Teaching volumetric modulated arc therapy (VMAT) treatment planning to therapeutic radiography students faces challenges, including time constraints and resource limitations. Gamification, an active learning strategy incorporating game-based elements, may enhance engagement and understanding of VMAT treatment planning.

A VMAT treatment planning session was implemented for 15 second-year undergraduate and postgraduate therapeutic radiography students using gamification. Participants were tasked with optimising a VMAT plan for a palliative prostate cancer patient using Eclipse treatment planning software. Students completed pre- and post-session questionnaires assessing perceived understanding and enjoyment. Plans were evaluated against clinical goals, and a leaderboard was used to rank top performers. Thematic analysis was applied to qualitative feedback.

About 86·7% of participants initially reported a limited understanding of VMAT planning structures. Post-session, all participants reported improved perceived understanding, with 93·3% finding the session beneficial and recommending its inclusion in the programme. While 66·6% enjoyed the gamified approach, technical issues limited individual optimisation time. Qualitative feedback highlighted increased confidence and engagement despite challenges.

Gamification enhanced student-reported understanding, enjoyment and engagement in VMAT planning. While technical issues affected session efficiency, feedback supports the integration of gamification in treatment planning sessions but should not be overused as its usefulness can wear off.

Squamous cell carcinoma of the external auditory canal is rare, with bilateral cases even rarer. We report the management of a patient with bilateral external auditory canal squamous cell carcinoma related to radiotherapy and immunosuppression.

A 47-year-old woman with a history of radiotherapy 14 years prior and renal transplantation 6 years prior presented with bilateral external auditory canal squamous cell carcinoma. Squamous cell carcinoma was excised with a purely surgical approach. The two operations included a tympanic membrane graft to preserve hearing on the left side. The patient remains disease-free six months post-op. She uses a bone-conduction hearing aid to good effect on the right side and has mild hearing loss on the left. The operative areas have healed well.

The patient’s previous radiotherapy and immunosuppression may have contributed to her bilateral external auditory canal squamous cell carcinoma. Preventative positron emission tomography scans have the potential to identify second malignancies early, allowing more conservative treatment plans.

Optimal radiotherapy technique selection for left-sided breast cancer remains challenging. This study compared volumetric-modulated arc therapy (VMAT), VMAT+IMRT (VMAT+IMRT) and IMRT+VMAT (IMRT+VMAT) using an innovative integrated scoring system and risk factor (RF) assessment.

Retrospectively analysed 41 patients with left-sided breast cancer. Treatment plans were evaluated using an integrated scoring system considering tumour coverage and organs at risk (OARs) sparing. RF analysis assessed potential adverse effects on the heart and lungs. Correlation analysis explored relationships between integrated scores and risk factors.

VMAT showed the best overall integrated score (1·0931 ± 0·1707), followed by IMRT+VMAT (1·2011 ± 0·2440) and VMAT+IMRT (1·2264 ± 0·2499). VMAT had the highest percentage of Excellent OAR plans (14·6%), while VMAT+IMRT and IMRT+VMAT showed better PTV coverage (53·7% and 51·2% Excellent, respectively). RF analysis revealed: VMAT (heart RF: 0·341, lung RF: 0·671), VMAT+IMRT (heart RF: 0·294, lung RF: 0·750) and IMRT+VMAT (heart RF: 0·533, lung RF: 0·546). Correlation analysis showed strong positive correlations between integrated scores and lung RF for VMAT (r = 0·671) and VMAT+IMRT (r = 0·750), with IMRT+VMAT showing moderate correlations for lung (r = 0·546) and heart (r = 0·533) RFs.

VMAT demonstrated the best balance between PTV coverage and OAR sparing, hybrid techniques improved target coverage but increased risk to OAR. The RF analysis highlighted varying impacts on heart and lung across techniques. This analysis provides valuable insights for technique selection, potentially improving treatment outcomes and reducing complications in left-sided breast cancer radiotherapy.

