Rates of GI and GU toxicity were acceptable, and deterioration of urinary and bowel function compared to baseline was just as common as improvement in function from baseline. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to investigate the patterns of practices of radiation oncologists (ROs) and urologists in Australia and New Zealand with respect to the utilisation of post‐prostatectomy radiation therapy (RT) and help guide the development of an update to the existing Faculty of Radiation Oncology Genito‐Urinary Group post‐prostatectomy guidelines. Methods: ROs and urologists with subspecialty practice in prostate cancer from Australia and New Zealand were invited to participate in an online survey comprised of clinical scenarios regarding post‐prostatectomy RT. Results: Sixty‐five ROs and 28 urologists responded to the survey. In the setting of low‐risk biochemical relapse, the threshold for initiating RT was lower for ROs than urologists. ROs were more likely than urologists to recommend adjuvant RT for node‐positive disease. When salvage RT was advised for a pT3N0R1 recurrence, there was no consensus amongst ROs on whether to add either ADT or nodal treatment over prostate bed RT alone. For a solitary PSMA‐avid pelvic lymph node recurrence, whole pelvis RT with androgen deprivation therapy was the preferred treatment option (72% ROs, 43% urologists). Most ROs (92%) recommended conventionally fractionated RT to 66–70 Gy, with a boost to any PSMA PET avid recurrent disease. Conclusion: This survey highlights the marked discordance in practice for the management of prostate cancer relapse post‐prostatectomy. This is seen not only between specialties but also within the radiation oncology community. This emphasises the need for an updated evidence‐based guideline to be produced. [ABSTRACT FROM AUTHOR]

The aim of this retrospective, secondary analysis study was to quantify the dosimetric impact of the lack of interobserver agreement on gross tumor volume (GTV) delineation for canine meningioma. This study used a previously reported population of 13 dogs with GTVs contoured on CT alone and on registered CT‐MR by 18 radiation oncologists. The "true" GTV was generated for each dog using a simultaneous truth and performance‐level estimation algorithm, and "true" brain was defined as the whole brain minus true GTV. Treatment plans were generated for each dog and observer combination, using criteria applied to the observer's GTV and brain contours. Plans were then categorized as a pass (met all planning criteria for true GTV and true brain) or fail. A mixed‐effects linear regression was performed to examine differences in metrics between CT and CT‐MR plans and mixed‐effects logistic regression was performed to examine differences in percentages of pass/fail between CT and CT‐MRI plans. The mean percent coverage of true GTV by prescribed dose was higher for CT‐MR plans than for CT plans (mean difference 5.9%; 95% CI, 3.7–8.0; P < 0.001). There was no difference in the mean volume of true brain receiving ≥24 Gy and in maximum true brain dose between CT plans and CT‐MR plans (P ≥ 0.198). CT‐MR plans were significantly more likely to pass the criteria for true GTV and true brain than CT plans (OR 1.75; 95% CI, 1.02–3.01; P = 0.044). This study demonstrated significant dosimetric impact when GTV contouring was performed on CT alone compared with CT‐MR. [ABSTRACT FROM AUTHOR]

Canine optic pathway structures are often contoured on CT images, despite the difficulty of visualizing the optic pathway with CT using standard planes. The purpose of this prospective, analytical, diagnostic accuracy study was to examine the accuracy of optic pathway contouring by veterinary radiation oncologists (ROs) before and after training on optic plane contouring. Optic pathway contours used as the gold standard for comparison were created based on expert consensus from registered CT and MRI for eight dogs. Twenty‐one ROs contoured the optic pathway on CT using their preferred method, and again following atlas and video training demonstrating contouring on the optic plane. The Dice similarity coefficient (DSC) was used to assess contour accuracy. A multilevel mixed model with random effects to account for repeated measures was used to examine DSC differences. The median DSC (5th and 95th percentile) before and after training was 0.31 (0.06, 0.48) and 0.41 (0.18, 0.53), respectively. The mean DSC was significantly higher after training compared with before training (mean difference = 0.10; 95% CI, 0.08–0.12; P < 0.001) across all observers and patients. DSC values were comparable to those reported (0.4–0.5) for segmentation of the optic chiasm and nerves in human patients. Contour accuracy improved after training but remained low, potentially due to the small optic pathway volumes. When registered CT‐MRI images are not available, our study supports routine addition of an optic plane with specific window settings to improve segmentation accuracy in mesaticephalic dogs ≥11 kg. [ABSTRACT FROM AUTHOR]

