We reported the clinical and radiological outcome of an aggressive dural arteriovenous fistula (DAVF) after combined glue embolization and hypofractionated helical TomoTherapy (Hypo-HT).

Eleven patients whose radiological examinations are consistent with aggressive DAVF were treated with combined glue embolization and Hypo-HT 30–36 Gy in 5–6 fractions. The dosimetric analysis, clinical response and radiological imaging obliteration rate by magnetic resonance angiography or computed tomography angiography were investigated.

There were eight males and three females with a male and female ratio of 2·67. The mean age was 51·2 years old (range 37–69). Anatomical imaging sites of disease included transverse-sigmoid sinuses (n = 7), superior sagittal sinus (n = 3) and tentorium cerebelli (n = 1). The mean pitch and MF of treatment plans were 0·273 ± 0·032 and 1·70 ± 0·31, respectively. The average size of PTV were 15·39 ± 7·74 cc whereas the Reff,PTV was 1·50 ± 0·25 cm. The average Dmax and Dmin were 37·52 ± 3·34 and 31·77 ± 2·64 Gy, respectively. HI, CI and CI50 were 0·16 ± 0·06, 1·80 ± 0·56 and 7·85 ± 4·16, respectively. The Reff,Rx and Reff,50%Rx were 1·80 ± 0·24 and 2·90 ± 0·45 cm, respectively. The Reff between 50%Rx and 100%Rx was 1·10 ± 0·28 cm on average. With a mean follow up of 28·5 months (range 9–48), the complete recovery of symptoms was found in 72·7 % (eight patients) within 2–12 months after completion Hypo-HT. Partial recovery was reported in 18·2% (two patients). No clinical response was found in 9·1% (one patient). The total radiographic obliteration rate was 27·3% (three patients), subtotal obliteration was 27·3% (three patients) and partial obliteration was 45·4% (five patients).

Satisfactory clinical response of aggressive DAVF was found in all treated patients by combining glue embolization and Hypo-HT. All dosimetric parameters were acceptable. We still need an extended follow up time to assess further radiographic obliteration rate and late side effects of the treatment.

Key advances in cancer treatment have led to an increasing number of long-term cancer survivors. Knowledge of the long-term effects of cancer treatment on leukaemia survivors is to some degree limited. This article investigates the effects of the treatment of childhood leukaemia on the quality of life (QOL), the physical and the psychological wellbeing and general development of survivors. This article reviews current literature to examine existing gaps in knowledge and identify a potential focus of future research and clinical practice.

Online systematic searching, along with historical searching took place in order to retrieve relevant primary research papers for the review. Strict inclusion and exclusion criteria were applied to the literature, to create a manageable amount of research papers.

The extent of intellectual impairment among radiotherapy patients was significantly greater than those treated with chemotherapy only. Body composition, including endocrine function, is readily affected by cancer treatment. Early identification and interventions can greatly improve the QOL of survivors.

Further research into the effect of treatment modality on the extent of chronic effects, along with investigations into the needs of the whole family unit, is required. Future practice must take into account long-term implications while ensuring effective holistic care.

To assess skin dose and incidence of skin reactions in early breast cancer patients treated via Intrabeam™ intraoperative radiation therapy (IORT) device.

In total, 250 breast cancer patients treated with a single fraction of 20 Gy using 50 kV photon were recruited. The applicator to skin distance (ASD) was measured before the initiation of the radiation and the skin dose in each patient was accordingly calculated based on the treatment planning system (TPS).

The average skin doses calculated were equal to 7·91, 5·83, 3·96 and 2·14 Gy for 6–10, 10–15, 15–20 and 20–30 mm ASD values, respectively. It is noticeable that the skin doses could be lower than the TPS measurements up to 45%, mostly due to lack of backscatter radiation in breast tissue compared with the full scatter condition in the Zeiss water phantom. Finally, only three patients showed low-grade skin reactions 1 week after IORT. A review of the related literature also revealed the incidence of lower skin complications among patients treated via Intrabeam™ compared with MammoSite™ machine.

The Intrabeam™ TPS did not seem to be very reliable for accurate skin dosimetry. However, breast cancer treatment using Intrabeam™ could result in fewer incidences of skin reactions than MammoSite™ machine.