The technological development of radiotherapy equipment enabled the changing of the dose rate over time during irradiation. Further, techniques, such as volumetric modulated arc therapy (VMAT), are becoming more widespread. This study aimed to assess the changes in radiation isocenter and beam alignment with different dose rates and investigate the dose error during VMAT plan delivery.

The Winston–Lutz (WL) test and three-dimensional water phantom profiles were measured at different dose rates using 4, 6 and 10 MV and flattening filter-free (FFF) at 6 and 10 MV of X-rays. Furthermore, the change in alignment with the dose rate was reproduced through beam parameter adjustments, and the change in dose difference (DD) in the VMAT plan was assessed.

The WL test revealed a 0·1–0·3 mm radiation isocenter displacement with dose rate. Further, the beam profile measurement results demonstrated a 0·3 mm beam centre position displacement in both the lateral and gun-target directions caused by the change in dose rate. VMAT plan delivery with a beam whose centre position changed by 0·3 mm caused a 0·2–3% decrease in the previous DD rate.

The radiation isocenter and beam alignment changed based on the dose rate. Evaluating the change in beam alignment at multiple dose rates is recommended when performing irradiation with different dose rates.

Radiotherapy is a critical component of head and neck cancer (HNC) management that requires reliable patient immobilization. Using thermoplastic masks helps to ensure reproducible patient positioning during radiotherapy, thus reducing the risk of a geographical miss. However, the use of these masks can also induce anxiety and distress, which can negatively impact treatment adherence and quality of life outcomes.

The research was a quantitative cross-sectional study that determined the prevalence and severity of thermoplastic mask-induced anxiety and assessed the scope of coping mechanisms used by HNC patients. Data were collected using a structured questionnaire from recruited participants and analysed with the Statistical Package for Social Sciences software, version 26·0. Relevant clinical and treatment-related data were retrieved from patients’ hospital-based medical records. Descriptive and inferential statistical analyses such as chi-square tests and likelihood ratios were conducted, with p-values < 0·05 considered statistically significant.

In all, there were 145 HNC patients with a male to female ratio of 1·9:1 and a median age of 52·8 years (IQR 20·7), ranging from 18 to 82 years. There was a high prevalence of thermoplastic mask-induced anxiety both during mask moulding (93·8%) and radiation therapy sessions (94·5%). Most participants (95·2%) adopted coping mechanisms including distraction (58%) and visualization techniques (46%).

Even though there was a high level of awareness and utilization of coping mechanisms, the high prevalence of thermoplastic mask-induced anxiety highlights a critical aspect of HNC patient care that may be overlooked in resource-limited settings.

Before COVID-19, breast cancer patients in the UK typically received 15 radiotherapy (RT) fractions over three weeks. During the pandemic, adoption of a 5-fraction treatment prescription and more advanced treatment techniques like surface-guided RT, meant a change in the duration and number of hospital visits for patients accessing treatment. This work sought to understand how breast cancer patients’ time in the RT department has changed, between 2018 and 2023.

Appointments for CT simulation, mould room, and RT, from January 2018 to December 2023, were extracted from the Mosaiq® Oncology Management System. Appointments lasting between 5 minutes and 5 hours were analysed. Total visit time was calculated from check-in to completion on the quality checklist.

In total, 29,523 attendances were analysed over 6 years. Average time spent in the department decreased during the pandemic but has since increased 12·4% above pre-COVID-19 levels. Early morning and late afternoon appointments resulted in the shortest visits, with early afternoon appointments leading to the longest visits. On average, patients spend the longest in the department on a Monday, and the least amount of time on a Friday. Friday was the least common day to start a 15-fraction treatment, whereas Tuesday and Friday were equally uncommon for the 5-fraction regime.