With complex head and neck diseases that closely approximate crucial organs or have advanced spread and cannot be surgically resected, intensity modulated proton beam radiotherapy is favored due to its superior dose targeting through magnetic manipulation of the proton energy. A radiation mask and an oral positioning device immobilize craniofacial, cervical, and oral structures for accurate and reliable radiation delivery. Widely available prefabricated thermoplastic oral positioning devices are manufactured in standardized forms and materials that unpredictably affect the proton beams' pathways and range. This technique article showcases a workflow that combines analog and digital dental techniques to produce a customized 3D‐printed oral positioning device within 2 appointments. [ABSTRACT FROM AUTHOR]

Introduction: Fostering a research culture is a key goal of the Royal Australian and New Zealand College of Radiologists, yet there has never been an organization‐wide enquiry into the extent to which this is being realized. The purpose of this work was to address that deficit for the Radiation Oncology (RO) Faculty to serve as a baseline for future comparison. The hypothesis was that such a culture is closer to fact than fantasy. Methods: With College approval, three de‐identified Excel spreadsheets detailing 25 research‐related sub‐categories of the Faculty's Continuing Professional Development (CPD) database were interrogated for the 2019–21 triennium, accepting that research activity in 2020–21 would be COVID‐19 suppressed. The numbers obligated to self‐report CPD were 482, 496 and 511, respectively. Primary endpoints were the percentages of ROs claiming at least one research‐related activity overall, and in each of the sub‐categories individually, by year. Secondary endpoints were the "breadth" (number of sub‐categories claimed/individual) and "depth" (percentages solely claiming in one of four lower‐level sub‐categories), by year. Results: ROs claimed in 23/25 sub‐categories. The percentages of ROs claiming at least one research‐related activity were 71%, 44%, and 62% in 2019–21, respectively. The median number of sub‐categories claimed by these ROs was 2 (range 1–10) in each year. The commonest activity was journal article co‐author (25%, 16% and 27%, respectively). For 2019, the most representative year, other common activities were inhouse/local meeting presentation (17%), invited lecture at state level or above (15%), manuscript peer review and research project principal investigator (14% each). The percentages of ROs solely claiming in one lower‐level activity ranged between 4.4% and 5.9% per year. Conclusion: A culture of research is arguably more fact than fantasy in ANZ. It is likely that Faculty curriculum requirements, research funding and other promotional initiatives have contributed substantively to this. [ABSTRACT FROM AUTHOR]

Introduction: The Royal Australian and New Zealand College of Radiologists (RANZCR) Faculty of Radiation Oncology Genitourinary Group (FROGG) guidelines and online EviQ protocols incorporate prostate‐specific membrane antigen (PSMA) positron emission tomography (PET)‐guided dose‐escalated intensity‐modulated radiation therapy (DE‐IMRT) for newly diagnosed lymph node (LN) positive prostate cancer. We evaluated late toxicity and efficacy outcomes following the FROGG and EviQ approach. Methods: Patients with LN‐positive‐only metastases on PSMA‐PET imaging were offered curative therapy with 3 months neoadjuvant androgen deprivation therapy (ADT) followed by DE‐IMRT and 3 years adjuvant ADT. IMRT was delivered via volumetric arc therapy (VMAT). We aimed to deliver 81 Gy in 45 fractions (Fx) to the prostate and PET‐positive LNs, and 60 Gy in 45 Fx to elective pelvic nodes, contoured using the PIVOTAL guidelines. Results: Forty‐five patients were included. The median number of PET‐positive nodes boosted was 2 (range 1–6) and median boost volume 1.16 cc (range 0.15–4.14). Seventeen (38%) patients had PET‐positive nodes outside of PIVOTAL contouring guidelines. With 60 months median follow‐up, disease‐free, metastasis‐free, prostate cancer‐specific and overall survival were 88.1%, 95.3%, 100% and 91.5%. There were no in‐field nodal failures. Late grade 1, 2 and 3 gastrointestinal toxicities occurred in 4%, 2% and 0% of patients, and genitourinary toxicity in 18%, 18% and 4%. Lower limb grade 2 lymphoedema occurred in three patients (7%). Conclusion: Outcomes following FROGG guidelines and EviQ are promising, with high long‐term disease control and low toxicity. Contouring guidelines require modification due to the high rate of PET‐positive nodes demonstrated beyond recommended coverage. [ABSTRACT FROM AUTHOR]

