20. Setting the pace for strengthening radiotherapy in Europe: the estro esquire project

In most medical specialties the success rate and outcome of treatment coincide and can be measured immediately. This is not the case for radiotherapy where debilitating of even lethal side effects may show up as late as 18 years after treatment. To determine the outcome or therapeutic ratio of radiotherapy, it is therefore necessary to link tumour control closely to the actuarial long-term disease free survival of the patient.The therapeutic window for radiotherapy is narrow. In walking the tightrope between cure and complications, radiotherapy can put the odds at its side. As a precautionary measure, strict quality assurance measures including the monitoring of side effects need to be put in place. Recent studies have demonstrated that every gain in the accuracy of the beam output and treatment delivery is translated into important gains in the uncomplicated cure probability, thus sparing the lives of thousands of patients every year. QA will become all the more mandatory now that new technological developments allow much more precision in the delivery of the intended dose to the intended target volume, thus making an escalation of the dose and hence the improvement of the cancer cure rata possible.Europe has only half the number of treatment units of America and Japan. However, it has also its own strengths. These are exactly in the field of quality assurance and education. ESTRO has become a world leader in the provision of teaching in the field of radiotherapy. The ESTRO teaching programme commands the admiration and even the envy of the International radiation oncology community. We need to capitalise on this achievement and keep it at the cutting edge of scientific and technological progress to offset, through the development of the human potential and optima) use of capital-intensive infrastructural resources, at least partially the shortage in capital investment and the past shortfall in spending for research.For this reason ESTRO is embarking on an ambitious new project called ESQUIRE (Education, Science and Quality Assurance In Radiotherapy in Europe) which it hopes to realise with the support of EU funding. The aim of this project is to increase the confidence level of clinicians for embracing optimised RT treatment regimes by making sure they can be introduced without an increase in severe side effects. Actions proposed for this purpose: monitoring the accuracy of the dose (Talk 1:E∼UAL) and the side effects (Task 2: REACT), by stepping up education for the implementation of new technology (Task 3: EDRO,) by developing quality assurance procedures for optimised RT (Task 5: QUASIMODO) and brachytherapy (Task 6: BRAPHY∼S), and establishing a procedure-based surveillance of quality in treatment and research (Task 4:EPOQART)

High sensitivity organic inorganic hybrid X-ray detectors with direct transduction and broadband response

X-ray detectors are critical to healthcare diagnostics, cancer therapy and homeland security, with many potential uses limited by system cost and/or detector dimensions. Current X-ray detector sensitivities are limited by the bulk X-ray attenuation of the materials and consequently necessitate thick crystals (~1 mm-1 cm), resulting in rigid structures, high operational voltages and high cost. Here we present a disruptive, flexible, low cost, broadband, and high sensitivity direct X-ray transduction technology produced by embedding high atomic number bismuth oxide nanoparticles in an organic bulk heterojunction. These hybrid detectors demonstrate sensitivities of 1712 µC mGy-1 cm-3 for "soft" X-rays and ~30 and 58 µC mGy-1 cm-3 under 6 and 15 MV "hard" X-rays generated from a medical linear accelerator; strongly competing with the current solid state detectors, all achieved at low bias voltages (-10 V) and low power, enabling detector operation powered by coin cell batteries

Quality assurance of the EORTC Trial 22881/10882: boost versus no boost in breast conserving therapy. An overview