During the COVID-19 pandemic, the number of visits a patient makes for breast cancer RT and related services dropped, and remained lower post-COVID-19, due to fewer treatment fractions being prescribed. Average time spent in the department initially decreased but has since increased beyond pre-COVID-19 levels.

Accurate delivery of radiotherapy to head, neck and brain cancer relies on the use of sophisticated immobilisation devices, usually using a restrictive thermoplastic mask. These masks can cause anxiety and can make treatment difficult for many patients. Open-face or maskless techniques are alternatives which can improve the patient experience. This systematic review aimed to compare the effectiveness of open-face (OF) masks and maskless surface guided radiotherapy (SGRT) with conventional masks.

Primary research papers from the last 10 years were gathered from Scopus, PUBMED, Web of Science and OVID databases. Quantitative data reporting interfractional set-up errors and intrafractional patient motion were extracted from included studies and subjected to descriptive statistical analysis. Additional qualitative data relating to patient tolerance were also extracted to inform discussion.

Ten studies were identified for inclusion. The data identified that OF masks can reproduce patient set-up with an accuracy of <2 mm and <1° and can restrict movement to <1 mm and 0·4°, while maskless SGRT can achieve accuracy to within 0·05 mm and 0·1°.

This review indicates comparable reduction of intrafractional motion between conventional masks, Open-Face masks and maskless SGRT techniques. More research is needed into the impact of maskless SGRT techniques on translational and rotational motions compared to traditional masks.

Palatine tonsil squamous cell carcinoma can be diagnosed with either tonsillectomy or tonsil biopsies. Biopsies are quicker to perform, less invasive, and provide potentially quicker results. Tonsillectomy minimises risk of missed pathology, but with greater associated morbidity. We compared whether tonsillectomy or biopsy affected surgical margin status at subsequent resection.

Our Business Intelligence Team provided a list of all patients with a primary tonsil squamous cell carcinoma who underwent surgery as their primary treatment modality in the last five years at University Hospitals Bristol. Demographic and treatment details were collected along with margin status following surgical resection.

Of the 31 patients that met inclusion criteria, 16 had biopsies and 15 had diagnostic tonsillectomies. The group who underwent tonsillectomy had a reduced risk of close or involved margins (< 5 mm) at subsequent curative-intent surgery (p < 0.001).

Our results suggest that tonsillectomy is associated with reduced likelihood of close or involved margins at subsequent curative-intent surgery. We hope this work can prompt larger multicentre comparisons between these two groups to investigate this relationship in more detail.

The presence of nodal disease at presentation of a head and neck mucosal-based squamous cell carcinoma has a significant impact upon outcomes.

This is a retrospective, ethics-approved study in which patients with squamous cell carcinoma of the larynx, oropharynx, hypopharynx and oral cavity were reviewed and compared with respect to nodal disease (N0 vs N1–N2 vs N3). Patient, disease and treatment parameters were evaluated with ultimate local control, regional control, cancer-specific survival and overall survival investigated.

In the cohort of 1265 patients, 764 presented with nodal disease (N3 = 60). The majority of the N3 group had oropharynx squamous cell carcinoma (52%) and experienced worse ultimate local control (63%; p < 0.001), regional control (67%; p < 0.001) and both squamous cell carcinoma and overall survival (log rank p < 0.001).

Patients presenting with N3 nodal disease had poor regional control, a lower cancer-specific survival and a worse overall survival compared to patients with lesser to no nodal disease.

Adaptive radiotherapy (ART) is commonly used to mitigate effects of anatomical change during head and neck (H&N) radiotherapy. The process of identifying patients for ART can be subjective and resource-intensive. This feasibility project aims to design and validate a pipeline to automate the process and use it to assess the current clinical pathway for H&N treatments.

The pipeline analysed patients’ on-set cone-beam CT (CBCT) scans to identify inter-fractional anatomical changes. CBCTs were converted into synthetic CTs, contours were automatically generated, and the original plan was recomputed. Each synthetic CT was evaluated against a set of dosimetric goals, with failed goals causing an ART recommendation.

