NEWSLETTER MAY - JUNE
ESTRO | EUROPEAN SOCIETY FOR RADIOTHERAPY & ONCOLOGY
SOCIETY LIFE
ESTRO and Elsevier announce
three new open access journals
BRACHYTHERAPY
Meet the new editor
RADIOBIOLOGY
Radiobiology committee:
changing the chair
N° 106 | BIMONTHLY | MAY - JUNE 2016
CONTENTS
NEWSLETTER N° 106
MAY - JUNE 2016
Editorial4
7
Society Life
Read it before your patients 16
Clinical46
Brachytherapy52
Physics61
RTT75
Radiobiology84
ESTRO School
91
Young ESTRO
109
Health Economics
123
European projects
128
Institutional Membership 133
ESTRO Conferences
139
Calendar of events
150
View of Barcelona - Spain, where the 6th ICHNO will take place, 18 - 19 March 2017.
ESTRO | EUROPEAN SOCIETY FOR RADIOTHERAPY & ONCOLOGY
5 - 9 May 2017
Vienna, Austria
#ESTRO36
WWW.ESTRO.ORG
EDITORIAL
Dear ESTRO colleagues,
In my inaugural newsletter editorial as ESTRO
President, my first words go to our outgoing
President, Philip Poortmans, who gave his heart
and soul, and much of his time, to ESTRO and
our mission over the past two years. I am sure
that you all share in my deep gratitude to Philip
for his accomplishments in carrying out ESTRO’s
vision and strengthening our role in cancer
care. Thank you Philip, and we count on your
continuing support as Past-President for the next
two years!
At the end of April, over 3,000 people came
to Turin for ESTRO 35, in another highly
successful annual meeting. This year, we
had a record-breaking number of submitted
abstracts, and many high-quality papers were
presented. On the clinical track, we were lucky
to have an interesting mix of sessions on the
typical tumour types (breast, head and neck,
upper and lower gastrointestinal, lung and
prostate), with less typical tumour types such
as gynaecology, haematology, central nervous
system and paediatrics. Many abstracts showed
a lot of strong data related to long-term followup, toxicity evaluation in cancer survivors, and
adverse effects after radiotherapy. I was also
pleased to see a growing interest in the sessions
on health economics, which covered topics on
health services research investigating access to
radiotherapy and its cost-effectiveness, but also
the introduction of technological innovations
into clinical practice. Meeting such an active
scientific community in my first days as President
gives me great expectations for the future.
Following up on the success of the charitable
run launched in Barcelona at the 3rd ESTRO
Forum last year, the second Super Run was a real
highlight of ESTRO 35. This year the run took a
different format as a team relay, with teams from
all over the world working really hard, not only at
running, but also at coming up with innovative
team names; just to name a few, we had “The
glamorous grannies”, the “Sweaty Cyclotrons”,
the “Breathing Phantoms” and “Usain Cobolt”!
Who says scientists can’t be funny?
The Super Run was again organised in support
of the ESTRO Cancer Foundation (ECF). The
ECF has started several initiatives together
with relevant stakeholders and industry
partners. The aim of the ECF is to bring cancer
treatment information to patients and their
families, placing the patient at the centre by
providing the fundamentals to enable them to
make the most informed decisions about their
treatment. Ultimately, the ECF’s objective is
for all cancer patients to have access to and
receive individualised, state-of-the-art radiation
oncology treatment in a multi-disciplinary
setting. Thank you to you all for showing your
support for the ECF by participating in the
Super Run.
Focusing on providing access to state-of-theart radiotherapy, ESTRO experts have been
contributing to the Global Task Force on
Radiotherapy for Cancer Control (GTFRCC).
The GTFRCC has raised awareness of the global
inequity in access to radiotherapy and the need
for boosting investment in equipment as well as
human resources. In addition, it demonstrated
that a judicious investment in radiotherapy
could provide a positive return on investment.
In this context, and in line with the ESTRO
Vision, ESTRO and the GTFRCC met in Turin
to showcase side by side the Health Economics
in Radiation Oncology (HERO) and GTFRCC
data. In a special session, the current state of
knowledge was highlighted and possibilities for
future analysis and collaboration were presented,
with a view to tackling the common goal of
closing the gap in radiotherapy provision and
utilisation worldwide. This special session was the
first step in setting up a global partnership, where
radiation oncology stakeholders will get together
with the aim of providing effective and efficient
radiotherapy in the context of multidisciplinary
cancer care. After Turin, we are now looking into
the barriers to state-of-the art radiotherapy, and
defining the strategic actions to overcome them.
At our annual meeting, we also welcomed some
new members to ESTRO’s governance structure:
first terms started for new education council
director Jesper Eriksen, new Board members
Matthias Guckenberger, Marianne Nordsmark
and Claudio Fiorino, and a second term for
Board member Conchita Vens. We welcome them
all warmly to their new roles, and are sure they
will be very helpful in further developing and
improving our Society.
I am also very happy to share with you the
news about our new ESTRO journals, which are
now up and running with open online access.
Over recent years Radiotherapy & Oncology
(the Green Journal) has noticed a big increase
in submissions, which suggested a demand for
additional publications. In line with ESTRO’s role
of science dissemination, we are now able to offer
three new open access platforms, mirroring the
professional communities in our Society: Physics
and Imaging for Radiation Oncology – piRO
(www.phiro.science), Clinical and Translational
Radiation Oncology – ctRO (www.ctro.science),
and Technical Innovations and Patient Support
in Radiation Oncology – tipsRO (www.tipsro.
science).
In June, although we will no doubt be thinking
ahead to our summer holidays, we will still be
busy with our work preparing for the second
Agora meeting which takes place that month, and
we will keep you informed about its conclusions
in future newsletters. The Agora meeting will
bring together young and talented radiation
oncology professionals with some of ESTRO’s
more senior governance volunteers, to discuss the
current key challenges in our discipline and to
define strategies to strengthen the role of ESTRO
in the future of multidisciplinary cancer care.
I hope you enjoy reading this newsletter, and I
look forward to meeting you again in the next
editorial.
Professor Yolande Lievens
President of ESTRO
SOCIETY LIFE
INTRODUCTION
PUBLICATIONS
ESTRO AND JASTRO
ECCO’S ONCOPOLICY COMMITTEE
REMEMBERING LEA MINNEN
SOCIETY LIFE
“Our annual
conference in Turin,
I’m sure you will agree,
was an exciting and
enjoyable meeting”
Welcome to the first newsletter after our annual conference in Turin,
which, I’m sure you will agree, was an exciting and enjoyable meeting.
It was a privilege to meet and network with many of you.
In this issue, we get a chance to catch up with some news concerning our
friends at the European CanCer Organisation (ECCO) as well as the
Japanese Society for Radiation Oncology (JASTRO).
YOLANDE LIEVENS
On a sad note, I regret to inform our members that Lea Minnen, a longtime member of ESTRO staff who worked here from our earliest days with
Emmanuel van der Schueren, died on 13 March after a brave battle against
cancer. We extend our heartfelt condolences to her family and friends.
At the end of this Corner you can read how Lea is remembered, missed
and celebrated by her colleagues.
Yolande Lievens
ESTRO President
INTRODUCTION
PUBLICATIONS
ESTRO AND JASTRO
ECCO’S ONCOPOLICY COMMITTEE
REMEMBERING LEA MINNEN
SOCIETY LIFE
ESTRO will launch three new journals that will cover:
ESTRO
PUBLICATIONS
• Radiobiology, epidemiology, oncopolicy, information sciences:
“Clinical and Translational Radiation Oncology - ctRO”
Editors in Chief:
Pierre Blanchard, Houston, USA
Daniel Zips, Tübingen, Germany
Three new ESTRO
journals coming soon
www.ctro.science | ctro@elsevier.com
• Medical physics in radiation oncology and imaging:
“Physics and Imaging in Radiation Oncology - phiRO”
Editors in Chief:
Lorenzo Bonomo, Rome, Italy
Ludvig Muren, Aarhus, Denmark
www.phiro.science | phiro@elsevier.com
• Technical and nursing aspects: “Technical Innovations and Patient
Support in Radiation Oncology - tipsRO”
Editors in Chief:
Sara Faithfull, Guildford, UK
Michelle Leech, Dublin, Ireland
tipsro@elsevier.com
INTRODUCTION
PUBLICATIONS
ESTRO AND JASTRO
ECCO’S ONCOPOLICY COMMITTEE
REMEMBERING LEA MINNEN
SOCIETY LIFE
ESTRO recognises
Professor Masahiro Hiraoka
for his instrumental
contribution in bringing
together JASTRO with our
own Society
INTRODUCTION
PUBLICATIONS
ESTRO and JASTRO
Former ESTRO President Professor Philip
Poortmans, attended the 8th Asian Oncology
Summit, Organisation for Oncology and
Translational Research 12th Annual Conference,
Kyoto Breast Cancer Consensus Conference, in
Kyoto, Japan, on 3 March. At this occasion he
also had the honour and pleasure to hand over
an appreciation tablet as a token of recognition
to Professor Masahiro Hiraoka, from Kyoto
University Hospital, for his instrumental
contribution in bringing together the Japanese
Society for Radiation Oncology (JASTRO) with
our own Society, which has led to a number
of joint activities in the field of scientific
dissemination, education and membership.
ESTRO AND JASTRO
Prof Masahiro Hiraoka (left) and Prof Philip Poortmans
(right)
ECCO’S ONCOPOLICY COMMITTEE
REMEMBERING LEA MINNEN
SOCIETY LIFE
Philip Poortmans is the new
chair of ECCO’s oncopolicy
committee
The European CanCer Organisation (ECCO)
is pleased to announce that the new chair of
its oncopolicy committee is Professor Philip
Poortmans.
Throughout his distinguished career, Philip
has had a strong focus on promoting multidisciplinarity in cancer treatment. He works
closely with ECCO’s diverse member societies to
foster a genuine multidisciplinary team spirit for
better outcomes and quality of life for patients.
With an impressive multidisciplinary track
record behind him, Philip steps into this new role
ready to lead the ECCO oncopolicy committee
in new initiatives addressing the key priorities in
European oncology today.
Prof Philip Poortmans
Philip is a member of the ECCO Board and the
past President of ESTRO.
For more information on ECCO oncopolicy visit
www.ecco-org.eu/Public-affairs/ECCOs-PolicyCommittee
INTRODUCTION
PUBLICATIONS
ESTRO AND JASTRO
ECCO’S ONCOPOLICY COMMITTEE
REMEMBERING LEA MINNEN
SOCIETY LIFE
Early in her career, Lea worked as the assistant to
Professor Emmanuel van der Schueren in Leuven.
Prior to this, she had also worked with his father.
This was how she came to support Prof-essor
van der Schueren in the foundation of ESTRO
in 1980. She continued to assist with ESTRO’s
congresses and journal, was Professor van der
Schueren’s right-hand person, and was
of vital importance to the Society.
Remembering
Lea Minnen
When Professor van der Schueren died in 1998,
she started to work full time in the ESTRO office.
We could always count on her, she was at every
ESTRO meeting, and even when she retired at the
end of 2011, she chose to remain involved in the
Society, helping out with the review of the publications, supporting the scientific programme and
abstract processing, and contributing to the big
ESTRO family.
We will miss her at work, where she has been an
example for all of us at ESTRO: the sense of
belonging and devotion, the spirit of service, the
knowledge, the dedication to be there to achieve
the best for all our members and activities. She is
part of what ESTRO has been and what ESTRO is
today.
She fought cancer with strength and grace,
together with her family. We will miss her
enormously.
Christine Verfaillie
Colleague and friend
Her knowledge of ESTRO, what happened, why
and when, and of ESTRO people and radiation
oncology, in general, was outstanding. She has
been the memory of ESTRO, and has embodied
its pioneer spirit, caring and compassionate character and its achieving attitude. Now we all have
the responsibility to preserve her legacy.
INTRODUCTION
PUBLICATIONS
ESTRO AND JASTRO
ECCO’S ONCOPOLICY COMMITTEE
REMEMBERING LEA MINNEN
SOCIETY LIFE
Memories and
reflections on the life
of Lea Minnen
“I always considered Lea to be our ‘mother’ at
ESTRO, making sure everything was taken care
of, so we could do ‘our’ thing. It’s a great loss for
ESTRO.”
Dirk Verellen
ESTRO office in 2003
“This is very sad news, not only for all of us, who
knew her well, but also for the whole radiooncology community. She was obviously part of
the pioneering phase of our actions, first in
Belgium, thereafter in Europe, and we should
never forget what she has accomplished at
ABRO-BVRO and ESTRO. Her courage will
remain a great example to follow.”
Jacques Bernier
“Lea was the memory of ESTRO ...”
Jean Bourhis
Lea and her husband Hugo in Brussels 2004
“Lea was part of ESTRO history and we will all
miss her a lot.”
Eric Lartigau
“To me, she was a sort of mother figure always
taking an interest in what I was doing and helping out for the many years I have been coming to
ESTRO.”
Marcel van Herk
9th Biennial Physics meeting, Barcelona, 2007
INTRODUCTION
PUBLICATIONS
ESTRO AND JASTRO
ECCO’S ONCOPOLICY COMMITTEE
REMEMBERING LEA MINNEN
“She was an amazing woman and a big part of the
history and success of ESTRO.”
Brad Wouters
“ESTRO has lost a unique person. She was greatly
respected and will be missed by everyone who
knew her.”
Mirjam Mast
CERRO or ‘ski meeting’ in Les Menuires, 2008
“It looked like Lea would also overcome this challenging last hurdle. It was not to be. She loved
life so much! A last ‘salut’ to a long time and
brave travelling companion!”
Germaine Heeren
“The core staff at ESTRO often called Lea ‘Mum’
– and I felt she was one. I miss her!”
George Kovacs
“She really did epitomise all that ESTRO stands
for and she will be much missed.”
Fiona Stewart
Team building event of ESTRO staff in Brussels, 2011
“Rest in peace, dear Lea, we shall never forget
you, your gentle energy, total dedication to the
successful building of European radiation therapy, physics and biology community. Give our
warmest regards to Manu*. We shall miss you
both as long as we live.”
Jean-Claude Horiot
INTRODUCTION
PUBLICATIONS
“She was such a lovely lady and the heart and soul
of ESTRO.”
Conchitta Vens
“The ESTRO family will never forget Lea.”
Daniel Zips
“A page in the history of ESTRO has just been
turned with the passing away of Lea. I met her
while she was the dedicated secretary of Manu*.
It is, in part, thanks to them that we were able
ESTRO AND JASTRO
to assist with the birth of this Society and see it
evolve to what it is today. In all this, Lea always
remained modest, discreet, but ever so efficient.”
Alain Gerbaulet
“Lea was extremely available, discreet and ready
to help. With a lot of tact and gentleness, she
taught me a lot during my first encounters at
ESTRO.”
Christine Haie
“This is a very sad day for ESTRO and the radiation oncology community.”
Jesper Eriksen
“Lea was one of the first people I met in ESTRO
many years ago. Her name is, and will always be,
linked to the Society that she helped to build.”
Núria Jornet
“Lea was the active shadow of Emmanuel van der
Schueren.” Pierre Scalliet
“From the foundation of ESTRO until now, Lea
has been a constant presence and force for good
in the Society. She has quietly and efficiently
helped all of us in all the different functions of
our work with ESTRO and been an effective and
lovely colleague. We are thankful to have known
her.”
Ann Barrett
* Emmanuel van der Schueren (otherwise known as
“Manu”), the founder of ESTRO
ECCO’S ONCOPOLICY COMMITTEE
REMEMBERING LEA MINNEN
COMMUNIT
Y
BEST PRACT
ICE
NETWORK
Discover the opportunities that only the ESTRO
membership can bring to you, your career, your
practice, your profession, and ultimately, your
patients.
MULTIDISCIPLINAR
ITY
ESTRO is devoted to advancing the goals of radiation oncology. This includes
providing its members with outstanding science and education in order to
support them in their career advancement.
COMMITME
N
T
PROFESSION
AL
DEVELOPME
NT
2016 ESTRO MEMBERSHIP
Join ESTRO and gain access to exclusive member benefits such as:
• Online subscription to Radiotherapy and Oncology
• Reduced fees for attending ESTRO courses, conferences and joint events
• Online access to scientific material (events webcasts, delineation cases, etc.)
through the e-library (DOVE)
• Eligibility for grants, awards, faculties and governance positions.
INTERDISCIPLINAR
ITY
SCIENCE
EDUCATION
AND TRAININ
G
INSPIRATIO
N
INTERNATIO
NAL
ENVIRONME
NT
ESTRO offers several categories of membership to fit your
professional needs.
Check them online on www.estro.org/members
READ IT BEFORE
YOUR PATIENTS
INTRODUCTION
BREAST
PROSTATE
HEAD &
NECK
CNS
PAEDIATRIC
BLOOD
ALZHEIMER’S
COLORECTAL
SQUAMOUS
HODGKIN’S
PALLIATION
LIVER
DECISION SUPPORT
SYSTEMS
LATE SIDE
EFFECTS
READ IT BEFORE
YOUR PATIENTS
Too important to miss...
A digest of essential
reading for all radiation
oncologists
PHILIPPE LAMBIN
BY PHILIPPE LAMBIN, DIRK DE RUYSSCHER AND HANS KAANDERS
DIRK DE RUYSSCHER
HANS KAANDERS
INTRODUCTION
BREAST
PROSTATE
HEAD &
NECK
CNS
PAEDIATRIC
BLOOD
ALZHEIMER’S
COLORECTAL
SQUAMOUS
HODGKIN’S
PALLIATION
LIVER
DECISION SUPPORT
SYSTEMS
LATE SIDE
EFFECTS
AIM
READ IT BEFORE
YOUR PATIENTS
Radiotherapy (RT) after breast-conserving
surgery (BCS) is a standard treatment option
for the management of ductal carcinoma in situ
(DCIS). We sought to determine the survival
benefit of RT after BCS on the basis of risk factors
for local recurrence.
BREAST
Patient prognostic score and
associations with survival
improvement offered by
radiotherapy after breastconserving surgery for ductal
carcinoma in situ: a populationbased longitudinal cohort study
Sagara Y, Freedman R.A, Vaz-Luis I, Mallory M.A, Wong S.M,
Aydogan F, DeSantis S, Barry W.T, Golshan M.
J Clin Oncol. 2016 Feb 1. Epub ahead of print
METHODS
A retrospective longitudinal cohort study was
performed to identify patients with DCIS diagnosed between 1988 and 2007 and treated with
BCS by using SEER data. Patients were divided
into the following two groups: BCS+RT (RT
group) and BCS alone (non-RT group). We used a
patient prognostic scoring model to stratify patients on the basis of risk of local recurrence. We
performed a Cox proportional hazards model with
propensity score weighting to evaluate breast cancer mortality between the two groups.
grade, younger age, and larger tumour size. The
magnitude of the survival difference with RT was
significantly correlated with prognostic score
(P < .001).
CONCLUSION
In this population-based study, the patient prognostic score for DCIS is associated with the
magnitude of improvement in survival offered
by RT after BCS, suggesting that decisions for RT
could be tailored on the basis of patient factors,
tumour biology, and the prognostic score.
RESULTS
We identified 32,144 eligible patients with DCIS,
20,329 (63%) in the RT group and 11,815 (37%) in
the non-RT group. Overall, 304 breast cancer
specific deaths occurred over a median follow-up
of 96 months, with a cumulative incidence of
breast cancer mortality at 10 years in the weighted
cohorts of 1.8% (RT group) and 2.1% (non-RT
group; hazard ratio, 0.73; 95% CI, 0.62 to 0.88).
Significant improvements in survival in the RT
group compared with the non-RT group were
only observed in patients with higher nuclear
INTRODUCTION
BREAST
PROSTATE
HEAD &
NECK
CNS
PAEDIATRIC
BLOOD
ALZHEIMER’S
COLORECTAL
SQUAMOUS
HODGKIN’S
PALLIATION
LIVER
DECISION SUPPORT
SYSTEMS
LATE SIDE
EFFECTS
READ IT BEFORE
YOUR PATIENTS
PROSTATE
Radiation therapy versus
prostatectomy for localised
prostate cancer: a (still) unsolved
dilemma. A critical reading of
the meta-analysis by Wallis et
al. ‘Surgery versus radiotherapy
for clinically localised prostate
cancer: a systematic review and
meta-analysis’
De Bari B, Bossi A, Zietman A, Poortmans P
European Urology, 15 December 2015.