Introduction: Many publications have proposed quality standards for stereotactic ablative body radiotherapy (SABR). However, data on the level of compliance with these guidelines is lacking in the literature. This study aimed to understand how these guidelines are applied in the clinic and to identify barriers to implementing such recommendations. Methods: Interviews were conducted with multidisciplinary staff at radiation oncology centres across New South Wales formulated around the RANZCR Guidelines for Safe Practice of Stereotactic Body (Ablative) Radiation Therapy. The interview responses were grouped into 20 topics, assessed against the guidelines and thematically analysed. Results: Good compliance with the guidelines was found, with more than 80% of centres achieving satisfactory results in more than half the topics. The areas with the lowest compliance were auditing, risk assessment and reporting recommendations. Barriers to the quality of SABR treatments included limited training opportunities, low patient numbers and a lack of clear requirements on comprehensive auditing and reporting. Conclusion: Overall, the centres surveyed reported good compliance with most of the RANZCR SABR guidelines. The tasks with the lowest compliance were those that monitor quality outcomes. Potential strategies for improvement include inclusion in clinical trials and the use of databases which link treatment parameters, dosimetry and outcomes. Further work will focus on the barriers identified in this survey and propose practical solutions to improve compliance in these areas. [ABSTRACT FROM AUTHOR]

Background: The literature on modern‐era outcomes of oropharyngeal squamous carcinoma (OPSCC) in India is limited. Materials and Methods: We analyzed records of consecutive patients with OPSCC treated using a curative SIB IMRT regimen of 66 Gy/30#/6 weeks. Results: One hundred fifteen patients from July 2011 to December 2018 were analyzed. Twenty of 69 patients tested positive for p16. In p16 positive patients, the K‐M probability of being disease free and alive at 2 years, with at least one follow‐up 3 months after treatment, was 83% (median not reached) compared with 48% if p16 was unknown/negative. Patients staged as IVB p16 negative had a 2‐year DFS of 25%. Patients unfit for cisplatin and consequently received other agents had 2‐year DFS estimated at 20%. Conclusions: Intensity‐modulated radiation therapy (IMRT) with simultaneous integrated boost (SIB) and concurrent chemotherapy was feasible, with toxicity and disease control comparable to available literature. AJCC Stage IVB p16 negative disease had notably poor outcome. [ABSTRACT FROM AUTHOR]