To validate pipeline performance, a ‘gold standard’ was synthesised by recomputing patients’ original plans on a rescan-CT acquired during treatment and identifying failed clinical goals. The pipeline sensitivity and specificity compared to this ‘gold standard’ were calculated for 12 ART patients. The pipeline was then run on a cohort of 12 ART and 14 non-ART patients, and its sensitivity and specificity were instead calculated against the clinical decision made.

The pipeline showed good agreement with the synthesised ‘gold standard’ with an optimum sensitivity of 0·83 and specificity of 0·67. When run over a cohort containing both ART and non-ART patients and assessed against the subjective clinical decision made, the pipeline showed no predictive power (sensitivity: 0·58, specificity: 0·47).

Good agreement with the ‘gold standard’ gives confidence in pipeline performance and disagreement with clinical decisions implies implementation could help standardise the current clinical pathway.

To gather and analyse information from the literature concerning the management of otitis media with effusion in adults.

A review of the English-language literature from 1970 to the present.

Ventilation tubes have been the standard treatment for otitis media with effusion in adults, but examination of the results of published studies shows that they are associated with disappointing outcomes and significant complications, notably intermittent or chronic discharge, particularly in cases associated with nasopharyngeal carcinoma. Balloon dilatation of the Eustachian tube, intratympanic steroid therapy and cortical mastoidectomy appear to be possible alternatives.

A rethink of the management of otitis media with effusion in adults is needed, together with further research. For cases not associated with nasopharyngeal carcinoma, intratympanic steroid therapy appears to be a promising option.

Sarcomas occurring during pregnancy are rare and they present significant challenges in clinical management, to optimise, investigations and treatment choices to ensure both maternal and foetal well-being.

A 32-year-old G1P0 female presented with a rapidly growing swelling in her right axilla. Ultrasound-guided core needle biopsy revealed a high-grade pleomorphic malignant tumour. The dilemmas and choices weighing the risks of staging studies, risks of contrast-enhanced scans, surgery during pregnancy and pre- and post-operative radiotherapy to both the mother and foetus are discussed in this case report

Decision of unenhanced whole-body MRI was chosen for staging studies to mitigate radiation and contrast risks to the foetus and mother. Imaging studies revealed a 10 cm tumour in the right axilla, displacing the subclavian neurovascular structures but without evidence of metastatic disease. Concerns about pre-operative radiotherapy including proton beam radiotherapy, given risk of tumour progression and surgical challenges post-radiation therapy, a consensus decision was reached to proceed with surgical resection followed by delivery of the baby and post-operative radiotherapy. Successful limb-preserving sarcoma surgery was performed at 26 weeks of gestation. She gave birth to a healthy female child at 38 weeks of gestation, and she is receiving post-operative radiotherapy.

Sarcomas diagnosed during pregnancy are rare and delicate balance is required for optimising oncologic outcomes and minimising risks to the mother and the foetus. Decision-making involving multiple specialties and multidisciplinary teams, a treatment plan was formulated that prioritised the safety of the patient and her baby.

Radiotherapy with androgen deprivation therapy (ADT) is the standard of care for locally advanced prostate cancer but causes erectile dysfunction (ED). Vacuum erectile devices (VED)s are a first-line treatment for ED along with phosphodiesterase-5 inhibitors (PDE5-Is), yet all evidence supporting their use arises from post-surgical ED. This study aimed to assess effectiveness of VEDs for patients with ED resulting from radiotherapy and ADT.

This service evaluation utilised a longitudinal survey method to gather ED scores at baseline, after commencing ADT and after receiving a VED. Patients who were undergoing ADT for prostate cancer either before or alongside radical radiotherapy and who had been referred to receive a VED were invited to participate. Data including how patients used the VED, psychosexual counselling and PDE5-Is were also collected. Thematic analysis was used to identify men’s perceptions of the VEDs.