Combined modality treatment regimens have provided modest gains in locoregional control rates of cancers of the head and neck (HNC), and intensity-modulated radiation therapy (IMRT) has gained widespread use. The methodology for determining contours of the gross tumour volume (GTV) in the radiation treatment plan is often based on combined anatomic and metabolic data from positron emission tomography–computed tomography (PET-CT). This study aimed to retrospectively evaluate the overall survival and disease-free survival outcomes of patients with HNC who received definitive IMRT with or without chemotherapy, planned with PET-CT.

A total of 1,200 patients underwent treatment for HNC during the study period, from 1 January 2002 to 31 December 2010. Of those, 261 cases had evaluable data that met the inclusion criteria for the study. The incidence and timing of locoregional recurrence, distant metastatic disease, new primary malignancies and death were evaluated retrospectively. Overall and disease-free survival (survival to time of first recurrence) were determined by the life table method. Incidence of distance metastatic disease and additional cancers were also studied.

Median follow-up from treatment initiation was 26·4 months (range 1·2–84·7 months). Overall survival and disease-free survival rates were 0·883 and 0·791, respectively, at 1 year; 0·793 and 0·688, respectively, at 2 years; and 0·732 and 0·619, respectively, at 3 years. The cumulative risk of recurrence was 22·6% at 3 years following definitive IMRT and the median time to recurrence was 345 days. There was an overall low incidence of distant metastatic disease (3·07%) and additional cancers (8·05%).

Overall and disease-free survival outcomes of a large cohort of HNC patients treated with definitive IMRT radiotherapy following treatment planning with PET-CT shows a similar high level of disease control and mortality rate as previously published outcome studies of shorter terms and/or smaller numbers of patients.

To evaluate the dosimetric errors associated with the effect of the collimator angle error in volumetric-modulated arc therapy (VMAT) treatments.

Four patients with different planning target volume (PTV) and localisations treated using VMAT were analysed (high-risk prostate, low-risk prostate, head and neck (H&N) and holocranial with hippocampus protection) in terms of dosimetric variations when errors in the collimator angle were introduced. Original plans underwent modifications of the planned collimator angles of ±0·5°, ±1° and ±1·5°. These modified plans were re-calculated using the same original plan fluencies, and the resulting dose–volume histograms and homogeneity index (HI-ICRU) were compared.

For the high-risk prostate case, there was a noticeable loss of PTV dose coverage for collimator angle errors larger than ±1°, with HI-ICRU relative variations up to 75% in the range analysed. The low-risk prostate case did not present significant changes in organs at risk or PTV dose coverage. For the H&N case, the spinal cord presented changes around 4% for D0·1 cc. In the holocranial case, optic lens showed dose variations up to 5% for collimator angle errors larger than ±1°.

The effect of the collimator error in VMAT increased as the PTV increased.

For selecting the position of the isocentre, one should be cautious, and whenever possible choose a position close to the geometrical centre of the PTVs in order to avoid or minimise errors from the calibration of the collimator angle.

The primary intent of cancer treatment is either curative, prolongation of patient life, or to improve patient quality of life; however, treatments are associated with various side effects that may impact patient wellbeing. Thus, understanding the patients’ wellbeing from the patient’s perspective is essential as it could help enable the provision of the necessary support for patients throughout their cancer journey.

We analysed Edmonton Symptom Assessment System (ESAS) questionnaire responses completed by 19,288 patients over 201,839 visits to our Cancer Centre. As part of their routine and standard of care, patients completing the questionnaire are asked to score 6 physical and 2 psychological symptoms as well as overall wellbeing using an 11-point numerical rating scale ranging from 0 to 10, where 0 means complete absence of the symptom or best overall wellbeing and 10 means worst possible symptom or worst overall wellbeing. We used the ESAS responses to characterise the relationship between the overall wellbeing score and concurrent symptoms scored by cancer patients.

Patients reported tiredness and nausea as the physical symptom causing the most and least distress respectively. Patients that reported severe (7–10) wellbeing also scored high mean scores for tiredness (6·2 ± 2·7), drowsiness (4·7 ± 3·1) and lack of appetite (4·4 ± 3·4). Univariate and multivariable logistic regression analysis suggests higher odds for patients to report moderate-to-severe (4–10) wellbeing when they report moderate-to-severe concurrent symptoms compared to none-to-mild concurrent symptoms.

Our findings suggest that patients’ overall wellbeing as reported by the ESAS system is influenced by a number of concurrent symptoms. Tiredness was found to impact patients’ overall wellbeing to a greater extent than other concurrent symptoms. The sum of physical or psychological symptom scores was stronger indicators of a patient’s overall wellbeing compared to the scores of individual symptoms.

