Intrafraction Imaging Can Replace the Midtreatment Cone Beam Tomography for Lung Stereotactic Ablative Radiation Therapy Patients for Increased Treatment Efficiency.

Purpose: To determine the feasibility of replacing the mid treatment cone beam computed tomography (MT CBCT) image with Intrafraction Imaging (IFI) acquired concurrently during dose delivery in lung Stereotactic Ablative Body Radiation therapy (SABR) patients, and thus improve treatment efficiency. Methods and Materials: A review of departmental imaging data was performed on ten lung SABR patients treated with dual arc volumetric modulated arc therapy (VMAT) on an Elekta Versa HD linear accelerator with XVI imaging software.IFI data was extracted and a database of the translational (TX, TY, TZ) and the rotational (RX, RY, RZ) position errors was created for retrospective comparison, with the values of the MT CBCT for the same patients, treated between March 2021 and March 2022 at our center. The data was evaluated for correlation between the values in all 6° of freedom. Results: The inter-class correlation (ICC) coefficient for Tx was 0.89 (95% CI, 0.80-0.94), Ty was 0.69 (95% CI, 0.49-0.82), Tz was 0.89 (95% CI, 0.82-0.95) in the translational planes, and Rx was 0.79 (95% CI, 0.65-0.88), Ry was 0.79 (95% CI, 0.65-0.88), and Rz was 0.91 (95% CI, 0.84-0.95) in rotational planes.The Bland-Altman (BA) statistics for Tx had a bias of -1.22 × 10-3, with an upper limit of agreement (UOA) of 0.07, and a lower limit of agreement (LOA) of -0.07, for Ty the bias was 0.01 (UOA: 0.18; LOA: -0.16), Tz bias was 2.6 × 10-3(UOA: 0.10; LOA: -0.09), Rx bias was 0.09 (UOA: 0.82; LOA: -0.64), Ry bias was -0.04 (UOA: 1.08; LOA: -1.16) and Rz was -0.03 (UOA: 0.44; LOA: -0.51). Conclusions: The ICC was excellent for Tx, Tz, Rx, y, z, and good for Ty. The data demonstrated promising correlation between IFI and MT CBCT values, and therefore supports the use of IFI for clinical decision making and improving treatment efficiency.

Efficacy of preoxygenation administration in volunteers, in extending the end-expiration breath-hold duration for application to abdominal radiotherapy.

Background and purpose: End expiration breath hold (EEBH) is the preferred motion management method for abdominal Stereotactic Ablative Body Radiotherapy (SABR) treatments. However, multiple short EEBHs are required to complete a single treatment session. The study aimed to determine the efficacy of preoxygenation with hyperventilation in extending an EEBH duration. Materials and methods: We randomised 10 healthy participants into two arms, each included breathing room air and oxygen at a rate of 10 L per minute (l/min) without hyperventilation for four minutes, and normally for four minutes and with hyperventilation for one minute at a rate of 20 breaths/minute for hyperventilation. The type of gas was blinded from the participants for each test. EEBH durations were then recorded, as well as systolic blood pressure, SpO2 and heart rate. A discomfort rating was also recorded after each breath hold. Results: A significant increase in duration of almost 50% was observed between normal breathing of room air and breathing oxygen normally followed by hyperventilation. Vital signs remained consistent between the 4 tests. The tests were well tolerated with 75% of participants recording none or minimal discomfort. Conclusion: Preoxygenation with hyperventilation could be used to increase the EEBH duration for abdominal SABR patients which would assist in the accuracy of these treatments and possibly resulting in a reduction of overall treatment times.

Radiation therapist-led telephone follow-up: identifying patients who require post-treatment care.