Data from the 15 participants demonstrated statistically significant treatment-related ED but failed to determine impact of VED on this. Qualitative data identified that participants found the VEDs to be unhelpful, too clinical, unappealing, emasculating and frustrating to use. Limited data suggested that VEDs are more effective at treating ED when used in combination with PDE5-Is.

Patients in this small sample generally reported dissatisfaction with VED usage. Limited engagement with the study frustrated attempts to draw conclusions regarding the effectiveness of VEDs for radiotherapy patients suffering from ED during ADT and a larger national study should be conducted to establish this. Improvements to the care pathway and access to psychosexual counselling are recommended.

Dental management is critical prior to radiotherapy (RT) for head and neck cancer (HNC) but cumbersome and time intensive. This qualitative study investigates dentists’ evaluative processes to identify areas for improvement.

Semi-structured interviews were conducted with dentists involved in the care of HNC patients. The interviews were guided by the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to identify factors influencing pre-RT dental management.

Five dentists were participated in the interviews. Key themes were identified through qualitative and quantitative evaluation and are as follows: Coordination among care providers, knowledge of the RT plan, visual depictions of dose distribution and understanding of the patient’s dental history.

This study demonstrates the complexity of pre-RT management and identifies key elements. Knowledge of the RT plan and improved interdisciplinary coordination represents opportunities for improvement. Visual dose prediction methods may expedite and improve pre-RT management.

Oral mucositis (OM) emerged in the late 1980s to describe the adverse effects of radiation therapy (RT) on the oral mucosa. OM is the most common and clinically significant acute adverse effect of radiotherapy for head and neck cancer. Symptoms of OM vary from pain and discomfort to an inability to tolerate food or fluids, and it may affect the quality of life, breaks in treatment, hospitalisation, and therefore cancer treatment and outcome. This study aimed to evaluate the pomegranate flower’s efficacy in preventing and treating radiation-induced mucositis due to antioxidant, anti-inflammatory and anti-cancer effects.

This phase II clinical trial was conducted on 50 patients (case and control) with head and neck malignancy. Patients in the case groups were instructed to rinse their mouths with 5 mg Pomegranate powder with 15 cc of sterile water three times a day. The patients in the control group rinsed their mouths with normal saline mouthwash, which is the most relatively accepted preventive and supportive care in this setting. The onset and degree of radiation-induced mucositis were graded during treatment, with ‘WHO mucositis grading’ and the ‘quality of life questionnaire’ (QLQ-OES18).

Forty-eight patients were analysed. There was a significant difference between the two groups on onset and severity of mucositis in the two groups. There were longer intervals for the incidence of different grades of mucositis in the case group, in comparison with the control groups (P value < 0·05). Also, Complaints of dysphagia in the case groups were lower than in the control.

Pomegranate flower seems to be effective at the time of onset, and the severity of oral mucositis during head and neck radiation. It could be a simple, potent, and inexpensive agent, which is easily available.

Valid and informed consent in healthcare is an ethical and legal requirement. This evaluation reports the practices within UK radiotherapy departments surrounding consent processes and therapeutic radiographer (TR) education. This article focuses on those patients who are considered to lack the capacity to consent.

This service evaluation adopted a qualitative research design. Seventy-six radiotherapy department managers were sent the online survey: containing a combination of open, closed and free text questions relating to consent practices. Descriptive analysis using Microsoft Excel was performed; additional correlation analysis was attempted with Fisher’s exact test using Statistical Package for the Social Sciences.

TRs from 39 radiotherapy departments (51%) completed the survey. Analysis of results demonstrated obtaining written consent before radiotherapy treatment was completed in all departments. Assessment methods used to determine capacity to consent varied across the departments. Responses identified 37 departments employ a different consent form for those considered to lack capacity. Thirty-eight departments have a policy surrounding consent; 16 departments reported no formal TR education in consent. Of the remaining 22 departments, 13 departments included lack of capacity within their education package.