Background: Voxel-Based (VB) analysis embraces a multifaceted ensemble of sophisticated techniques, lying at the boundary between image processing and statistical modeling, that allow for a frequentist inference of pathophysiological properties anchored to an anatomical reference. VB methods has been widely adopted in neuroimaging studies and, more recently, they are gaining momentum in radiation oncology research. However, the price for the power of VB analysis is the complexity of the underlying mathematics and algorithms. Purpose: In this paper, we present the Multi-pAradigM voxel-Based Analysis (MAMBA) toolbox, which is intended for a flexible application of VB analysis in a wide variety of scenarios in medical imaging and radiation oncology. Methods: The MAMBA toolbox is implemented in Matlab. It provides opensource functions to compute VB statistical models of the input data,according to a great variety of regression schemes, and to derive VB maps of the observed significance level, performing a non-parametric permutation inference. The toolbox allows for including VB and global outcomes, as well as an arbitrary amount of VB and global Explanatory Variables (EVs). In addition, the Matlab Parallel Computing Toolbox is exploited to take advantage of the perfect parallelizability of most workloads. Results: The use of MAMBA was demonstrated by means of several realistic examples on a synthetic dataset mimicking a radiation oncology scenario. Conclusion: MAMBA is an open-source toolbox, freely available for academic and non-commercial purposes. It is designed to make state-of -the-art VB analysis accessible to research scientists without the programming resources needed to build from scratch their own software solutions. At the same time, the source code is handed out for more experienced users to complement their own tools, also customizing user-defined models. MAMBA guarantees high generality and flexibility in the design of the statistical models, significantly expanding on the features of available free tools for VB analysis. The presented toolbox aims at increasing the reach of VB studies as well as the sharing of research results. [ABSTRACT FROM AUTHOR]

Introduction: Balancing disease control and treatment‐related toxicities can be challenging when treating higher‐risk brain metastases (BMs) that are larger in size or eloquent anatomical locations. Hypofractionated stereotactic radiosurgery (hfSRS) is expected to offer superior or equal efficacy with lower toxicity profile compared with single‐fraction SRS (sfSRS). We report the efficacy and toxicity profiles of hfSRS in a consecutive cohort of patients to support this predicted benefit from hfSRS for high‐risk BMs. Methods: We retrospectively analysed 185 consecutive individual lesions from 152 patients with intact BMs treated with hfSRS between 1 July 2016 and 31 October 2019 and followed up to 30 April 2022 with serial brain magnetic resonance imaging (MRI). The primary endpoint was the event of radiation necrosis (RN). Local control (LC) rate and distant brain failure (DBF) were reported as secondary outcomes. Kaplan–Meier method was used to report the cumulative incidence of RN and overall survival and the incidence of DBF. Potential risk factors for RN were assessed using univariable Cox regression analysis. Results: The median follow‐up was 38.0 months, and the median survival post‐SRS was 9.5 months. The cumulative incidence rate of RN was 13.2% (95% CI: 7.0–24.7%), and 18.1% of patients with confirmed RN were symptomatic. Higher mean dose delivered to planning target volume (PTV) (HR 1.22, 95% CI: 1.05–1.42, P = 0.01), higher mean BED10 (biological equivalent dose assuming a tissue α/β ratio of 10) (HR 1.12, 95% CI: 1.04–1.2, P < 0.001), and higher mean BED2 (HR 1.02, 95% CI: 1–1.04, P = 0.04) delivered to the lesion was associated with increased risk of RN. LC rate was 86% and the cumulative incidence of DBF was 36% with a median onset of 28.4 months. Conclusions: Our results support the predicted radiobiological benefit of the use of hfSRS in high‐risk BMs to limit treatment‐related toxicity with low risk for symptomatic RN comparable with lower risk population receiving sfSRS while achieving satisfactory local disease control. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to explore problems in radiotherapy for breast cancer patients in Yogyakarta, Indonesia, focusing on overall treatment time (OTT) and completion rate. Methods: A retrospective cohort study was conducted based on data from the Insurance Unit at a tertiary hospital in Yogyakarta, Indonesia. The study included all female outpatients with breast cancer who were treated with radiotherapy from January to December 2017 and met the inclusion criteria. The primary outcomes were OTT and completion rate. The secondary outcomes included the number of radiotherapy fractions, radiotherapy doses, number of radiotherapy interruption days, and reasons for radiotherapy interruption. The chi‐squared and Mann–Whitney U tests were used to assess the differences in outcomes between two insurance schemes (JKN‐PBI (Beneficiaries of Health Insurance Contribution Assistance) and JKN‐NON‐PBI (Non‐Beneficiaries of Health Insurance Contribution Assistance)). Results: The sample included 285 breast cancer patients (mean age: 53 years). The median OTT was 38 days (IQR: 17–48 days), with 123 (43.2%) patients having prolonged OTT. The completion rate was 57.9%. No significant differences in OTT (44.4% vs. 35.7%, p = 0.445) and completion rate (57.2% vs. 61.9%, p = 0.569) were found between the JKN‐NON‐PBI and JKN‐PBI groups, respectively. In all, the data reported 3,022 interrupted days of radiotherapy across a total of 227 patients. The most common reason for radiotherapy interruption was unknown. Conclusion: There are problems in timely delivery and low completion rate of radiotherapy among breast cancer patients in Indonesia. There are no significant differences in OTT and completion rate between the insurance schemes. [ABSTRACT FROM AUTHOR]

