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Total body irradiation (TBI) is a kind of external beam radiotherapy, used in conjunction with chemotherapy with the purpose of immunosuppression. Since the target in TBI is the whole body, so achieving uniform dose distribution throughout the entire body during TBI is necessary. As recommended by AAPM dose variation must be within ±10% of the prescription dose. With the evidences from literature there is limited substantiation to consider a treatment method better than others, but with regard to the size of the treatment room, workload of the radiotherapy department and prevalent technology used within each treatment department it is recommended to make the suitable and optimum method in each department. In this work, a review study was performed on different TBI techniques with the purpose of assessment and comparison of dose distribution homogeneity in these methods.

Background and Purpose: Paragangliomas are rare tumors of the head and neck. Their management remains problematic and varies considerably depending on the center. This study reported 14 years of experience in the management of head and neck paraganglioma (HNPGls). We aimed to assess the therapeutic results of these tumors in terms of local control and overall survival. Materials and Methods: We included 16 patients followed for HNPGls and treated by radiotherapy from January 2006 to June 2018 in the National Institute of Oncology in Rabat. Results: The median age was 44.5 years (15 - 67). 13 patients were female and three male with a sex ratio of 4.3. Cervical mass was the common sign (56.3%). All patients received radiation therapy. This radiation was exclusive in 43.7% of cases or adjuvant to partial surgical resection in 56.3%. The median dose of radiotherapy was 54 Gy (46 - 60) and it was delivered by a three-dimensional conformal radiotherapy technique in 15 patients and volumetric modulated arc therapy in one. There were few acute complications such as grade I and II mucositis and dermatitis. After a median follow-up of 5.6 years (2 - 13.4), local control, defined by radiological stability or regression, was obtained in 14 patients, two patients progressed and one died. Progression-free survival rates at 5 and 7 years were 93.8% and 78.1% respectively, and overall survival at 5 and 7 years was 92.3%. Conclusions: Surgery is the first-line treatment for HNPGls. When surgery is not possible or incomplete, radiotherapy has its place in the therapeutic strategy of this rare disease for long-term local control.

The massive incidence of COVID-19 has led to reorganization of medical care for cancer patients. While maintaining an individual approach and maximum effectiveness, we're considering the possibility of changing the radiation therapy treatment in each clinical case. Spatio-temporal separation of patient's streams and algorithms for building the radiotherapy department were introduced to minimize the risk of COVID-19 infection of medical personnel and patients.

One of the elements of the quality of medical care is its accessibility, which depends on the material and technical baseof the institution, as well as on the availability of stuff and work management. Implementation of the new clinical guidelines of the Association of Oncologists of Russia (AOR) for the treatment of non-melanoma skin cancer (NRC), revealedthe problem of increasing the load on stuff and equipment.Purpose of the study.To investigate and forecast the load of the kilovoltage X-ray therapy unit taking into account theupdated clinical guidelines for the treatment of patients with non-melanoma skin cancer using radiotherapy. Determinethe clinical and organizational changes in the technology of x-ray therapy for non-melanoma skin cancer within theday-hospital department for the skin cancer size more than 2 cm after implementation of new clinical guidelines andfraction regimes in compare with previously used schemes; derive a mathematical model of the work of the kilovoltagex-ray therapy room.Materials and methods. Data from the kilovoltage X-ray therapy office of radiotherapy unit No. 2 of the Sverdlovsk Regional Oncology Dispensary (SROD) were used. The average duration of radiotherapy sessions per patient was estimatedand calculated using timekeeping. The results were evaluated using correlation analysis. In order to forecast the use ofmaterial and human resources, an economic method of mathematical modeling was used.Results. The analysis of the kilovoltage X-ray therapy unit of radiotherapy department No. 2 of the SROD for 3 yearsshowed an increase from 10.4 to 17.3 in the average number of therapeutic fractions per patient after the implementation of the updated clinical guidelines. An increase in the average number of radiotherapy sessions leads to a doublingof the average bed-day of the patient's stay in the day-hospital. The formula was proposed for predicting the work of theunit. There is a clear correlation between the duration of treatment, the dynamics of hospitalization and the number oftreated patients. The calculated results obtained using a mathematical model fully correspond to the actual performanceof the radiotherapy room.Conclusion. To ensure optimal availability of medical care, it is necessary to match treatment technologies with availableresources of the organization. The introduction of new treatment programs may require both the expansion of staff(medical, nursing), and an increase in the number of units of medical equipment. The obtained mathematical modelof the kilovoltage X-ray therapy room allows to predict the optimal mode of work of employees while maintaining thequality and accessability of medical care.

COVID-19 pandemic represents a challenge for entire medical world, with profound implications in daily practice, making a compromise between risk of infection with SARS-COV2 and oncological treatment continuing, in conditions in which must be balanced, for each patient, the risk of infection with COVID-19. We are presenting the recommendations of professional societies and actions take in Radiotherapy Department of Sf. Ap. Andrei Emergency Clinical Hospital, Galati in order to limit the spread of COVID-19 infection and concomitant with radiotherapy performing, without compromising the quality of medical act. © 2020 Bucharest College of Physicians. All rights reserved.