Recently, Wallis et al. published a meta-analysis
suggesting the superiority of radical prosta
tectomy (RP) over radiation therapy (RT) in
the treatment of clinically localised prostate
cancer (PC) [1]. Up to now, no randomised
trials have been published directly comparing
RP and RT in this clinical setting, with or
without hormonal therapy (HT), despite the
fact that these approaches continue to represent
the two unique curative options for clinically
localised PC [2,3]. The topic of meta-analysis
has been of real interest in uro-oncology for
some time. Generally, authors have focused their
analysis on the effect on survival rates of each
of the treatment approaches, rather than on
biochemical failure, which cannot be considered
a surrogate for overall and prostate cancerspecific mortality. Despite the effort put into this
latest comprehensive review, and its attempt to
provide accurate risk estimates through the use of
multivariable adjusted hazard ratios (aHRs), this
meta-analysis shares the same methodological
limits of other meta-analyses that have examined
these issues. Moreover, there are some important
clinical biases that could also have influenced the
results of this meta-analysis.
Looking at the methodological aspects, the
authors say that they will include “studies
reporting on men of any age with non-metastatic
prostate cancer treated with any commonlyutilised form of RT including conformal
external beam (EBRT), intensity-modulated
(IMRT), brachytherapy, or a combination of
INTRODUCTION
BREAST
PROSTATE
HEAD &
NECK
CNS
PAEDIATRIC
BLOOD
ALZHEIMER’S
COLORECTAL
SQUAMOUS
radiotherapy modalities with curative treatment
intent”. In table 1 of the study, the authors
summarise its main characteristics. It is clear
that it is impossible to conclude anything about
the effectiveness of RT when 11 of 19 studies
included give no information about the total
delivered dose, a factor which is known to
influence the outcome [4]. In addition, mixing
studies of patients treated with brachytherapy
with patients treated with EBRT is questionable.
The authors adapted the Newcastle-Ottawa Scale
(NOS) [5] to perform a preliminary evaluation
of the biases in the studies and to select those
suitable for inclusion in their analysis. However,
there is a problem with this selection method as
a threshold score distinguishing between ‘good’
and ‘poor’ quality studies is still lacking in the
NOS, as is stated on the NOS website [5]. Thus,
the initial criteria, even if reasonable, introduce a
systematic bias in the preliminary selection of the
studies.
More than 80% of the data are taken from registries. Their importance in driving the therapeutic
choices of physicians is well known, as are the
potential major limits of the data quality within
them, a factor that strongly influences the final
quality of the interpretation of the results [6].
From a clinical point of view, some other limitations should be underlined. The analysis does
not take into account the dose and duration
of RT, and this is clearly a limitation in the
evaluation of the outcomes of patients treated
HODGKIN’S
PALLIATION
LIVER
DECISION SUPPORT
SYSTEMS
LATE SIDE
EFFECTS
with RT. Nevertheless, looking at the enrolment
periods, it is very likely that the total delivered
doses would now be considered insufficient.
The authors probably tried to overcome this
limitation by analysing the outcomes of patients
treated before 2005 against those treated after.
This criterion cannot be a surrogate of the dose
levels, as we only recently acquired the strong
evidence of the impact of dose escalation on
treatment outcomes, based on randomised trials.
Looking at the Forrest plot (Fig. 2a and b in the
article), RT patients experienced an increased
risk of overall mortality compared with RP. It
is worth noting that a selection bias affects the
results: patients presenting higher comorbidity
scores, strongly influencing the mortality risk,
were more frequently excluded from surgery and
treated with RT (as shown in table 2). It must also
be kept in mind that it has already been shown
that candidates for RP have a substantially lower
risk of all-cause mortality than expected [7], and
that the use of the Charlson comorbidity score
often fails to adjust for residual confounding
factors, as the authors themselves acknowledge.
Randomised and retrospective studies have
already shown the impact of adjuvant and/or
salvage RT in improving disease-free survival
and overall survival [8,9]. The information on the
proportion of patients having received RT after
prostatectomy is lacking in this meta-analysis:
this is another important limitation of the studied
INTRODUCTION
BREAST
PROSTATE
HEAD &
NECK
CNS
data, and hence of the results.
The importance of the concomitant and adjuvant
HT in improving the outcomes of intermediaterisk and high-risk PC patients treated with RT,
in terms of disease control and overall survival
for patients with prostate cancer, has been
confirmed in several randomised trials [10], and
these findings have been substantiated in current
guidelines [2,3]. In this review most of the studies
did not actually compare RP with treatment
that was consistent with standard of care,
thereby ignoring level one evidence on the use
of androgen deprivation therapy (ADT) and RT.
Last but not least, in a decision-making process,
a potential excess of mortality associated with
RT should be balanced against the higher rate of
urinary incontinence, erectile dysfunction, and
the higher 30-day, 60-day, and 90-day mortality
rate associated with RP [11].
Clearly, this meta-analysis presents a
confounding by severity bias: most likely, in the
considered patients, the severity of the disease
as a confounding factor, as prostatectomy will
likely be proposed earlier to patients with a good
performance status and/or earlier-stage disease
[12].
In conclusion, any analysis aiming to obtain
results based on weak data will be affected by
major methodological biases, leading to weak
conclusions. Only the on-going prospective
randomised trials will answer the yet unsolved
question addressed by Wallis et al. In just a few
PAEDIATRIC
BLOOD
ALZHEIMER’S
COLORECTAL
SQUAMOUS
months, the British ProtecT randomised trial
(NCT02044172) will report on large numbers
of men managed by high-quality surgery or
radiation therapy or by active surveillance, with
a median follow-up of over ten years. Whatever
the results of that trial, it will have far greater
meaning and influence, leaving this meta-analysis
redundant. Until that point in time, RT +/hormonal therapy should be considered a valid
first-choice curative option in the therapeutic
approach to prostate cancer.
REFERENCES
[1] Wallis CJD, et al. ‘Surgery versus radiotherapy for
clinically localised prostate cancer: a systematic review
and meta-analysis’. Eur Urol (2015), http://dx.doi.
org/10.1016/j.eururo.2015.11.010.
[2] National Comprehensive Cancer Network Guidelines
for Prostate Cancer. Available at www.nccn.org/patients/
guidelines/prostate/files/assets/common/downloads/
files/prostate.pdf Accessed online on 08/03/2016.
[3] European Association of Urology Guidelines for
Prostate Cancer (2015). Available at http://uroweb.
org/wp-content/uploads/09-Prostate-Cancer_LR.pdf.
Accessed online on 08/03/2016.
[4] Zaorsky NG, Palmer JD, Hurwitz MD,
Keith SW, Dicker AP, Den RB. ‘What is the
ideal radiotherapy dose to treat prostate cancer? A
meta-analysis of biologically equivalent dose escalation’.
Radiother Oncol. 2015 Jun; 115(3):295-300.
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[5] Wells GA, Shea B, O’Connell D, et al. ‘The NewcastleOttawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses, 2011’. Available at
www.ohri.ca/programs/clinical_epidemiology/oxford.
asp. Accessed online on 13/02/2016.
[12] Salas M, Hofman A, BHC Stricker. ‘Confounding
by indication: an example of variation in the use of
epidemiologic terminology’. Am J Epidemiol 1999;
149:981-3.
[6] Giordano SH, Kuo Y-F, Duan Z, Hortobagyi GN,
Freeman J, Goodwin JS. ‘Limits of observational data
in determining outcomes from cancer therapy’. Cancer
2008; 112:2456–66.
[7] Eifler JB, Humphreys EB, Agro M, et al. ‘Causes
of death after radical prostatectomy at a large tertiary
centre’. J Urol 2012; 188:798-801.
[8] Arcangeli S, Ramella S, De Bari B, Franco P,
Alongi F, D’Angelillo RM. ‘A cast of shadow on adjuvant
radiotherapy for prostate cancer: A critical review based
on a methodological perspective’. Crit Rev Oncol
Hematol. 2016 Jan; 97:322-7.
[9] Freedland SJ, Rumble RB, Finelli A, Chen RC,
Slovin S, Stein MN, Mendelson DS, Wackett C, Sandler
HM; American Society of Clinical Oncology. ‘Adjuvant
and salvage radiotherapy after prostatectomy: American
Society of Clinical Oncology clinical practice guideline
endorsement’. J Clin Oncol. 2014 Dec; 1;32(34):3892-8.
[10] D’Angelillo RM, Franco P, De Bari B, Fiorentino
A, Arcangeli S, Alongi F. ‘Combination of
androgen deprivation therapy and radiotherapy for
localised prostate cancer in the contemporary era’. Crit
Rev Oncol Hematol. 2015 Feb; 93(2):136-48.
[11] Hansen J, Gandaglia G, Bianchi M, et al. ‘Reassessment of 30-, 60- and 90-day mortality rates in nonmetastatic prostate cancer patients treated either with
radical prostatectomy or radiation therapy’. Can Urol
Assoc J 2014; 8:E75-E80.
INTRODUCTION
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HEAD &
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CNS
PAEDIATRIC
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ALZHEIMER’S
COLORECTAL
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PALLIATION
LIVER
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PURPOSE
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A validated tumor control
probability model based
on a meta-analysis of low,
intermediate, and high-risk
prostate cancer patients treated
by photon, proton, or carbon-ion
radiotherapy
Seán Walsh, Erik Roelofs, Peter Kuess, Philippe Lambin,
Bleddyn Jones, Dietmar Georg and Frank Verhaegen
Med Phys. 2016 Feb;43(2):734. doi: 10.1118/1.4939260.
A fully heterogeneous population averaged
mechanistic tumour control probability (TCP)
model is appropriate for the analysis of external
beam radiotherapy (EBRT). This has been accomplished for EBRT photontreatment of intermediate-risk prostate cancer. Extending the TCP
model for low and high-risk patients would be
beneficial in terms of overall decision making.
Furthermore, different radiation treatment
modalities such as protons and carbon-ions are
becoming increasingly available. Consequently,
there is a need for a complete TCP model.
METHODS
A TCP model was fitted and validated to a
primary endpoint of 5-year biological no evidence of disease clinical outcome data obtained from a review of the literature for low,
intermediate, and high-risk prostate cancer
patients (5,218 patients fitted, 1088 patients
validated), treated by photons, protons, or
carbon-ions. The review followed the preferred
reporting item for systematic reviews and metaanalyses statement. Treatment regimens include
standard fractionation and hypofractionation
treatments. Residual analysis and goodness of fit
statistics were applied.
of 0.77 and a weighted root mean squared error
(wRMSE) of 1.2%, to the fitted clinical outcome
data. Validation of the model utilising three independent datasets obtained from the literature
resulted in an adjusted-weighted-R2 value of
0.78 and a wRMSE of less than 1.8%, to the
validation clinical outcome data. The weighted
mean absolute residual across the entire dataset is
found to be 5.4%.
CONCLUSIONS
This TCP model fitted and validated to clinical
outcome data, appears to be an appropriate
model for the inclusion of all clinical prostate
cancer risk categories, and allows evaluation of
current EBRT modalities with regard to tumour
control prediction.
RESULTS
The TCP model achieves a good level of fit
overall, linear regression results in a p-value of
<0.000 01 with an adjusted-weighted-R2 value
INTRODUCTION
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PAEDIATRIC
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SQUAMOUS
HODGKIN’S
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AIM
Over the past decade, intensity-modulated
radiation therapy (IMRT) has replaced conventional radiation techniques in the management
of head and neck cancers (HNCs). We conducted
this population-based study to evaluate the influence of radiation oncologist experience on
outcomes in patients with HNC treated with
IMRT compared with patients with HNC treated
with conventional radiation therapy.
HEAD & NECK
Importance of radiation
oncologist experience among
patients with head-and-neck
cancer treated with intensitymodulated radiation therapy
METHODS
We identified radiation providers from Medicare
claims of 6,212 Medicare beneficiaries with HNC
treated between 2000 and 2009. We analysed the
impact of provider volume on all-cause mortality,
HNC mortality, and toxicity end points after
treatment with either conventional radiation
therapy or IMRT. All analyses were performed
by using either multivariable Cox proportional
hazards or Fine-Gray regression models controlling for potential confounding variables.
Boero IJ, Paravati AJ, Xu B, Cohen EE, Mell LK, Le QT,
Murphy JD.
J Clin Oncol. 2016 Jan 4. Epub ahead of print
per year (hazard ratio [HR], 0.79; 95% CI, 0.67
to 0.94). Patients treated with IMRT by highervolume providers had decreased HNC-specific
mortality (subdistribution HR, 0.68; 95% CI,
0.50 to 0.91) and decreased risk of aspiration
pneumonia (subdistribution HR, 0.72; 95% CI,
0.52 to 0.99).
CONCLUSION
Patients receiving IMRT for HNC had improved
outcomes when treated by higher-volume
providers. These findings will better inform
patients and providers when making decisions
about treatment, and emphasize the critical
importance of high-quality radiation therapy for
optimal treatment of HNC.
RESULTS
Among patients treated with conventional
radiation, we found no significant relationship
between provider volume and patient survival or
any toxicity end point. Among patients receiving
IMRT, those treated by higher-volume radiation
oncologists had improved survival compared
with those treated by low-volume providers. The
risk of all-cause mortality decreased by 21% for
every additional five patients treated per provider
INTRODUCTION
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CNS
PAEDIATRIC
BLOOD
ALZHEIMER’S
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SQUAMOUS
HODGKIN’S
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LIVER
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AIM
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We conducted a retrospective evaluation of the
IMCL-9815 study to examine the association of
human papillomavirus (HPV) and p16 protein
expression status with outcomes in patients
with oropharyngeal carcinoma (OPC) receiving
radiotherapy (RT) plus cetuximab or RT alone.
HEAD & NECK
Association of human
papillomavirus and p16 status
with outcomes in the IMCL9815 phase III registration trial
for patients with locoregionally
advanced oropharyngeal
squamous cell carcinoma of
the head and neck treated with
radiotherapy with or without
cetuximab
Rosenthal DI, Harari PM, Giralt J, Bell D, Raben D, Liu J,
Schulten J, Ang KK, Bonner JA.
J Clin Oncol. 2015 Dec 28. Epub ahead of print
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METHODS
patients with p16-positive/HPV-positive OPC
(n = 49) and those with p16-positive/HPVnegative OPC (n = 14) were compared.
CONCLUSION
p16 status was strongly prognostic for patients
with OPC. The data suggest that the addition of
cetuximab to RT improved clinical outcomes
regardless of p16 or HPV status versus RT alone.
In the IMCL-9815 study, patients were randomly
allocated to receive RT plus weekly cetuximab or
RT alone. A subpopulation of patients with p16evaluable OPC was retrospectively evaluated on
the basis of locoregional control (LRC), overall
survival (OS), and progression-free survival
(PFS). Evaluable samples from patients with p16positive OPC were also tested for HPV DNA.
RESULTS
Tumour p16 status was evaluable in 182 patients
with OPC enrolled in the IMCL-9815 study; 41%
were p16 positive. When treated with RT alone
or RT plus cetuximab, p16-positive patients had
a longer OS than p16-negative patients (hazard
ratio, 0.40; 95% CI, 0.21 to 0.74 and hazard ratio,
0.16; 95% CI, 0.07 to 0.36, respectively). The addition of cetuximab to RT increased LRC, OS,
and PFS in both patients with p16-positive OPC
and those with p16-negative disease. Interaction
tests for LRC, OS, and PFS did not demonstrate
any significant interaction between p16 status
and treatment effect (P = .087, .085, and .253,
respectively). Similar trends were observed when
PAEDIATRIC
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BACKGROUND
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We conducted a large international study to
estimate fractions of head and neck cancers
(HNCs) attributable to human papillomavirus
(HPV-AFs) using six HPV-related biomarkers
of viral detection, transcription, and cellular
transformation.
HEAD & NECK
METHODS
HPV involvement in head and
neck cancers: comprehensive
assessment of biomarkers in
3,680 patients.
Castellsagué X, Alemany L, Quer M, Halec G, Quirós B,
Tous S, Clavero O, Alòs L, Biegner T, Szafarowski T, Alejo M,
Holzinger D, Cadena E, Claros E, Hall G, Laco J, Poljak M,
Benevolo M, Kasamatsu E, Mehanna H, Ndiaye C, Guimerà
N, Lloveras B, León X, Ruiz-Cabezas JC, Alvarado-Cabrero
I, Kang CS, Oh JK, Garcia-Rojo M, Iljazovic E, Ajayi OF,
Duarte F, Nessa A, Tinoco L, Duran-Padilla MA, Pirog EC,
Viarheichyk H, Morales H, Costes V, Félix A, Germar MJ,
Mena M, Ruacan A, Jain A, Mehrotra R, Goodman MT,
Lombardi LE, Ferrera A, Malami S, Albanesi EI, Dabed P,
Molina C, López-Revilla R, Mandys V, González ME, Velasco
J, Bravo IG, Quint W, Pawlita M, Muñoz N, Sanjosé Sd, Xavier
Bosch F; ICO International HPV in Head and Neck Cancer
Study Group.
J Natl Cancer Inst. 2016 Jan 28;108(6).
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Formalin-fixed, paraffin-embedded cancer tissues
of the oral cavity (OC), pharynx, and larynx were
collected from pathology archives in 29 countries.
All samples were subject to histopathological
evaluation, DNA quality control, and HPV-DNA
detection. Samples containing HPV-DNA were
further subject to HPV E6*I mRNA detection
and to p16(INK4a), pRb, p53, and Cyclin D1
immunohistochemistry. Final estimates of HPVAFs were based on HPV-DNA, HPV E6*I mRNA,
and/or p16(INK4a) results.
Eastern Europe, and Northern Europe, and
lowest in Southern Europe. Women showed
higher HPV-AFs than men for cancers of the
oropharynx in Europe and for the larynx in
Central-South America.
CONCLUSIONS
HPV contribution to HNCs is substantial but
highly heterogeneous by cancer site, region,
and sex. This study, the largest exploring HPV
attribution in HNCs, confirms the important role
of HPVs in oropharyngeal cancer and drastically
downplays the previously reported involvement
of HPVs in the other HNCs.
RESULTS
A total of 3,680 samples yielded valid results:
1,374 pharyngeal, 1,264 OC, and 1,042 laryngeal
cancers. HPV-AF estimates based on positivity
for HPV-DNA, and for either HPV E6*I mRNA
or p16(INK4a), were 22.4%, 4.4%, and 3.5% for
cancers of the oropharynx, OC, and larynx,
respectively, and 18.5%, 3.0%, and 1.5% when
requiring simultaneous positivity for all three
markers. HPV16 was largely the most common
type. Estimates of HPV-AF in the oropharynx
were highest in South America, Central and
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AIM
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To investigate the impact of hypoxia-induced
gene expression and cancer stem cell (CSC)
marker expression on outcome of postoperative
cisplatin-based radiochemotherapy (PORT-C)
in patients with locally advanced head and neck
squamous cell carcinoma (HNSCC).
HEAD & NECK
Low CSC marker expression
and low hypoxia identify good
prognosis subgroups in HPV(-)
HNSCC after postoperative
radiochemotherapy: a multicenter
study of the DKTK-ROG
METHODS
Linge A, Lock S, Gudziol V, Nowak A, Lohaus F, von
Neubeck C, Jutz M, Abdollahi A, Debus J, Tinhofer I, Budach
V, Sak A, Stuschke M, Balermpas P, Rodel C, Avlar M, Grosu
AL, Bayer C, Belka C, Pigorsch S, Combs SE, Welz S, Zips D,
Buchholz F, Aust DE, Baretton GB, Thames H, Dubrovska A,
Alsner J, Overgaard J, Baumann M, Krause M.
Clin Cancer Res. 2016 Jan 11. Epub ahead of print
RESULTS
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Expression of the CSC markers CD44, MET
and SLC3A2, and hypoxia gene signatures
were analysed in the resected primary tumours
using RT-PCR and nanoString technology in a
multicenter retrospective cohort of 195 patients.
CD44 protein expression was further analysed in
tissue-microarrays. Primary endpoint was locoregional tumour control.
CD44: HR 3.36, p=0.054; CD44 protein n/a
because of no event in the CD44 negative group)
in the HPV16 DNA negative subgroup.
CONCLUSIONS
We have shown for the first time that high
hypoxia-induced gene expression and high CSC
marker expression levels correlate with tumour
recurrence after PORT-C in patients with
HPV16 DNA negative HNSCC. After validation
in a currently ongoing prospective trial, these
parameters may help to further stratify patients
for individualised treatment de-escalation or
intensification strategies.
Univariate analysis showed that hypoxia-induced
gene expression was significantly associated with
a high risk of loco-regional recurrence using
the 15-gene signature (p=0.010) or the 26-gene
signature (p=0.002). In multivariate analyses,
in patients with HPV16 DNA negative, but not
with HPV16 DNA positive tumours the effect of
hypoxia-induced genes on loco-regional control
was apparent (15-gene signature: HR 4.54,
p=0.006; 26-gene signature: HR 10.27, p=0.024).
