Patient engagement with radiation therapists: Patient perspectives, challenges, and opportunities. A systematic review.

INTRODUCTION: Radiotherapy is a major component of cancer care and treatment is delivered almost exclusively by therapeutic radiographers/radiation therapists (RTTs). Numerous government and professional guidance publications have recommended a person-centred approach to healthcare through communication and collaboration between professionals, agencies, and users. With approximately half of patients undergoing radical radiotherapy experiencing some degree of anxiety and distress, RTTs are uniquely placed as frontline cancer professionals to engage with patients regarding their experience. This review seeks to map the available evidence of patient reported views of their experience of being treated by RTTs and any impact, this treatment had on the patient's frame of mind or perception of treatment. METHODS: In line with the principles of the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) systematic review methodology, a review of relevant literature was conducted. Electronic databases MEDLINE, PROQUEST, EMBASE and CINAHL were searched. RESULTS: Nine hundred and eighty-eight articles were identified. Twelve papers were included in the final review. CONCLUSION: Increased time with, and continuity of RTTs during treatment has a positive influence on patients' perspectives of RTTs. A positive patient perspective of their engagement with RTTs can be a strong predictor of overall satisfaction in radiotherapy. IMPLICATIONS FOR PRACTICE: RTTs should not underestimate the impact of their supportive role in guiding patients through treatment. A standardised method for integrating patients' experience and engagement with RTTs is lacking. Further RTT led research is required in this area.

Patient-reported perspectives of therapeutic radiographers when undergoing radiotherapy: A European multi-centre study.

INTRODUCTION: Radiotherapy is delivered almost exclusively by therapeutic radiographers/radiation therapist (RTTs). Patient's perspectives of RTTs affect levels of trust and confidence in the profession and can have a significant impact on overall radiotherapy experience. The study reports patients' perspectives of RTTs from their experience of undergoing radiotherapy. Four partner sites collaborated in this research and included Malta, Poland, Portugal, and the UK (lead site). METHODS: A survey was developed to gather information from patients receiving radiotherapy or who had had radiotherapy within the previous 24 months. Participants ranked their responses to 23 statements relating to person-centred care on a 5-point scale of 1 (strongly disagree) to 5 (strongly agree). Mann-Whitney or Kruskal Wallis tests were applied to test differences in responses to 5 key statements for patient characteristics including gender, age group, diagnosis, country, time spent with RTTs and number of fractions remaining at survey completion. RESULTS: Three hundred and forty-seven surveys are included. Patients report a positive perception of RTTs (95.4% agree with 'I feel cared for'). Statistically significant differences in responses were found between gender, diagnosis, country, time spent with RTTs and fractions of radiotherapy remaining. Patients who had more time with RTTs and completed their surveys during radiotherapy had a more positive perception of RTTs. CONCLUSION: This study suggests that sufficient time with RTTs is key to ensuring a positive radiotherapy patient experience. RTTs being attentive, understanding, and informative are most predictive of a positive overall patient experience. Timing of survey completion can influence responses. IMPLICATIONS FOR PRACTICE: RTT education programmes should incorporate training on person-centred care at all levels. Further research into patient experience of RTTs is warranted.

An investigation of digital skills of therapeutic radiographers/radiation therapists: A european survey of proficiency level and future educational needs.

INTRODUCTION: This study aims to assess the proficiency level of digital skills, the factors influencing that level and the training needs of Therapeutic Radiographers/Radiation Therapists (TR/RTTs), due to the differences in technology availability and accessibility, variations in the regulation and education of TR/RTTs in European countries, and the lack of a digital skills framework. METHODS: An online survey was distributed to TR/RTTs working in Europe to capture their self-assessment of proficiency levels of digital skills when performing their clinical role. Information was also gathered regarding training, work experience and level of information and communication technology (ICT) skills. Quantitative measures were analysed using descriptive statistics and correlation between variables, and qualitative responses using thematic analysis. RESULTS: 101 respondents from 13 European countries completed the survey. Digital skills in treatment planning followed by management and research were the least developed skills, while the most developed were transversal digital skills followed by digital skills in treatment delivery. The Radiotherapy areas of practice where TR/RTT has experience (e.g. Planning Image, Treatment Planning, Treatment), as well as the level of generic ICT skills (communication, content creation and problem-solving), was related to the level of proficiency of TR/RTT digital skills. Greater scope of practice and level of generic ICT were associated with a higher level of TR/RTT digital skills. Thematic analysis allowed the identification of new sub-themes to be included in the training of TR/RTTs. CONCLUSION: Education and training of TR/RTTs should be improved and adapted to the current needs of digitalisation to avoid differences in digital proficiency levels. IMPLICATIONS FOR PRACTICE: Aligning TR/RTTs' digital skill sets with emerging digitalisation will improve current practice and ensure the best care to all RT patients.