• Survey of European radiotherapy department heads after 1 year of Covid-pandemic. • A decrease in patient volume was reported in 53%. • Enrollment in clinical studies was decreased in 58%. • Concerns were expressed related to well-being of staff in 76% of the departments.

Aim: The aim of this service review was to review whether implementing a formal training package increased therapeutic radiographer confidence and competence in recognising neutropenic sepsis in radiotherapy patients. In addition, authors also investigated whether the introduction of a weekly National Early Warning Score (NEWS) protocol had been successful in identifying cases of neutropenic sepsis. Material and Methods: Therapeutic radiographer (n = 13) views on the new protocol were collected through an online questionnaire. A review of the clinical observation sheets of patients who received chemo-radiotherapy (n = 49) between 18 April 2019 and 31 October 2019 was undertaken. Information on disease site, NEWS scores, number of patients who had become neutropenic and action taken by therapeutic radiographers was collected. Results: The majority of respondents to the questionnaire found that training benefitted both professionals and patients. Some challenges were highlighted relating to increased workload. For patients receiving regular observations, NEWS scores ranged from 0 to 4. When a patient scored on NEWS, the most common score was 1 across all treatment sites except cervix. Findings: Implementing a neutropenic sepsis protocol appears to be beneficial to therapeutic radiographers as professionals, increasing their confidence in patient assessment and monitoring. Regular observations may help to identify deteriorating patients alongside clinical judgement and symptom reviews.

BackgroundAgreement between planners and treating radiation oncologists (ROs) on plan quality criteria is essential for consistent planning. Differences between ROs and planning medical physicists (MPs) in perceived quality of head and neck cancer plans were assessed.Materials and MethodsFive ROs and four MPs scored 65 plans for in total 15 patients. For each patient, the clinical (CLIN) plan and two or four alternative plans, generated with automated multi-criteria optimization (MCO), were included. There was always one MCO plan aiming at maximally adhering to clinical plan requirements, while the other MCO plans had a lower aimed quality. Scores were given as follows: 1–7 and 1–2, not acceptable; 3–5, acceptable if further planning would not resolve perceived weaknesses; and 6–7, straightway acceptable. One MP and one RO repeated plan scoring for intra-observer variation assessment.ResultsFor the 36 unique observer pairs, the median percentage of plans for which the two observers agreed on a plan score (100% = 65 plans) was 27.7% [6.2, 40.0]. In the repeat scoring, agreements between first and second scoring were 52.3% and 40.0%, respectively. With a binary division between unacceptable (scores 1 and 2) and acceptable (3–7) plans, the median inter-observer agreement percentage was 78.5% [63.1, 86.2], while intra-observer agreements were 96.9% and 86.2%. There were no differences in observed agreements between RO–RO, MP–MP, and RO–MP pairs. Agreements for the highest-quality, automatically generated MCO plans were higher than for the CLIN plans.ConclusionsInter-observer differences in plan quality scores were substantial and could result in inconsistencies in generated treatment plans. Agreements among ROs were not better than between ROs and MPs, despite large differences in training and clinical role. High-quality automatically generated plans showed the best score agreements.

Background:The COVID-19 pandemic has required a rapid and evolving response in order to enable the continued delivery of radiotherapy, whilst effectively managing the risk of infection to patients and staff. In early March 2020, we were presented with the challenge of achieving safe delivery of care in clinical practice for a group of patients that are already at higher risk of morbidity from COVID-19 with only limited guidance.Purpose:This article outlines the adjustments made at The Christie at Oldham satellite centre in order to promote optimal care to our patients receiving radiotherapy, and to mitigate infection risk at the department for both patients and staff.Materials and Methods:We share insight into some of the evolving processes that our team have developed since March 2020 in promoting optimal care to patients receiving radiotherapy at The Christie at Oldham satellite centre. These include changes to the department floor, paper flow, supportive care and staffing.Results and Conclusions:As we continue to progress through this pandemic, we accept that there will be an ongoing journey of learning with adjustments to practice and evolving ‘new norm’, thereby ensuring we keep our patients and team safe and well. We also hoped that our experience would support radiotherapy-related practices in surges of the pandemic in other parts of the world or in case of the second wave.

Purpose: To study the number of disruptions in patient processes in a radiotherapy centre after the replacement of an Electronic Health Record (EHR), integrating information tools for patient care and billing.Methods: Our self-made Electronic Medical Record was replaced by a new EHR, including clinical path and workflow-management. A social-technological approach was used to reduce complexity. We measured disruptions in patient processes by the number and type of EHR related root causes and EHR-related incidents that reached patients, in our patient safety system 12 months before implementing the new EHR, 6 months after implementation (transition period) and 24 months after the transition period. We used Mann-Whitney U and X-2 tests to compare data before and after implementation.Results: An increase of disruptions occurred only temporarily during 6 months. After this period, the number stabilized to the level before implementation while having more functionalities and benefits. Neither the number nor the severity of incidents reaching patients increased.Conclusions: Disruptions in patient processes are considered as a main barrier for implementing an EHR. Using a social/technical approach, the increase in disruptions did only temporarily occur and did not reach patients. We think it is important to share this insight with physicians because literature shows that their long-term opinion regarding the usefulness of the EHR is often based on the experience in the first months after implementation. Management of expectations is recommended.Advances in knowledge: This study is the first of its kind measuring long-term effects of EHR on patient processes in radiotherapy.