The Varian Trilogy linear accelerator’s multi-leaf collimator moves on a carriage with a maximum leaf span of 15 cm. The traditional open and limited X-jaw technique of volumetric-modulated arc radiotherapy (VMAT) yields a relatively compromised dose distribution within the planning target volume (PTV) region. This study aimed to determine whether the split X-jaw planning technique for VMAT improves plan quality regarding target dose coverage and organs at risk (OAR) sparing for PTVs that require a field size of more than 15 cm in the X-jaw direction in prostate cancer patients.

Computed tomography data sets from 15 patients with prostate cancer were enrolled in the study. Only the PTVs requiring a field size larger than 18 cm in the X-jaw position were considered, and a dose of 4500 cGy in 25 fractions was prescribed. For each case, three separate treatment plans were generated: open, limited and split X-jaw planning techniques with similar planning objectives

The split X-jaw technique resulted in statistically significant superior coverage of PTV when compared with the open (P < 0·0001) and limited methods (P < 0·001). The split technique delivered a lower dose to the OARs, although statistical significance could not be achieved. D2% (cGy) was lowest for the PTV in the split technique (4684·8 ± 18·16) and highest for the open technique (4710 ± 18·75), P < 0·001.

The x-split jaw technique can replace the traditional open X-jaw practice of VMAT for PTVs requiring an X-jaw width of more than 15 cm in the Varian linear accelerator.

While paediatric arteriovenous malformations (AVMs) often require aggressive therapeutic intervention due to their high bleeding incidence, choosing a course of treatment for deep and eloquent areas and asymptomatic cases is difficult. Sequelae are a concern in children, as they survive for longer after treatment. The authors have long recommended and implemented staged Gamma Knife radiosurgery (GKRS) in their treatment guidelines to maximise therapeutic effects.

Fifty-eight paediatric patients with AVM and ≤15 years old who underwent GKRS under general anesthesia from 2002 to 2020 were followed up for an average of 81·5 months. Obliteration dynamics and clinical outcomes were analysed.

The mean patient age was 10·5 years. The mean nidus volume was 6·6 cm3, the complete occlusion rate was 69%, the annual post-irradiation bleeding rate was 2·19% and nine (16%) cases had transient radiation-induced changes. One (1·7%) patient had sequela, and three (5·1%) developed encapsulated hematomas and cysts. Additionally, the 3- and 5-year cumulative occlusion rates were 39·0% and 53·3%, respectively. Multivariate analysis showed significantly higher occlusion rates in patients ≤12 years old and with a nidus volume of ≤4 cm3.

GKRS is a useful treatment for paediatric AVM; however, its use poses some challenges.

The Virtual Environment for Radiotherapy Training (VERT) is a simulator used to train radiotherapy students cost-effectively with limited risk. VERT is available as a two-dimensional (2D) and a more costly three-dimensional (3D) stereoscopic resource. This study aimed to identify the specific benefits afforded by stereoscopic visualisation for student training in skin apposition techniques.

Eight participants completed six electron skin apposition setups in both 2D and 3D views of VERT using a 7 cm × 10 cm rectangular applicator setup to 100 cm focus skin distance (FSD). The standard deviation (SD) of the mean distance from each corner of the applicator to the virtual patient’s skin surface [which we define as apposition precision (AP)] was measured along with the time taken to achieve each setup. Participants then completed a four-question Likert-style questionnaire concerning their preferences and perceptions of the 2D and 3D views.

There was little difference in mean setup times with 218·43 seconds for 2D and 211·29 seconds for 3D (3·3% difference). There was a similarly small difference in AP with a mean SD of 5·61 mm for 2D and 5·79 mm for 3D (3·2% difference) between views. The questionnaire results showed no preference for the 3D view over the 2D.

These findings suggest that the 2D and 3D views result in similar setup times and precision, with no user preference for the 3D view. It is recommended that the 2D version of VERT could be utilised in similar situations with a reduced logistical and financial impact.

Prostate implants at the British Columbia Cancer Agency are performed using a pre-planned technique. Physicians can augment the dose distribution using one to five non-planned ‘extra’ seeds and this option is determined without intraoperative feedback. The purpose of this research is to quantify the dosimetric impact of extra seeds and to assess the circumstances under which they are considered necessary.

Implanting physicians used a questionnaire to record the three-dimensional location and their rationale for using extra seeds. A plan reconstruction algorithm was used to distinguish the extra seeds from the planned seeds. Distributions with and without extra seeds were calculated to quantify the dosimetric impact to the prostate, urethra and rectum.

