Permanent Indian ink tattoos for breast cancer radiotherapy: A United Kingdom study of the emotional impact on patients following radiotherapy.

INTRODUCTION: Post-operative radiotherapy for early breast cancer is recommended for over 30,000 people every year in the United Kingdom. The majority of these patients will be advised to have radiotherapy alignment tattoos; permanent skin marks applied with Indian ink and a lancing needle, black/green/blue in colour and approximately 2 mm in diameter. The tattoos assist the therapeutic radiographers to position the patient accurately and reproducibly for each treatment fraction. The aim of this study was to investigate the emotional impact of radiotherapy tattoos on people following breast cancer radiotherapy. METHODS: An electronic questionnaire was distributed by the charitable organisation, Breast Cancer Now, to their members who had undergone radiotherapy for early breast cancer. Based on the responses to the open and closed questions, an overall impact score was assigned to each respondent, and representative quotes extracted to contextualise the themes identified. Statistical tests were performed to evaluate the relationship between overall impact scores and several variables such as age at the time of radiotherapy, skin type, and age at the time of completing the questionnaire. RESULTS: 204 people responded to the questionnaire. 100% had permanent Indian ink tattoos during breast cancer radiotherapy. 95% could still see the midline tattoo. 22 subthemes were identified; 4 positive, 4 neutral and 14 negative. Radiotherapy tattoos served as a constant negative reminder for 27% and affected clothing choices in 14% of respondents. 11% described feelings of 'hating' them. 6% were assigned positive overall impact scores, 43% neutral, and 51% had negative overall impact scores. The black/green/blue ink pigment used was commonly described as unnatural; contributing strongly to the negative appearance of the tattoos. CONCLUSION: Permanent Indian ink tattoos have a negative impact on emotional well-being in the months and years following radiotherapy for early breast cancer for many people. In contrast, a very small minority feel positively about the tattoos. IMPLICATIONS FOR PRACTICE: Our findings are unlikely to be unique to this diagnostic cohort and supports the need to offer alternatives that are less-impactful to the recipient, accessible for people of all skin colours, and fit-for-purpose in terms of radiotherapy set-up. Acknowledgement of the significant negative impact and collaboration between industry, healthcare professionals and patient representatives is key to identifying and implementing suitable alternatives as standard of care.

Identifying Surrogates for Heart and Ipsilateral Lung Dose to Guide Field Placement and Treatment Modality Selection during Virtual Simulation of Breast Radiotherapy.

AIMS: Virtual simulation (VSim) of tangential photon fields is a common method of field localisation for breast radiotherapy. Heart and ipsilateral lung dose is unknown until the dosimetric plan is produced. If heart and ipsilateral lung tolerance doses are exceeded, this can prolong the pre-treatment pathway, particularly if a change of technique is required. The aim of this study was to identify predictive surrogates for heart and ipsilateral lung dose during VSim to aid optimum field placement and treatment modality selection. MATERIALS AND METHODS: Computed tomography data from 50 patients referred for left breast/chest wall radiotherapy were retrospectively analysed (model-building cohort). The prescribed dose was 40.05 Gy in 15 fractions using a tangential photon technique. The heart and ipsilateral lung contours were duplicated, cropped to within the field borders and labelled heart-in-field (HIF) and ipsilateral lung-in-field (ILF). The percentage of HIF (%HIF) and ILF (%ILF) was calculated and correlated with mean heart dose (MHD) and volume of the ipsilateral lung receiving 18 Gy (V18Gy). Linear regression models were calculated. A validation cohort of 10 left- and 10 right-sided cases with an anterior supraclavicular fossa (SCF) field, and 10 left- and 10 right-sided cases including the internal mammary nodes using a wide tangential technique and anterior SCF field, tested the predictive model. Threshold values for %HIF and %ILF were calculated for clinically relevant MHD and ipsilateral lung V18Gy tolerance doses. RESULTS: For the model-building cohort, the median %HIF and MHD were 2.6 (0.4-16.7) and 2.3 (1.2-8) Gy. The median %ILF and ipsilateral lung V18Gy were 12.1 (2.8-33.6) and 12.6 (3.3-35) %. There was a statistically significant strong positive correlation of %HIF with MHD (r2 = 0.97, P < 0.0001) and of %ILF with ipsilateral lung V18Gy (r2 = 0.99, P < 0.0001). For the validation cohort, the median %HIF and MHD were 3.9 (0.6-8) and 2.5 (1.4-4.7) Gy. The median %ILF and ipsilateral lung V18Gy were 20.1 (12.4-32.0) and 20.9 (12.4-34.4) %. The validation cohort confirmed that %HIF and %ILF continue to be predictive surrogates for heart and ipsilateral lung dose during VSim of left- and right-sided cases when including the SCF ± internal mammary nodes with a three-field photon technique. DISCUSSION: The ability to VSim breast radiotherapy (±nodal targets) and accurately predict the heart and ipsilateral lung doses on the dosimetric plan will ensure that tolerance doses are not exceeded, and identify early in the pre-treatment pathway those cases where alternative techniques or modalities should be considered.

Defining the target in cancer of the oesophagus: direct radiotherapy planning with fluorodeoxyglucose positron emission tomography-computed tomography.

AIMS: Target definition in radiotherapy treatment planning (RTP) of oesophageal cancer is challenging and guided by a combination of diagnostic modalities. This planning study aimed to evaluate the contribution of single positron emission tomography-computed tomography (PET-CT) in the treatment position to RTP. MATERIALS AND METHODS: Nineteen patients referred for radiotherapy from April to December 2008 were retrospectively identified. Two sets of target volumes were delineated using the planning CT and the (18)F-fluoro-deoxy-D-glucose ((18)F-FDG) PET-CT data sets, respectively. Target volumes were compared in length, volume and geographic conformality. Radiotherapy plans were generated and compared for both data sets. RESULTS: PET-CT planning target volume (PET-CT(PTV)) was larger than the CT target (CT(PTV)) in 12 cases and smaller in seven. The median PTV conformality index was 0.82 (range 0.44-0.98). Radiotherapy plans conforming to normal tissue dose constraints were achieved for both sets of PTV in 16 patients (three patients could not be treated to the prescription dose with either technique due to very large target volumes and significant risk of normal tissue toxicity). Previously undetected locoregional nodal involvement seen on PET-CT in three cases was localised and included in the PTV. In nine cases, the CTPTV plan delivered less than 95% dose to 95% of the PET-CT(PTV), raising concern about potential for geographical miss. CONCLUSION: A single scan with diagnostic PET-CT in the treatment position for RTP allows greater confidence in anatomical localisation and interpretation of biological information. The use of PET-CT may result in larger PTV volumes in selected cases, but did not exclude patients from radical treatment within accepted normal tissue tolerance.