It has been proven that humanization plays a key role in hospitals and other environments. Enhancing the humanistic atmosphere in hospitals can help improve mood and reduce stress. Therefore, this article designs the waiting area so that the waiting area can reduce the patient’s anxiety and other negative emotions, and enhance the patient’s confidence in treatment. Due to the similarities between current general radiotherapy and proton therapy, this article sorts out the design directions and design methods of many cancer hospitals. At the same time, the author conducts a questionnaire interview on the behavior of patients during the waiting time before radiotherapy through field investigations in the radiotherapy department of the tumor hospital, To further explore the needs of patients in the waiting area, in order to find the direction of the interior design of the waiting area of the proton radiotherapy hospital in the future, and provide a reliable basis for the design direction of the proton hospital in the future.

OBJECTIVES: To report the impact of the COVID-19 pandemic on patient attendance at a radiotherapy department two months after the implementation of specific policies regarding the pandemic. METHODS: The proposed treatment schemes, favoring hypofractionated schedules, and COVID-19 management strategies regarding irradiation are presented. Attendance after two months of implementation of these policies was measured and compared with that during the same period in 2019. RESULTS: A 10% reduction in the number of treated patients and a 26% reduction in the number of sessions was observed. The main impact was a decrease in the treatment of benign diseases and gastrointestinal tumors, with a general increase in breast cancer treatments. Eighteen (1.7%) patients were confirmed as having COVID-19 during radiotherapy in April and May 2020, three of whom were hospitalized, and one patient died because of COVID-19. Among the 18 patients, 12 had their treatments interrupted for at least 15 days from symptom appearance. CONCLUSION: There was a decrease in the number of treated patients in our radiotherapy department, with a greater decrease in the total number of sessions. This indicated, overall, a smaller number of fractions/patients treated, despite our efforts to maintain the treatment routine. We had several patients who were infected with COVID-19 and one related death during treatment in the first few months of the pandemic in São Paulo Brazil.

Introduction Cervical cancer is diagnosed 60–70% at an advanced stage in low countries. Hydronephrosis is a common occurrence in patients with advanced cervical cancer (14 to 44%). We aimed to describe the survival in those patients and comfort after urinary diversion. Methods This is a cross-sectional study during 25-month that included 82 patients with stage IIIB cervical cancer in a public hospital Joseph Ravoahangy Andrianavalona oncology and radiotherapy Department. Results Thirty-one patients (37%) underwent diversion. Twelve patients (38.7%) had improvement of renal function. Half the patients had improvement in lumbar pain hydronephrosis-related. Complications after diversion was mainly surgical site infection (19%). Median overall survival was for those patients underwent or no urinary diversion was 90 days. The median survival in patients who underwent diversion was 90 days and 60 days whom required diversion but elected not to receive it. The survival with unilateral and bilateral hydronephrosis was 195 days and 75 days. Median survival was 90 days and 60 days for patients with and without chemotherapy after diversion. No patients received radiation because a public centre was not available during the study period due to costs. Conclusion Hydronephrosis is a predictor of poor survival in patients with advanced stage cervical cancer. Urinary diversion improves the lumbar pain hydronephrosis-related, improve renal function, confers a short-time survival benefit. It could provide conditions for patients receiving treatment for advanced cervical cancer.

Background:Cancers commonly known as head and neck cancers typically begin in the squamous cells that line the moist, mucosal surfaces within the head and neck. Oral mucositis is erythematous and ulcerative lesion of the oral mucosa in patients with cancer being treated with chemotherapy/ radiation therapy in the areas of oral cavity. Objectives:To assess the grade of the oral mucositis among head & neck cancer patients receiving radiotherapy. 2. To evaluate the effectiveness of mixture of honey and coffee application on radiation induced oral mucositis among the study group. 3. To find the association between the radiation induced oral mucositis with selected demographic variables. Method:quasi experimental non randomized control group design was applied and 60 samples (30 in each group) were selected by convenience sampling technique. The mixture of honey and coffee was applied to the study group before and after 15 minutes of radiotherapy till the continuation of radiotherapy and no intervention was given in the control group. Result:The result revealed that the application of honey and coffee mixture was significantly effective on oral mucositis (p Conclusion:The study concluded that, application of mixture of honey and coffee is an effective method of reducing the onset and severity of oral mucositis in comparison with no intervention.