INTRODUCTION: Radiation therapists implemented telephone follow-up (TFU) in 2015 as an additional point of care post-treatment. The purpose of this study was to determine whether TFU identified patients who required additional post-treatment care before the next scheduled review. METHODS: Between January 2015 and July 2016, all patients who were prescribed curative intent treatment aged 18 years or over were called 10 days post-radiation therapy (RT). Eight questions were developed and included asking patients how they were coping, if their side effects were improving, if they needed to contact the hospital and if more dressings were required. Patients who could not be contacted after two attempts were excluded from the study. Microsoft Excel and Statistical Package for Social Sciences (SPSS) were used to analyse the responses. RESULTS: Data were collected from 850 patients. A total of 28/846 (3%) of patients reported they were not coping after RT, with 26/830 (3%) reporting their side effects were getting worse. A total of 97/826 (12%) of patients felt they needed to contact the hospital because they were unwell. This study identified 104/677 (15%) of patients who responded required more dressings, with 67/104 (65.7%) and 10/104 (9.8%) of this cohort identified in the breast, and head and neck groups, respectively. CONCLUSION: Radiation therapist-led TFU has shown to be beneficial in identifying a small cohort of breast and head and neck cancer patients who required additional care post-radiation treatment.

Stereotactic body radiotherapy in the management of hepatocellular carcinoma: An Australian multi-institutional patterns of practice review.

INTRODUCTION: Stereotactic body radiotherapy (SBRT) is an emerging, therapeutic option in the management of hepatocellular carcinoma (HCC). A multicentre Liver Ablative Stereotactic Radiation (LASR) database was established to provide a collaborative platform for Australian institutions to define the practice of liver SBRT for HCC. This study explores the patterns of SBRT practice amongst Australian institutions. METHODS: This was a multi-institutional retrospective study of patients treated with SBRT for HCC at 10 institutions between January 2013 and December 2019. Patients' demographics, disease characteristics and SBRT details were evaluated. RESULTS: Three hundred and seventeen patients were evaluated with a median age of 67 years (range, 32-90). Liver cirrhosis was present in 88.6%, baseline Child-Pugh score was A5/6 in 85.1% and B7/8 in 13.2%. Median size of HCC treated was 30 mm (range, 10-280). 63.1% had early-stage disease (Barcelona clinic liver cancer (BCLC) stage 0/A) and 36% had intermediate/advanced-stage disease (BCLC B/C). In 2013/2014, six courses of SBRT were delivered, increasing to 108 in 2019. SBRT was prescribed in five fractions for 71.3% of the cohort. The most common dose fractionation schedule was 40 Gy in five fractions (24.3%). Median biologically effective dose (BED10 ) delivered was 85.5 Gy for early-stage and 60 Gy for intermediate/advanced disease, respectively. The most common prescription range was 100-120 Gy BED10 (32.8%). CONCLUSION: SBRT utilisation for HCC is increasing in Australia. There was wide variation in size of tumours and disease stages treated, and prescription patterns. Uniform reporting of clinical and dosimetric details are important in refining the role of liver SBRT.

Patient-Specific Heart Constraint: A Tool for Optimization and Evaluation of Mean Heart Dose in Breast Cancer Patients.

PURPOSE: Our institution introduced a patient-specific heart constraint (PSHC) and a mean heart dose (MHD) constraint of 4 Gy for all patients receiving breast radiation therapy (RT) with a simultaneous boost (SIB). This was introduced as a method to calculate the predicted MHD before optimizing IMRT fields. We sought to determine whether the introduction of a PSHC reduced MHD, while maintaining optimally dosed treatment plans. MATERIAL/METHODS: Patients were retrospectively divided into 2 groups, pre- and postintroduction of the PSHC. The breast and SIB Planning Target Volumes (PTVs) were prescribed to 50 Gy and 57 Gy, respectively, in 25 fractions. Plans were generated using a hybrid IMRT technique, 30 Gy using an open tangential field arrangement, and 27 Gy using IMRT fields. The PSHC was calculated using MHD of open tangential field × 2. A paired t test compared PTV coverage and heart doses between cohorts (P < .05 significant). RESULTS: A total of 264 patients were included (138 pre-PSHC and 126 post-PSHC) with 137 right-sided and 127 left-sided treatments. MHD was significantly reduced across both right-sided (-0.4 Gy, P < .0001) and left-sided (-1.2 Gy, P < .0001) treatments overall. Left-sided treatments were further examined between free breathing and deep inspiration breath-hold (DIBH). DIBH showed reduction in MHD, although it was not significant (-0.46 Gy, P = .34). Heart V5 Gy showed reduction in right-sided (-1%, P = .002) and left-sided (-9.2%, P < .0001) treatments overall. Left-sided free breathing showed significant reduction (-8.8%, P < .0001), and DIBH also showed significant reduction (-5.1%, P = .0034). Tumor bed doses remained above the 54.15 Gy (95% of 57 Gy) threshold for all plans. CONCLUSION: Introduction of a PSHC can reduce MHD and V5 Gy for patients receiving whole breast RT with SIB while maintaining optimally dosed plans, with the greatest benefit shown for left-sided, free-breathing treatments.

