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BackgroundThe use of magnetic resonance (MR) imaging as a part of preparation for radiotherapy is increasing. For delineation of the prostate several publications have shown decreased delineation variability using MR compared to computed tomography (CT). The purpose of the present work was to investigate the intra- and inter-physician delineation variability for prostate and seminal vesicles, and to investigate the influence of different MR sequence settings used clinically at the five centers participating in the study.MethodsMR series from five centers, each providing five patients, were used. Two physicians from each center delineated the prostate and the seminal vesicles on each of the 25 image sets. The variability between the delineations was analyzed with respect to overall, intra- and inter-physician variability, and dependence between variability and origin of the MR images, i.e. the MR sequence used to acquire the data.ResultsThe intra-physician variability in different directions was between 1.3 - 1.9 mm and 3 – 4 mm for the prostate and seminal vesicles respectively (1 std). The inter-physician variability for different directions were between 0.7 – 1.7 mm and approximately equal for the prostate and seminal vesicles. Large differences in variability were observed for individual patients, and also for individual imaging sequences used at the different centers. There was however no indication of decreased variability with higher field strength.ConclusionThe overall delineation variability is larger for the seminal vesicles compared to the prostate, due to a larger intra-physician variability. The imaging sequence appears to have a large influence on the variability, even for different variants of the T2-weighted spin-echo based sequences, which were used by all centers in the study.

Objective: To investigate the necessity of performing MRI in the radiotherapy position when using MRI for prostatic radiotherapy. Methods: 20 prostate patients received a CT, diagnostic MRI and an MRI scan in the radiotherapy position. The quality of registration between CT and MRI was compared between the two MRI set-ups. The prostate and seminal vesicles were contoured using all scans and intensity modulated radiotherapy (IMRT) plans were generated. Changes in the target volume and IMRT plans were investigated. Two-tailed paired Student's ttests determined the statistical significance.Results: There was a decrease in the mean distance from the centre of the bony anatomy between CT and MRI (from 3.9 to 1.9 mm, p-value,0.0001) when the MRI scan was acquired in the radiotherapy position. Assuming that registering CT with an MRI scan in the radiotherapy position is the gold standard for delineating the prostate and seminal vesicles, using a planning target volume delineated on the CT with a diagnostic MRI scan viewed separately, resulted in a mean conformation number of 0.80 instead of the expected 0.98 (p,0.0001). Conclusion: By registering CT with an MRI scan in the radiotherapy position, there is a statistically significant improvement in the registration and IMRT quality. Advances in knowledge: To achieve an acceptable registration and IMRT quality in prostatic radiotherapy, neither CT with a separate diagnostic MRI nor CT registered to a diagnostic MRI will suffice. Instead, a CT registered with an MRI in the radiotherapy position should be used.

Understanding the impact of the COVID-19 pandemic on systemic anticancer therapy delivery (SACT) is crucial to appreciate the short- and long-term consequences for cancer patients and plan future care. Here, we report real-time national SACT delivery data from NHS Scotland. We demonstrate an initial rapid reduction in patient attendance of 28.7% with subsequent rapid recovery following service redesign. The smallest decrease was seen in breast cancer (19.7%), which also had the most rapid recovery and the largest decrease seen in colorectal cancer (43.4%). Regional variation in the magnitude of impact on SACT delivery was observed, but nadirs occurred at the same time and the rate of recovery was similar across all regions. This recovery reflected a coordinated national approach and associated patient and clinician support structures, which facilitated the creation of COVID-19-protected areas for SACT delivery in Scottish cancer centres enabling rapid sharing of successful and innovative strategies. The data show that these actions have limited the disadvantage to cancer patients.

Objective To determine the rates of germline BRCA1 and BRCA2 mutations in Scottish patients with ovarian cancer, before and after a change in testing policy. Design Retrospective cohort study. Setting Four cancer/genetics centres in Scotland. Population Patients with ovarian cancer undergoing germline BRCA1 and BRCA2 (gBRCA1/2) sequencing before 2013 (under the ‘old criteria’, with selection based solely on family history), after 2013 (under the ‘new criteria’, with sequencing offered to newly presenting patients with non‐mucinous ovarian cancer), and in the ‘prevalent population’ (who presented before 2013, but were not eligible for sequencing under the old criteria but were sequenced under the new criteria). Methods Clinicopathological and sequence data were collected before and for 18 months after this change in selection criteria. Main outcome measures Frequency of germline BRCA1, BRCA2, RAD51C, and RAD51D mutations. Results Of 599 patients sequenced, 205, 236, and 158 were in the ‘old criteria’, ‘new criteria’, and ‘prevalent’ populations, respectively. The frequency of gBRCA1/2 mutations was 30.7, 13.1, and 12.7%, respectively. The annual rate of gBRCA1/2 mutation detection was 4.2 before and 20.7 after the policy change. A total of 48% (15/31) ‘new criteria’ patients with gBRCA1/2 mutations had a Manchester score of <15 and would not have been offered sequencing based on family history criteria. In addition, 20 patients with gBRCA1/2 were identified in the prevalent population. The prevalence of gBRCA1/2 mutations in patients aged >70 years was 8.2%. Conclusions Sequencing all patients with non‐mucinous ovarian cancer gives a much higher annual gBRCA1/2 mutation detection rate, with the frequency of positive tests still exceeding the 10% threshold upon which many family history‐based models operate. Tweetable abstract BRCA sequencing all non‐mucinous cancer patients increases mutation detection five fold.

Management of early endometrial cancer is contentious these days with little agreement between oncologists as well as across MDTs or tumour boards and indeed across countries. This is because of the state of knowledge with regards to risk factors in early endometrial cancer; although we recognise risk factors affect outcome, we haven't yet been able to demonstrate that our treatments make a significant difference. We have reviewed available literature on LVSI and are able to demonstrate that it is an independent risk factor for nodal metastasis as well as distant recurrence. We need a randomised trial integrating grade and LVSI and testing therapeutic options of radiotherapy and chemotherapy. However, it is unlikely to see the light of day. Therefore, we are left with this knowledge of prognostic factors and it is our duty to integrate this into our decision-making during our multidisciplinary team meetings and make decisions tailored to individual patient circumstances.

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Brachytherapy is an essential part of radiotherapy treatment for cervical cancer. Over the decades, it has evolved from manual loading of radium and caesium to remote after-loaders and from low-dose and medium-dose rates to high-dose rates. Over the past 10 years, 3D image-based Brachytherapy has evolved and established itself as the gold standard, improving local control and overall survival, and significantly reducing toxicity. In this article, we review some of the available literature on gynaecologic brachytherapy, more specifically on topics such as dose rates, high-dose-rate/pulsed-dose-rate (HDR/PDR) brachytherapy and image-based brachytherapy (IBBT), and present some of the evidence that establishes IBBT.