Patients' perspectives of the skills and competencies of therapy radiographers/radiation therapists (TRs/RTTs) in the UK, Portugal and Malta; a qualitative study from the SAFE Europe project.

INTRODUCTION: The role of the Therapy Radiographer/Radiation Therapist (TR/RTT) is to provide radiotherapy to patients with a cancer diagnosis. This includes, not only administration of treatment, but also management of side-effects and provision of support/care. Despite this role being consistent throughout Europe, there is currently no standardisation of education for TRs/RTTs. The SAFE EUROPE project aims to standardize TR/RTT education to enable 'safe and free exchange' of TRs/RTTs across Europe. Consequently, this study aims to explore patients' perspectives regarding the current skills and competencies of TRs/RTTs. METHODS: From May 2021 to February 2022, semi-structured interviews were conducted with patients who had recently received radiotherapy in the UK, Malta and Portugal. Ethical approval for this study was granted by the NHS Research Ethics Committee with additional local approvals obtained. RESULTS: Forty-eight participants from the UK (n = 18), Portugal (n = 19), and Malta (n = 11) completed interviews. Participants described high satisfaction with TRs'/RTTs' competence and skills in all three countries. The main theme arising from the analysis was the importance of trust building with TRs/RTTs. Six factors were identified as influencing levels of trust: communication; side-effect management; team consistency; relational skills; patient dignity; and competence. A small number of patients reported feeling rushed and not having their physical and emotional needs met by TRs/RTTs. CONCLUSION: This multicentre study demonstrated that patients perceive TRs/RTTs in the UK, Malta and Portugal as highly competent and skilled. Practical recommendations are provided to address identified deficits in practice, which can be addressed through adaptation of TR/RTT education/training and clinical practice. IMPLICATIONS FOR PRACTICE: Recommendations arising from this study are important to ensure that TRs/RTTs have transferable skills that provide consistently high quality care to patients throughout Europe.

An evaluation of knowledge of circular economy among Therapeutic Radiographers/Radiation Therapists (TR/RTTs): Results of a European survey to inform curriculum design.

INTRODUCTION: Global warming and the increase in greenhouse gases are a current concern worldwide. The healthcare sector constitutes about 4.4% of all emissions. This study aims to evaluate the knowledge, awareness and attitudes of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) regarding environment-related concepts to inform the development of educational curriculum. METHODS: A validated self-designed survey was distributed to TR/RTTs across Europe by the SAFE EUROPE partners and via social media between October 2021 and February 2022. The survey was divided into six sections: (i) demographics, (ii) knowledge of Circular Economy (CE) and Green Skills (GS), (iii) personal attitudes, (iv) TR/RTTs attitudes, (v) the importance of CE, and (vi) education. Questions consisted of mostly Likert scales complemented with other closed- and open-ended questions. RESULTS: 31%-42% of participants are aware of national and departmental policies in CE and GS concepts. Even though half of the participants considered that they advocate and practice CE, the open questions indicated that participants only focus on waste management, ignoring all the other dimensions of CE in healthcare. Personal attitudes and lifestyles also did not reflect CE. TR/RTTs considered CE practices and GS development essential. However, the suggested academic level at which these skills should be developed was split between High School (44%) and Bachelor's degree (32%). CONCLUSION: It is essential to raise awareness among TR/RTTs about the various dimensions of CE applied to healthcare: "green transportation", "environment-friendly procurement", "hospital building design", "food process optimisation", "water reduction", "energy efficiency", and "waste management". IMPLICATIONS FOR PRACTICE: These GS must be developed by TR/RTTs to decrease their impact on the environment. Their training may need to be lifelong, starting during basic high school education and continuing as healthcare professionals after graduation.

Digital skills of therapeutic radiographers/radiation therapists - Document analysis for a European educational curriculum.