Furthermore, MET, SLC3A2, CD44 and CD44
protein showed an association with loco-regional
tumour control in multivariate analyses (MET:
HR 3.71, p=0.016; SLC3A2: HR 8.54, p=0.037;
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ABSTRACT
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Development and evaluation
of an online three-level proton
vs photon decision support
prototype for head and neck
cancer – Comparison of dose,
toxicity and cost-effectiveness
To quantitatively assess the effectiveness of proton therapy for individual patients, we developed
a prototype for an online platform for proton
decision support (PRODECIS) comparing photon
and proton treatments on dose metric, toxicity
and cost-effectiveness levels. An evaluation was
performed with 23 head and neck cancer datasets.
Cheng Q, Roelofs E, Ramaekers B LT, Eekers D, van Soest J,
Lustberg T, Hendriks T, Hoebers F, van der Laan H.P,
W. Korevaar E, Dekker A, Langendijk J.A, Lambin P
Radiother Oncol. 2016 Feb 26. pii: S0167-8140(16)00031-1.
doi: 10.1016/j.radonc.2015.12.029. [Epub ahead of print]
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CNS
PAEDIATRIC
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ALZHEIMER’S
COLORECTAL
SQUAMOUS
HODGKIN’S
PALLIATION
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IMPORTANCE
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Glioblastoma is the most devastating primary
malignancy of the central nervous system in
adults. Most patients die within 1 to 2 years of
diagnosis. Tumour-treating fields (TTFields) are
a locoregionally delivered antimitotic treatment
that interferes with cell division and organelle
assembly.
CNS
Maintenance therapy with tumortreating fields plus temozolomide
vs temozolomide alone for
glioblastoma: a randomized
clinical trial
Stupp R, Taillibert S, Kanner AA, Kesari S, Steinberg DM,
Toms SA, Taylor LP, Lieberman F, Silvani A, Fink KL, Barnett
GH, Zhu JJ, Henson JW, Engelhard HH, Chen TC, Tran DD,
Sroubek J, Tran ND, Hottinger AF, Landolfi J, Desai R, Caroli
M, Kew Y, Honnorat J, Idbaih A, Kirson ED, Weinberg U, Palti
Y, Hegi ME, Ram Z.
JAMA. 2015 Dec 15;314(23):2535-43. doi: 10.1001/
jama.2015.16669.
OBJECTIVE
To evaluate the efficacy and safety of TTFields
used in combination with temozolomide
maintenance treatment after chemoradiation
therapy for patients with glioblastoma.
After completion of chemoradiotherapy,
patients with glioblastoma were randomised
(2:1) to receive maintenance treatment with
either TTFields plus temozolomide (n = 466) or
temozolomide alone (n = 229) (median time from
diagnosis to randomization, 3.8 months in both
groups). The study enrolled 695 of the planned
700 patients between July 2009 and November
2014 at 83 centers in the United States, Canada,
Europe, Israel, and South Korea. The trial was
terminated based on the results of this planned
interim analysis.
Treatment with TTFields was delivered continuously (>18 hours/day) via 4 transducer arrays
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MAIN OUTCOMES AND MEASURES
The primary end point was progression-free
survival in the intent-to-treat population
(significance threshold of .01) with overall
survival in the per-protocol population (n = 280)
as a powered secondary end point (significance
threshold of .006). This prespecified interim
analysis was to be conducted on the first 315
patients after at least 18 months of follow-up.
RESULTS
DESIGN, SETTING, AND
PARTICIPANTS
INTERVENTIONS
INTRODUCTION
placed on the shaved scalp and connected to a
portable medical device. Temozolomide (150-200
mg/m2/d) was given for 5 days of each 28-day
cycle.
SQUAMOUS
The interim analysis included 210 patients randomized to TTFields plus temozolomide and
105 randomised to temozolomide alone, and was
conducted at a median follow-up of 38 months
(range, 18-60 months). Median progression-free
survival in the intent-to-treat population was 7.1
months (95% CI, 5.9-8.2 months) in the TTFields
plus temozolomide group and 4.0 months (95%
CI, 3.3-5.2 months) in the temozolomide alone
group (hazard ratio [HR], 0.62 [98.7% CI, 0.430.89]; P = .001). Median overall survival in the
per-protocol population was 20.5 months (95%
CI, 16.7-25.0 months) in the TTFields plus
temozolomide group (n = 196) and 15.6 months
(95% CI, 13.3-19.1 months) in the temozolomide
alone group (n = 84) (HR, 0.64 [99.4% CI, 0.420.98]; P = .004).
HODGKIN’S
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DECISION SUPPORT
SYSTEMS
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CONCLUSIONS AND RELEVANCE
In this interim analysis of 315 patients with
glioblastoma who had completed standard
chemoradiation therapy, adding TTFields to
maintenance temozolomide chemotherapy
significantly prolonged progression-free and
overall survival.
INTRODUCTION
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CNS
PAEDIATRIC
BLOOD
ALZHEIMER’S
COLORECTAL
SQUAMOUS
HODGKIN’S
PALLIATION
LIVER
DECISION SUPPORT
SYSTEMS
LATE SIDE
EFFECTS
BACKGROUND
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Among patients in whom childhood cancer
was diagnosed in the 1970s and 1980s, 18% of
those who survived for 5 years died within the
subsequent 25 years. In recent decades, cancer
treatments have been modified with the goal of
reducing life-threatening late effects.
PAEDIATRIC
METHODS
Reduction in late mortality
among 5-year survivors of
childhood cancer
Armstrong G.T, Chen Y, Yasui Y, Leisenring W, Gibson
T.M, Mertens A.C, Stovall M, Oeffinger K.C, Bhatia S, Krull
K.R, Nathan P.C, Neglia J.P, Green D.M, Hudson M.M and
Robison L.L
January 13, 2016DOI: 10.1056/NEJMoa1510795
We evaluated late mortality among 34,033
patients in the Childhood Cancer Survivor
Study cohort who survived at least 5 years after
childhood cancer (i.e., cancer diagnosed before
the age of 21 years) for which treatment was
initiated during the period from 1970 through
1999. The median follow-up was 21 years (range,
5 to 38). We evaluated demographic and disease
factors that were associated with death from
health-related causes (i.e., conditions that exclude
recurrence or progression of the original cancer
and external causes but include the late effects of
cancer therapy) using cumulative incidence and
piecewise exponential models to estimate relative
rates and 95% confidence intervals.
RESULTS
in the early 1970s to 6.0% in the 1990s, P<0.001
for trend) and from health-related causes (from
3.5% to 2.1%, P<0.001 for trend). These reductions
were attributable to decreases in the rates of death
from subsequent neoplasm (P<0.001), cardiac
causes (P<0.001), and pulmonary causes (P=0.04).
Changes in therapy according to decade included
reduced rates of cranial radiotherapy for acute
lymphoblastic leukemia (85% in the 1970s, 51% in
the 1980s, and 19% in the 1990s), of abdominal
radiotherapy for Wilms’ tumour (78%, 53%,
and 43%, respectively), of chest radiotherapy
for Hodgkin’s lymphoma (87%, 79%, and 61%,
respectively), and of anthracycline exposure.
Reduction in treatment exposure was associated
with reduced late mortality among survivors of
acute lymphoblastic leukemia and Wilms’ tumor.
CONCLUSIONS
The strategy of lowering therapeutic exposure
has contributed to an observed decline in late
mortality among five-year survivors of childhood
cancer. (Funded by the National Cancer Institute
and the American Lebanese–Syrian Associated
Charities.)
Of the 3,958 deaths that occurred during the
study period, 1,618 (41%) were attributable to
health-related causes, including 746 deaths from
subsequent neoplasms, 241 from cardiac causes,
137 from pulmonary causes, and 494 from other
causes. A reduction in 15-year mortality was
observed for death from any cause (from 12.4%
INTRODUCTION
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PAEDIATRIC
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BACKGROUND
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PAEDIATRIC
Long-term toxic effects of proton
radiotherapy for paediatric
medulloblastoma: a phase 2
single-arm study
Yock TI, Yeap BY, Ebb DH, Weyman E, Eaton BR, Sherry NA,
Jones RM, MacDonald SM, Pulsifer MB, Lavally B, Abrams
AN, Huang MS, Marcus KJ, Tarbell NJ.
Lancet Oncol. 2016 Jan 29. pii: S1470-2045(15)00167-9.
doi: 10.1016/S1470-2045(15)00167-9. [Epub ahead of
print]
Compared with traditional photon radiotherapy,
proton radiotherapy irradiates less normal tissue
and might improve health outcomes associated
with photon radiotherapy by reducing toxic
effects to normal tissue. We did a trial to assess
late complications, acute side-effects, and survival
associated with proton radiotherapy in children
with medulloblastoma.
METHODS
In this non-randomised, open-label, singlecentre, phase 2 trial, we enrolled patients aged
3-21 years who had medulloblastoma. Patients
had craniospinal irradiation of 18-36 Gy radiobiological equivalents (GyRBE) delivered at 1•8
GyRBE per fraction followed by a boost dose. The
primary outcome was cumulative incidence of
ototoxicity at 3 years, graded with the Pediatric
Oncology Group ototoxicity scale (0-4), in the
intention-to-treat population. Secondary outcomes were neuroendocrine toxic effects and
neurocognitive toxic effects, assessed by intention-to-treat. This study is registered at
ClinicalTrials.gov, number NCT00105560.
FINDINGS
We enrolled 59 patients from 20 May 2003,
to 10 December 2009: 39 with standard-risk
disease, six with intermediate-risk disease, and
14 with high-risk disease. 59 patients received
chemotherapy. Median follow-up of survivors
was 7•0 years (IQR 5•2-8•6). All patients received
INTRODUCTION
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PAEDIATRIC
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SQUAMOUS
the intended doses of proton radiotherapy. The
median craniospinal irradiation dose was 23•4
GyRBE (IQR 23•4-27•0) and median boost
dose was 54•0 GyRBE (IQR 54•0-54•0). Four
(9%) of 45 evaluable patients had grade 3-4
ototoxicity according to Pediatric Oncology
Group ototoxicity scale in both ears at follow-up,
and three (7%) of 45 patients developed grade 3-4
ototoxicity in one ear, although one later reverted
to grade 2. The cumulative incidence of grade 3-4
hearing loss at 3 years was 12% (95% CI 4-25).
At five years, it was 16% (95% CI 6-29). Pediatric
Oncology Group hearing ototoxicity score at
a follow-up of 5•0 years (IQR 2•9-6•4) was the
same as at baseline or improved by 1 point in 34
(35%) of 98 ears, worsened by 1 point in 21 (21%),
worsened by 2 points in 35 (36%), worsened by
3 points in six (6%), and worsened by 4 points
in two (2%). Full Scale Intelligence Quotient
decreased by 1•5 points (95% CI 0•9-2•1) per year
after median follow-up up of 5•2 years (IQR 2•66•4), driven by decrements in processing speed
and verbal comprehension index. Perceptual
reasoning index and working memory did not
change significantly. Cumulative incidence of
any neuroendocrine deficit at five years was 55%
(95% CI 41-67), with growth hormone deficit
being most common. We recorded no cardiac,
pulmonary, or gastrointestinal late toxic effects.
Three-year progression-free survival was 83%
(95% CI 71-90) for all patients. In post-hoc
analyses, five-year progression-free survival was
80% (95% CI 67-88) and five-year overall survival
was 83% (95% CI 70-90).
HODGKIN’S
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INTERPRETATION
Proton radiotherapy resulted in acceptable
toxicity and had similar survival outcomes to
those noted with conventional radiotherapy,
suggesting that the use of the treatment may be
an alternative to photon-based treatments.
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HIGHLIGHTS
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RNA-SEQ OF TUMOREDUCATED PLATELETS
ENABLES BLOOD-BASED
PAN-CANCER, MULTICLASS,
AND MOLECULAR PATHWAY
CANCER DIAGNOSTICS
Best M.G, Sol N, Kooi I, Tannous J, Westerman B.A,
Rustenburg F, Schellen P, Verschueren H, Post E, Koster J,
Ylstra B, Ameziane N, Dorsman J, Smit E.F, Verheul H.M,
Noske D.P, Reijneveld J.C, Nilsson J, Tannous B.A, Wesseling
P, Wurdinger T
Cancer cell, Volume 28, Issue 5, p666–676, 9 November
2015
• Tumours “educate” platelets (TEPs) by altering
the platelet RNA profile
• TEPs provide a RNA biosource for pan-cancer,
multiclass, and companion diagnostics
• TEP-based liquid biopsies may guide clinical
diagnostics and therapy selection
• A total of 100–500 pg of total platelet RNA is
sufficient for TEP-based diagnostics.
SUMMARY
Tumour-educated blood platelets (TEPs) are
implicated as central players in the systemic and
local responses to tumour growth, thereby altering their RNA profile. We determined the diagnostic potential of TEPs by mRNA sequencing
of 283 platelet samples. We distinguished 228
patients with localised and metastasised tumours
from 55 healthy individuals with 96% accuracy.
Across six different tumour types, the location of
the primary tumour was correctly identified with
71% accuracy. Also, MET or HER2-positive, and
mutant KRAS, EGFR, or PIK3CA tumours were
accurately distinguished using surrogate TEP
mRNA profiles. Our results indicate that blood
platelets provide a valuable platform for pancancer, multiclass cancer, and companion diagnostics, possibly enabling clinical advances in
blood-based “liquid biopsies”.
This is an open access article under the CC BY
license (http://creativecommons.org/licenses/
by/4.0/).
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ALZHEIMER’S
Androgen Deprivation Therapy
and Future Alzheimer’s Disease
Risk
Nead K.T, Gaskin G, Chester C, Swisher-McClure S, Dudley
J.T, Leeper N.J, and Shah N.H
J Clin Oncol. 2016 Feb 20;34(6):566-71. doi: 10.1200/
JCO.2015.63.6266. Epub 2015 Dec 7.
PURPOSE
To test the association of androgen deprivation
therapy (ADT) in the treatment of prostate
cancer with subsequent Alzheimer's disease risk.
association between ADT use and Alzheimer's
disease risk. We also observed a statistically
significant increased risk of Alzheimer's disease
with increasing duration of ADT (P = .016).
METHODS
CONCLUSION
We used a previously validated and implemented
text-processing pipeline to analyse electronic
medical record data in a retrospective cohort
of patients at Stanford University and Mt. Sinai
hospitals. Specifically, we extracted International
Classification of Diseases-9th revision diagnosis
and Current Procedural Terminology codes,
medication lists, and positive-present mentions
of drug and disease concepts from all clinical
notes. We then tested the effect of ADT on risk
of Alzheimer's disease using 1:5 propensity scorematched and traditional multivariable-adjusted
Cox proportional hazards models. The duration
of ADT use was also tested for association with
Alzheimer's disease risk.
Our results support an association between the
use of ADT in the treatment of prostate cancer
and an increased risk of Alzheimer's disease
in a general population cohort. This study
demonstrates the utility of novel methods to
analyse electronic medical record data to generate
practice-based evidence.
RESULTS
There were 16,888 individuals with prostate
cancer meeting all inclusion and exclusion
criteria, with 2,397 (14.2%) receiving ADT
during a median follow-up period of 2.7 years
(interquartile range, 1.0-5.4 years). Propensity
score-matched analysis (hazard ratio, 1.88;
95% CI, 1.10 to 3.20; P = .021) and traditional
multivariable-adjusted Cox regression analysis
(hazard ratio, 1.66; 95% CI, 1.05 to 2.64; P =
.031) both supported a statistically significant
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ABSTRAC
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Preserved genetic diversity in
organoids cultured from biopsies
of human colorectal cancer
metastases
Weeber F, van de Wetering M, Hoogstraat M, Dijkstra K,
Krijgsman O, Kuilman T, Gadellaa-van Hooijdonk C, van der
Velden D.L, Peeper D.S, Cuppen E, Vries R.G, Clevers H and
Voest E
Proc Natl Acad Sci U S A. 2015 Oct 27;112(43):13308-11. doi:
10.1073/pnas.1516689112. Epub 2015 Oct 12.
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Tumour organoids are 3D cultures of cancer
cells. They can be derived from the tumour
of each individual patient, thereby providing
an attractive ex vivo assay to tailor treatment.
Using patient-derived tumour organoids for
this purpose requires that organoids derived
from biopsies maintain the genetic diversity
of the in vivo tumour. In this study tumour
biopsies were obtained from 14 patients with
metastatic colorectal cancer (i) to test the
feasibility of organoid culture from metastatic
biopsy specimens and (ii) to compare the genetic
diversity of patient-derived tumour organoids
and the original tumour biopsy. Genetic analysis
was performed using SOLiD sequencing for 1,977
cancer-relevant genes. Copy number profiles
were generated from sequencing data using
CopywriteR. Here we demonstrate that organoid
cultures can be established from tumour biopsies
of patients with metastatic colorectal cancer
with a success rate of 71%. Genetic analysis
showed that organoids reflect the metastasis
from which they were derived. Ninety percent
of somatic mutations were shared between
organoids and biopsies from the same patient,
and the DNA copy number profiles of organoids
and the corresponding original tumour show a
correlation of 0.89. Most importantly, none of the
mutations that were found exclusively in either
the tumour or organoid culture are in driver
genes or genes amenable for drug targeting. These
findings support further exploration of patient-
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derived organoids as an ex vivo platform to
personalise anticancer treatment.
SIGNIFICANCE
Chemotherapy has been proven in clinical
studies to improve overall survival significantly.
Unfortunately, there is a significant degree of
heterogeneity in tumour chemosensitivity, often
resulting in unnecessary treatment and needless
exposure to toxic side-effects. A platform is
needed that can identify preemptively which
patients will or will not benefit from treatment.
Tumour organoids, 3D cultures of cancer cells,
present such an individualised platform. In this
study we demonstrate that organoid cultures can
be established from metastatic biopsy specimens
with a high success rate and genetically represent
the metastasis they were derived from. These
data support the translation of this innovative
technology to the clinic as an ex vivo screening
platform for tailoring treatment.
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BACKGROUND:
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External validation of a
prognostic CT-based radiomic
signature in oropharyngeal
squamous cell carcinoma
Leijenaar RT, Carvalho S, Hoebers FJ, Aerts HJ, van Elmpt
WJ, Huang SH, Chan B, Waldron JN, O’sullivan B, Lambin P.
Acta Oncol. 2015;54(9):1423-9. doi:
10.3109/0284186X.2015.1061214. Epub 2015 Aug 12.
Oropharyngeal squamous cell carcinoma
(OPSCC) is one of the fastest growing disease
sites of head and neck cancers. A recently
described radiomic signature, based exclusively
on pre-treatment computed tomography (CT)
imaging of the primary tumor volume, was
found to be prognostic in independent cohorts of
lung and head and neck cancer patients treated
in the Netherlands. Here, we further validate
this signature in a large and independent North
American cohort of OPSCC patients, also
considering CT artifacts.
METHODS
A total of 542 OPSCC patients were included for
which we determined the prognostic index (PI) of
the radiomic signature. We tested the signature
model fit in a Cox regression and assessed model
discrimination with Harrell's c-index. KaplanMeier survival curves between high and low
signature predictions were compared with a
log-rank test. Validation was performed in the
complete cohort (PMH1) and in the subset of
patients without (PMH2) and with (PMH3)
visible CT artifacts within the delineated tumor
region.
PMH1 (n = 542), 0.855 (H0: β = 1, p = 0.524)
in the PMH2 (n = 267) and 1.99 (H0: β = 1, p =
0.002) in the PMH3 (n = 275) cohort. Harrell's
c-index was 0.628 (p = 2.72e-9), 0.634 (p = 2.7e6) and 0.647 (p = 5.35e-6) for the PMH1, PMH2
and PMH3 cohort, respectively. Kaplan-Meier
survival curves were significantly different (p <
0.05) between high and low radiomic signature
model predictions for all cohorts.
CONCLUSION
Overall, the signature validated well using all
CT images as-is, demonstrating a good model fit
and preservation of discrimination. Even though
CT artifacts were shown to be of influence,
the signature had significant prognostic power
regardless if patients with CT artifacts were
included.
RESULTS
We identified 267 (49%) patients without and 275
(51%) with visible CT artifacts. The calibration
slope (β) on the PI in a Cox proportional hazards
model was 1.27 (H0: β = 1, p = 0.152) in the
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PAEDIATRIC
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BACKGROUND
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Survivors of Hodgkin's lymphoma are at increased risk for treatment-related subsequent
malignant neoplasms. The effect of less toxic
treatments, introduced in the late 1980s, on the
long-term risk of a second cancer remains unknown.
HODGKIN’S
METHODS
Second Cancer Risk Up to
40 Years after Treatment for
Hodgkin’s Lymphoma
Schaapveld M, Aleman BM, van Eggermond AM, Janus CP,
Krol AD, van der Maazen RW, Roesink J, Raemaekers JM, de
Boer JP, Zijlstra JM, van Imhoff GW, Petersen EJ, Poortmans
PM, Beijert M, Lybeert ML, Mulder I, Visser O, Louwman
MW, Krul IM, Lugtenburg PJ, van Leeuwen FE.