Background Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition. However, long-term nasogastric (NGT) feeding is still commonplace in China. We surveyed Chinese clinicians’ opinions toward PEG feeding in order to identify the potential barriers to acceptancy of PEG feeding. Methods A self-reported questionnaire was developed and distributed to 600 doctors. Five-point Likert scales were used for most responses. Results Of 525 respondents, the mainly nutritional support method was NGT while PEG was less used. Doctors working in the tertiary class A hospitals and radiotherapy department were more likely to choose PEG feeding (p = 0.000). Overall, 241 (46%) participants did not know PEG and 284 (54%) have different understanding degree of PEG. Age (p = 0.002), working life (p = 0.044) and professionalism (p = 0.005) were significantly related to the understanding of PEG. Levels of agreement was high (score of 3.47) for using PEG in patients with prolonged stroke-associated dysphagia. There was high agreement level in the statement that PEG was unnecessary when NGT could sustain the basic needs of patients, though better outcome can be predicted with PEG feeding. The highest scoring factor (score of 3.91) that influenced clinicians’ choice of PEG was resistance from patients and families and the second one was the poor cooperation among departments (score of 3.80). Conclusions Doctors’ insufficient knowledge of PEG feeding, resistance from patients and families, poor cooperation among departments, all these factors leading physicians to prefer more conservative treatment to avoid disputes rather than better ones.

The COVID-19 outbreak grows exponentially in our country. Despite most of patients develops benign symptoms, cancer patients are at risk of a severe form of the disease. Radiotherapy centres are a potential contamination place due to the number of patients treated and staff present. Their organization during the outbreak period aims to ensure continuity of care while limiting the risk of death from COVID-19. In the radiotherapy department of Mulhouse hospital (France), we pointed five points out: protection of medical and paramedical staff, protection of patients undergoing treatment, detection of patients suspected of being infected by SARS-CoV-2 and their management, reorganization of the patient circuit and measures regarding the quality management. This reflection, which began at the beginning of the outbreak in our city, allows us to preserve the access to radiotherapy treatments by anticipating the risk of spreading the virus. Through biweekly meetings, we continue to adapt to the epidemic in our department, considering our material resources. The ability to perform diagnostic tests in all suspect patients would also allow us to refine our procedures.

Summary Introduction Radiation therapy is a core modality for cancer treatment. Around 40% of cancer cures include the use of radiotherapy, either as a single strategy or combined with other treatments. In the past decade, substantial technical advances and novel insights into radiobiological properties have considerably improved patients’ outcomes. This study overviewed the landscape of clinical research at our radiotherapy department. Methods We surveyed our institutional database of clinical trials to collect information for completed or ongoing radiation therapy clinical trials, from 2005 to December 2017 at the Lucien Neuwirth cancer institute. Results A total of 31 clinical trials were undertaken during the study period, of which 4 studies (12.9%) were industry-sponsored and 3 studies (9.7%) were launched by our radiotherapy unit. The vast majority of clinical trials (83.9%) were dedicated to unique organ localization, especially urological cancer (prostate or bladder) (42%). We also observed a shift towards more phase II trials during the study period as well as a special focus on elderly population. Over the last decade, the number of included patients increased by a 5.3 fold input, with 135 inclusions before 2011 and 720 inclusions after 2011. Discussion This study provided an observational and comprehensive analysis of radiotherapy research. From a monocentric point-of-view, these results reflected the on-going progress of worldwide radiotherapy research. Based on a 13-years’ experience, this study aimed at highlighting essential cues to ensure efficient and perennial research.

Introduction The international move towards digital healthcare record keeping has seen an increase in the number of radiotherapy departments moving towards a paperless framework. With the recent transition to a paperless radiation oncology framework at the Princess Alexandra Hospital Brisbane, it was crucial to perform a prospective risk assessment to quantify the most significant sources of risk in the electronic environment. Methods A failure mode and effects analysis (FMEA) was performed using a web-based three-round Delphi technique. Participants included Radiation Therapists and Radiation Oncologists. A detailed process map was created of all process steps and their sub-processes from patient booking to treatment. The first round was an open qualitative round to identify failure modes. The subsequent rounds were used to score all failure modes using the risk priority number (RPN) scoring method, based on the product of occurrence, severity and detectability scoring. The final round was also used to identify risk mitigation strategies. Results The process map consisted of 60 process steps and 141 sub-processes. A list of 83 failure modes was identified and consensus was achieved regarding the risk scoring for a prioritised list of 20. Four of the top five failure modes were related to communication errors. Eighteen feasible solutions were recommended for incorporating into clinical practice to increase patient safety. Conclusion The FMEA proved a valuable systematic method of prospectively identifying vulnerabilities in a paperless radiotherapy department. In particular, this FMEA identified numerous failure modes concerning communication and documentation, highlighting the need for sustained vigilance when performing all electronic processes.