Extra seeds resulted in mean relative increases to V100, V150 and V200 of 3·7%, 13% and 19·1%, respectively. Mean prostate D90 increased from 147 to 156 Gy. Improvements in post-implant quality assurance codes were recorded in 30% of the implants with minimal dose increase to the rectum and urethra. Extra seeds were mainly deposited in the prostate anterior–superior quadrant.

The use of two to five extra seeds can result in improvements to pre-planned prostate implants, whereas the costs in terms of increased rectal and prostatic urethral dose are relatively minor.

Direct observation in the radiotherapy clinic remains the primary method for the assessment of procedural skills. But with increasing automation and reductions in clinical placement time during the recent pandemic, the role of summative, simulation-based assessment is being revisited. The aim of this article is to share early experiences of using Virtual Environment for Radiotherapy Training (VERT) in the assessment of a palliative, parallel pair, external beam treatment delivery technique in a new pre-registration undergraduate programme.

Eight first-year students completed a campus-based individual virtual assessment using virtual patient plans representing metastatic disease in the brain and pelvis and late-stage primary lung tumours. Performance was logged on a 25-item checklist for pre and post-procedure checks and treatment delivery tasks.

All eight students participated in the assessment with seven students (87·5%) achieving a pass grade at first attempt. The course team observed that participants demonstrated a range of skills and abilities and were able to compare and contrast individual approaches to patient positioning. Specific feed-forward action points were also highlighted as areas for students’ to focus on during their second placement. The project also identified logistical benefits for assessment teams.

While these experiences are a single snapshot, a VERT simulation-based summative assessment is feasible and identified benefits included controlled observation and structured feedback on individual performance and scheduling pressure reductions for clinical teams. However, more work is needed to determine the psychometric qualities and predictability of performance in more complex techniques.

Variation in delineation of target volumes/organs at risk (OARs) is well recognised in radiotherapy and may be reduced by several methods including teaching. We evaluated the impact of teaching on contouring variation for thoracic/pelvic stereotactic ablative radiotherapy (SABR) during a virtual contouring workshop.

Target volume/OAR contours produced by workshop participants for three cases were evaluated against reference contours using DICE similarity coefficient (DSC) and line domain error (LDE) metrics. Pre- and post-workshop DSC results were compared using Wilcoxon signed ranks test to determine the impact of teaching during the workshop.

Of 50 workshop participants, paired pre- and post-workshop contours were available for 21 (42%), 20 (40%) and 22 (44%) participants for primary lung cancer, pelvic bone metastasis and pelvic node metastasis cases, respectively. Statistically significant improvements post-workshop in median DSC and LDE results were observed for 6 (50%) and 7 (58%) of 12 structures, respectively, although the magnitude of DSC/LDE improvement was modest in most cases. An increase in median DSC post-workshop ≥0·05 was only observed for GTVbone, IGTVlung and SacralPlex, and reduction in median LDE > 1 mm was only observed for GTVbone, CTVbone and SacralPlex. Post-workshop, median DSC values were >0·7 for 75% of structures. For 92% of the structures, post-workshop contours were considered to be acceptable or within acceptable variation following review by the workshop faculty.

This study has demonstrated that virtual SABR contouring training is feasible and was associated with some improvements in contouring variation for multiple target volumes/OARs.

This study aims to experimentally determine field output factors using the methodologies suggested by the IAEA-AAPM TRS-483 for small field dosimetry and compare with the calculation from Monte Carlo (MC) simulation.

The IBA-CC01, Sun Nuclear EDGE and IBA-SFD detectors were employed to determine the uncorrected and the corrected field output factors for 6 MV photon beams. Measurements were performed at 100 cm source to axis distance, 10 cm depth in water, and the field sizes ranged from 1 × 1 to 10 × 10 cm2. The use of field output correction factors proposed by the TRS-483 was utilised to determine field output factors. The measured field output factors were compared to that calculated using the egs_chamber user code.

The decrease in the percentage standard deviation of the measured three detectors was observed after applying the field output correction factors. Measured field output factors using CC01 and EDGE detectors agreed with MC values within 3% for field sizes down to 1 × 1 cm2, except the SFD detector.

The corrected field output factors agree with the calculation from MC, except the SFD detector. CC01 and EDGE are suitable for determining field output factors, while the SFD may need more implementation of the intermediate field method.