N Engl J Med. 2015 Dec 24;373(26):2499-511.
We enrolled 3,905 people in the Netherlands
who had survived for at least five years after the
initiation of treatment for Hodgkin's lymphoma.
Patients had received treatment between 1965
and 2000, when they were 15 to 50 years of age.
We compared the risk of a second cancer among
these patients with the risk that was expected on
the basis of cancer incidence in the general population. Treatment-specific risks were compared
within the cohort.
RESULTS
With a median follow-up of 19.1 years, 1,055
second cancers were diagnosed in 908 patients,
resulting in a standardised incidence ratio (SIR)
of 4.6 (95% confidence interval [CI], 4.3 to 4.9) in
the study cohort as compared with the general
population. The risk was still elevated 35 years
or more after treatment (SIR, 3.9; 95% CI, 2.8 to
5.4), and the cumulative incidence of a second
cancer in the study cohort at 40 years was 48.5%
(95% CI, 45.4 to 51.5). The cumulative incidence
of second solid cancers did not differ according
to study period (1965-1976, 1977-1988, or 1989-
INTRODUCTION
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2000) (P=0.71 for heterogeneity). Although the
risk of breast cancer was lower among patients
who were treated with supradiaphragmatic-field
radiotherapy not including the axilla than among
those who were exposed to mantle-field irradiation (hazard ratio, 0.37; 95% CI, 0.19 to 0.72), the
risk of breast cancer was not lower among patients treated in the 1989-2000 study period than
among those treated in the two earlier periods.
A cumulative procarbazine dose of 4.3 g or more
per square meter of body-surface area (which has
been associated with premature menopause) was
associated with a significantly lower risk of breast
cancer (hazard ratio for the comparison with
no chemotherapy, 0.57; 95% CI, 0.39 to 0.84) but
a higher risk of gastrointestinal cancer (hazard
ratio, 2.70; 95% CI, 1.69 to 4.30).
CONCLUSIONS
The risk of second solid cancers did not appear
to be lower among patients treated in the most
recent calendar period studied (1989-2000) than
among those treated in earlier periods. The
awareness of an increased risk of second cancer
remains crucial for survivors of Hodgkin's lymphoma.
Funded by the Dutch Cancer Society.
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PURPOSE
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To compare short-course radiotherapy (RT)
(4 Gy × 5) to longer-course RT (3 Gy × 10) for
metastatic epidural spinal cord compression
(MESCC).
PALLIATION
PATIENTS AND METHODS
Radiotherapy with 4 Gy × 5
Versus 3 Gy × 10 for metastatic
epidural spinal cord compression:
cinal cesults of the cCORE-2 crial
(ARO 2009/01)
Rades D, Šegedin B, Conde-Moreno AJ, Garcia R, Perpar
A, Metz M, Badakhshi H, Schreiber A, Nitsche M, Hipp P,
Schulze W, Adamietz IA, Norkus D, Rudat V, Cacicedo J,
Schild SE.
J Clin Oncol. 2016 Jan 4. pii: JCO640862. [Epub ahead of
print]
Two hundred and three patients with MESCC
and poor to intermediate expected survival were
randomly assigned to 4 Gy × 5 in 1 week (n =
101) or 3 Gy × 10 in 2 weeks (n = 102). Patients
were stratified according to ambulatory status,
time developing motor deficits, and primary
tumor type. Seventy-eight and 77 patients,
respectively, were evaluable for the primary
end point, 1-month overall response regarding
motor function defined as improvement or no
further progression of motor deficits. Other study
end points included ambulatory status, local
progression-free survival, and overall survival.
End points were evaluated immediately after RT
and at 1, 3, and 6 months thereafter.
also not significantly different. Six-month local
progression-free survival was 75.2% after 4 Gy
× 5 and 81.8% after 3 Gy × 10 (P = .51); 6-month
overall survival was 42.3% and 37.8% (P = .68).
CONCLUSION
Short-course RT with 4 Gy × 5 was not
significantly inferior to 3 Gy × 10 in patients
with MESCC and poor to intermediate expected
survival.
RESULTS
At one month, overall response rates regarding
motor function were 87.2% after 4 Gy × 5 and
89.6% after 3 Gy × 10 (P = .73). Improvement
rates were 38.5% and 44.2%, respectively, no
further progression rates 48.7% and 45.5%,
respectively, and deterioration rates 12.8% and
10.4%, respectively (P = .44). Ambulatory rates at
one month were 71.8% and 74.0%, respectively (P
= .86). At other times after RT, the results were
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PAEDIATRIC
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COMMENT ON “RADIOTHERAPY
WITH 4 GY × 5 VERSUS 3 GY × 10
FOR METASTATIC EPIDURAL SPINAL CORD COMPRESSION: FINAL
RESULTS OF THE SCORE-2 TRIAL
(ARO 2009/01)”
by Prof Dirk De Ruysscher, Maastro clinic,
Maastricht, The Netherlands:
It should be emphasized that patients with a
relatively good long-term survival such as those
with a primary diagnosis of multiple myeloma,
but also some subgroups of other cancer patients who have a molecular driver amenable for
targeted treatments or who are expected to have
a reasonable chance for long-term survival for
other reasons would not have been eligible in
this study. The consensus is to treat these individuals to higher radiotherapy doses that do not
exceed the tolerance of the spinal cord.
DIRK
DE RUYSSCHER
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PURPOSE
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Cancer-induced bone pain (CIBP) affects one
third of patients with cancer. Radiotherapy
remains the gold-standard treatment; however,
laboratory and clinical work suggest that pregabalin may be useful in treating CIBP. The
aim of this study was to examine pregabalin in
patients with CIBP receiving radiotherapy.
PALLIATION
Randomized double-blind trial
of pregabalin versus placebo
in conjunction with palliative
radiotherapy for cancer-induced
bone pain
Fallon M, Hoskin PJ, Colvin LA, Fleetwood-Walker SM,
Adamson D, Byrne A, Murray GD, Laird BJ.
J Clin Oncol. 2015 Dec 7. pii: JCO.2015.63.8221. [Epub
ahead of print]
PATIENTS AND METHODS
A multicenter, double-blind randomized trial
of pregabalin versus placebo was conducted.
Eligible patients were age ≥ 18 years, had
radiologically proven bone metastases, were
scheduled to receive radiotherapy, and had pain
scores ≥ 4 of 10 (on 0-to-10 numeric rating scale).
Before radiotherapy, baseline assessments were
completed, followed by random assignment.
Doses of pregabalin and placebo were increased
over four weeks. The primary end point was
treatment response, defined as a reduction of ≥ 2
points in worst pain by week four, accompanied
by a stable or reduced opioid dose, compared
with baseline. Secondary end points assessed
average pain, interference of pain with activity,
breakthrough pain, mood, quality of life, and
adverse events.
the pregabalin arm, 45 patients (38.8%) achieved
the primary end point, compared with 47 (40.2%)
in the placebo arm (adjusted odds ratio, 1.07;
95% CI, 0.63 to 1.81; P = .816). There were no
statistically significant differences in average
pain, pain interference, or quality of life between
arms. There were differences in mood (P = .031)
and breakthrough pain duration (P = .037)
between arms. Outcomes were compared at four
weeks.
CONCLUSION
These findings do not support the role of
pregabalin in patients with CIBP receiving
radiotherapy. The role of pregabalin in CIBP
with a clinical neuropathic pain component is
unknown.
RESULTS
A total of 233 patients were randomly assigned:
117 to placebo and 116 to pregabalin. The most
common cancers were prostate (n = 88; 38%),
breast (n = 77; 33%), and lung (n = 42; 18%). In
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PAEDIATRIC
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LIVER
Outcomes after stereotactic body
radiotherapy or radiofrequency
ablation for hepatocellular
carcinoma
Wahl DR, Stenmark MH, Tao Y, Pollom EL, Caoili EM,
Lawrence TS, Schipper MJ, Feng M.
J Clin Oncol. 2015 Nov 30. pii: JCO614925. [Epub ahead of
print]
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PURPOSE
Data guiding selection of nonsurgical treatment
of hepatocellular carcinoma (HCC) are lacking.
The authors therefore compared outcomes
between stereotactic body radiotherapy (SBRT)
and radiofrequency ablation (RFA) for HCC.
RFA compared with SBRT (HR, 3.35; P = .025).
Acute grade 3+ complications occurred after 11%
and 5% of RFA and SBRT treatments, respectively
(P = .31). Overall survival one and two years after
treatment was 70% and 53% after RFA and 74%
and 46% after SBRT.
PATIENTS AND METHODS
CONCLUSION
From 2004 to 2012, 224 patients with inoperable,
nonmetastatic HCC underwent RFA (n = 161)
to 249 tumours or image-guided SBRT (n =
63) to 83 tumors. The group applied inverse
probability of treatment weighting to adjust for
imbalances in treatment assignment. Freedom
from local progression (FFLP) and toxicity were
retrospectively analysed.
Both RFA and SBRT are effective local treatment
options for inoperable HCC. Although these
data are retrospective, SBRT appears to be a
reasonable first-line treatment of inoperable,
larger HCC.
RESULTS
RFA and SBRT groups were similar with respect
to number of lesions treated per patient, type
of underlying liver disease, and tumor size
(median, 1.8 v 2.2 cm in maximum diameter;
P = .14). However, the SBRT group had lower
pretreatment Child-Pugh scores (P = .003),
higher pretreatment alpha-fetoprotein levels (P =
.04), and a greater number of prior liver-directed
treatments (P < .001). One and two year FFLP for
tumors treated with RFA were 83.6% and 80.2%
v 97.4% and 83.8% for SBRT. Increasing tumor
size predicted for FFLP in patients treated with
RFA (hazard ratio [HR], 1.54 per cm; P = .006),
but not with SBRT (HR, 1.21 per cm; P = .617).
For tumors ≥ 2 cm, there was decreased FFLP for
PAEDIATRIC
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ABSTRACT
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DECISION
SUPPORT SYSTEMS
Decision support systems for
personalized and participative
radiation oncology
Lambin P, Zindler J, Vanneste BG, De Voorde LV, Eekers
D, Compter I, Panth KM, Peerlings J, Larue RT, Deist TM,
Jochems A, Lustberg T, van Soest J, de Jong EE, Even AJ,
Reymen B, Rekers N, van Gisbergen M, Roelofs E, Carvalho
S, Leijenaar RT, Zegers CM, Jacobs M, van Timmeren J,
Brouwers P, Lal JA, Dubois L, Yaromina A, Van Limbergen EJ,
Berbee M, van Elmpt W, Oberije C, Ramaekers B, Dekker A,
Boersma LJ,Hoebers F, Smits KM, Berlanga AJ, Walsh S.
Adv Drug Deliv Rev. 2016 Jan 14. pii: S0169409X(16)30008-4. doi: 10.1016/j.addr.2016.01.006.
[Epub ahead of print]
INTRODUCTION
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A paradigm shift from current population based
medicine to personalised and participative
medicine is underway. This transition is being
supported by the development of clinical decision
support systems based on prediction models of
treatment outcome. In radiation oncology, these
models 'learn' using advanced and innovative
information technologies (ideally in a distributed
fashion - please watch the animation: http://
youtu.be/ZDJFOxpwqEA) from all available /
appropriate medical data (clinical, treatment,
imaging, biological/genetic, etc.) to achieve
the highest possible accuracy with respect to
prediction of tumour response and normal tissue
toxicity. In this position paper, we deliver an
overview of the factors that are associated with
outcome in radiation oncology and discuss the
methodology behind the development of accurate
prediction models, which is a multi-faceted
process. Subsequent to initial development/
validation and clinical introduction, decision
support systems should be constantly reevaluated (through quality assurance procedures)
in different patient datasets in order to refine and
re-optimize the models, ensuring the continuous
utility of the models. In the reasonably near
future, decision support systems will be fully
integrated within the clinic, with data and
knowledge being shared in a standardized,
dynamic, and potentially global manner enabling
truly personalised and participative medicine.
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BACKGROUND
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Cardiovascular disease after
treatment for Hodgkin’s
lymphoma: an analysis of nine
collaborative EORTC-LYSA trials
Maraldo MV, Giusti F, Vogelius IR, Lundemann M, van
der Kaaij MA, Ramadan S, Meulemans B, Henry-Amar M,
Aleman BM, Raemaekers J, Meijnders P, Moser EC, KluinNelemans HC, Feugier P, Casasnovas O, Fortpied C, Specht
L; European Organisation for Research and Treatment of
Cancer (EORTC) Lymphoma Group.
Lancet Haematol. 2015 Nov;2(11):e492-502. doi: 10.1016/
S2352-3026(15)00153-2. Epub 2015 Oct 22.
INTRODUCTION
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Cardiovascular disease after treatment is an
important concern in cancer survivors. However,
knowledge of cardiotoxicity is limited by the
retrospective nature of data, which often does
not contain details of treatment exposure. To
facilitate individual risk counselling of patients,
we aimed to quantify the effect of anthracyclines,
vinca-alkaloids, and radiotherapy on the risk
of cardiovascular disease in patients treated for
Hodgkin's lymphoma.
METHODS
In 2009-10, a Life Situation Questionnaire (LSQ)
was distributed to patients by mail to assess lateonset effects of Hodgkin's lymphoma treatment
in patients who were included in nine successive
European Organisation for Research and
Treatment of Cancer (EORTC) and the Groupe
d'Etude des Lymphomes de l'Adulte (GELA,
now renamed LYSA) randomised trials between
1964 and 2004. We reconstructed the mean
radiation doses to the heart and carotid arteries
and the cumulative doses of anthracyclines
and vinca-alkaloids for all patients. Incidence
of cardiovascular disease was reported during
follow-up and updated through the LSQ. We
applied Cox proportional hazards regression
analyses to quantify the effect of chemotherapy
and radiation on the risk of a first cardiovascular
disease event.
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FINDINGS
Information of primary treatment was complete
for 6039 patients (median age at diagnosis 30
years [IQR 23-40]; median length of followup 9 years [6-14]). 1919 patients responded to
the LSQ. 1,238 first cardiovascular events were
recorded in 703 patients, most were ischaemic
heart disease (132 [19%]), congestive heart failure
(85 [12%]), arrhythmia (110 [16%]), and valvular
disease (77 [11%]). The mean heart radiation
dose per 1 Gy increase (HR 1•015 [95% CI 1•0061•024], p=0•0014) and the dose of anthracyclines
per 50 mg/m(2) increase in cumulative dose
(1•077 [1•021-1•137], p=0•0064) were significant
predictors of cardiovascular disease. Cumulative
dose of vinblastine (unadjusted model p=0•77),
vincristine (p=0•36), and mean radiation dose
to the left (p=0•41) or right (p=0•70) internal
carotid artery did not predict for cardiovascular
events.
INTERPRETATION
Quantification of the increased cardiovascular
risk with specific doses of radiation and
anthracycline exposure will enable a quantitative
assessment of the optimum combination of
systemic therapy and radiation, which will help
clinicians to balance the risks and benefits of
different regimens for individual patients.
HODGKIN’S
PALLIATION
LIVER
DECISION SUPPORT
SYSTEMS
LATE SIDE
EFFECTS
INTRODUCTION
BREAST
PROSTATE
HEAD &
NECK
CNS
PAEDIATRIC
BLOOD
ALZHEIMER’S
COLORECTAL
SQUAMOUS
HODGKIN’S
PALLIATION
LIVER
DECISION SUPPORT
SYSTEMS
LATE SIDE
EFFECTS
DYNAMIC ONCOLOGY
VIRTUAL ESTRO
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CLINICAL
INTRODUCTION
CLINICAL COMMITTEE NEW MEMBERS’ PROFILES
CLINICAL
Dear colleagues,
Professors Corinne
Faivre-Finn, Lorenzo
Livi, and Pedro Carlos
Lara Jiménez: welcome
on board!
Under ESTRO by-laws, the clinical committee regularly renews
its membership. As such, three committee colleagues, Dr Anne
Hansen Ree, Dr Renzo Corvo and Dr Kevin Harrington, have
recently finished their term. On behalf of the committee and
ESTRO I would like to thank Anne, Renzo and Kevin for their
valuable contribution and enduring commitment to our Society.
I am sure they will continue to play an active role in ESTRO and
we look forward to working with them in the future as colleagues
and friends.
DANIEL ZIPS
It is also my pleasure to announce that we have three new members
on the committee who have kindly accepted the invitation to
join and will be picking up from where Anne, Renzo and Kevin
left off. Professors Corinne Faivre-Finn, Lorenzo Livi, and Pedro
Carlos Lara Jiménez: welcome on board! In the following pages
they introduce themselves. We look forward to their impact on the
committee’s work.
If you have questions or comments about the work of the
committee, or other ESTRO-related activities, please send me an
email at: Daniel.Zips@med.uni-tuebingen.de
Daniel Zips
Chair of the clinical committee
INTRODUCTION
CLINICAL COMMITTEE NEW MEMBERS’ PROFILES
CLINICAL COMMITTEE
NEW MEMBERS’ PROFILES
CLINICAL
Professor Corinne Faivre-Finn
Professor of Thoracic Radiation Oncology
Institute of Cancer Sciences
University of Manchester, UK
and
Honorary Consultant Clinical Oncologist
The Christie
Wilmslow Road
Manchester, UK
CORINNE
FAIVRE-FINN
INTRODUCTION
Corinne Faivre-Finn, FRCR, MD, PhD, is a
Professor of Thoracic Radiation Oncology at
the University of Manchester, and an Honorary
Consultant Clinical Oncologist at The Christie
with an interest in lung cancer. Professor FaivreFinn trained in Paris until 1998 and took a
consultant post at The Christie (UK) in 2001.
and is the chief investigator of the international
CONVERT study (limited-disease SCLC),
PIT (mesothelioma), Isotoxic IMRT (stage III
NSCLC), MEKRT (MEK inhibitor combined with
thoracic radiotherapy in NSCLC) and PARIS
(pembroluzimab and combined with thoracic
radiotherapy in NSCLC) studies.
Her interests involve the development of
multimodality treatments for stage III nonsmall-cell lung cancer and limited disease
small-cell lung cancer. She is also interested in
the development of stereotactic radiotherapy,
intensity modulated radiotherapy and early
phase trials combining thoracic radiotherapy and
mechanism-based therapies.
She says: “I agreed to be a member of the clinical
committee because I am passionate about
evidence-based medicine and hope to be able to
promote research aiming to support the use of
advanced radiotherapy techniques.”
She is an active member of the European
Organisation for Research and Treatment of
Cancer (EORTC) Radiotherapy and Lung groups,
and became the radiotherapy chair of the EORTC
Lung Group in 2008. She is also the radiotherapy
research lead for the Cancer Research UK
(CRUK) Lung Cancer Centre of Excellence; the
Manchester Cancer Research Centre and the
Lung Disease Site Coordinator for the Elekta and
Philips MR Linac Research Consortium. She is
involved with the trial management groups of
several UK / European lung cancer clinical trials
CLINICAL COMMITTEE NEW MEMBERS’ PROFILES
CLINICAL COMMITTEE
NEW MEMBERS’ PROFILES
CLINICAL
Professor Pedro
Carlos Lara Jiménez
Radiation oncologist
Head of Department of Radiation Oncology
Hospital Universitario de Gran Canaria Doctor Negrin
Las Palmas, Spain
Professor Pedro Lara was born and raised in
Granada, Spain. He obtained his medical degree
in 1985 from the University of Granada. After
graduating, he continued with his studies,
working as a research fellow at the university
from 1985 to 1987. It was during this time that
he began his training in the field of radiation
oncology, going on to obtain a PhD in this subject
area from the University of Granada in 1988.
In 1991 he moved to the Radiation Oncology
Department at the University Hospital of Las
Palmas, as Consultant Radiation Oncologist
and Associate Professor of Radiation Oncology.
In 1995 he joined the European Cancer Centre
Fellowship Programme, to develop a project on
translational research at The Netherlands Cancer
Institute in Amsterdam, under the supervision of
Professors Harry Bartelink and Adrian Begg.
In 1996, after being appointed as a Professor
of Radiation Oncology at the University of Las
Palmas, he returned to the Canary Islands, where
he established a new translational research group
focused on biologically individualised radiotherapy and predictive assays of normal toxicity.
PEDRO CARLOS
LARA JIMÉNEZ
INTRODUCTION
From 2011 until the present day, Prof Lara has
been the Director of the Canarian Institute
for Cancer Research. Since 2009, he has also
been the Head of the Department of Radiation
Oncology in Las Palmas University Hospital.
This department is devoted to the comprehensive
treatment of cancer patients, being very active in
both clinical oncology and medical treatments.
His particular areas of interest are breast/prostate
cancer and radioimmunotherapy, fields in which
he has conducted national and international
clinical trials.