INTRODUCTION: It is estimated that around 50% of cancer patients require Radiotherapy (RT) at some point during their treatment, hence Therapeutic Radiographers/Radiation Therapists (TR/RTTs) have a key role to play in patient management. It is essential for TR/RTTs to keep abreast with new technologies and continuously develop the digital skills necessary for safe RT practice. The RT profession and education is not regulated at European Union level, which leads to heterogeneity in the skills developed and practised among countries. This study aimed to explore the white and grey literature to collate data on the relevant digital skills required for TR/RTTs practice. METHODS: An exhaustive systematic search was conducted to identify literature discussing digital skills of TR/RTTs; relevant grey literature was also identified. A thematic analysis was performed to identify and organise these skills into themes and sub-themes. RESULTS: 195 digital skills were identified, organised in 35 sub-themes and grouped into six main themes: (i) Transversal Digital Skills, (ii) RT Planning Image, (iii) RT Treatment Planning, (iv) RT Treatment Administration, (v) Quality, Safety and Risk Management, and (vi) Management, Education and Research. CONCLUSION: This list can be used as a reference to close current gaps in knowledge or skills of TR/RTTs while anticipating future needs regarding the rapid development of new technologies (such as Artificial Intelligence or Big Data). IMPLICATIONS FOR PRACTICE: It is imperative to align education with current and future RT practice to ensure that all RT patients receive the best care. Filling the gaps in TR/RTTs skill sets will improve current practice and provide TR/RTTs with the support needed to develop more advanced skills.

Competency level in radiotherapy across EU educational programmes: A cross-case study evaluating stakeholders' perceptions.

INTRODUCTION: The education of Therapeutic Radiographers (TRs) is regulated in some countries but is not standardised across the EU, leading to differences in competencies between and within member states. This study aimed to explore stakeholders' perceptions regarding underdeveloped competencies of TRs practising on the linear accelerator, identified in a previous study by the same research team. METHODS: Interviews with stakeholders from four countries (selected based on the characteristics of their degrees) were performed as part of this cross-case study. Stakeholders were asked to provide their perception regarding the least developed competencies identified in a previous study. RESULTS: The 27 stakeholders confirmed that Pharmacology, Quality Assurance (QA), Management and Leadership, Research (from the previous study) were underdeveloped and identified Image Verification and Critical Thinking as additional underdeveloped competencies. Suggested causes included: lack of regulation of required competencies at the national level, lack of training dedicated to radiotherapy (RT) (taught within generic modules) and lack of time within the degree programme. The ideal academic level to develop these competencies and whether they are essential varied between country and stakeholder. CONCLUSION: It is essential to regulate learning outcomes at the national level to ensure a high level of care is provided to all RT patients and, ideally, standardise it across Europe. Education institutions should review their curricula to ensure that sufficient time is dedicated to RT and that the essential competencies are developed. Due to time constraints within some programmes, some competencies must be developed after graduation. IMPLICATIONS FOR PRACTICE: Lack of regulation of learning outcomes (at European level and national level in many countries) and lack of RT-specific training lead to underdeveloped competencies that may compromise patient care.

Evaluation of radiotherapy education across the EU and the impact on graduates' competencies working on the linear accelerator.

INTRODUCTION: Regulation and education of the professionals administering radiotherapy treatments in the linear accelerator varies across the EU. However, how different programme characteristics affect the level of competency of these professionals has never been studied before. This study also aimed to assess which are the least and most developed competencies in radiotherapy across the EU. METHODS: An online questionnaire was distributed to academic staff teaching radiotherapy across the EU. Staff were asked to identify the characteristics of the course programmes and to classify the level of competency of graduates regarding linear accelerator tasks. RESULTS: Fifty respondents from 19 EU countries answered the questionnaire. The least developed competency theme was pharmacology followed by equipment quality assurance and management and leadership. The most developed competency was positioning and immobilisation, followed by radiotherapy treatment delivery and professional and ethical practice. Some competencies are developed at the same level across EU countries, while others vary considerably between member-states. Longer programmes, with more placements, and larger proportions of radiotherapy in the programme showed significant increase in the development of some competencies. Longer placements in skills labs was correlated with a decrease in competency. CONCLUSION: There is no harmonisation of radiotherapy eduction across the EU and the differences in programme characteristics are reflected in differences in competency levels of radiotherapy radiographers. This may hinder movement of professionals and create disparities in the level of care offered across the EU. IMPLICATIONS FOR PRACTICE: Longer programmes, with longer clinical practice and adequate proportion of radiotherapy in the course are essential to ensure that these professionals are competent at similar levels across the EU and to ensure patient safety.