Background and purposeAchieving daily consistent bladder volume is acknowledged as challenging for patients undergoing radiotherapy to the cervix or endometrium. We investigated if use of an ultrasound bladder volume scanner (BioCon-700) improves bladder reproducibility when used during an active volume correction protocol.Materials and methodsDuring our method-comparison study, prospectively recruited patients (n=20) followed a fluid-loading protocol to achieve acceptable bladder volume. Bladder ultrasound was performed daily to verify planned volume, with patients actively correcting volumes outside a planned range up to a maximum of three times. Using the Bland–Altman method, we compared mean ultrasound readings (USMean) with mean cone-beam computed tomography (CBCT) volumes (CBCTMean). We also conducted staff focus groups exploring issues encountered during implementation of bladder scanning.ResultsComparing USMean with CBCTMean produced a mean of the differences −10±49·92 mL (1 SD), demonstrating that bladder volume scanning is equivalent to our standard measure for the stated confidence levels. The cohort mean bladder volume decrease from week 1 to 5 was only 8·4%. Mean USMean was 323 mL, mean CBCTMean was 313 mL. Staff experience with the scanner overall was positive.ConclusionsThe BioCon-700 is suitable for the purpose of daily pre-treatment volume verification, facilitating daily assessment and modification of bladder volume, resulting in reproducible treatment volumes.

The master planning of new radiotherapy facilities requires the input and engagement of a range of highly specialised professionals, both in the construction and health sector. Although radiation protection and safety aspects of radiotherapy services are universal, low and middle income countries are often presented with unique challenges that also need to be considered, e.g. competing needs within the health sector, lack of financial and human resources, environmental factors like poor provision of transport or electrical power, inadequate regulatory infrastructure, etc. Efforts to establish, upgrade or expand radiotherapy services should therefore not only focus on the technology that is appropriate and sustainable, but also be mindful of the need for quality, safety and optimal utilisation of technology. The workflow in a radiotherapy department can be facilitated by strategic placement of the main functional areas into the concept design.

Information received by cancer patients has gained importance in recent decades. The aim of this study was to evaluate the perception of information received by oncological patients in a radiotherapy department and to measure the importance of the other information sources. A cross-sectional study was conducted, evaluating patients who received radiotherapy. All the patients were asked two questionnaires: the EORTC QLQ-INFO26 module evaluating their satisfaction with received information, and a questionnaire analyzing other sources of information search. One hundred patients between 27 and 84 years were enrolled. Breast cancer (26 %) was the commonest cancer. Patients felt better informed about the medical tests and secondly about the performed treatment. The younger patients were those who were more satisfied with the information received and patients with no formal education felt less satisfied, with statistically significant differences. Patients did not seek external information; at the most, they asked relatives and other people with cancer. Patients were satisfied with the received information, although a high percentage would like more information. In general, patients did not search for external information sources. Age and educational level seem to influence in the satisfaction with the received information.

Aim The aim of the study was the evaluation of the effectiveness of radiotherapy in patients with the feet pain caused by heel spurs. Background Treatment options for patients reporting these symptoms include use of suitable orthopedic footwear, the use of general or topical non-steroidal anti-inflammatory drugs or steroids, physiotherapy, manual therapy, shock wave or appropriate surgical procedures. Radiotherapy is one of the method used in patients with chronic pain syndrome. Materials and methods The material consisted of 47 patients treated in Radiotherapy Department at the Holycross Cancer Center. The time of follow-up ranged from 1 to 129 months. After treatment patients were observed. Results During the first follow-up visit a complete relief of symptoms was observed in 37 patients, and the pain was felt by 10 patients for 4 months after the treatment. One patient was re-irradiated 6 months after treatment because of persistent pain. At 16 and 17 months after the onset of treatment, pain was reported by two patients. These patients were re-irradiated. One patient had recurrence of pain 48 months after completion of radiation. After the second irradiation the pain was relieved. The remaining patients, with the exception of two, experienced remission of pain, which has been documented. Tolerance of the treatment was very good. No complications of radiation were observed. Conclusions Radiotherapy remains an attractive treatment for patients with inflammation of the heel fascia.

Patient satisfaction is an important quality outcome indicator of health care in the hospital setting. Patients are nowadays care-partners with caregivers. This relation is practically important for patients presenting chronic diseases, especially cancer. The aim of this study is to evaluate cancer patient satisfaction, treated at the Department of Radiotherapy in Hassan II University Hospital, and to study the different components of this satisfaction. A prospective transversal study was conducted between December 2016 and January 2017. Data was collected by three investigators based on structured interviews, a validated, anonymous and a standardized questionnaire. During this period, we have included 230 patients: 159 women (69.1%), 71 men (30.9%) and the sex ratio (women/men) was 2.23. Half of the investigated patients have never been schooled (52.61%). The majority had urban origin (71.3%) and 90% of patients declared being satisfied with the care at Radiotherapy department. 93.48% of cases recommended Radiotherapy department to other patients and 95.65% will want to continue their treatment at this department. Reception conditions were judged as favorable in 92.14%. Satisfaction rates regarding the availability of medical and paramedics, health-care workers were 86.52% and 83.9%, respectively. The quality of medical and paramedical care was judged as excellent or good in 78% cases. However, 44.34% of patients complained about the complexity of administrative formalities. 60.87% of cases judged that the waiting time was too long, whereas 31.4% of patients claimed that care-quality of their pain was insufficient or bad. The majority of patients declared being very satisfied or at least satisfied with different care services. For items that were judged as less satisfactory, some recommendations will be taken especially at the level of pain’s and palliative care as well as the organization of patients’ circuit inside the department. The satisfaction’s variations can be attributed to personally patients factors as well as systemic ones at the level of the hospital. Assessing and understanding these factors are essential in developing appropriate measures to improve patient satisfaction.