In 2013 he obtained the national accreditation as
Full Professor and Chair of Radiation Oncology
and from then onwards he has been the Academic Chair of Clinical Oncology and Haematology
at the Las Palmas University Medical School.
He is member of the Sociedad Española de
Oncología Radioterápica, Asociación Española
de Investigación sobre el Cáncer, European
Association for Cancer Research, European
Organisation for Research and Treatment of
Cancer and ESTRO, and regularly reviews and
publishes scientific journal papers.
He says: “I think that clinical / radiation
oncologists play a central role in comprehensive
oncology treatment. Nevertheless, our
contribution is frequently overlooked by health
CLINICAL COMMITTEE NEW MEMBERS’ PROFILES
providers and policymakers. Evidence-based
data are sorely needed to provide sound and
convincing data and information that ensure
that cancer patients get access to the optimal
level of radiation therapy. But evidence is no
longer about technological advances alone.
Biologically-oriented clinical radiation research
also relates to the integration of drugs as an
essential component of successful clinical /
radiation oncology treatments. ESTRO can play
an essential role in facilitating research that
leads towards individualised radiation therapy,
among other areas, by encouraging its members
to be fully aware of our own potential, seeing
ourselves as oncologists who treat cancer patients
with radiation, integrated with other therapies,
to provide state-of-the-art care to those who
desperately need it throughout the course of their
clinical journey.”
INTRODUCTION
CLINICAL COMMITTEE NEW MEMBERS’ PROFILES
CLINICAL COMMITTEE
NEW MEMBERS’ PROFILES
CLINICAL
Lorenzo Livi
Professor in Radiation Oncology and Head of the Radiation
Oncology Department
University of Florence
Florence, Italy
LORENZO LIVI
INTRODUCTION
Lorenzo Livi was born and raised in Pistoia,
Italy. From 1991 to 1997 he studied medicine
in Florence. He was then a resident in radiation
oncology at the University of Florence in the
group led by Professor Giampaolo Biti. After
spending six months as a visiting doctor in
the department of radiation oncology at The
Royal Marsden in London, he was appointed as
a consultant radiation oncologist in Florence.
Building on his clinical science career, he established the following main area of work and
interest: individualised treatment for breast
cancer and urogenital cancer; multi-modal
management of soft tissue sarcoma; and clinical
appropriateness of new radiation oncology
technologies. In 2009, he specialised in medical
oncology at the University Cattolica del Sacro
Cuore in Rome. In 2012, he was appointed
Professor and Chair of Radiation Oncology at
the University of Florence. In 2013, he became
Director of the Radiation Oncology Unit at the
University of Florence. He has published more
than 100 scientific papers and book chapters.
on the Committee I hope to stimulate further
collaboration between scientific European
societies in order to concentrate our efforts to
promote the exchange of knowledge, facilities
and people.”
He says: “I enthusiastically accepted the
opportunity to join the Clinical Committee as
ESTRO plays a vital role in supporting scientific
activities in Europe by providing a platform for
academic and professional exchange. In my term
CLINICAL COMMITTEE NEW MEMBERS’ PROFILES
BRACHYTHERAPY
INTRODUCTION
MEET THE NEW EDITOR
EDITORS’ PICKS
BRACHYTHERAPY
IN THIS EDITION OF
THE BRACHYTHERAPY
CORNER, WE INTRODUCE TWO NEW
EDITORS
In this edition of the Brachytherapy Corner, we introduce two new editors:
Åsa Carlsson Tedgren from the Karolinska University Hospital in Stockholm,
Sweden, and Robert Hudej from the Institute of Oncology Ljubljana in
Slovenia. Both medical physicists with a strong commitment to brachytherapy,
you can read their profiles in this Corner. We wish them a warm welcome and
look forward to reading some interesting articles in the field of brachytherapy.
The new editors are replacing Kari Tanderup who did an excellent job with
great dedication. We thank Kari for the time and effort she spent on each
edition of the Brachytherapy Corner, providing us with a diverse range of
newsworthy articles.
In the editors’ pick section, we present two clinical studies on endometrial
cancer and prostate cancer and one physics study on in vivo dosimetry.
We hope you enjoy reading this edition.
Peter Hoskin, Bradley Pieters, Åsa Tedgren & Robert Hudej
(sta
N
IO )
IT 2014
ED ber
ND ecem
CO d
SE rt in
The GEC ESTRO
Handbook of
Brachytherapy
Editors
Erik Van Limbergen
Richard Pötter
Peter Hoskin
Dimos Baltas
New chapter on endometrium cancer
is now available in the GEC-ESTRO
Handbook of brachytherapy 2nd
edition, accessible via DOVE
www.estro.org
PETER HOSKIN
INTRODUCTION
BRADLEY PIETERS
MEET THE NEW EDITOR
ÅSA CARLSSON
TEDGREN
ROBERT HUDEJ
EDITORS’ PICKS
BRACHYTHERAPY
MEET THE NEW EDITOR
Robert Hudej
Medical physicist
Institute of Oncology Ljubljana
Ljubljana, Slovenia
I would like to thank the GEC-ESTRO
Committee for inviting me to become the new
co-editor of the Brachytherapy Corner. It will be
impossible to fill Kari's shoes, but I will do my
best.
My career has not progressed in a typical manner
for a medical physicist. My early research
work was in the field of materials science,
and I completed my PhD in physics at the
University of Nova Gorica, Slovenia, in organic
semiconductors. It was during my postdoctoral
position at the International School for Advanced
Studies and at the Elettra Synchrotron Light
Laboratory in Trieste, Italy, that I first started
working in radiation physics. It was during that
time that I decided I would like to continue my
work in medical physics and I took a position as
a medical physicist at the Institute of Oncology
Ljubljana in 2006. The Institute was one of the
early adopters of 3D MRI-based brachytherapy,
and since joining I have been primarily
involved in the development of this technique
for gynaecology and prostate brachytherapy.
Currently, my research work is focused on the
development of individualised brachytherapy
applicators.
In addition to this clinical and research work,
I have taught on ESTRO educational courses
(Modern Brachytherapy Techniques, Imaging
for Physicists), helping to share and promote
knowledge of modern brachytherapy with expert
colleagues from all over the world.
At ESTRO, it is our mission to help patients from
anywhere in the world in any way that is possible
through clinical work, research and education
and I believe that the newsletter is an important
part of this mission.
ROBERT HUDEJ
INTRODUCTION
MEET THE NEW EDITOR
EDITORS’ PICKS
BRACHYTHERAPY
MEET THE NEW EDITOR
Åsa Carlsson Tedgren
Medical physicist, Associate Professor
Department of Medical Physics,
Karolinska University Hospital
Stockholm, Sweden
ÅSA CARLSSON
TEDGREN
INTRODUCTION
I am a medical physicist, and specialised in
brachytherapy (BT) for my PhD, which I received
from Stockholm University in 2003. As part of
my PhD, which was entitled ‘Development of
dose calculation algorithms for BT treatment
planning’, I adapted the ‘collapsed cone’ photon
dose calculation algorithm from external beams
for BT applications. Since then, I have worked as
a postdoctoral researcher at Linköping University
and broadened my focus to include experimental
dosimetry and translational research between
medical radiation physics and mathematical
optimisation for BT treatment planning. In
addition to working in an adjunct research
position at the university, I have also worked
at the Swedish secondary standard dosimetry
calibration laboratory. Last year, I took on a new
position as a medical physicist at the Karolinska
University Hospital, providing me with the
opportunity to work and train in clinical BT for
the first time. The Karolinska treats around 150
prostate, 60 gynaecology, 60 head and neck, and
70 eye patients with BT each year using 192Ir,
125I and 106Ru.
as well as the latest news from the field. In BT
physics we see a current interest in experimental
dosimetry, including online in vivo dosimetry,
and in the use of model-based dose calculations.
I hope to contribute to the Corner by bridging
the gap between more theoretically oriented and
clinical medical physics perspectives.
I have long enjoyed reading the Brachytherapy
Corner and look forward to being one of its
editors. I think it provides an inspiring and
varied mix of articles on clinical BT and physics,
MEET THE NEW EDITOR
EDITORS’ PICKS
EDITORS’ PICKS
BRACHYTHERAPY
Highlight Brachytherapy Papers
Medically inoperable endometrial cancer in
patients with a high body mass index (BMI):
patterns of failure after 3D image-based high dose
rate (HDR) brachytherapy
Acharya S, Esthappan J, Badiyan S, DeWees TA, Tanderup K,
Schwarz JK, Grigsby PW.
Radiotherapy Oncology 2016 Jan, 118(1):167-72. doi: 10.1016/j.
radonc.2015.12.019. Epub 2015 Dec 29.
Longitudinal assessment of quality of life after
surgery, conformal brachytherapy, and intensitymodulated radiation therapy for prostate cancer
In vivo rectal wall measurements during
HDR prostate brachytherapy with MOSkin
dosimeters integrated on a trans-rectal US probe:
comparison with planned and reconstructed
doses
Carrara M, Tenconi C, Rossi G, Borroni M, Cerrotta A,
Grisotto S, Cusumano D, Pappalardi B, Cutajar D, Petasecca
M, Lerch M, Gambarini G,Fallai C, Rosenfeld A, Pignoli E
Radiother Oncol. 2016 Jan;118(1):148-53. doi: 10.1016/j.
radonc.2015.12.022. Epub 2016 Jan 12.
Zelefsky MJ, Poon BY, Eastham J, Vickers A, Pei X, and Scardino
PT
Radiother Oncol. 2016 Jan;118(1):85-91. doi: 10.1016/j.
radonc.2015.11.035. Epub 2016 Jan 9.
INTRODUCTION
MEET THE NEW EDITOR
EDITORS’ PICKS
EDITORS’ PICKS
BRACHYTHERAPY
Medically inoperable
endometrial cancer in patients
with a high body mass index
(BMI): patterns of failure after
3D image-based high dose rate
(HDR) brachytherapy
Acharya S, Esthappan J, Badiyan S, DeWees TA, Tanderup
K, Schwarz JK, Grigsby PW.
Radiotherapy Oncology 2016 Jan, 118(1):167-72. doi:
10.1016/j.radonc.2015.12.019. Epub 2015 Dec 29.
Highlight Brachytherapy Papers
What was your motivation for initiating
this study?
High body mass index (BMI) is an established
risk factor for the development of endometrial
cancer. High BMI not only increases the risk
of developing endometrial cancer, but also
complicates treatment. The standard of care
for early stage endometrial cancer is total
abdominal hysterectomy and bilateral salpingooophorectomy (TAH/BSO). However, approximately 10% of early stage endometrial
cancer patients are medically inoperable
due to comorbid conditions related to high
BMI, such as cardiovascular disease, obesityhypoventilation syndrome and diabetes-related
end organ damage. Definitive radiation is an
alternative therapy for these patients, but data on
patterns of failure after definitive radiotherapy
are lacking. Therefore, our goal was to describe
our institutional clinical outcomes and patterns
of failure in medically inoperable patients with
endometrial cancer treated with 3D image-based
brachytherapy.
What were the main challenges during
the work?
SAHAJA ACHARYA
INTRODUCTION
PERRY W GRIGSBY
Given that the project was designed as a retrospective review, it was fairly straightforward to
MEET THE NEW EDITOR
carry out. There were no significant challenges in
undertaking this project.
What are the most important findings of
your study?
With 3D image-based brachytherapy, we were
able to achieve a low rate of pelvic failures (less
than 10%) with minimal acute toxicity. Patients
with grade 3 disease had a four-fold increase in
risk of failure compared to patients with grade 1
disease.
What are the implications of this
research?
Definitive radiation with 3D image-based
brachytherapy is a viable alternative to surgery
for patients who are medically inoperable due
to comorbid conditions related to high BMI.
Although definitive radiation results in low rates
of pelvic failure and minimal toxicity, patients
with grade 3 disease are at a higher risk of failing
and therefore may warrant closer follow up.
Sahaja Acharya & Perry W Grigsby
Department of Radiation Oncology
Mallinckrodt Institute of Radiology
Washington University School of Medicine
St Louis, USA
EDITORS’ PICKS
EDITORS’ PICKS
BRACHYTHERAPY
In vivo rectal wall measurements
during HDR prostate
brachytherapy with MOSkin
dosimeters integrated on
a trans-rectal US probe:
comparison with planned and
reconstructed doses
Carrara M, Tenconi C, Rossi G, Borroni M, Cerrotta A,
Grisotto S, Cusumano D, Pappalardi B, Cutajar D, Petasecca
M, Lerch M, Gambarini G,Fallai C, Rosenfeld A, Pignoli E.
Radiother Oncol. 2016 Jan;118(1):148-53. doi: 10.1016/j.radonc.2015.12.022. Epub 2016 Jan 12.
MAURO CARRARA
INTRODUCTION
Highlight Brachytherapy Papers
What was your motivation for initiating
this study?
In light of the increasing complexity and high
amount of dose per fraction delivered in HDR
brachytherapy in recent years the scientific
community has implemented rigorous quality
assurance (QA) procedures for independent
verification of this treatment. One of the main
concerns is that human inaccuracies or error may
lead to a significant degradation of the treatment,
which might not be detected in the treatmentplanning phase. There are several other technical
and clinical factors that might also influence the
quality of the treatment.
Our work, which is the result of a fruitful
collaboration between the Centre for Medical
Radiation Physics (CMRP), University of
Wollongong (Australia) and the Fondazione
IRCCS Istituto Nazionale dei Tumori, Milan
(Italy), focused on the implementation of a
reliable in vivo dosimetry (IVD) procedure to be
applied in the clinical routine of HDR prostate
BT with trans-rectal ultrasound (TRUS)-guided
online treatment planning. We were particularly
interested in finding out whether:
1) IVD, performed with a dosimeter
developed at CMRP called ‘MOSkin’, was
adequate for evaluating the quality of such
treatments; and
2) the quality of treatment delivered is
influenced by possible patient movements
and internal anatomy alterations taking place
during treatment planning (i.e. even if it takes
a limited time lapse of one to two hours).
The American industrialist Henry Ford famously
said: “Quality means doing it right when no one
is looking.” To reach this ultimate goal of quality
in brachytherapy, every step of the treatment
procedure should be examined, and we believe
that IVD is a very powerful tool for doing this.
What were the main challenges during
the work?
The main challenges that we faced were the
common ones associated with the use of IVD in
HDR brachytherapy – that is keeping positional
and dosimetric uncertainties of the dosimeters
as low as possible. In this, we kept in mind the
words of the physicist Brian Green: “Exploring
the unknown requires tolerating uncertainty.”
We tried to limit this uncertainty, which is
unavoidable in HDR brachytherapy due to the
ANATOLY
ROSENFELD
MEET THE NEW EDITOR
EDITORS’ PICKS
steep dose gradients, by placing the dosimeters
directly on the TRUS-probe to form what we
called a ‘dual purpose probe’. Coupling the
dosimeters to the TRUS imaging system was
an interesting and convenient solution to the
problem, meaning that we could accurately
determine the dosimeters position with respect
to the rectal wall without needing any further
equipment. With the longitudinal locations of
the dosimeters directly related to the transversal
image shown by the TRUS-probe, their position was easily obtainable at any moment of
the treatment with longitudinal and radial
uncertainties of less than ±1mm and ±0.5mm
respectively. To the best of our knowledge, this
is the first time that such an instrument has been
applied clinically in HDR prostate brachytherapy.
What are the most important findings of
your study?
Regarding dosimetric uncertainty, the team
led by Professor Anatoly Rosenfeld at CMRP
has done an excellent job in the past few years,
developing and improving MOSkin dosimeters.
MOSkins are particularly suited for IVD in HDR
brachytherapy, having a very small sensitive
volume (i.e. 4.8 x 10-6mm3), which is ideal for
point dose measurements in high dose gradient
regions. Furthermore, MOSkin probes are
almost water equivalent and particularly thin (i.e.
3mm wide, 0.4mm thick and 330mm long, and
including an embedded sensor) and this helps
their positioning in clinically relevant regions,
which are normally difficult to reach without
further invasive procedures.
In general, our work was an example of how
useful IVD can be as a tool to not only limit
random human or technical errors, but also
possible systematic sub-optimal aspects of the
overall treatment procedure. As the 1960s US
free jazz musician Ornette Coleman said: “It was
when I found out I could make mistakes that I
knew I was on to something.”
INTRODUCTION
First, that MOSkin dosimeters coupled to a
TRUS-probe to form a dual-purpose probe
proved to be an accurate instrument to perform
IVD measurements on the rectal wall. With this
instrument we demonstrated that uncertainty on
the delivered dose depends on the time interval
between pre-treatment imaging and end of
treatment, showing that discrepancy between
planned and delivered doses to the rectum wall
can increase significantly for treatment planning
times greater than one and a half hours. The
reason for this is most likely down to the possible
intra-fraction motion of the prostate as well as
its swelling due to the oedema caused by needle
insertion.
What are the implications of this
research?
This research demonstrates the practical and
cultural importance of IVD in the clinical routine
for HDR brachytherapy. Practical, because it
represents an instrument to perform an overall
MEET THE NEW EDITOR
independent QA of the treatment procedure.
Cultural, because it forces the brachytherapy
team to be self-critical and to examine in depth
any possible source of discrepancy between
calculated and measured dose. In particular, we
found that intra-fraction motion and change of
the prostate might take place in HDR prostate
brachytherapy with TRUS-guided online
treatment planning. In light of this finding,
time between imaging and treatment should be
kept as low as possible to reduce dose delivery
uncertainties. Strategies are currently being
developed to reduce this time gap in our unit.
Overall, this work has reminded us of the truth of
the words of the writer Fyodor Dostoevsky: “The
cleverest of all, in my opinion, is the man who
calls himself a fool at least once a month.”
Mauro Carrara
Medical Physics Unit
Department of Diagnostic Imaging and
Radiotherapy
Fondazione IRCCS Istituto Nazionale dei Tumori
Milan, Italy
Anatoly Rosenfeld
Centre for Medical Radiation Physics
University of Wollongong
Wollongong, Australia
EDITORS’ PICKS
BRACHYTHERAPY
Longitudinal assessment of
quality of life after surgery,
conformal brachytherapy, and
intensity-modulated radiation
therapy for prostate cancer
Zelefsky MJ, Poon BY, Eastham J, Vickers A, Pei X, and
Scardino PT
Radiother Oncol. 2016 Jan;118(1):85-91. doi: 10.1016/j.radonc.2015.11.035. Epub 2016 Jan 9.
What was your motivation for initiating
this study?
Our motivation was to perform a carefully
designed longitudinal quality-of-life analysis,
which would compare quality-of-life outcomes
between intensity-modulated radiotherapy
(IMRT), conformal brachytherapy and surgery.
Previous quality-of-life studies had not routinely
incorporated patients who had been treated
exclusively with highly conformal radiotherapy
treatments, such as IMRT or brachytherapy with
intraoperative real-time planning, and so this was
an opportunity to gather prospectively qualityof-life assessments on patients receiving state of
the art radiotherapy approaches.
What was the main challenge during the
work?
The main challenge was to obtain the quality-oflife assessments at the appropriate point in time
and to get patients to complete their surveys. In
this study we obtained baseline assessments as
well as post-treatment assessments at 3, 6, 9, 12,
15, 18, 24, 36, and 48 months after treatment.
What are the most important findings of
your study?
MICHAEL J. ZELEFSKY
INTRODUCTION
We found that at 48 months after therapy,
patients who underwent radical prostatectomy
still showed persistently worse urinary
incontinence scores compared to those patients
who were treated with IMRT or conformal
brachytherapy. As shown in other studies,
MEET THE NEW EDITOR
EDITORS’ PICKS
Highlight Brachytherapy Papers
troublesome urinary symptoms ended up being
more prevalent in the radiotherapy-treated
patients. A very interesting finding in this study
is that while all patients experienced decrement
of their sexual function, patients treated with
prostatectomy experienced significantly greater
decline in their sexual function compared to
patients treated with IMRT and brachytherapy.
Finally, in contrast to other quality of life
studies, our report demonstrated that patients
treated with IMRT and brachytherapy did not
show worsening of rectal symptoms with time,
presumably related to the fact that these patients
were treated with highly conformal techniques.
What are the implications of this
research?
One of the first dilemmas that faces patients who
present with clinically localised prostate cancer
is selecting their optimal therapy. This quality of
life study could be very helpful for those patients,
and their physicians, as it draws on information
from those treated with modern radiotherapy
techniques.
Michael J. Zelefsky
Department of Radiation Oncology
Memorial Sloan Kettering Cancer Centre
New York, USA
EDITORS’ PICKS
PHYSICS
INTRODUCTION
LET’S CALL THE WHOLE THING OFF
EDITORS’ PICKS
WIL VAN DER PUTTEN
Dear colleagues,
PHYSICS
What is in a name? That is the topic of the article of Dirk Verellen
explaining to us all the names nowadays used for high-precision radiation
therapy that is delivered in only one or a few fractions. Have a read of the
article and let us know what you think.
