For the first time, KIM has been used for real-time image guidance during cancer radiotherapy. The measured accuracy and precision were both submillimeter for the first treatment fraction. This clinical translational research milestone paves the way for the broad implementation of real-time image guidance to facilitate the detection and correction of geometric and dosimetric errors, and resultant improved clinical outcomes, in cancer radiotherapy.
Introduction: The aim of this study was to investigate the feasibility of injecting a temporary spacer between the rectum and the prostate and to quantify the degree of rectal dosimetric improvement that might result. Methods: Ten patients underwent CT and MRI before and after injection of 10 cc of hydrogel and at completion of radiotherapy. Hydrogel was injected under general anaesthetic using a transperineal approach. The primary endpoints were perioperative toxicity and rectal dosimetry (V80, V75, V70, V65, V40 and V30). Secondary endpoints were acute gastrointestinal toxicity during and 3 months following radiotherapy and the stability of the hydrogel. Treatment for all patients was planned incorporating volumetric modulated arc therapy with a D95 of 80 Gy in 40 fractions to the prostate and proximal seminal vesicles on both the pre-and post-hydrogel scans. Toxicity was scored with the Common Terminology Criteria, v. 3.0. Results: In the first 24 h, two patients described an increase in bowel movement frequency. The comparison plans had identical prescription doses. Rectal doses were significantly lower for all hydrogel patients for all dose endpoints (V80 = 7% vs. 0.1%, V75 = 10.3% vs. 1.1%, V70 = 13.2% vs. 2.7%, V65 = 15.8% vs. 4.6%, V40 = 35.2% vs. 23.3%, V30 = 52.6% vs. 38.5%; P < 0.001). Post-treatment MRI showed gel stability. Grade 1 bowel toxicity was reported in six patients during radiotherapy and two patients at 3 months' follow-up. No Grade 2 or Grade 3 acute bowel toxicity was reported. Conclusion: SpaceOAR hydrogel was successfully injected in 10 patients with minimal side effects. Rectal dosimetry was significantly improved in all patients. This study has been extended to 30 patients with longer follow-up planned.
IntroductionAccurate delivery of radiation while reducing dose to organs at risk is essential in prostate treatment. The Calypso motion management system detects and corrects both inter‐ and intra‐fraction motion which offers potential benefits over standard alignment to fiducial markers. The aims of this study were to implement Calypso with Dynamic Edge™ gating and to assess both the motion seen, and interventions required.MethodsAn implementation group was formed which assessed changes needed to standard workflows. Three patients had Calypso beacons inserted into their prostate. All patients were treated using volumetric modulated arc therapy to a dose of 80 Gy in 40 fractions. Standard inter‐fraction motion correction using either kilovoltage (kV) orthogonal paired imaging or cone beam computed tomography (CBCT) image‐guided radiotherapy techniques, were used along with the Calypso system to compare accuracy. A gating threshold of >0.5 cm was used during treatment. Workflow variations along with inter‐ and intra‐fraction motion and interventions required were assessed.ResultsA total of 116 fractions were treated using Calypso with Dynamic Edge™ gating. There was a strong concordance between aligning beacons using kV orthogonal imaging or CBCT and Calypso (mean variation ≤0.06 cm). The mean intra‐fraction motion detected was ≤0.2 cm in all directions with the largest motion recorded being 2.2 cm in the left direction while the treatment beam was off. Prostate rotation was largest in the pitch direction and 28 fractions exceeded the 10° tolerance. A total of 78 couch shift corrections of ≥0.3 cm were required, usually following standard imaging, and before treatment starting. Three gating events due to intra‐fraction motion occurred during treatment.ConclusionsIntra‐fraction motion monitoring with Calypso was successfully implemented. Greatest movement was seen between time of standard imaging and treatment starting with more than half the treatments requiring a ≥0.3 cm adjustment. This would not have been detected without intra‐fraction monitoring.
The purpose of this discussion article is to explore the implementation of radiation therapist‐led treatment reviews as a form of advanced practice for radiation therapists in Australia. The feasibility of such a role, the impact on cancer care services and implementation requirements to enable the position to be implemented effectively in an Australian environment are explored. Current practice involving weekly patient treatment reviews and cases where health professionals other than radiation oncologists have undertaken this role will be evaluated. Recommendations on its implementation in an Australian environment are also given. An extensive literature review was conducted through the databases ScienceDirect, Medline and CINAHL. Searches were carried out using the following keywords; “radi*” and “prescribing”, “radi*” and “patient review” and “radi*” and “role development”. Abstracts of the yielded results were appraised and those that matched criteria for analysis underwent critical review for inclusion in the discussion. Although steps have been taken to implement the advanced practice role of a treatment review radiation therapist in Australia, little has been done to formalise the role. It is evident from the international literature that the radiation therapist‐led reviewer role has resulted in benefits to patients, medical specialists and therapists. This advanced practice role has the potential to increase radiation therapist retention and recruitment. Implementation of this role in the Australian environment would be advantageous; however criteria outlining the scope of practice and remuneration packages need to be established to facilitate the synthesis of this role in a clinical environment.
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