A service evaluation of 2D planar vs 3D volumetric on-treatment verification for radiotherapy to the upper gastrointestinal tract

INTRODUCTION On-treatment verification using image-guided radiotherapy (IGRT) techniques is fundamental in upper GI radiotherapy for ensuring treatment accuracy. Strategies may include 2D kV planar and 3D kV volumetric cone-beam computed tomography (CBCT) imaging, but required frequencies are under debate. There is currently no national UK imaging standard with many departments adopting their own local protocols. Therefore, understanding potential differences between the modalities and their impact on plan objectives is important. METHODS The aim of this service evaluation was to determine the validity of 2D kV planar imaging compared with 3D volumetric kV-CBCT imaging for correcting patient set-up errors. This was investigated through retrospective assessment of various region of interest (ROI) boxes on 150 CBCT images of 50 patients, by examining any significant differences between bony anatomy and soft tissue matching. Discrepancies in different translational parameters and anatomical distinctions were calculated and a pilot dosimetric assessment was conducted to determine whether 2D kV planar imaging was sufficient or whether daily 3D kV CBCT imaging was warranted to meet plan objectives. RESULTS The key findings of this study were; (a) Inter-observer variability when conducting a bone match is minimal. (b) The greatest difference in patient set-up error correction between a bone and soft tissue match, occurred in the longitudinal direction, for patients with tumours of the lower oesophagus and GOJ/stomach. (c) Only a small percentage of patients required a re-plan or a change to daily CBCT imaging during their treatment course. (d) Only 14% of the overall study cohort had a mean systematic difference in couch shifts between the bone and soft tissue match of +/-0.3cm or greater over the course of treatment. (e) The pilot dosimetry assessment showed that even for the ‘worst-case’ mean systematic difference reported between a bone and soft tissue match, a bone match was sufficient to achieve plan objectives. CONCLUSION The acquisition of 2D kV planar images is a quick and straightforward method of performing on-treatment verification and can be considered an accurate modality for the correction of patient set-up errors in upper GI radiotherapy. Although the value of kV-CBCT imaging for providing indispensable soft tissue detail is well understood, the evidence suggests that the additional concomitant dose factor may not be justified for daily use in this patient group if not deemed absolutely necessary and that kV planar imaging is a sufficient alternative that can be conducted with a reduced dose to the patient

The value of pre-application clinical department visits in radiotherapy: a qualitative evaluation

AbstractBackgroundThe mandatory clinical radiotherapy department visit undertaken by potential applicants aims to provide understanding of the profession and therefore reduce attrition. Increasing pressure on clinical departments makes visits a logistical challenge. This additional step may also present as an unnecessary barrier to applicants. With no evidence relating to visits, this study aimed to explore the perceptions of both students and clinical educators concerning potential benefits and challenges.MethodA focus group interview method was used to gather in-depth qualitative data concerning the clinical department visit experiences from first-year undergraduate students and clinical educators.ResultsThree themes emerged from the student focus groups: the perceived purpose of the clinical visit, the visit content and the outcomes and impact arising from the visit. Clinical educator data also followed these themes in addition to ‘logistical impact’ theme.ConclusionThe clinical visit has value to applicants in affirming their decision to study radiotherapy. There is variation in expectation and content for these visits and they are logistically challenging. Nationally agreed guidelines for visit structure and content could improve visit efficiency and effectiveness. A national clinical visit form may reduce workload for educators and applicants.</jats:sec

The design and construction of a simulated linac control area (SLCA) for Radiation Therapy

Purpose Knowledge and skills needed by radiation therapists (therapeutic radiographers) in cutting edge radiation therapy are wide ranging – combining care for patients with high level technical and medical skills. In the UK pre-registration training takes place in both university and clinical departments. But increasing pressures on clinical departments means training time is limited; extending training into simulated environments has been proven to be highly effective [1] giving students more time to learn and develop, in a safe, non-clinical environment, using the same equipment, methods and discipline of the real clinic. This project aims to extend our simulation facilities to include a Linac control area, to complement students’ skills to safely and effectively ensure accurate and precise patient set-up and delivery of treatment. This paper describes the design and construction of such an area within our simulation centre. Methods Our aim was to create an SLCA with hardware and software components for patient selection, set-up, on-treatment image acquisition and registration and radiation delivery (with and without treatment interruptions). Using true-to-life components was as a high priority. The SLCA was designed around ARIA software, our Virtual Environment for RT (VERT) system, an indexed, flatbed motorised couch, a screened area to create a treatment bunker, a CCTV system, a real Linac function keypad with a specially designed MU counter/sound module, real controlled area/radiation on lighting panels and a simulated door interlock system. Results A schematic of the SLCA is shown in fig 1. All electronic components were built or assembled with documented specifications and design briefs. Screens create a ‘bunker’ so students set-up a patient in front of/using the VERT system and leave the room to the SLCA, as in a real bunker. The patient is visible all the time through the CCTV system. Patient and treatment plan can be selected on ARIA. CBCT acquisition and image registration is possible through the VERT system. The function keypad (from a decommissioned Elekta Linac) is interfaced to the MU counter and radiation-on light. MU are programmed into the counter and verified, before ‘beam-on’ is pressed, starting the MU counter, radiation-on sound (at realistic doserates) and radiation-on light. Conclusion All components have been designed and assembled; all work well as per design specification, enabling true-to-life patient set-up, patient selection and plan check, on-treatment CBCT verification and radiation-on effect with sound and light. The MU counter can be programmed with interruptions, so error scenarios can be simulated for training. The SLCA door interlock is being completed so simulated radiation cannot be initiated without a completed door interlock; and simulated radiation is interrupted when the door interlock is broken. Evaluation is on-going with clinical and university staff and UG/PG Radiation Therapy students. Ref: [1] S-J Ketterer et al. Simulated versus traditional therapeutic radiography placements: a randomized controlled trial. Radiog 2020;26:140-146. https://doi.org/10.1016/j.radi.2019.10.005 Keywords: Radiotherapy, Simulation, Lina