Competencies of therapeutic radiographers working in the linear accelerator across Europe: A systematic search of the literature and thematic analysis.

INTRODUCTION: The literature identifies various competences required for therapy radiographers (TR), however, these are varied and scattered among different publications. The aim of this study was to identify the competences required by therapy radiographers practising on the linear accelerator in the European setting, according to published literature. METHODS: A systematic approach was performed to find relevant literature. The literature was then scrutinised for competences practised by linac TRs. Thematic analysis was performed to organise the competences according to themes. RESULTS: A list of 170 competences were generated based on the assessment of 28 publications. The competences were organised in themes, including "delivery of treatment", "verification of patient setup", "patient care" and "teamwork and multidisciplinarity". The competences of the therapeutic radiographers encompass multiple themes, evidence of the complexity of the role of these professionals. CONCLUSION: Radiographers across Europe must be trained to the highest standards to ensure the best care possible is given to patients, irrespective of the country the radiographer trained in. This will also promote for free movement of professionals across countries. The competences identified can be used as reference for the design of academic curriculum for TRs practising across Europe.

An evaluation of the educational requirements to practise radiography in the European Union.

INTRODUCTION: Radiography is practised world wide, however, the definition of the profession varies across countries. As there is no regulation of the profession or education at EU level, different national regulations might result in educational differences that can compromise the movement of professionals or the safety of patients. The aim of this study was to identify the commonalities and discrepancies in national regulation of radiography. METHODS: National competent authorities from all EU countries where the profession is regulated (n = 27) were invited to identify the legal requirements to practise radiography and the data was analysed using thematic analysis. RESULTS: One country does not regulate the profession in the EU. Although, a single profession is regulated in 83% of the cases, 21% regulate separate professions for different specialisms (diagnostic radiography, radiotherapy and nuclear medicine). All countries (n = 27) define education as requirement to practise, however, the academic level varies from secondary school to Master's degree with required programmes varying from 2 to 4 years and from 120 to 240 ECTS. In addition, the subjects covered in the education programme showed great heterogeneity. These subjects were not identified by 35% of the respondents (n = 23) and only 26% define the subjects in terms of competencies. CONCLUSION: Education is a requisite to practise all over the EU, however, the lack of EU-wide regulation leads to a variation of national regulations. These differences may lead to inhomogeneity of competencies being developed, compromising the movement of professionals across Europe and patient safety.

Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo.

The purpose of this study was to describe 3-dimensional scapular motion patterns during dynamic shoulder movements with the use of a direct technique. Direct measurement of active scapular motion was accomplished by insertion of 2 1.6-mm bone pins into the spine of the scapula in 8 healthy volunteers (5 men, 3 women). A small, 3-dimensional motion sensor was rigidly fixed to the scapular pins. Sensors were also attached to the thoracic spine (T3) with tape and to the humerus with a specially designed cuff. During active scapular plane elevation, the scapula upwardly rotated (mean [SD] = 50 degrees [4.8 degrees ]), tilted posteriorly around a medial-lateral axis (30 degrees [13.0 degrees ]), and externally rotated around a vertical axis (24 degrees [12.8 degrees ]). Lowering of the arm resulted in a reversal of these motions in a slightly different pattern. The mean ratio of glenohumeral to scapulothoracic motion was 1.7:1. Normal scapular motion consists of substantial rotations around 3 axes, not simply upward rotation. Understanding normal scapular motion may assist in the identification of abnormal motion associated with various shoulder disorders.

Estradiol concentration and the regulation of locomotor activity.

We predicted that female prairie voles (Microtus ochrogaster) would not increase in locomotor activity during "induced" proestrus. We developed and tested two alternative a priori hypotheses to explain this predicted lack of activity. The Non-Response Hypothesis in which voles cannot, physiologically, increase activity in response to estradiol and, the Threshold Effect Hypothesis in which a minimal concentration of estradiol is necessary to achieve estrus, while higher concentrations influence other behavioral parameters. The non-response hypothesis predicts that hormone concentration will not affect locomotor activity, while the threshold effects hypothesis predicts that voles achieve estrus at low concentrations, while higher concentrations should trigger increasing locomotor activity. Initial results using running wheels indicated that females decreased activity during induced proestrus. Radioimmunoassay revealed that induced proestrus was achieved at relatively low concentrations of estradiol. Results from a dose response experiment allowed for rejection of the nonresponse hypothesis and supported the threshold effects hypothesis as females decreased activity at low concentrations of estradiol, showed no relative change at moderate concentrations, and increased activity at higher concentrations.