Bladder Care in Palliative Care Inpatients: A Prospective Dual Site Cohort Study.

Background: Urinary catheterization is often undertaken to relieve distressing bladder symptoms in palliative care. Objective: The primary aim of this study was to determine the incidence of, and clinical indications that predispose patients admitted to palliative care units to, urinary catheterization. The secondary aims were to determine causal factors, including the type of malignancy, antecedent medications, and duration of admission in these patients. Methods: This was a prospective observational dual site cohort study in palliative care inpatients. Univariate categorical chi-square analysis was performed to compare patients with and without urinary catheterization, and to identify risk factors associated with urinary catheter use. Results: The incidence of catheterization in this cohort was 41% (43/104) and urinary retention (63%) was the most common cause. Agitation (47%) and urinary incontinence (70%) were common symptoms in those catheterized. Medications that were significantly associated with the need for urinary catheterization were benzodiazepines (p < 0.01) and antipsychotics (p = 0.01). All measures that define poor functional status were found to be significant (p < 0.01). Patients with prolonged hospitalization of greater than three weeks were catheterized more frequently (p = 0.017). The majority of patients catheterized (79%) were admitted for terminal care. Conclusions: The high incidence of urinary catheterization highlights the need for good bladder care for all patients in the palliative care setting. Patients with risk factors include the use of antipsychotics and benzodiazepines, declining functional status and prolonged hospital admission are more likely to be catheterized.

Long-term outcomes in 1121 Australian prostate cancer patients treated with definitive radiotherapy.

INTRODUCTION: Optimal definitive treatment of prostate cancer is controversial, especially in high-risk patients. We report the largest prospective cohort of Australian patients treated with radiotherapy for localised prostate cancer. METHODS: One thousand, one hundred and twenty-one patients with prostate cancer were prospectively registered and treated to a dose of 70-74 Gy. Patients were classified as low, intermediate or high risk based on PSA, clinical staging and Gleason score. Intermediate-risk patients were treated with 0-6 months of hormonal therapy (ADT) and high-risk patients were offered neoadjuvant and adjuvant ADT. Overall survival (OS) and biochemical relapse-free survival (bNED) were calculated using the Kaplan-Meier method. RESULTS: Median follow-up was 92 months. Eight-year OS and bNED were 78.4% and 68.1% respectively in the entire cohort. OS for the low, intermediate and high-risk groups was 84.5%, 78.4% and 68% respectively. For these risk groups, bNED was 80.3%, 65.7% and 53.7% respectively. In the intermediate and high-risk group, OS and bNED decreased with increasing number of risk factors. CONCLUSION: Definitive radiotherapy is an effective treatment for prostate cancer, including in high-risk cases.

Defining a Leader Role curriculum for radiation oncology: A global Delphi consensus study.

BACKGROUND AND PURPOSE: The need for radiation oncologists and other radiation oncology (RO) professionals to lead quality improvement activities and contribute to shaping the future of our specialty is self-evident. Leadership knowledge, skills and behaviours, like other competencies, can be learned (Blumenthal et al., 2012). The objective of this study was to define a globally applicable competency set specific to radiation oncology for the CanMEDS Leader Role (Frank et al., 2015). METHODS: A modified Delphi consensus process delivering two rounds of on-line surveys was used. Participants included trainees, radiation/clinical oncologists and other RO team members (radiation therapists, physicists, and nurses), professional educators and patients. RESULTS: 72 of 95 (76%) invitees from nine countries completed the Round 1 (R1) survey. Of the 72 respondents to RI, 70 completed Round 2 (R2) (97%). In R1, 35 items were deemed for 'inclusion' and 21 for 'exclusion', leaving 41 'undetermined'. After review of items, informed by participant comments, 14 competencies from the 'inclusion' group went into the final curriculum; 12 from the 'undetermined' group went to R2. In R2, 6 items reached consensus for inclusion. CONCLUSION: This process resulted in 20 RO Leader Role competencies with apparent global applicability. This is the first step towards developing learning, teaching and assessment tools for this important area of training.