// Christian Borel 1, 7 , Olivier Regnier-Gavier 2 , Helene Carinato 1 , Sebastien Guihard 3, 7 , Delphine Antoni 3, 9 , Martin Demarchi 1 , Florian Sirlin 4 , Delphine Exinger 2 , Emilie Petit-Jean 2 , Alicia Thiery 5 , Guy Bronner 6 , Philippe Schultz 6 , 8 , Henri Flesch 6 , Veronique Frasie 4 , Danielle Prebay 2 , Thierry Petit 1 , Alain C. Jung 7, 10 , Mickael Burgy 1 and Pierre Coliat 2, 7, 10 1 Medical Oncology Department, Centre Paul Strauss, Strasbourg, France 2 Pharmacy Department, Centre Paul Strauss, Strasbourg, France 3 Radiotherapy Department, Centre Paul Strauss, Strasbourg, France 4 Supportive Care Department, Centre Paul Strauss, Strasbourg, France 5 Biostatistics Department, Centre Paul Strauss, Strasbourg, France 6 ENT Specialist, Strasbourg, France 7 Universite de Strasbourg, Inserm IRFAC UMR_S1113, group « STREINTH », Strasbourg, France 8 Department of Otolaryngology Head and Neck Surgery, Hopitaux Universitaires de Strasbourg, Strasbourg, France 9 Radiobiology Laboratory, Centre Paul Strauss, Universite de Strasbourg, Strasbourg, France 10 Tumor biology Laboratory, Centre Paul Strauss, Universite de Strasbourg, Strasbourg, France Correspondence to: Pierre Coliat, email: pcoliat@strasbourg.unicancer.fr Keywords: HNSCC; EXTREME; re-challenge; platinum free Interval Received: November 27, 2018 Accepted: December 13, 2018 Published: December 25, 2018 ABSTRACT Background: The EXTREME protocol is the standard of care for recurrent or metastatic head and neck squamous-cell carcinoma (R/M HNSCC) in first line. Beyond the first-line except immunotherapy, poor efficacy was reported by second-line chemotherapy. Re-challenge strategies based on a repetition of the first line with platinum and cetuximab regimens might have been an option to consider. Methods: We performed a retrospective study in order to assess the efficacy of the cetuximab plus platinum doublet-based chemotherapy regimen in patients with R/M HNSCC progressing after at least 3 months of cetuximab maintenance (EXTREME protocol). We complete a retrospective review of all medical records from R/M HNSCC patients treated after 16 weeks with the EXTREME regimen and treated with a re-challenge strategy between January 2010 and December 2014 in our institution (Centre Paul Strauss, Strasbourg, France). Results: 33 patients were identified. The re-challenged strategy provided an ORR in 33.3% of cases and a DCR of 69.6% of cases. The median OS and PFS observed from the second line were 11.2 months and 6.5 months for the subset re-challenged by EXTREME or PCC regimens respectively. The response rate between patients with a platin free interval within 3 and 6 months and greater than 6 months were equal. Drugs dose intensity were better with the PCC protocol than the EXTREME regimen used as a rechallenge. Conclusions: This study suggest re-challenging strategy by these regimens could be considered beyond the first line as an option when the platin free interval is greater than 3 months.

Objective This descriptive cross-sectional study assessed cancer patients' use of traditional healers, the association between delay in coming to this clinic and patients' use of traditional healers, reasons cancer patients use western medicine after trying traditional treatment and the cost of obtaining traditional treatment. Methods Participants were made of 400 consecutive and consenting new patients in the Department of Radiotherapy, University College Hospital (UCH), Ibadan. A validated interviewer-administered semi-structured questionnaire was used for data collection. Data was analyzed using descriptive and inferential statistics. Focus group discussions were held with some of the clients as well as the traditional healers. Results It showed that 34.5% of the patients patronized traditional healers, while 65.5% used only hospitals. The most common reason given among patients who patronized traditional healers for doing so was their desire to be healed and to be rid of pains (45.9%), while the most common reason they opt for western medicine afterwards was lack of improvement in their health condition (70.1%). The cost of traditional treatment for cancer ranged between no cost to N5,000 (that is approximately $31.25 @ $1 = N160) to be treated. The cost of orthodox care would range from a minimum of N40,000 to several millions of naira. Conclusions Patients patronize traditional healers to be rid of pains; hence physicians should endeavor to control cancer-related symptoms, especially pains as the patients await diagnosis. Also, the low cost of obtaining traditional treatment, regular assurance of cure and other assistances given to them, could be an enticing factor in its use. Copyright © 2015 John Wiley & Sons, Ltd.