Potential compounds for monitoring method performance in the determination of selected organochlorine pesticides and polychlorinated biphenyls in human serum.

Four compounds--2,2', 3,4'-tetrachlorobiphenyl, decachlorodiphenylether, 1,1-dichloro-2,2-bis(p-ethylphenyl)ethane, and dichlorobenzophenone--are recommended for monitoring the within-sample behavior of an analytical method that quantifies chlorinated pesticides and polychlorinated biphenyls (such as Aroclor 1260) in serum using packed column gas chromatography with electron capture detection. Percent recoveries of these surrogates averaged greater than 80%, except with dichlorobenzophenone, which had an average recovery of greater than 70%.

Determination of selected organochlorine pesticides and polychlorinated biphenyls in human serum.

A method is presented that can be used to determine the residue level of certain chlorinated pesticides and polychlorinated biphenyls (as Aroclor 1260) in serum. The method involves the following: (1) extraction of denatured serum with organic solvents; (2) elution of the organic extract through micro-Florisil columns to obtain two fractions; (3) acid treatment of the less polar Florisil fraction and its subsequent elution through deactivated silica gel to obtain two fractions; and (4) analysis of all three fractions using gas-liquid chromatography with electron capture detection. The method produced in vitro recoveries for 10 pesticides spiked in the range of 1-10.7 ppb of 50.4% to 121.6%, and in the range of 4.98-21 ppb, recoveries ranged from 47.7 to 112.6. In vivo "recoveries" of Aroclor 1260 averaged 104.8% and 92.3% for concentration levels of approximately 10 and approximately 30 ppb, respectively. The method could not be compared with the more commonly used hexane extraction technique because of the deleterious effect these extracts had on the gas chromatographic system.

Use of reference pools to compare the qualitative and quantitative determination of polychlorinated biphenyls by packed and capillary gas chromatography with electron capture detection. Part 1. Serum.

Serum for reference pools of in vivo polychlorinated biphenyls (PCBs) was obtained from four goats that had received one dose (100 mg kg-1) of a selected technical Aroclor (AR) (1016, 1242, 1254 or 1260) and were allowed to recover for 30 d. These pools were used to assess the differences in an analytical method that determines and quantifies PCBs using packed-column gas chromatography (PCGC) (quantified on the basis of mean mass percent. data for grouped PCB peaks) and capillary-column gas chromatography (CCGC) (quantified on the basis of percent. composition data for specific congeners). With CCGC, results were statistically significantly different (p less than or equal to 0.0002) from results with PCGC for ARs 1016, 1242 and 1254 but not for AR 1260 (p = 0.23). When comparing these gas chromatographic methods using bovine serum spiked in vitro with the same ARs at 17-25 p.p.b., it was found that the methods were not statistically significantly different for any of the ARs (p = 0.30-0.92). Levels of serum PCB determined by the two methods for 12 persons, divided into two groups according to exposure, were compared using the paired t-test. Group 1 consisted of three persons with dietary and/or environmental exposure; one with dietary and/or environmental exposure in addition to occupational exposure dating back 20 years. Group 2 consisted of eight persons with recent occupational exposure.(ABSTRACT TRUNCATED AT 250 WORDS)

Nitrate-induced changes in protein synthesis and translation of RNA in maize roots.

