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Imaged-guided radiotherapy (IGRT) is not a new technique; rather, it has evolved over the past few decades. It has been defined in many ways, but for the purposes of this Editorial it can be thought of as any imaging at pretreatment and delivery, the result of which is acted upon, that improves or verifies the accuracy of radiotherapy. Although imaging at the time of treatment delivery, for example electronic portal imaging, has been available since the early 1990s, the consistency and frequency of use throughout the UK has been variable. This led to the publication of On target: ensuring geometric accuracy in radiotherapy in 2008 [1] detailing guidance for twodimensional imaging, which included explanations of methods to determine set-up error and to calculate treatment set-up margins. In parallel with the publication of On target: ensuring geometric accuracy in radiotherapy [1], the National Radiotherapy Advisory Group report [2] set the national strategy for radiotherapy and advised that the National Health Service should aspire to image-guided fourdimensional adaptive radiotherapy as the future standard of care for radical radiotherapy treatment [2]. Since then, significant technical advances have occurred in all aspects of radiotherapy from target delineation, radiotherapy planning and treatment delivery and, in particular, verification. Therefore, the effective implementation and evaluation of new IGRT techniques is essential. Although IGRT is an essential component of fourdimensional adaptive radiotherapy, it should also be a core component of all radiotherapy treatments, both radical and palliative. As with the widespread implementation of intensity-modulated radiotherapy (IMRT), there is a lack of high-level evidence to show benefit in local

To evaluate the impact of a customized immobilisation system on field placement accuracy, simulation and treatment delivery time, radiographer convenience and patient acceptability.Thirty men receiving radical radiotherapy for prostate cancer were randomised using a cross over trial design to have radiotherapy planning and treatment given either in a conventional treatment position (CTP) or using an immobilisation system (IMS). The randomisation was to have either the CTP or IMS for the initial 3 weeks of radiotherapy after which patients were replanned and changed to the alternative treatment set-up. Treatment accuracy was measured using an electronic portal imaging device. Radiographers and patients completed weekly questionnaires.Median simulation time was 22.5 min (range 20-30 min) in the CTP and 25 min (range 15-40 min) for the IMS (P0.001). Median treatment time was 9 min for CTP (range 8-10 min), and 10 min (range 8.5-13.5 min) for IMS (P0.001). Median isocentre displacement for anterior fields was 1.7 mm from the simulated isocentre for the CTP compared to 2.0 mm for IMS (P = 0.07). For left lateral fields values were 1.8 and 1.8 mm (P = 0.98), and for right lateral fields 2.1 and 1.7 mm (P = 0.06), respectively. No clinically significant reduction in either systematic or random field placement errors was demonstrated. Radiographers reported that patients found the IMS more comfortable than CTP (P0.001), but when using the IMS, they noticed greater difficulty in patient positioning (P0.001), and alignment to skin tattoos (P0.001).Although IMS may have been more comfortable, treatment accuracy was not improved compared to the CTP in our department. In addition, treatment took longer and patient set-up was more difficult.

Introduction The anti-inflammatory role of dietary fibre, its impact on bowel frequency and stool consistency is inadequately studied. Therapeutic radiotherapy for prostate cancer provides a unique opportunity to assess the potential efficacy of fibre in protecting the rectum from cumulative, radiation-therapy induced, inflammatory insults. The rectum inevitably receives some radiation dose during prostate irradiation. Rectal function in most men, will be normal before the radiotherapy starts and a predictable inflammatory response occurs during radiotherapy which peaks during the second week of treatment, causing the worst symptoms by the fourth to fifth weeks. We investigated whether patients could follow a fluid and fibre prescription designed to regularise bowel habit commencing before and continuing for the 6–9 weeks of radiotherapy. Additionally, the effect of the diet on gastrointestinal symptoms, rectal distension and stool consistency was examined. Methods Fibre and fluid intake was assessed at baseline and individualised prescriptions given to regularise frequency of bowel motion to at least 1 motion/day and ensure adequate fluid intake. Compliance was measured daily as was stool frequency and type (consistency) using the Bristol Stool Form 7-point scale. Symptoms were assessed at baseline and at end-RT (end of radiotherapy) using a modified IBDQ (Inflammatory Bowel Disease Questionnaire) and IBDQ-B, bowel subset. Rectal gas (5-point scale) and distension (rectal Cross Sectional Area in cm2) defined as rectal volume/length were measured throughout treatment from serial CT scans. Result 22 patients were invited to participate. 21 (median: 71 years; range: 59–82 years) provided evaluable data. Between baseline and end-RT, 14 patients increased fibre intake (NSP: Englyst) and seven decreased intake (5 g/day and -2 g/day, respectively). 13 patients exceeded and eight patients did not meet their prescribed fibre intake. Stool frequency increased from mean 1.9 to 2.4 motions/day at end-RT. The mean fall in IBDQ-B scores (n=21) was 10.8 points which was similar in both the increasing and decreasing fibre groups (10.3 vs 11.6 points, respectively). The mean fall in IBDQ scores was twofold greater in the decreasing fibre group compared to increasing (34.6 vs 17.6, respectively). Rectal distension was significantly correlated with rectal gas (p=0.04) but was not associated with change in fibre intake. Mean rectal CSAcm2 decreased from 7.5 cm2 at baseline to 6.8 cm2 at end-RT. Conclusion Patients are able to follow fibre prescriptions based on normally-consumed foods for prolonged periods but there is a tendency to exceed dose and therefore it is important to set upper limits. Increased fibre intake (25% more than habitually consumed) appeared to offer protection from symptoms and did not have an adverse effect on rectal gas, distension, stool frequency or consistency.