BACKGROUND: The initial quality assurance programme of the EORTC Radiotherapy Cooperative Group in trial 22881/10882 is described. The implications of its results for quality assurance in future trials are discussed. METHODS: In the EORTC trial 22881/10882 patients with stage I or II breast cancer are treated with tumor excision, axillary dissection, 50 Gy whole breast irradiation and then randomized to receive a boost dose of 15 Gy or no boost following complete tumor excision or between 10 Gy or 25 Gy in case of incomplete excision. To avoid or diminish protocol deviations and to quantify inevitable variations an extensive initial quality assurance programme was conducted. The programme consisted of a dummy run procedure an individual case review procedure, in vivo dosimetry studies and phantom dosimetry studies. RESULTS: This combination of quality assurance procedures allows a good estimation of patient to patient and inter-institutional variations, and early detection of (potential) systematic protocol deviations of 3 types: 1. Deviations due to ambiguities in the protocol prescriptions. 2. Deviations not known to the institution, such as mistakes in implementation of treatment planning algorithms resulting in a systematic overdosage or underdosage. 3. Inability of an institution to cope with (precise) protocol prescriptions for technical or logistic reasons. DISCUSSION: The first 2 types of deviations may be corrected or avoided by direct discussions and recommendations. With respect to the third type it is up to the trial coordinator to accept participation or not, depending upon the relative importance of the particular deviation(s) for the trial end points. To be effective, such a quality assurance programme must be implemented as early as possible in the course of a clinical tria

In vivo dosimetry during tangential breast treatment

The 3-dimensional (3-D) dose distribution as calculated in clinical practice for tangential breast treatment was verified by means of in vivo dosimetry. Clinical practice in our institution implies the use of 8 MV X-ray beams, a 2-D treatment planning system, collimator rotation and a limited set of patient data for dose calculations. By positioning diodes at the central beam axes as well as in the periphery of the breast the magnitude of the dose values at the isocentre and in points situated in the high-dose regions behind the lung could be assessed. The position of the diodes was verified by means of an on-line portal imaging device. The reproducibility of these in vivo dose measurements was better than 2% (1 SD). Our study showed that on the average the dose delivery at the isocentre is 2% less and at the points behind the lung, 5.7% higher with respect to the calculated dose values. Detailed analysis of these in vivo dosimetry results, based on dose measurements performed with a breast shaped phantom, yielded the magnitudes of the errors in the predicted dose due to several limitations in the dose calculation algorithms and dose calculation procedure. These limitations are each introducing an error of several percent but are compensating each other for the dose calculation at the isocentre. We concluded that the dose distribution in a patient for our treatment technique and dose calculation procedure can be predicted with a 2-D treatment planning system in an acceptable way. A more accurate prediction of the dose distribution can be performed but requires an estimation of the lack of scatter due to missing tissue, the change in the dose distribution due to oblique incident beams and the incorporation of the actual output of the treatment machine in the assessment of the number of monitor unit

Quality assurance of the EORTC trial 22881/10882: "assessment of the role of the booster dose in breast conserving therapy": the Dummy Run. EORTC Radiotherapy Cooperative Group

The EORTC trial 22881/10882 is a randomised trial with the aim to assess the role of the boost dose in breast conserving therapy in stage I and II breast cancer. In order to detect potential protocol deviations concerning irradiation technique and in the dose specification procedure of participating institutions before actual patient accrual, a Dummy Run was performed. Three transverse sections of a patient were sent to 16 participating institutions with a request to make a three-plane treatment plan according to the protocol prescriptions. A treatment chart and beam data were also requested for recalculation of the dose. Additional information was asked in a questionnaire. On evaluation, the techniques differed considerably with respect to photon beam energy, varying between 60Co gamma-rays and 8 MV X-rays, and the use of wedge filters. Two institutions did not apply wedges, whereas wedge angles in the other institutions varied between 6 degrees and 45 degrees. Twelve institutions used collimator rotation and/or a table wedge to diminish the amount of irradiated lung volume. The dose was specified in a point according to the protocol prescription in 11 institutions and to the 90, 95 or 100% isodose curve in four. Twelve institutions applied lung density corrections during treatment planning, while nine reported problems with their planning system in off-axis dose distribution calculation and/or the simulation of collimator rotation. Recalculation of the dose at the isocentre showed agreement within 2% compared with the stated dose. The dose reported in the tumour excision area varied between 93 and 100%.(ABSTRACT TRUNCATED AT 250 WORDS