Background: Not all patients with locally advanced head and neck cancer (HNC) who are eligible for adjuvant radiotherapy (RT) following upfront surgery appear to receive it. Methods: Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Selected patients from 2009 to 2018 had locally advanced HNC, underwent upfront surgery, and were eligible for adjuvant RT. Multivariable logistic regression and chi‐squared test were used to analyze available patient and tumor characteristics. Results: Of 12 549 patients, 84.5% underwent adjuvant RT, 15.5% did not. Characteristics associated with lowest adjuvant RT utilization included cancers of the larynx (p < 0.0001) and gingivae (p < 0.0001), age 80 and above (p < 0.0001), unpartnered status (p < 0.0001), and residence within a nonmetropolitan area (p < 0.0024). Conclusions: Tumor subsite, age, partnered status, and rural/urban residence correlate with omission of adjuvant RT in locally advanced HNC. [ABSTRACT FROM AUTHOR]

Introduction: Despite progress of women in science and medicine, women remain underrepresented in academic publication. The aim of this study was to evaluate potential gender differences in women authorship in the Journal of Medical Imaging and Radiation Oncology (JMIRO). Methods: Gender of the first and senior author of all articles published in JMIRO between 2012 and 2021 were examined. Changes over time and differences among groups were compared using the chi‐square test. Results: In total, 1,138 articles were assessed. Women were first and senior authors on 34% and 25% of all articles respectively. The proportion of women as first author was 30%, 41% and 36% for medical imaging (MI), radiation oncology (RO) and combined MI/RO articles respectively. Similarly, the proportion of women as senior author was lower than men at 22%, 32% and 23% for MI, RO and MI/RO articles respectively. Women first authorship over the study period remained stable from 2014 (36%) to 2020 (38%); however, it decreased dramatically in 2021 to 28%. There was a trend of increasing women senior authorship from 2013 (15%) to 2017 (35%) but decreased to 23% in 2021. Conclusion: Over the past 10 years of publications, one in three first authors were women and only one in four senior authors were women. The acknowledgement of this imbalance is the first step to pave the way towards addressing underlying systemic issues related to academic publication and disparities in gender and other inequities. [ABSTRACT FROM AUTHOR]

Introduction: There has been a groundswell of discussion and activism surrounding gender diversity. Given the growing importance of this issue, a working group was established under the Faculty of Radiation Oncology (FRO) of the Royal Australian and New Zealand College of Radiologists' (RANZCR) Economics and Workforce Committee (EWC) to review the current status of gender diversity within radiation oncology (RO) in Australia and New Zealand. Methods: De‐identified data were provided from two recent FRO workforce censuses conducted in 2014 and 2018 with permission from the EWC. Further data were provided via direct correspondence with staff at the RANZCR and the Trans‐Tasman Radiation Oncology Group (TROG), the major RO research group in Australasia. The data were collated in February 2021. Results: Our results showed that compared to females, male radiation oncologists were more likely to be engaged in full‐time active clinical work, hold a postgraduate degree and obtain a consultant or fellowship position following graduation. Male fellows were more likely to have leadership positions within RANZCR and TROG and self‐identify as holding any leadership position. The 2018 census revealed that within the trainee cohort, there was almost an equal number of male and female trainees as well as an equal number of male and female trainees holding a postgraduate degree. Conclusion: This review is an important first exploration into gender diversity across Australia and New Zealand's RO workforce. Whilst our study indicates that gender disparities exist, there are some indications that this may be equalizing out over time. [ABSTRACT FROM AUTHOR]