Squamous cell carcinoma of the lip in Australian patients: definitive radiotherapy is an efficacious option to surgery in select patients.

BACKGROUND: In Australia, squamous cell carcinoma (SCC) of the lip is a consequence of chronic sun exposure and treated as a nonmelanoma skin cancer. Patients may be recommended radiotherapy (RT) as a treatment modality. OBJECTIVE: To analyze the outcome of patients with early-stage SCC of the lip treated with definitive RT at Westmead Hospital, Sydney, Australia, between 1980 and 2012. METHODS AND MATERIALS: Ninety-three patients with early-stage SCC of the lip underwent RT. All patients were clinically node negative based on examination and/or relevant investigations. Retrospective chart review was performed. Patients treated since 2000 had data collected and entered prospectively. RESULTS: The most frequently involved site was the lower lip (93%). Fifty-six patients (60%) had T1N0 and 37 patients (40%) had T2N0 disease. Most patients were treated with superficial or orthovoltage RT, with the median RT dose delivered 55 Gy (range, 40 to 70 Gy). Local recurrence occurred in 5 patients (5%), whereas regional metastases developed in 5 patients (5%). One patient developed concurrent local and regional relapse. No patient developed distant metastases. The 5-year recurrence-free survival was 90%. CONCLUSION: The findings confirm the efficacy of RT as an efficacious treatment option in early-stage lip SCC.

Improving the identification of high risk precursor B acute lymphoblastic leukemia patients with earlier quantification of minimal residual disease.

The stratification of patients with acute lymphoblastic leukemia (ALL) into treatment risk groups based on quantification of minimal residual disease (MRD) after induction therapy is now well accepted but the relapse rate of about 20% in intermediate risk patients remains a challenge. The purpose of this study was to further improve stratification by MRD measurement at an earlier stage. MRD was measured in stored day 15 bone marrow samples for pediatric patients enrolled on ANZCHOG ALL8 using Real-time Quantitative PCR to detect immunoglobulin and T-cell receptor gene rearrangements with the same assays used at day 33 and day 79 in the original MRD stratification. MRD levels in bone marrow at day 15 and 33 were highly predictive of outcome in 223 precursor B-ALL patients (log rank Mantel-Cox tests both P<0.001) and identified patients with poor, intermediate and very good outcomes. The combined use of MRD at day 15 (≥ 1 × 10(-2)) and day 33 (≥ 5 × 1(-5)) identified a subgroup of medium risk precursor B-ALL patients as poor MRD responders with 5 year relapse-free survival of 55% compared to 84% for other medium risk patients (log rank Mantel-Cox test, P = 0.0005). Risk stratification of precursor B-ALL but not T-ALL could be improved by using MRD measurement at day 15 and day 33 instead of day 33 and day 79 in similar BFM-based protocols for children with this disease.

Early-stage squamous cell carcinoma of the lip: the Australian experience and the benefits of radiotherapy in improving outcome in high-risk patients after resection.

BACKGROUND: The purpose of this study was to analyze the outcome of Australian patients treated for early lip cancer. METHODS: Data on 217 patients with T1 to T2 squamous cell carcinoma (SCC) of the lip and treated with radical intent were analyzed. RESULTS: The addition of local adjuvant radiotherapy in patients with a close/positive margin was associated with a significant improvement in relapse-free survival (RFS; p = .008). Tumor thickness (≤4 mm vs >4 mm) was also significantly associated with RFS (p = .01). The 5-year RFS was 51% after surgery, 87% after radiotherapy, and 92% after adjuvant radiotherapy. CONCLUSIONS: Patients with a tumor thickness >4 mm experienced an increased risk of recurrence, especially nodal. Compared with patients having any radiotherapy, those undergoing surgery experienced a higher rate of locoregional recurrence. The addition of adjuvant radiotherapy in patients with inadequate excision significantly decreased the risk of recurrence.