What is in a name?
That is the topic of the
article of Dirk Verellen
explaining to us all the
names nowadays used for
high-precision radiation
therapy that is delivered
in only one or a few
fractions
This corner also highlights four scientific papers covering a broad range
of topics in the field of radiotherapy physics. BrachyView is a device
developed by Mitra Safavi Naeini and co-workers to track in real time
the location of the brachytherapy source. Roel Rozendaal investigated the
impact of daily anatomical changes in EPID-based in vivo dosimetry.
An important outcome of this and a follow-up study is that there is room
for margin reduction for the treatment of head and neck cancer. Dualenergy X-ray imaging is a promising technique to enhance automated
lung tumor tracking. However, Martin Menten, demonstrated in an
experimental as well as in a simulation study that patient geometry is still
the most important factor determining the success of tumor tracking.
Finally, Massimo Pinta describes the construction of a novel and a
functional graphite calorimeter as a standard of absorbed dose to water in
medium energy X-rays.
MISCHA
HOOGEMAN
BRENDAN
MCLEAN
The corner ends with an obituary for Wil van der Putten remembering his
great contributions to the field of medical physics in Ireland and outside.
Wil van der Putten passed away on 26 February this year.
Best regards,
Mischa Hoogeman (m.hoogeman@erasmusmc.nl)
Brendan Mclean (Brendan.McClean@slh.ie)
and Christian Richter (christian.richter@oncorayde)
INTRODUCTION
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CHRISTIAN
RICHTER
WIL VAN DER PUTTEN
PHYSICS
Potato… potato,
tomato… tomato.
Let’s call the whole
thing off
DIRK VERELLEN
INTRODUCTION
Controversies and uncertainties around the use
of the term ‘stereotactic’ in radiotherapy
Stereotactic radiosurgery (SRS), stereotactic
frameless image-guided radiotherapy, stereotactic
body radiotherapy (SBRT), stereotactic ablative
radiotherapy (SABR), … radiotherapy; even
if we don’t get confused, our colleagues from
other disciplines and policy makers surely will.
More to the point: why this strange affection for
“stereotaxis” when, in most cases, the invasive
frame with its reference co-ordinate system is
no longer used, and image-guidance is key for
high precision and managing sharp dose falloff in a non-rigid human body? To increase the
confusion even more, some groups started using
the term SABR, it being more catchy, as in: “Let’s
SABR the tumour”. In many cases though, we do
not want to be ablative, yet we’re stuck with this
label “stereotactic”.
The need for appropriate labelling is illustrated
by the fact that it is a recurring topic during
coffee breaks on the ESTRO course “Clinical
practice and implementation of image-guided
stereotactic body radiotherapy”. To be stereotactic
or not to be, inspired one of the participants
(Anna Ralston) to rename the thing HAMLET
(Hypofractionated And Motion Limited
LET’S CALL THE WHOLE THING OFF
External Therapy). My personal favourite is
HIGHP (pronounced “hype”) referring to
Hypofractionated Image-Guided High Precision
radiotherapy.
According to the American Association of
Physicists in Medicine (AAPM) task group 101
report, the major feature separating SBRT from
conventional radiation treatment is the delivery
of large doses in a few fractions, which results in a
high biological effective dose [1]. The Netherlands
Commission on Radiation Dosimetry (NCS)
report 25 on “Process Management and Quality
Assurance for Intracranial Stereotactic Treatment” also struggled with the definition of
“stereotactic treatment”, defining it as a collective
substitute for high-fraction dose, high-precision
techniques [2]. In any case, we can offer many
arguments against the use of (invasive) framebased techniques and thus omit the stereotactic
label. But that’s not the point. After all, almost
everyone calls the delicious, golden brown, crispy
finger-like potato chips fried in oil, “French fries”,
whereas the French had little to do with their
invention (the Belgian author acknowledges a
possible bias on this matter).
Drawing a parallel to our own discipline, a
similar confusion exists with the label IMRT.
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WIL VAN DER PUTTEN
The good-old shielding block, is it not some kind
of binary intensity modulation? From shielding
block, to wedge, to dynamic wedge to moving
leaves; where do we draw the line for separating
open beam from intensity modulated? Yet,
everyone understands what we mean by “IMRT”.
So, why not keep the label “SBRT”, because it is
generally accepted to cover the concept of a highdose-per-fraction-high-precision technique. After
all, HDFHPRT is not catchy.
The central issue in this discussion, however, is
not the name. The discussion hides a much more
fundamental question in that what we used to
call stereotactic (body) radiotherapy is simply a
high-precision conformal radiotherapy technique
that comes in a variety of fractions (in many
cases not ablative, by the way). Basically, it refers
to exploiting new insights in radiobiology and
managing sharp dose gradients in a changing
anatomy.
The AAPM task group 101 reports: “The
practice of SBRT [therefore] requires a high
level of confidence in the accuracy of the entire
treatment delivery process”. One can argue,
however, that this has been the leading theme
of radiotherapy all along. Today’s conventional
radiotherapy is, by definition, high precision
(image-guided) covering a whole spectrum of
dose fractionations. With the current generation
of treatment machines, there is no longer a
technical barrier to warrant segregation between
SRS / SBRT and good practice radiotherapy.
INTRODUCTION
Of course, innovative techniques need to be
accompanied by appropriate and dedicated
quality assurance procedures, maintaining a safe
and patient-friendly clinical implementation.
Each new treatment modality inevitably comes
with new dosimetric and radiobiological
challenges. New processes need to be carefully
validated, and non-conventional fractionation
schemes need to be carefully monitored in wellconducted clinical trials. But again, this has
been the modus operandi of radiotherapy since
the beginning of the previous century. In the
early days of development of IMRT and SRS,
target localisation was distinctly different from
mainstream conventional radiotherapy. But,
with the mainstream adoption of volumetric
modulated arc therapy (VMAT) and cone beam
computed tomography (CBCT) (just to give one
example), do we still have arguments to draw
what becomes a purely artificial line?
REFERENCES
[1] Benedict SH, et al Stereotactic body radiation therapy: the report of AAPM task group 101. Med Phys 2010;
37(8): 4078-4101.
[2] Report 25 of the Netherlands Commission on Radiation Dosimetry: Process Management and Quality Assurance for Intracranial Stereotactic Treatment.
[3] George and Ira Gershwin, Let’s call the whole thing
off, 1937.
To conclude with the lyrics of George and Ira
Gershwin [3]: “Potato, potahto, tomato, tomahto.
Let’s call the whole thing off.”
Dirk Verellen
Physics committee member
Medical Physics Radiation Oncology
UZ Brussel
Vrije Universiteit Brussel (VUB)
Brussels, Belgium
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PHYSICS
Highlight Radiotherapy Physics Papers
BrachyView, a novel in-body imaging system
for HDR prostate brachytherapy: experimental
evaluation
Impact of daily anatomical changes in EPID-based in
vivo dosimetry of VMAT treatments of head & neck
cancer
Safavi-Naeini M, Han Z, Alnaghy S, Cutajar D, Petasecca M,
Lerch M L F, Franklin D R, Bucci J, Carrara M, Zaider M, and
Rosenfeld A B
Med. Phys. 42, 7098 (2015); doi: 10.1118/1.4935866
Rozendaal RA, Mijnheer BJ, Hamming-Vrieze O, Mans A, van
Herk M.
Radiother Oncol. 2015 Jul; 116(1):70-4. doi: 10.1016/j.radonc.
2015.05.020. Epub 2015 Jun 30
Using dual-energy X-ray imaging to enhance
automated lung tumour tracking during realtime adaptive radiotherapy
A graphite calorimeter for absolute measurements
of absorbed dose to water: application in mediumenergy x-ray filtered beams
Menten MJ, Fast MF, Nill S, and Oelfke U
Medical Physics 42, 7098 (2015); doi: 10.1118/1.4935866
Pinto M, Pimpinella M, Quini M, D’Arienzo M, Astefanoaei I,
Loreti S, Guerra AS
Phys Med Biol. 2016 Feb 21;61(4):1738-64. doi: 10.1088/00319155/61/4/1738. Epub 2016 Feb 3
INTRODUCTION
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PHYSICS
BrachyView, a novel
in-body imaging system
for HDR prostate
brachytherapy:
experimental
evaluation
Safavi-Naeini M, Han Z, Alnaghy S, Cutajar D, Petasecca M,
Lerch M L F, Franklin D R, Bucci J, Carrara M, Zaider M, and
Rosenfeld A B
Medical Physics 42, 7098 (2015); doi: 10.1118/1.4935866
MITRA
SAFAVI NAEINI
INTRODUCTION
What was your motivation for initiating
this study?
In 2015, more than 25% of all new cases of cancer
in males were prostate cancer. High dose-rate
prostate brachytherapy (HDR-PBT), in which
a single high-activity gamma source is inserted
into the prostate, moved through a pre-planned
series of positions and then removed, is a popular
treatment option for localised advanced prostate
cancer (stage T3).
HDR-PBT has been shown to provide good
relapse-free survival outcomes compared to
other forms of radiation treatments. An imagebased treatment planning system is used to
generate a map of the optimal source positions
and dwell times in order to maximise tumour
destruction and minimise harm to surrounding
tissues (such as the rectum, bladder and urethra).
A mechanism for providing accurate real-time
source position tracking will allow the operator
to guarantee the correct delivery of radiation
to the treatment volume, and fine-tune source
positioning or dwell time – for example, in
response to anatomical changes that may occur
throughout the treatment process, and which
may extend over two days.
Our study demonstrates that BrachyView, our
in-body source tracking system, is capable
of tracking the source in real time with submillimetre accuracy throughout the entire
prostate volume.
What were the main challenges during
the work?
Accurately fabricating a tungsten pinhole
collimator with the required geometry proved
very challenging, and the final design includes
a calibration step post assembly, to account for
unavoidable variability in the manufacturing
process. The detectors also typically include some
dead or noisy pixels; these need to be carefully
masked and filtered in software. Material
selection was also critical, as the probe needs to
comply with clinical regulations while avoiding
backscatter radiation and other undesirable side
effects.
What are the most important findings of
your study?
This study experimentally confirmed our
previously published simulation results; more
than 90% of the evaluated source positions were
resolved with an error of less than 1mm. The
results of this study inspired several additional
ANATOLY
ROSENFELD
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Highlight Radiotherapy Physics Papers
improvements in the design of HDR BrachyView
(both in hardware and software), and we expect
to be able to achieve further improvements in
accuracy ahead of clinical trials.
What are the implications of this
research?
BrachyView provides valuable real-time quality
assurance information throughout the HDRPBT procedure. Our device will allow clinicians
to quantify any deviation from the pre-planned
dose with high precision. By integrating real-time
position feedback into the treatment planning
and delivery process, it will also be possible
to modify the plan in real time in response to
anatomical changes or other detected positioning
errors.
Mitra Safavi-Naeini and Anatoly Rosenfeld
Centre for Medical Radiation Physics,
University of Wollongong
Wollongong, Australia
INTRODUCTION
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PHYSICS
Impact of daily anatomical
changes in EPID-based in
vivo dosimetry of VMAT
treatments of head & neck
cancer
Rozendaal RA, Mijnheer BJ, Hamming-Vrieze O, Mans A, van
Herk M.
Radiother Oncol. 2015 Jul; 116(1):70-4. doi: 10.1016/j.
radonc.2015.05.020. Epub 2015 Jun 30
What was your motivation for initiating
this study?
Patient-specific quality assurance is performed
in our clinic by using 3D in vivo electronic portal
imaging device (EPID) dosimetry. In routine
clinical practice, the EPID images recorded
during treatment of the patient, together with
the planning-CT, are used to reconstruct the
delivered in vivo 3D dose distribution in the
patient. For head-and-neck volumetric modulated
arc radiotherapy (VMAT) treatments, a relatively
large number of deviations in the in vivo dose
distribution are observed. Also, it is known from
Image Guided Therapy (IGRT) that anatomical
deformations are quite common in head-andneck cancer patients. Thus, we decided to try to
quantify the effect of anatomical changes on in
vivo EPID dosimetry.
What were the main challenges during
the work?
ROEL ROZENDAAL
INTRODUCTION
In order to quantity the effect of anatomical
changes, daily anatomical information in the
form of cone-beam CTs (CBCTs) was used. By
reconstructing the in vivo dose distribution for all
fractions twice, once using the planning-CT and
once using the CBCT, we were able to accurately
calculate the change in delivered dose due to
anatomical changes. Furthermore, it allowed us
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to inspect dosimetric differences over time. For
reference, we also needed to include the effect
of anatomical changes on the TPS-calculated
dose. All in all, the main challenge consisted of
gathering and processing lots of data in different
places: 600 CBCTs and 1,200 EPID films were
used to create an additional set of 600 TPS dose
distributions, based on CBCT-anatomy, and
two sets of 600 in vivo dose distributions each
based on either CBCT-anatomy or on planningCT-anatomy. Adding to the complexity of the
task was the need to use deformable image
registration for registering the planning-CT to
the CBCT, as the CBCTs are not suitable for dose
computations directly.
What is the most important finding of
your study?
The most important finding is that the effect of
anatomical changes on planning target volume
(PTV) coverage is much smaller than expected.
According to treatment planning system (TPS)
calculations alone, the effect is negligible.
However, transit-dosimetry is more sensitive to
anatomical changes because changes at both the
entrance and the exit side of the patient influence
the signal. But even then, the effect is quite small:
the anatomical changes account for only 20%
of the observed transit-dosimetry deviation.
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Another finding is that the observed impact of
anatomical changes can be well explained by a
very simple model of the anatomical changes
present.
What are the implications of this
research?
In practice, these results mean that the
logistically rather complicated method of CBCTinclusion for transit in vivo dosimetry is not
needed in clinical practice for verification of
head and neck cancer treatments. Also, it was
a first indication that there is room for margin
reduction for head and neck VMAT treatments in
our institute. Further investigations showed that
there was indeed room for margin reduction for
these treatments.
Roel Rozendaal
Department of Radiation Oncology
The Netherlands Cancer Institute
Amsterdam
The Netherlands
INTRODUCTION
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PHYSICS
Using dual-energy X-ray
imaging to enhance
automated lung tumour
tracking during real-time
adaptive radiotherapy
Menten MJ, Fast MF, Nill S, and Oelfke U
Med Phys 42, 6987 (2015); http://dx.doi.org/10.1118/1.4935431
What was your motivation for initiating
this study?
Lung tumour motion may diminish the effect of
radiotherapy as it can cause under-dosage of the
target and additional irradiation of surrounding
healthy tissue. Recent research has focused on
mitigating the impact of tumour motion by
adapting the treatment in real-time. This can be
achieved, for example, by gating the treatment
beam, repositioning the entire patient using a
robotic treatment couch or adapting the radiation
beam by changing the multi-leaf collimator’s
aperture, the position of the treatment head or
entire linear accelerator.
In order to succeed, all of these adaptation
methods require real-time information about
the tumour position. One way to obtain this
information is by continuously acquiring
radiographs of the patient undergoing treatment
using an on-board kV imager featured on most
modern clinical linear accelerators. However,
bony anatomy, for example ribs or the spine, can
obscure the tumour in these images. Differential
motion of the tumour and superimposed bones
decreases the accuracy of automated tumour
localisation algorithms.
MARTIN J MENTEN
INTRODUCTION
UWE OELFKE
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Research in diagnostic kV imaging has shown
that dual-energy (DE) imaging is able to reduce
the visibility of bones in chest radiographs.
DE imaging exploits the dependency of tissue
contrast on the imaging energy by acquiring two
kV images at different energies and combining
them via weighted logarithmic subtraction.
This study was motivated by the potential of
harnessing DE imaging for real-time lung
tumour tracking. We wanted to investigate
whether its deployment would allow for accurate
and reliable automated tumour localisation.
What were the main challenges during
the work?
Our work is split into an experimental and a
computer simulation part, which both featured
unique challenges. We began our study by
experimentally acquiring DE images of an
anthropomorphic breathing chest phantom with
a modified X-ray volume imaging (XVI) system
(Elekta AB, Stockholm, Sweden). We showed
that DE imaging was able to increase tumour
localisation accuracy by reducing the visibility
of the phantom’s artificial ribs. However, we
realised that the phantom’s simplistic geometry
was a shortcoming of our experiment. The main
problems were the large tumour size and the low
radiodensity of the foam material functioning as
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lung tissue. These resulted in an unrealistically
high tumour-to-background contrast.
As we were not able to experimentally acquire
DE images of actual lung cancer patients, we
decided to develop a Monte Carlo simulation
based on Geant4 to generate such radiographs.
The simulation included the XVI system’s X-ray
tube, voxelised patient geometries based on CT
scans and the flat panel detector. Each of these
components had to be validated separately by
comparing it to experiments or results reported
by others. Another challenge regarding the
Monte Carlo simulation was the large amount of
computational time required to generate all 72 kV
images used in this study (six patients from four
imaging beam angles at three imaging energies).
What is the most important finding of
your study?
We found that the visibility of bones obscuring
the tumour in X-ray images was reduced through
DE imaging. For some simulated patient cases
and imaging beam angles, this resulted in
increased tumour localisation accuracy. However,
DE imaging was still affected by some of the
same limitations as single-energy projection
X-ray imaging, in particular; poor tumour-tosoft-tissue contrast, caused by large patient size or
INTRODUCTION
the tumour being obscured by the mediastinum
or diaphragm, could inhibit reliable automated
determination of the tumour position.
What are the implications of this
research?
The accuracy of automated tumour localisation
without the use of additional fiducials inserted
near the tumour depends very much on
tumour-to-soft-tissue contrast, which cannot
be meaningfully increased by DE imaging. As
this contrast is dictated by the specific patient
geometry and the angle of the imaging beam, we
believe that successful clinical implementation of
markerless real-time tumour tracking based on
X-ray projection imaging would rely on careful
pre-selection of patients based on these criteria.
Martin J Menten and Uwe Oelfke
Joint Department of Physics
Institute of Cancer Research and
The Royal Marsden NHS Foundation Trust
London, UK
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PHYSICS
A graphite calorimeter for
absolute measurements of
absorbed dose to water:
application in mediumenergy x-ray filtered
beams
Pinto M, Pimpinella M, Quini M, D’Arienzo M, Astefanoaei I,
Loreti S, Guerra AS
Phys Med Biol. 2016 Feb 21;61(4):1738-64. doi:
10.1088/0031-9155/61/4/1738. Epub 2016 Feb 3
MASSIMO PINTO
INTRODUCTION
What was your motivation for initiating
this study?
Medium-energy X-rays are currently used for
treating skin cancers and other benign skin
diseases, and their dosimetry should be based
on the quantity absorbed dose to water (Dw),
as recommended by the International Atomic
Energy Agency (IAEA) Technical Report Series
(TRS) 398 international protocol for dosimetry
in radiotherapy. However, after more than a
decade from the publication of the IAEA TRS
398, a robust system of Dw primary standards is
still lacking for kilovoltage X-rays, and reference
dosimetry still requires application of correction
and conversion factors that are, in general,
affected by a large uncertainty. To overcome
this condition, the Italian National Institute of
Ionizing Radiation Metrology (ENEA-INMRI)
decided to build a graphite calorimeter, in a water
phantom, and verified its operation – in mediumenergy X-ray filtered beams – as a primary
standard instrument to measure the physical
quantity Dw.
Our new Dw primary standard adds to three
water calorimeters already operative in the EU,
as Dw standards for medium-energy X-rays.
The standard will therefore contribute towards
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establishing a reference Dw system, based on
different calorimeters and measuring methods,
that is expected to improve the accuracy of
radiotherapy dosimetry in the medium-energy
range, towards the accuracy level that is currently
achieved in the high-energy range.
What were the main challenges during
the work?
Our major challenges were the construction of
the calorimeter itself, and the conversion of the
quantity that we measured directly, absorbed
dose to graphite, to the quantity of interest in
radiation therapy dosimetry, absorbed dose
to water. This required conversion coefficients
and correction factors that we calculated using
the Monte Carlo method. The nature of these
corrections and conversions is due to differences
in the scattering and absorption properties
of graphite relative to water, which become
substantial at lower photon energies. We had
to split the physical problems in many parts to
appreciate the details of the phenomena involved.
Together with that, we had to take into account
the very fine construction details of the core
of the calorimeter, which contains other nongraphite materials that are essential for the
operation of the standard, but which are very
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different from graphite, including the very thin
platinum-iridium electrical wires. The low signalto-noise ratio was an additional challenge.
What is the most important finding of
your study?
Since the aim of the study was the construction
of a novel instrument to measure absorbed dose
to water, the main finding is arguably that the
instrument was completed successfully, and
that it performed as expected. To verify this, we
compared the measurement obtained with the
newly established standard with that of another,
more indirect method that we had available in
our institute, and we have reported this in the
manuscript. But, more importantly, we compared
the results of our measurements to those made
with the three water calorimeters that existed
in the EU. Results of this first international
measurement comparison of absorbed dose to
water in medium-energy X-ray beams are being
reported in another paper.