Keywords: diversity; equity and inclusion; gender; radiation oncology; workforce EN diversity equity and inclusion gender radiation oncology workforce 212 215 4 03/29/23 20230301 NES 230301 Women are an integral part of the radiation oncology workforce in Australia, New Zealand and Singapore, representing 40% of the workforce in 2018.[1] Women radiation oncologists within the Royal Australian and New Zealand College of Radiologists (RANZCR) make significant contributions across all domains: clinical, research/academia, education, policy and advocacy. In the Australian public sector, incremental pay increases occur according to accrued time in service and career gaps such as unpaid parental leave can delay pay increases. The gender wage gap among medical specialists: a quantitative analysis of the hourly pay of publicly employed senior doctors in New Zealand. [Extracted from the article]

The most common cancer caused by human papillomavirus (HPV) infection in the United States is oropharyngeal cancer (OPC), and its incidence has been rising since the turn of the century. Because of substantial long‐term morbidities with chemoradiation and the favorable prognosis of HPV‐positive OPC, identifying the optimal deintensification strategy for this group has been a keystone of academic head‐and‐neck surgery, radiation oncology, and medical oncology for over the past decade. However, the first generation of randomized chemotherapy deintensification trials failed to change the standard of care, triggering concern over the feasibility of de‐escalation. National database studies estimate that up to one third of patients receive nonstandard de‐escalated treatments, which have subspecialty‐specific nuances. A synthesis of the multidisciplinary deintensification data and current treatment standards is important for the oncology community to reinforce best practices and ensure optimal patient outcomes. In this review, the authors present a summary and comparison of prospective HPV‐positive OPC de‐escalation trials. Chemotherapy attenuation compromises outcomes without reducing toxicity. Limited data comparing transoral robotic surgery (TORS) with radiation raise concern over toxicity and outcomes with TORS. There are promising data to support de‐escalating adjuvant therapy after TORS, but consensus on treatment indications is needed. Encouraging radiation deintensification strategies have been reported (upfront dose reduction and induction chemotherapy‐based patient selection), but level I evidence is years away. Ultimately, stage and HPV status may be insufficient to guide de‐escalation. The future of deintensification may lie in incorporating intratreatment response assessments to harness the powers of personalized medicine and integrate real‐time surveillance. [ABSTRACT FROM AUTHOR]

Introduction: To evaluate the feasibility of prostate intrafraction motion monitoring using the SeedTracker real‐time image guidance system in order to improve targeting accuracy in prostate radiotherapy. Methods: SeedTracker was used to monitor prostate gold fiducial seeds with kV x‐ray imaging during radiotherapy in 30 patients. Feedback from radiation therapists was collected via the use of a user evaluation form. The impact on treatment time was established by using a record and verify system. The effective dose and a risk of exposure‐induced cancer death (REID) were estimated for a 60‐year‐old patient when using the SeedTracker system. Results: A total of 22 radiation therapists completed user evaluation forms. The time taken to prepare a reference data set for one patient varied with three (13.6%) radiation therapists taking less than 2 min, 10 (45.5%) between 2 and 4 min, eight (36.4%) between 4 and 6 min and one (4.5%) between 6 and 8 min. The useability of the SeedTracker system was reported as 'easy' by 21 (95.5%) radiation therapists and 'hard' by 1 (4.5%) radiation therapist. Mean treatment time changed from 6 to 7 min with prostate‐only radiotherapy treatment and from 6.9 to 10.2 min with prostate and whole pelvis radiotherapy treatments. The maximum effective dose with the SeedTracker was 1.6276 mSv, and increase in REID was 0.007%. Conclusion: The SeedTracker real‐time image guidance system is a feasible tool to use in radiotherapy departments to monitor and correct for prostate intrafraction motion. [ABSTRACT FROM AUTHOR]