To ensure best practice throughout the UK, is it recommended that radiotherapy departments review their consent processes to ensure they are in the best interests of the patient. It is recommended that TRs are familiar with their regulatory body standards and the ethical and legal issues surrounding consent; all departments should consider capacity and those considered to lack capacity within their education and training framework.

Second primary breast cancers are among the most common risks to female patients who have received radiotherapy for mediastinal lymphoma.

This study aims to audit breast dose in women who received mediastinal radiotherapy for lymphoma and compare the combined dose parameter values measured to those in the literature.

Twenty-three patient datasets from 2017 to 2021 were obtained. Inclusion criteria, such as female gender and 30Gy prescription dose, were applied. Target volumes were delineated using involved site radiotherapy and planned on Eclipse (Varian, Palo Alto, CA) using either fixed field or VMAT. Breast contours were retrospectively outlined according to RTOG/EORTC guidance and descriptive statistics were used to compare findings to those from the literature.

Differences were found in V4gy, V5Gy and mean dose compared to the literature with mean dose being 2Gy in the literature and 4Gy in this audit.

Breast dose parameter values between patients in this study vary due to multiple factors. These include the treatment delivery method used and the position of the treatment field in relation to the location of breast tissue. Mean dose and V4% and V5% to breast tissue found in this study differ from that found in the literature. This study highlights the importance of accurate contouring and optimising breast tissue when possible.

This project developed and validated an automated pipeline for prostate treatments to accurately determine which patients could benefit from adaptive radiotherapy (ART) using synthetic CTs (sCTs) generated from on-treatment cone-beam CT (CBCT) images.

The automated pipeline converted CBCTs to sCTs utilising deep-learning, for accurate dose recalculation. Deformable image registration mapped contours from the planning CT to the sCT, with the treatment plan recalculated. A pass/fail assessment used relevant clinical goals. A fail threshold indicated ART was required. All acquired CBCTs (230 sCTs) for 31 patients (6 who had ART) were assessed for pipeline accuracy and clinical viability, comparing clinical outcomes to pipeline outcomes.

The pipeline distinguished patients requiring ART; 74·4% of sCTs for ART patients were red (failure) results, compared to 6·4% of non-ART sCTs. The receiver operator characteristic area under curve was 0·98, demonstrating high performance. The automated pipeline was statistically significantly (p < 0·05) quicker than the current clinical assessment methods (182·5s and 556·4s, respectively), and deformed contour accuracy was acceptable, with 96·6% of deformed clinical target volumes (CTVs) clinically acceptable.

The automated pipeline identified patients who required ART with high accuracy while reducing time and resource requirements. This could reduce departmental workload and increase efficiency and personalisation of patient treatments. Further work aims to apply the pipeline to other treatment sites and investigate its potential for taking into account dose accumulation.

The posterior pharyngeal wall is an anatomical subsite of both the oropharynx and hypopharynx. The treatment outcomes of squamous cell carcinoma (SCC) of these sites are generally published together, which makes the interpretation of data challenging. The aim of this analysis was to determine if there is any difference in the treatment outcomes of these two rare disease entities.

Retrospetive analysis showed that the posterior pharyngeal wall was the primary subsite in 17 patients (1.65 per cent) out of 1031 patients with oropharyngeal SCC, and in 23 patients (11.73 per cent) out of 196 patients with hypopharyngeal SCC.

The five-year overall survival was 45 per cent for oropharyngeal origin and 53 per cent for hypopharyngeal origin patients. There was no significant difference in survival and locoregional control between these two groups of patients.

Squamous cell carcinoma of the posterior pharyngeal wall is a rare entity, which in our series represents 1.65 per cent of oropharyngeal cases and 11.73 per cent of hypopharyngeal tumours. There was no difference in treatment outcomes between the two groups.