What are the implications of this
research?
graphite calorimeter as a standard of absorbed
dose to water in medium energy X-rays was, to
our knowledge, unprecedented. In metrology
science we know that to avoid bias it’s very
important to measure a physical quantity with
as many different methods as possible. When
this happens, and the different measurements
agree, we say that that specific metrology got
stronger, and we collectively gain confidence in
what we are measuring. To say that with more
confidence, however, we will need to increase
the measurement accuracy of our new graphite
calorimeter. We are already working on that and
the first results look very promising.
Massimo Pinto
Istituto Nazionale di Metrologia delle Radiazioni
Ionizzanti
Centro Ricerche ENEA Casaccia
Rome, Italy
There is an additional implication which will
impact on clinical dosimetry: the availability
of a robust system of Dw primary standards
will contribute not only to improved accuracy
of dosimetry in medium-energy X-rays, by
providing measurement traceability to absorbed
dose to water primary standards, but also by
reducing the uncertainty of ionisation chamber
correction factors, compared to the values that
are used currently.
Graphite calorimeters have already been used
as standards of absorbed dose to water at higher
photon energies, such as those emitted by
Cobalt-60 sources. But establishing a functional
INTRODUCTION
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WIL VAN DER PUTTEN
PHYSICS
It was with great
sadness that we heard
of the death of our close
friend and colleague,
Wil Van Der Putten
It was with great sadness
that we heard of the death
of our close friend and
colleague, Wil Van Der
Putten, on 26 February this
year. In 1995 Wil founded
the Department of Medical
Physics and Bioengineering
at University Hospital
Galway, Ireland, and worked there as Chief
Physicist and head of the department until his
recent retirement in February 2016.
As an Adjunct Professor at the National
University of Ireland (NUI) Galway, he also
created an MSc in Medical Physics in 2003
and was particularly proud when it achieved
accreditation from the Commission on
Accreditation of Medical Physics Education
Programmes (CAMPEP) in 2015. He shared his
great knowledge and enthusiasm for physics with
generations of MSc and PhD students over the
years, and many graduates of the Galway MSc in
Medical Physics are now working professionally
or academically in the field across the world.
BRENDAN
MCLEAN
INTRODUCTION
European Federation of Organisations in Medical
Physics (EFOMP) and the International Atomic
Energy Agency (IAEA) for many years and
attended ESTRO Physics Committee meetings on
a number of occasions to represent the views of
EFOMP.
Within Ireland, Wil was well known to medical
physicists across the disciplines of diagnostic
imaging, radiotherapy and radiation protection,
as well as clinical engineering. Across Europe and
further afield in Canada, he was also known and
respected. His enthusiasm, energy and creative
thinking made an impact on everyone who met
him. He was very generous with his time and
everyone who worked with him felt the warmth
of his personality. He will be greatly missed by all
who knew him.
May he rest in peace.
Brendan McClean
Physics Corner editor
Wil was also a Director and co-founder of the
CAMPEP medical physics residency training
programme in Ireland. He was involved with the
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RTT
INTRODUCTION
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
Welcome to the RTT Corner. For all of you who joined us at the ESTRO
meeting in Turin, we hope that you had an enjoyable and productive time.
RTT
Ultrasound images, in
addition to being able
to guide radiotherapy,
can be used to gather
important information,
for instance, on bladder
filling
To round off the series of paper reviews on different image-guided radiation
therapy (IGRT) topics, Philipp Scherer reviews two reports on the use of
ultrasound images to guide radiotherapy. Along with the use of surface
scanners and the increasingly popular option of magnetic resonance (MR)guided radiotherapy, this method offers the possibility of image guidance
without administering additional radiation doses. These articles also show
that ultrasound images, in addition to being able to guide radiotherapy, can
be used to gather important information, for instance, on bladder filling.
Furthermore, in honour of the 20th anniversary of the Irish national RTT
society, the Irish Institute of Radiography and Radiation Therapy (IIRRT),
our colleagues from Ireland offer us an insight into their national society
and how it has developed over the years. In particular, they chart its
evolution from a typical radiographers’ society, which due to the size of the
profession was mainly led by radiographers, towards one where RTTs are
equal partners within a mixed society. This shift in the society’s character
can also be seen at different stages in some other European societies.
PHILIPP SCHERER
DANILO PASINI
We hope that you enjoy reading this RTT Corner. If you would like to
contribute or have ideas for future inclusions in the RTT Corner or ESTRO
newsletter, please don’t hesitate to contact Philipp (p.scherer@salk.at) or
Danilo (danilo_pasini@yahoo.it). Also, if you would like to contribute to
the work of the ESTRO RTT committee and missed the chance to chat
with us in Turin, please get in touch with us, or contact Viviane van Egten
(vvanegten@estro.org) at the ESTRO office.
Philipp Scherer and Danilo Pasini
p.scherer@salk.at - danilopasini@yahoo.it
INTRODUCTION
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
RTT
PAPER REVIEW:
A comparative assessment
of prostate positioning
guided by threedimensional ultrasound
and cone beam CT
Li M, Ballhausen H, Hegemann NS,
Ganswindt U, Manapov F, Tritscher S, Roosen
A, Gratzke C, Reiner M and Belka C
Radiation Oncology (2015) 10:82
In this small study with six patients the authors
aim to evaluate the accuracy of a threedimensional ultrasound system used for prostate
positioning and compare the data with seedand bone-based positioning using kilo-voltage
cone-beam computed tomography (CBCT). 3D
ultrasound (3DUS) scans were performed and
CBCT was only required twice a week. This
resulted in a total of 78 ultrasound scans being
compared to the CBCT scans. The reference
3DUS scan was recorded directly before the
planning CT with a slice thickness of 3mm. The
3DUS was performed directly on the CT couch
and with minimal time between the two scans
to minimise the risk of patient/organ motion.
Likewise, after the patients were positioned
using skin marks, the 3DUS performed and the
CBCT were performed successively with minimal
interval. In 84% of the fractions the 3DUS
could be used to record the prostate position
successfully with insufficient bladder filling
and patient movement being the main reason
hindering the 3DUS.
The comparison of the 3DUS data and the seed
matching using the CBCT showed differences
ranging from 5.6mm to -6.9mm in lateral,
2.9mm to -10mm in longitudinal and 7.2mm to
-7.3mm in vertical direction. The corresponding
INTRODUCTION
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
average discrepancies and standard deviations
were -0.2mm ± 2.7mm, -1.9mm ± 2.3mm and
0.0mm ± 3.0mm. The vertical difference in
longitudinal direction was statistically significant
with a p-value <0.001 while the discrepancies
in the other directions were not statistically
significant. The comparison of the 3DUS and
CBCT bone match showed not statistically
different values and similar average position
errors. The authors do not report the in-depth
analysis of the discrepancies between bone match
and 3DUS. However, the detected mean position
errors and standard deviations relative to the
seed match show similar values. These lead the
authors to the conclusion, that the 3DUS can
safely be used with an accuracy similar to that
of a CBCT with bone matching, and improving
the accuracy compared to positioning on skin
marks only (especially in longitudinal and
vertical direction). In the discussion, the authors
explain that the professionals using the 3DUS
have to be well trained, because there is evidence
that the pressure applied during the 3DUS has
an impact on the position of the prostate. Taking
this into account, the authors conclude that the
3DUS can achieve a similar accuracy as a CBCT
bone match, but without the need of applying an
addition radiation dose.
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
RELEVANCE TO RTTS
This article, together with others, reports on
the pros and cons of the use of ultrasound for
image guidance, and shows that 3DUS can be
used to detect and correct for the position of
the prostate in IGRT. However, as stated by
the authors, appropriate training is essential to
ensure that adequate pressure is used to minimise
prostate displacement due to the 3DUS procedure
itself. Interestingly, the authors only state that
insufficient bladder filling hindered the 3DUS,
but did not actually reflect on the detection
of insufficient bladder filling due to time and
workflow issues. Quickly detecting insufficient
bladder filling and asking the patient to drink
and wait until the bladder is sufficiently filled
could have added an additional reportable benefit
of an ultrasound-based system.
Philipp Scherer
RTT corner co-editor
INTRODUCTION
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
RTT
PAPER REVIEW:
Assessing the daily
consistency of bladder
filling using an ultrasonic
Bladderscan device in men
receiving radical conformal
radiotherapy for prostate
cancer
Hynds S, McGarry CK, Mitchell DM, Early S,
Shum L, Stewart DP, Harney JA, Cardwell CR
and O’Sullivan JM
The British Journal of Radiology, 84 (2011), 813-818
The authors present a study on evaluating the
effectiveness of a bladder-filling protocol to
achieve a consistent and reproducible bladder
volume using the data of 30 patients. The
instructions of the bladder filling protocol were to
“void the bladder and then drink 500ml of water
within the next 15 minutes”. Thirty minutes
later the patient should have their planning scan
taken or receive treatment. The bladder volume
was recorded prior to the planning scan in the
treatment position and prior to each treatment
fraction respectively. The measurements were
performed using a transabdominal bladder
ultrasound device. Additionally, as this protocol
relies on a consistent rate of bladder filling
throughout the whole treatment, the bladder
inflow throughout the approximately 45 minutes
was also evaluated. Data on the bladder filling
post-void and immediately before the planning
scan were used and compared to an equivalent
measurement at the final radiotherapy fraction.
The authors report that the comparison of the
bladder volumes showed that in more than 50%
of the fractions the bladder volumes differed
by more than <100ml from the volume at the
planning scan. Additionally, the volumes varied
a lot between the patients with volumes at the
planning scan ranging from 89ml of 608ml and
INTRODUCTION
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
64ml of 339ml on the last fraction respectively.
Furthermore, huge variations were found in
the bladder filling of each patient – based on
the coefficient of variation the authors report
that the patient with the least variable bladder
volume showed data with a range of 29ml of
461ml. A search for correlations between patient
characteristics, GFR and IPSS score with the
bladder volume data showed no correlations. A
further analysis showed that the average bladder
inflow was nearly reduced to half the amount
resulting in 2.5ml/min (SD ±2.9 ml/min) on the
last fraction compared to 4.6ml/min (SD ±1.8ml/
min) at time of the planning scan. Last but not
least, the authors compared the bladder volumes
measured with the ultrasound to the volumes in
the planning scan and report a congruence of the
values.
In addition to the conclusion that using the
bladder filling protocol failed to provide
consistent and reproducible bladder volumes, the
authors discuss how bladder filling and inflow
is affected by several factors, such as state of
hydration, concomitant medication, compliance,
and several others. Furthermore, the authors
discuss the possible impact of the daily variation
of bladder volumes and acknowledge that the
small number of patients used in the study limits
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
the results. However, they also conclude that the
transabdominal ultrasound was quick, effective,
well tolerated and an accurate method to assess
bladder volumes.
REFERENCES
[1] Chang JS et al.: ‘Bladder filling variations
during concurrent chemotherapy and pelvic
radiotherapy in rectal cancer patients: early experience of bladder volume assessment using ultrasound scanner’. Radiation Oncology Journal 2013;
31(1):41-47
RELEVANCE TO RTTS
This study clearly demonstrated the difficulties
we face when trying to achieve a consistent and
reproducible bladder filing in our patients. But
maybe even more interesting, is that they also
provide us with the idea of using an ultrasound
to check the bladder filling prior to each fraction.
In a setting where we check the bladder filling
of our patients prior to administering a fraction,
the bladder filling protocol – and to some extent
the compliance – could be checked without
additional radiation dose and with little effort.
Another application of an ultrasound scanner
used to assess bladder volumes can be found in
the article [1] by Chang JS. Therefore, we should
keep in mind that there are other options than
kV and MV-Images that allow us to monitor
our patients. However, the pros and cons of each
option have to be prudentially compared before
choosing the modality for your IGRT protocols.
Philipp Scherer
RTT corner co-editor
INTRODUCTION
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
RTT
Creating a successful joint
national society: 20th
anniversary of the Irish
Institute of Radiography
and Radiation Therapy
(IIRRT)
The IIRRT was founded in 1996 as the Irish
Institute of Radiography, representing those
working in diagnostic imaging, nuclear medicine
and radiotherapy. It was set up following
extensive consultation and represented a break
away from the UK Society and College of
Radiographers. There were very few radiation
therapists (RTTs) in Ireland at that time and
the Council had one RTT representative. The
numbers of RTTs grew over the following years
as the service developed and expanded, and this
was reflected in a larger number of dedicated
RTT seats on the Council. Dedicated seats were
considered essential, as the initial process of open
regional representation would have mitigated
against the election of RTTs to Council. Over
the years the collaboration between the two
professions as equal partners in the Institute
flourished, leading ultimately, in 2005, to the
renaming of the Institute as the Irish Institute of
Radiography and Radiation Therapy.
The IIRRT supports the science and practice
of radiography and radiation therapy, and its
activities are directed at improving patient care
within healthcare settings by raising education
standards, encouraging research and producing
best practice guidelines. In particular, the IIRRT
facilitates continuing professional development of
INTRODUCTION
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
its members and encourages role development to
improve patient care and align with service need.
The IIRRT is celebrating 20 years as a successful
joint diagnostic imaging and radiation therapy
society. As a model, the joint approach to
a national society has benefits in terms of
protecting and promoting radiography and
radiation therapy, addressing issues that affect
both professions, while promoting the unique
agendas of each profession and safeguarding
their professional interests at local, national
and European levels. This is possible and has
worked successfully in the Irish context as both
professions have some common goals, such
as improving patient care and safety through
evidence-based practice and education. Coupled
with this, both professions are equal in all
society affairs, including management, decisionmaking and resource allocation. The society
ensures this equal attention to matters through
the establishment of the IIRRT national council,
where clinical representatives are included from
all regional areas and represent both professions
with dedicated seats, as well as management,
academic and student representatives for both
professions to ensure each profession – from
student to practitioner to management – has a
voice at a national level.
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
One recent example of this joint approach was
a meeting with the Minister of Health in 2015
to promote the agenda for both diagnostic and
therapy professionals in relation to advanced
practice roles, diagnostic decision-making and
prescribing rights.
MARY COFFEY
IIRRT President and founding
member (1986-1988). Current
ESTRO Board member
LAURA MULLANEY
IIRRT President (2009-2011)
Current ESTRO youth
committee member
It is a challenge for any joint national society
to ensure parity of representation when one
profession is significantly smaller than the other,
as is frequently the case in diagnostic imaging
and radiation therapy across Europe. However,
instead of perceiving this as a weakness, RTTs in
Ireland have worked tirelessly with the support of
their diagnostic colleagues to ensure that this has
become a particular strength of the IIRRT.
The presidential role is alternated every two
years between the two professions to ensure
both have the opportunity to steer the individual
professional agenda. The society also offers
representation for each profession both nationally
and internationally.
INTRODUCTION
THERESA O’DONOVAN
Current IIRRT President
A/Deputy RTSM, Cork
University Hospital
MICHELLE LEECH
IIRRT Secretary (20092011). Current ESTRO RTT
committee chairperson
Ireland is a relatively small country, and the
IIRRT has found it very beneficial to have
both professions represented in a joint society
in order to raise pertinent professional issues
with the government. As both professions
have common generic professional issues
(improved recognition, continuous professional
development requirements and progression
to advanced practice) these can be raised
simultaneously in national discussions. Even
though a small profession, RTTs are afforded the
same opportunities as other professional groups
to contribute to meetings with health agencies
relating to national policy and development, as a
result of our position within a larger joint society.
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
In order to ensure that RTTs are equally
represented in a joint society, adequate
representation of RTTs on the society council or
board is paramount. This gives a stronger voice
to RTT issues within the society. Establishing
common goals for both professions to work
towards also permits a synergistic effort, which
benefits all. The society maintains open lines of
communication to all members using website,
email, social media updates and its journal, which
was established in 1998. The journal includes a
news section, thus ensuring that members are
updated on scientific, professional and social
issues that affect them and bridging the gap
between the Institute’s council and members in
clinical departments.
Best practice guidelines relative to both general
and specialist practice were drawn up in the early
days of the Institute and are regularly updated.
A joint professional group established the Irish
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
Institute of Radiography and Radiation Therapy
Qualifications Recognition Board in 2000. Over
its duration, a joint delegation met regularly
with the Ministry of Health and Children to
discuss professional issues. A mixed professional
group also participated in the multi-professional
working party charged with drafting the
Heads of Bill that led to the development of the
Statutory Body in 2014.
collaborative framework, but the rewards are
worth it.
Pictured are past IIRRT Presidents,
Mary Coffey, Laura Mullaney, current IIRRT
President, Theresa O’Donovan and past Secretary,
Michelle Leech.
An annual conference was organised at the
outset of the Institute with invitations extended
to speakers from other jurisdictions. In the
early phase of the Institute the links with the
larger Society and College of Radiographers
(UK) was maintained by joint attendance at the
annual conferences and an associated meeting
between the presidents and secretaries of the two
Institutes. This conference runs annually and has
a dedicated radiotherapy programme, coupled
with joint symposia.
The Irish experience has shown that RTTs can
be a strong force in a joint national society. It
requires commitment and dedication over an
extended time frame to achieve autonomy in a
INTRODUCTION
PAPER REVIEW: A COMPARATIVE
ASSESSMENT OF PROSTATE POSITIONING
PAPER REVIEW: ASSESSING THE DAILY
CONSISTENCY OF BLADDER FILLING
20TH ANNIVERSARY OF THE IRISH INSTITUTE OF
RADIOGRAPHY AND RADIATION THERAPY
RADIOBIOLOGY
INTRODUCTION
INTERVIEW WITH BRAD WOUTERS
INTERVIEW WITH ROB COPPES
RADIOBIOLOGY
His most recent
achievements as
committee chair include
the initiation of the
Radiobiology College, a
web-based radiobiology
network and registry of
radiobiology labs
Dear colleagues,
Our radiobiology committee has been chaired by Brad Wouters for a number
of years now, but this year he is handing over his responsibilities to a new chair,
Rob Coppes. As the chair of our committee, Brad has contributed to the ESTRO
scientific council, numerous scientific advisory groups and chaired many
radiobiology tracks at our ESTRO conferences. Our committee strongly supports
the radiobiology teaching courses, and under his guidance, the former molecular
radiobiology course was restructured and transformed into our current BBPRO
(Biological Basis of Personalised Radiation Oncology) course, with a stronger
link to clinical issues and the inclusion of important new themes, such as the
biology of imaging and the biological basis of radiotherapy immunotherapy combinations.
Throughout the years, Brad has been involved in many ESTRO conference
programmes, often seeking synergy by combining radiobiology topics and
symposia with the clinical. His most recent achievements as committee chair
include the initiation of the Radiobiology College, a web-based radiobiology
network and registry of radiobiology labs, and the organisation of a series of
workshops exploring the needs and opportunities in radiation oncology, a
collaboration between the ESTRO radiobiology and clinical committees.
ANNE KILTIE
We are very thankful for Brad’s commitment, guidance, creativity and valuable
input throughout the years. He has made a positive impact on our committee,
and we will be sad to see him leave. We took the occasion to interview him on
his past activities for this issue.
However, we are sure that with Rob Coppes we have found another strong
committee chair. Rob is a renowned professor of radiobiology, with strong
clinical links and a normal-tissue toxicity research focus. He has been a regular
at our ESTRO conferences, contributing with his research and on scientific
advisory boards. He also has recently become part of the clinical radiobiology
ESTRO course faculty. We are pleased to introduce you to Rob, our new
radiobiology committee chair, in the second short interview in this Corner.
INTRODUCTION
CONCHITA VENS
INTERVIEW WITH BRAD WOUTERS
MARTIN PRUSCHY
INTERVIEW WITH ROB COPPES
RADIOBIOLOGY
INTERVIEW WITH BRAD
WOUTERS, OUTGOING
CHAIR OF THE RADIOBIOLOGY COMMITTEE,
by Conchita Vens
Brad, you have been the chair of our
committee for many years. We very
much appreciated your guidance and
input and are sad to see you leave.
Looking back, which parts of this role
did you enjoy most?
Are there any particular investments
and launches that you would like to see
developed further?
Your commitment to ESTRO and our
committee has been remarkable, on a
scientific and professional level, but also
on a personal level as it often required
you to travel long distances. Where do
you get this energy from and what drives
you?
In these past years as chair, what
developments in ESTRO radiobiology
and radiobiology in general have you
witnessed?
The most enjoyable part of leading this
committee was our 'blue-sky' discussions on
how our committee could have an impact on
the wider ESTRO community. This involved
discussion on the best way to structure
our meetings, the messages we wanted to
communicate in our teaching courses, and the
ways in which the biology community could help
stimulate future research in our discipline.