It has been estimated that half of all cancer patients should receive radiotherapy during the course of the disease. Actual Radiotherapy Utilization (RTU) rates are usually lower than the optimal rates.Data were collected from all radiotherapy departments (RTD) in New South Wales (NSW) and the Australian Capital Territory (ACT) for the period 2004-06 and were linked to Central Cancer Registries. Geographic Information System (GIS) software was used to calculate road distance between patient residence and the closest RTD. Patients were excluded from the study if their nearest RTD was outside NSW.The overall RTU rate was 26%. The RTU rates decreased with increasing travel distance from patient residence to the nearest RTD (p0.0001). Multivariate logistic regression shows that male gender, younger age and shorter travel distance were significantly associated with receiving radiotherapy. Patients were 10% less likely to receive radiotherapy for each additional 100 km distance from the nearest RTD (p0.001).There was a statistically significant reduction in radiotherapy access with longer road distance between patient residence and radiotherapy department.

Image-guided radiation therapy consists in acquiring in-room images to improve patient and mainly tumour set up accuracy. Many devices based on ionising or non-ionising radiations were designed in recent years. The use of such devices is of major importance in the management of patient radiotherapy courses. Those imaging sessions require to clearly define procedures in each radiotherapy department (image modality, acquisition frequency, corrective action, staff training and tasks). A quick review of the different existing image-guided radiation therapy devices is presented. In addition, the results of a French national survey about image-guided radiation therapy are presented: the survey is about both equipment and procedures. A total of 57 radiotherapy departments have participated, representing more than 160 treatment devices. About three linear accelerators out of four are equipped with an image-guiding device. The most common equipment is the CBCT system. Most centres have set up training sessions for the technicians to allow them to analyse online daily images. The management of in-room imaging dose is still under investigation, but many centres use an accounting scheme. While the devices are used to adjust the positioning of patients, in more than half of the centres, the practice had an impact on the choice of clinical and planning target volume margins. This survey led to an inventory in 2015, and could be renewed in some years.

Objectives: The objective of the study was to examine the dosimetry of intracavitary radiotherapy (ICRT) in carcinoma of the cervix using cobalt-60 (Co-60) as source of ICRT, and as an alternative to iridium-192 (Ir-192).Design: This was a retrospective study.Subjects and setting: The study was on 80 ICRT patients attending the radiotherapy department at Maharana Bhupal Government Hospital, Udaipur, India.Outcome measures: The dosimetry of ICRT was studied retrospectively in 80 related applications. The dose to point A, 60 Gy isodose reference volume, and bladder and rectum maximum and mean doses were defined.Results: It was found that dosimetry with Co-60 as a brachytherapy source was consistent with the International Commission on Radiation Units (ICRU 38) recommendations.Conclusion: Co-60 is a logical alternative to Ir-192 in low socio-economic settings when repeated changing of the source is not an option.

Introduction To review the dose delivered to patients in time-resolved computed tomography (4D CT) used for radiotherapy treatment planning. Methods 4D CT is used at Peter MacCallum Cancer Centre since July 2007 for radiotherapy treatment planning using a Philips Brilliance Wide Bore CT scanner (16 slice, helical 4D CT acquisition). All scans are performed at 140 kVp and reconstructed in 10 datasets for different phases of the breathing cycle. Dose records were analysed retrospectively for 387 patients who underwent 4D CT procedures between 2007 and 2013. Results A total of 444 4D CT scans were acquired with the majority of them (342) being for lung cancer radiotherapy. Volume CT dose index (CTDIvol) as recorded over this period was fairly constant at approximately 20 mGy for adults. The CTDI for 4D CT for lung cancers of 19.6 ± 9.3 mGy (n = 168, mean ± 1SD) was found to be 63% higher than CTDIs for conventional CT scans for lung patients that were acquired in the same period (CTDIvol 12 ± 4 mGy, sample of n = 25). CTDI and dose length product (DLP) increased with increasing field of view; however, no significant difference between DLPs for different indications (breast, kidney, liver and lung) could be found. Breathing parameters such as breathing rate or pattern did not affect dose. Conclusion 4D CT scans can be acquired for radiotherapy treatment planning with a dose less than twice the one required for conventional CT scanning.

This paper describes the development of a scintillator dosimeter prototype for radiotherapic applications based on plastic scintillating fibers readout by Silicon PhotoMultipliers. The dosimeter, whose probes are water equivalent, could be used for quality control measurements, beam characterization and in vivo dosimetry, allowing a real time measurement of the dose spatial distribution. This paper describes the preliminary percentual depth dose scan performed with clinical 6 and 18 MV photon beams, comparing the results with a reference curve. The measurements were performed using a Varian Clinac iX linear accelerator at the Radiotherapy Department of the St. Anna Hospital in Como (IT). The prototype has given promising results, allowing real time measurements of relative dose without applying any correction factors.