Quality assuring "Plan of the day" selection in a multicentre adaptive bladder trial: Implementation of a pre-accrual IGRT guidance and assessment module

Background and purpose Hypofractionated bladder RT with or without image guided adaptive planning (HYBRID) is a multicentre clinical trial investigating "Plan of the Day" (PoD) adaptive radiotherapy for bladder cancer. To ensure correct PoD selection a pre-accrual guidance and assessment module was developed as part of an image guided radiotherapy quality assurance (IGRT QA) credentialing programme. This study aimed to evaluate its feasibility and effectiveness across multiple recruiting centres.Materials and methods Individuals from participating centres remotely accessed an image database in order to complete the PoD module. An assessment score of ≥83% was required in order to receive QA approval. A questionnaire was used to gather user feedback on the module. PoD decisions for the first patient at each recruiting centre were retrospectively reviewed for protocol adherence.Results 71 radiation therapists (RTTs) from 10 centres completed the PoD module. The median assessment score was 92% (Range: 58-100%) with 79% of RTTs passing the assessment on first attempt. All questionnaire respondents reported that the PoD module prepared them for plan selection. In 51/60 of on-trial treatments reviewed, the PoD selected by the centre agreed with QA reviewers.Conclusions The PoD QA module was successfully implemented in a multicentre trial and enabled pre-accrual assessment of protocol understanding. This increased operator confidence and resulted in appropriate PoD selection on-trial

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

The use of emoji to establish student wellbeing: does the image reflect the reality?

Abstract Introduction: The impact of COVID-19 social restrictions on mental wellbeing of health professional students during placement is largely unknown. Conventional survey methods do not capture emotional fluctuations. Increasing use of smartphones suggests short message service (SMS) functionality could provide easy, rapid data. This project tested the feasibility and validity of gathering data on Therapeutic Radiography student mental wellbeing during clinical placement via emoji and SMS. Methods: Participants provided anonymous daily emoji responses via WhatsApp to a dedicated mobile phone. Additional weekly prompts sought textual responses indicating factors impacting on wellbeing. A short anonymous online survey validated responses and provided feedback on the method. Results: Participants (n = 15) provided 254 daily responses using 108 different emoji; these triangulated with weekly textual responses. Feedback concerning the method was positive. ‘Happy’ emoji were used most frequently; social interaction and fatigue were important wellbeing factors. Anonymity and opportunity to feedback via SMS were received positively; ease and rapidity of response engendered engagement throughout the 3-week study. Conclusions: The use of emoji for rapid assessment of cohort mental wellbeing is valid and potentially useful alongside more formal evaluation and support strategies. Capturing simple wellbeing responses from a cohort may facilitate the organisation of timely support interventions. </jats:sec

The design and construction of a simulated linac control area (SLCA) for Radiation Therapy

Purpose Knowledge and skills needed by radiation therapists (therapeutic radiographers) in cutting edge radiation therapy are wide ranging – combining care for patients with high level technical and medical skills. In the UK pre-registration training takes place in both university and clinical departments. But increasing pressures on clinical departments means training time is limited; extending training into simulated environments has been proven to be highly effective [1] giving students more time to learn and develop, in a safe, non-clinical environment, using the same equipment, methods and discipline of the real clinic. This project aims to extend our simulation facilities to include a Linac control area, to complement students’ skills to safely and effectively ensure accurate and precise patient set-up and delivery of treatment. This paper describes the design and construction of such an area within our simulation centre. Methods Our aim was to create an SLCA with hardware and software components for patient selection, set-up, on-treatment image acquisition and registration and radiation delivery (with and without treatment interruptions). Using true-to-life components was as a high priority. The SLCA was designed around ARIA software, our Virtual Environment for RT (VERT) system, an indexed, flatbed motorised couch, a screened area to create a treatment bunker, a CCTV system, a real Linac function keypad with a specially designed MU counter/sound module, real controlled area/radiation on lighting panels and a simulated door interlock system. Results A schematic of the SLCA is shown in fig 1. All electronic components were built or assembled with documented specifications and design briefs. Screens create a ‘bunker’ so students set-up a patient in front of/using the VERT system and leave the room to the SLCA, as in a real bunker. The patient is visible all the time through the CCTV system. Patient and treatment plan can be selected on ARIA. CBCT acquisition and image registration is possible through the VERT system. The function keypad (from a decommissioned Elekta Linac) is interfaced to the MU counter and radiation-on light. MU are programmed into the counter and verified, before ‘beam-on’ is pressed, starting the MU counter, radiation-on sound (at realistic doserates) and radiation-on light. Conclusion All components have been designed and assembled; all work well as per design specification, enabling true-to-life patient set-up, patient selection and plan check, on-treatment CBCT verification and radiation-on effect with sound and light. The MU counter can be programmed with interruptions, so error scenarios can be simulated for training. The SLCA door interlock is being completed so simulated radiation cannot be initiated without a completed door interlock; and simulated radiation is interrupted when the door interlock is broken. Evaluation is on-going with clinical and university staff and UG/PG Radiation Therapy students. Ref: [1] S-J Ketterer et al. Simulated versus traditional therapeutic radiography placements: a randomized controlled trial. Radiog 2020;26:140-146. https://doi.org/10.1016/j.radi.2019.10.005 Keywords: Radiotherapy, Simulation, Lina