Nitrate regulation of protein synthesis and RNA translation in maize (Zea mays L. var B73) roots was examined, using in vivo labeling with [(35)S]methionine and in vitro translation. Nitrate enhanced the synthesis of a 31 kilodalton membrane polypeptide which was localized in a fraction enriched in tonoplast and/or endoplasmic reticulum membrane vesicles. The nitrate-enhanced synthesis was correlated with an acceleration of net nitrate uptake by seedlings during initial exposure to nitrate. Nitrate did not consistently enhance protein synthesis in other membrane fractions. Synthesis of up to four soluble polypeptides (21, 40, 90, and 168 kilodaltons) was also enhanced by nitrate. The most consistent enhancement was that of the 40 kilodalton polypeptide. No consistent nitrate-induced changes were noted in the organellar fraction (14,000g pellet of root homogenates). When roots were treated with nitrate, the amount of [(35)S]methionine increased in six in vitro translation products (21, 24, 41, 56, 66, and 90 kilodaltons). Nitrate treatment did not enhance accumulation of label in translation products with a molecular weight of 31,000 (corresponding to the identified nitrate-inducible membrane polypeptide). Incubation of in vitro translation products with root membranes caused changes in the SDS-PAGE profiles in the vicinity of 31 kilodaltons. The results suggest that the nitrate-inducible, 31 kilodalton polypeptide from a fraction enriched in tonoplast and/or endoplasmic reticulum may be involved in regulating nitrate accumulation by maize roots.

Computed tomography of benign ovarian masses.

Although ultrasound is the primary imaging modality for evaluating benign gynecologic pelvic masses, CT may provide diagnostic information regarding ovarian masses that are discovered fortuitously. The relatively infrequent use of CT in evaluating the adnexa has resulted in a paucity of literature regarding the CT characteristics of benign ovarian masses. The CT appearances of 24 benign ovarian masses are presented. Pathologic diagnoses were ovarian cyst (nine), endometrioma (five), teratoma (three), serous cystadenoma (two), mucinous cystadenoma (two), thecoma (one), cystadenofibroma (one), and Brenner tumor (one). Benign ovarian cysts have characteristic homogeneous water density and smooth walls on CT. Single internal septations and slight wall irregularity are also common features, but soft-tissue mural or septal nodules are uncommon. Computed tomography can be diagnostic in evaluating cystic teratomas. Other benign ovarian masses exhibit a spectrum of CT appearances that is often nonspecific, and surgical or biopsy proof may be necessary to exclude malignancy.

Selection, Isolation, and Characterization of Cadmium-Resistant Datura innoxia Suspension Cultures.

Datura innoxia cells from suspension cultures were selected for their ability to grow and divide rapidly in normally lethal concentrations of cadmium. Cells resistant to 12.5, 25, 50, 100, 160, 200, and 250 micromolar cadmium chloride were isolated and utilized to initiate cell suspension cultures resistant to this toxic metal ion. Variant cell lines retained their ability to grow in cadmium after being grown in its absence for more than 400 generations. Resistance to cadmium was correlated with the synthesis of low molecular weight, cysteine-rich, cadium-binding proteins. Synthesis of these proteins was induced rapidly in cadmium-resistant cells in response to a challenge of cadmium. Induction was detectable within one hour after exposure of the cells to the metal ion. Accumulation of protein bound cadmium reached a maximum eight to twelve hours following exposure. Metal-binding proteins were not detectable in the cadmium sensitive D. innoxia cells from which resistant cells were derived.

Autoerythrocyte sensitization.

We have seen six examples of autoerythrocyte sensitization in children that allow a definition of the disorder in the pediatric age group. The typical skin lesion is a painful, erythematous bruise that starts after minor trauma or surgery and often involves an area away from the injury site. The skin manifestations can be debilitating, and reappear unpredictably for an indefinite period. Somatic symptoms can be associated with the bruising. Usually the children have a disturbed psychological background. Characteristically, multiple detailed investigations are performed before the diagnosis is made. An intradermal injection of autologous red cells may or may not give a "positive" ecchymotic reaction. Pediatric patients seem to respond well to psychotherapy, which is usually the only effective form of treatment.

Hodgkin's disease in children: treatment results with MOPP and low-dose, extended-field irradiation.

Combined therapy with MOPP and extended-field irradiation for all children with Hodgkin's disease (except those with favorable clinical stage [CS] 1) was effective in disease control. Overall 5-year survival and relapse-free survival rates were 92% and 82%, respectively. Only one of 27 CS 2 and 3 patients has relapsed (median followup, 4.3 years). Two patients in complete remission died of viral infection. The cost-benefit ratio for such treatment remains to be determined. Morbidity was decreased by the omission of staging laparotomy with splenectomy and by reduction in radiation dose and to a lesser extent volume, but it was increased by the addition of MOPP. In such combined treatment, the smallest number of cycles of MOPP, the lowest radiation dose, and the smallest radiation volume that may be used without loss of treatment effectiveness remain to be determined.