The existing two‐story parkade is being replaced by a four‐story parkade on a hospital campus. The parkade is across a two‐lane access road from a cancer center with a nine‐linear accelerator radiotherapy department in the basement. The new parkade is supported by over 280 drilled and cased pilings installed at depths between 10 and 25 m depending on the underlying soil strata and varying diameters, up to 1.5 m. The construction work in such close proximity to the radiation therapy department resulted in significant vibrations being felt in the simulation and treatment vaults. The amplitude and frequency of the vibration was measured. Using vendor supplied documentation, the total vibratory amplitude of the linear accelerators in use within the department was calculated. The results fell outside of specification, resulting in changes to the way the project preceded following discussion with the project management team.

The purpose of this report is to review and compile what have been and can be learnt from incidents and accidents in radiation oncology, especially in external beam and brachytherapy. Some major accidents from the last 20 years will be discussed. The relationship between major events and minor or so-called near misses is mentioned, leading to the next topic of exploring the knowledge hidden among them. The main lessons learnt from the discussion here and elsewhere are that a well-functioning and safe radiotherapy department should help staff to work with awareness and alertness and that documentation and procedures should be in place and known by everyone. It also requires that trained and educated staff with the required competences are in place and, finally, functions and responsibilities are defined and well known.

One of the oral complications in head and neck radiotherapy is xerostomia. The severity of xerostomia can be observed using objective examination (unstimulated salivary flow rate measurement) and subjective examination (assessment using xerostomia questionnaires). There are two questionnaires used in assessment of xerostomia in head and neck cancer radiotherapy namely Xerostomia Questionnaire (XQ) and Groningen Radiotherapy-Induced Xerostomia Questionnaire (GRIX). Objective: To know the correlation between unstimulated salivary flow rate and severity of xerostomia assessment using two questionnaires. Methods: 30 head and neck cancer patients undergoing radiotherapy at Radiotherapy Department of RSUP Dr. Sardjito Yogyakarta between January-April 2013 were involved in this study. The assessment of xerostomia used xerostomia questionnaires (XQ and GRIX). Unstimulated salivary flow rate was measured in ml/minutes. Data was analyzed using Spearman Rank Correlation. Results: There is a negative significant correlation between salivary flow rate and severity of xerostomia with correlation coefficient -0.452 (pConclusions: There is a correlation between unstimulated salivary flow rate and severity of xerostomia assessment using XQ and GRIX for head and neck cancer patients undergoing radiotherapy at RSUP Dr. Sardjito Yogyakarta.

Background Metastatic vertebral instability has not yet been clearly defined in the literature; there still exists a paucity of reliable criteria to assess the risk of vertebral collapse. Purpose We performed an independent interobserver and intraobserver agreement evaluation of the Spine Instability Neoplastic Score (SINS) and correlated the score with selected clinical cases and the treatment they received. Study design Independent reliability study for the newly created SINS. Patient sample Thirty patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected from the orthopedic surgery and radiotherapy department's databases. Outcome measures Patients were rated and classified for spinal stability using SINS. Intraclass correlation coefficient (ICC) and Fleiss's kappa measures were occupied for reliability analysis. Methods Patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected and classified for spinal stability using the SINS by orthopedic surgeons and nonorthopedic oncology specialists. ICC and Fleiss's kappa were calculated for inter- and intraobserver agreement. A comparative analysis of SINS and the actual management was also conducted. Results Interobserver ICC reliability for the SINS was 0.79; κ values for location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement were 0.81, 0.58, 0.21, 0.45, 0.42, and 0.29 respectively. Intraobserver ICC for the SINS scores was 0.96; ICC values for the same components were 0.98, 0.98, 0.87, 0.88, 0.92, and 0.86, respectively. Potentially unstable lesions (SINS score≥7) were operated on in 62.5%. Conclusions SINS seem to be a reproducible tool that could be used equally by multiple specialists to estimate metastatic vertebral stability; however, prospective clinical validation is still pending.

Purpose Recent studies on patients undergoing radiotherapy of left side breast demonstrate that late heart damage is directly related to the average doses to the entire organ, apparently without threshold [1] , and the maximum doses to its principal arteries [2] . The VBH technique makes it possible to reduce the dose to the heart compared to FB [3] . Methods and materials This technique can be done in three different ways: (a) with active breathing control devices, based on spirometric systems; (b) with respiratory gating based on the visualization, by infrared camera, of the reflecting markers of a phantom placed on the chest of the patient; (c) with tattoo visual control based technique that identifies the patient’s position in deep inhale, both in simulation CT scan and in the treatment phase. While the first two techniques require investment in equipment and accessories, the third, adopted by our center, is achievable with what is normally available in a radiotherapy department. For the first 9 patients, treatment plans were implemented in both FB and VBH. Results The results obtained, reported in Table 1, are encouraging. At equal coverage of target and dose to the lung, there is a noticeable decrease in dose to the heart and to the left anterior descending artery. Conclusions The adopted technique is a valid aid to the radiotherapy of breast cancer in selected patients.

A 50-year-old woman affected by an ovarian cancer (Figo IV) was referred to our Radiotherapy Department. She had a history of a slow disease progression for over 6 years as a result of several adjuvant chemotherapy regimens. During the last chemotherapy session, she developed a gastric outlet