Energy comes from my colleagues within the
ESTRO community. ESTRO places a strong
emphasis on biology and gives us the opportunity
to have impact. I am energised by the effort and
passion of the ESTRO staff and by the same effort
and passion of my colleagues who dedicate their
time to the Society.
I am particularly excited about two recent
initiatives that our committee started. The first
is a series of workshops that we hope will set
the stage for future research efforts in the area
of biology that can have impact on our field.
These workshops are focused on identifying
opportunities and setting challenges to
improve local control, systemic disease, and
patient toxicity. The second initiative is a new
Radiobiology College, which will serve as a home
to enable increased participation and interaction
amongst radiobiologists.
The Society has grown tremendously and the
role of biologists has changed. Many of our
“radiobiologists” are in fact cancer biologists.
It is essential that we continue to attract strong
biologists into our community and to ensure
that our discipline works together to identify
opportunities that can be addressed by the
biologists.
BRAD WOUTERS
INTRODUCTION
INTERVIEW WITH BRAD WOUTERS
INTERVIEW WITH ROB COPPES
What do you think are the most relevant
challenges that radiobiology is facing in
the future?
The discipline of radiation oncology is at an
inflection point. The incredible advances in
technology and dose delivery have produced
high-quality and safe therapies. The challenge for
our field is to embrace biology in a similar way to
the way that we have embraced physics.
Any tips for your successor Rob?
Speak up, have influence, and embrace your
biology colleagues. It’s your time now!
INTRODUCTION
INTERVIEW WITH BRAD WOUTERS
INTERVIEW WITH ROB COPPES
RADIOBIOLOGY
INTERVIEW WITH ROB
COPPES, INCOMING
CHAIR OF THE RADIOBIOLOGY COMMITTEE,
by Conchita Vens
Rob, please tell our readers a little about
who you are and your main research
aims.
I am professor of radiotherapy, with a focus on
the radiobiology of normal tissues, and I’m based
at the University Medical Centre Groningen,
The Netherlands. I work in the department of
Radiation Oncology, and since 2000, I’ve had
my own lab in the department of Cell Biology.
My lab developed in vivo and in vitro models
on purification and characterisation of mice,
rat and human salivary and thyroid glands, and
oesophagus stem / progenitor cells. Recently,
we developed a protocol for adult stem-cell
therapy for radiation-induced hyposalivation
and consequential xerostomia, which is now
being translated to the clinic. Another focus
of the lab is examining how tissues interact
within the radiation response, such as the now
commonly known interaction between lung and
heart damage. Currently, we are investigating
the possibly of growing patient-derived adult
tissue stem cells, as tissue resembling organoids
as well as tumour-derived organoids resembling
the original tumour (see diagrams at the end of
this article). We are investigating if the chemoradiation response of these organoids can be used
as a treatment predictor. In this way, we could
help to develop personalised medicine. Moreover,
these organoids could be used to study radiationinduced tumours and normal tissue effects and
carcinogenesis.
Is there a future for radiobiology?
In my opinion the future of radiobiology is
very bright. Using new techniques in the field
of DNA / RNA sequencing and DNA editing,
together with novel patient-specific models, such
as the organoid culture technique, we can study
treatment resistance, define resistance signatures
and use this knowledge to develop novel
therapeutics. Alongside this, current knowledge
of radiobiology can be translated to the clinic,
such as that of tissue interactions and the sparing
of parts of organs to allow maximal postirradiation normal tissue regeneration. Novel
techniques using proton and carbon ions will be
beneficial in this.
Where do you think radiobiology is
heading?
In the end, this must lead to a form of
personalised medicine, combining patients’
specific genetic, anatomical and (micro-)
environmental information.
How do you think radiobiologists can
contribute to the radiation oncology
field?
Improve our knowledge on normal tissue and
tumour response to radiation using the above
mentioned methods. In addition, more interaction between clinicians and physicists is
needed to translate these findings from biology to
the clinic.
ROB COPPES
INTRODUCTION
INTERVIEW WITH BRAD WOUTERS
INTERVIEW WITH ROB COPPES
What role does radiobiology have in
ESTRO?
I think biology should guide and teach. We
should find and develop useful tools for the
clinic to increase tumour response and decrease
toxicities. We should educate the radiation
oncology community on past, present and future
developments in the field of biology. Yes, not only
radiobiology, but also biology. Novel techniques in
biology show tremendous potential and should be
used to optimise radiotherapy.
How do you think the radiobiology
committee can contribute to ESTRO’s
vision?
How and where do you see your role as
chair of the radiobiology committee?
To help guide radiobiology into a novel and
exciting era of science where we all benefit
optimally from current developments and shared
knowledge.
What is your vision for the future of
radiobiology?
My aim for the future is for radiobiology to help
to optimise radiation oncology with patientspecific optimised tumour control with as low
as possible side-effects using biology-derived
therapies and predictive models.
By arranging interactions between everyone in
the field to collaborate, inform and teach.
How does the radiobiology committee
support ESTRO radiobiology members?
We are a platform for science interaction and
knowledge sharing. Joint meetings, such as
the Wolfsburg meeting are very important
for interactions between biologists (and bioclinicians), to share knowledge and have indepth discussions on sometimes very complex
issues. In this, we need to shape the scientific
direction of the field. In addition to this, the
ESTRO Radiobiology College, which is currently
being developed, aims to bring all European
radiobiology labs together to share knowledge
and techniques.
INTRODUCTION
Figure 1: Organoids as predictors of treatment response.
Biopsies are taken from the patient’s tumour and normal
tissue is expanded to organoids resembling the original
tissue. Patient-specific organoid-derived cells are treated with X-rays with or without chemotherapy and dose
response curves are created. DNA sequence and RNA
(ribonucleic acid) expression profiles are obtained from
the tumour and normal organoids. Meanwhile, the patient undergoes treatment and imaging of response. The
response of the organoids, DNA and RNA profiles and
patient response are linked to yield predictive, response
and resistance signatures.
INTERVIEW WITH BRAD WOUTERS
Figure 2: Salivary gland organoids (see Maimets et al.
Stem Cell Reports 2016, 6, 150-162).
INTERVIEW WITH ROB COPPES
ESTRO SCHOOL
OF RADIOTHERAPY AND ONCOLOGY
2016
WWW.ESTRO.ORG
POSTGRADUATE COURSES
IN EUROPE
BEST PRACTICE IN RADIATION ONCOLOGY –
A WORKSHOP TO TRAIN RTT TRAINERS
In collaboration with the IAEA
Part I - Train the RTT (Radiation Therapists)
trainers
MULTIDISCIPLINARY MANAGEMENT OF
HEAD AND NECK ONCOLOGY
26 - 29 June 2016 | Florence, Italy
ESNM/ESTRO COURSE ON MOLECULAR
IMAGING AND RADIATION ONCOLOGY
HAEMATOLOGICAL MALIGNANCIES
In collaboration with ILROG
19 - 22 May 2016 | Lisbon, Portugal
1 - 3 September 2016 | Vienna, Austria
MULTIDISCIPLINARY MANAGEMENT OF
PROSTATE CANCER
PALLIATIVE CARE AND RADIOTHERAPY
A course on prognosis, symptom control,
re-irradiation, oligometastases
22 - 26 May 2016 | Istanbul, Turkey
LOWER GI: TECHNICAL AND
CLINICAL CHALLENGES FOR
RADIATION ONCOLOGISTS
NEW
NEW
ACCELERATED PARTIAL BREAST
IRRADIATION
8 - 10 September 2016 | Brussels, Belgium
BASIC TREATMENT PLANNING
ADVANCED BRACHYTHERAPY PHYSICS
14 - 18 September 2016 | Cambridge, UK
BRACHYTHERAPY FOR PROSTATE CANCER
5 - 7 June 2016 | Brussels, Belgium
CLINICAL PRACTICE AND
IMPLEMENTATION OF IMAGE-GUIDED
STEREOTACTIC BODY RADIOTHERAPY
5 - 9 June 2016 | Athens, Greece
EVIDENCE BASED RADIATION ONCOLOGY
How to evaluate the scientific evidence and apply
it to daily practice
18 - 22 September 2016 | Florence, Italy
COMPREHENSIVE QUALITY MANAGEMENT
IN RADIOTHERAPY - RISK MANAGEMENT
AND PATIENT SAFETY
4 - 6 April 2016 | Toronto, Canada
MULTIDISCIPLINARY MANAGEMENT OF
BREAST CANCER
1 - 4 October 2016 | Avignon, France
20 - 22 May 2016 | Tokyo, Japan
BIOLOGICAL BASIS OF PERSONALISED
RADIATION ONCOLOGY
MULTIDISCIPLINARY MANAGEMENT OF
LUNG CANCER
17 - 20 October 2016 | Montpellier, France
26 - 28 June 2016 | Moscow, Russia
IMAGE-GUIDED AND ADAPTIVE
RADIOTHERAPY IN CLINICAL PRACTICE
BASIC CLINICAL RADIOBIOLOGY
3 - 7 July 2016 | Chengdu, China
23 - 27 October 2016 | Madrid, Spain
RADIOTHERAPY TREATMENT PLANNING AND DELIVERY
BIOLOGY
ADVANCED TECHNOLOGIES
6 - 10 December 2016 | Pune, India
UNDERGRADUATE COURSES
4 - 15 July 2016 | Groningen, The Netherlands
19 - 23 June 2016 | Dublin, Ireland
MULTIMODAL CANCER TREATMENT
3 - 5 December 2016 | Bangkok, Thailand
4TH ESO-ESTRO MASTERCLASS IN
RADIATION ONCOLOGY
IMAGE-GUIDED CERVIX CANCER
RADIOTHERAPY - WITH A SPECIAL FOCUS
ON ADAPTIVE BRACHYTHERAPY
IMAGING FOR PHYSICISTS
29 May - 1 June 2016 | Vienna, Austria
PAEDIATRIC RADIATION ONCOLOGY
MEDICAL SCIENCE SUMMER SCHOOL
ONCOLOGY FOR MEDICAL STUDENTS
POSTGRADUATE COURSES
OUTSIDE EUROPE
ADVANCED TREATMENT PLANNING
20 - 25 November 2016 | Sydney, Australia
13 - 16 November 2016 | Paris, France
19 - 23 November 2016 | Prague, Czech Republic
9 - 13 September 2016 | Cambridge, UK
28 - 31 May 2016 | Brussels, Belgium
ESOR/ESTRO MULTIDISCIPLINARY
APPROACH OF CANCER IMAGING
10 - 12 November 2016 | Amsterdam, The Netherlands
11 - 15 September 2016 | Athens, Greece
UPPER GI: TECHNICAL AND
CLINICAL CHALLENGES FOR
RADIATION ONCOLOGISTS
ADVANCED SKILLS IN MODERN
RADIOTHERAPY
NEW
PHYSICS FOR MODERN RADIOTHERAPY
A joint course for clinicians and physicists
25 - 27 May 2016 | Brussels, Belgium
12 - 17 June 2016 | Porto, Portugal
24 - 28 October 2016 | Vienna, Austria
EVIDENCE BASED RADIATION ONCOLOGY
How to evaluate the scientific evidence and apply
it to daily practice
IMAGING
BEST PRACTICE
ESO-ESSO-ESTRO MULTIDISCIPLINARY
COURSE IN ONCOLOGY FOR MEDICAL
STUDENTS
29 August - 9 September 2016 | Poznan, Poland
NEW
NEW
ESTRO SCHOOL
INTRODUCTION
E-CONTOURING
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WHO’S WHO?
ESTRO SCHOOL
The new education
council is responsible for
developing the School’s
strategy
The ESTRO School is undergoing important changes this year
with the appointment of a new chair of the education council,
Jesper Eriksen and a new structure, with the education council
directly linked to the ESTRO Board. These changes are designed
to consolidate and strengthen education and training in the
radio-oncology field in Europe and worldwide, and were officially implemented at ESTRO 35.
The new education council is responsible for developing the
School’s strategy. Its goals and objectives will be implemented
through six programmes:
• Live course programme
• Blended-learning programme
• International education programme
• Core Curriculum / UEMS / exams / fellows programme
• Pedagogical programme
• Mobility programme.
MARIE-CATHERINE
VOZENIN
Member of the education
council
CHRISTINE VERFAILLIE
ESTRO Managing director
education and science
The members engaged in teaching on and developing these
programmes will provide ESTRO with the best operational
tools and content so that we can deliver our educational aims.
A summary article outlining the new structure and activities of
the education council, including relevant contact details, will be
published in a future ESTRO School Corner.
JESPER ERIKSEN
Member and Chair of the
education council
INTRODUCTION
E-CONTOURING
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WHO’S WHO?
ESTRO SCHOOL
Summer 2016
UNDERGRADUATE TRAINING
FOR MEDICAL STUDENTS
Education
Council
Live
programme
Blended
learning
programme
Intl. education
programme
Core curriculum
UEMS/exams/
Fellow programme
Spread the word to your students!
Pedagogical
programme
Mobility
programme
MEDICAL SCIENCE SUMMER SCHOOL
ONCOLOGY FOR MEDICAL STUDENTS
4 - 15 July 2016 | Groningen, The Netherlands
FALCON
The education council, the ESTRO Board and all the ESTRO
community want to say farewell to Ann Barrett and Fiona
Stewart who leave office, and a warm thanks for their dedication
and commitment over the years: “you have done a magnificent
job and we will do our best to continue”. Our thanks are also
due to our former chair, Richard Pötter, who is not leaving the
School, but will take on different duties as chair of the international education programme.
ESO-ESSO-ESTRO MULTIDISCIPLINARY
COURSE IN ONCOLOGY
FOR MEDICAL STUDENTS
29 August - 9 September 2016 | Poznan, Poland
Marie-Catherine Vozenin and Jesper Eriksen, respectively member
and chair of the education council, now join Christine Verfaillie in
editing the School Corner of the newsletter.
INTRODUCTION
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ESTRO SCHOOL
2016 FALCON ONLINE SCHEDULE
Workshop Topic
OAR - Thorax
E-CONTOURING
Join a FALCON online
workshop
Check out the 2016 dates
ESTRO members can:
• Access for free the FALCON cases available on
the ESTRO website
• Benefit from a discount on the registration fee
to attend an online workshop.
Paediatric cancer
Oesophagus Cancer
Dates
Time CET
Faculty
17 May 2016
18.00-19.00 hrs
23 May 2016
18.00-20.00 hrs
Workshop director:
Sofia Rivera
30 May 2016
18.00-20.00 hrs
24 May 2016
18.00-19.00 hrs
31 May 2016
19.00-20.00 hrs
7 June 2016
18.00-19.00 hrs
5 September 2016
18.00-19.00 hrs
12 September 2016
18.00-20.00 hrs
19 September 2016
18.00-19.30 hrs
Cancer specialist:
Ursula Nestle
Workshop director:
Umberto Ricardi
Cancer specialists:
Rolf-Dieter Kortmann,
Silvia Scoccianti
Workshop director:
Berardino De Bari
Cancer specialist:
Oscar Matzinger
FALCON
Fellowship in Anatomic deLineation & CONtouring
INTRODUCTION
E-CONTOURING
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COURSE REPORTS
ESTRO SCHOOL
Target volume determination – from imaging to
margins
Basic Clinical Radiobiology
27 February – 2 March 2016, Budapest, Hungary
Dose modelling and verification for external
beam radiotherapy
10 – 13 April 2016, Barcelona, Spain
Report on ESTRO Particle Therapy Course
Krakow 2016
6 – 10 March 2016, Utrecht, The Netherlands
Image-guided cervix cancer radiotherapy – with a
special focus on adaptive brachytherapy
4 – 6 April, 2016, Toronto, Canada
INTRODUCTION
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ESTRO SCHOOL
BASIC CLINICAL
RADIOBIOLOGY
27 February – 2 March 2016
Budapest, Hungary
Course director: Michael Joiner, Radiation Biologist
Wayne State University
Detroit, USA
At the end of February 2016, participants from 38
different countries gathered in Budapest for the
37th Basic Clinical Radiobiology course. Since
1990, this course has demonstrated its significant
clinical relevance, providing an important basis
for our everyday decision-making.
Despite the varied fields of expertise among the
120 participants – there were medical physicists,
radiation and clinical oncologists, radiobiologists,
therapists, dosimetrists and others – the course
content was presented in a very understandable
fashion, beginning with the fundamentals, and
then opening up to a more advanced level. The
subjects ranged from an insight in to cellular
mechanisms, to the development of treatments
and their clinical outcome, with a special
emphasis on equivalent dose in 2 Gy (EQD2)
calculations applicable for unseen changes in
treatment flow. Also, the lecturers were able to
strike a balance between showing promising new
results in animal trials, while at the same time
pointing to where there is a lack of human trials,
especially when it comes to normal tissue repair
in cases of re-irradiation. The lectures drawing on
real clinical cases were particularly rewarding and
interactive, as the knowledge and perspectives of
both lecturers and other experienced participants
could be shared. Also, the team of lecturers
was present during every lecture, ready to
comment, clarify or answer any questions from
the audience, which led to some very interesting
discussion.
In addition to the academic benefits, the city of
Budapest has much to offer. After long days of
lectures, it was delightful to let the hard-working
brain rest with some sightseeing among the city’s
beautiful architecture, or with a visit to one of its
famous spas. I would really recommend taking
a refreshing run up the Gellért Hill to admire
the scenery, preferably in the early morning. It
is also worth mentioning the social event, which
was a lovely dinner on a riverboat cruise on the
Danube, with live music and a beautiful view of
Buda Castle and the Hungarian Parliament.
The course attendees were the last generation to
have had the honour of being lectured by Albert
van der Kogel, a prominent radiobiologist who
is retiring from his ESTRO teaching. Luckily the
rest of the team remains, and will be welcoming a
new lecturer, Rob Coppes.
Finally, I would like to extend my gratitude
towards the ESTRO staff for a well-organised
course, and for making everyone feel so welcome.
Johanna A. Hundvin
Physicist at Department of Oncology and Medical
Physics
Helse Bergen HF, Haukeland University Hospital
Bergen, Norway
johanna.austrheim.hundvin@helse-bergen.no
JOHANNA A.
HUNDVIN
INTRODUCTION
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This year, the “Dose modelling and verification for
external beam radiotherapy” course was held in
the beautiful city of Utrecht in The Netherlands.
The venue for the course was the auditorium of the
radiotherapy department of the University Medical
Centre, a beautiful space with pleasant views.
ESTRO SCHOOL
DOSE MODELLING
AND VERIFICATION
FOR EXTERNAL BEAM
RADIOTHERAPY
The course teachers included Tommy Knöös
(course director), Brendan McClean (course
director), Anders Ahnesjö, Maria Mania
Aspradakis and Nuria Sala. The participants
were all physicists, from masters-level students to
practising medical physicists.
6 – 10 March 2016
Utrecht, The Netherlands
Course directors: Tommy Knöös, physicist, Skåne University
Hospital, Lund, Sweden
Brendan Mc Clean, physicist, St Luke’s Hospital, Dublin,
Ireland
ANETTE HOUWELING
INTRODUCTION
On a sunny Sunday morning, the course started
with basic concepts (including nice formulas)
on dose delivery, dose measurements, linac head
design and detectors. On the second and third
days, lectures went deeper into dose modelling
algorithms and measuring and calculating the
dose in treatment small fields. The final part of
the course addressed more practical issues like
commissioning the treatment planning system, 2D
/ 3D detectors and their use in clinic, and in vivo
dosimetry. A practical session on dose modelling
showed how Excel could be used for these
purposes. On the last days, we had enthusiastic
discussions involving the audience and teachers.
The radiotherapy department in Utrecht is
developing a linac with integrated MRI, the MRlinac. A valuable addition to this year’s course
were the lectures about the MR-linac, describing
the concept of this machine and the challenges
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in treatment delivery, which resulted in some
animated discussion. In addition to the lectures,
a tour of the MR-linac facility was arranged. We
visited the first prototype MR-linac, the first
clinical prototype MR-linac and the MR guided
brachytherapy treatment room. The tour was
very impressive, and left everyone feeling very
enthusiastic.
The course also included a social event in Utrecht.
First, we went to the museum Speelklok, where
there were all kinds of self-playing musical
instruments. We were welcomed with a drink,
including beers from Utrecht. During the tour
around the museum, we saw and heard a variety of
instruments, including some very impressive alarm
clocks. We were even allowed to play a barrel-organ
ourselves, which revealed some surprising talent in
the group! After the visit to this museum we had a
lovely dinner in De winkel van Sinkel, a converted
warehouse dating from 1839.
This course gave a fascinating insight into dose
modelling and the challenges we face in this
area; the city of Utrecht, with its beautiful canals,
terraces and (luckily for us) lovely sunny days,
was a perfect place to learn about the latest
developments in this field.
Anette Houweling, PhD
Medical physicist resident
Academic Medical Centre
Amsterdam, The Netherlands
a.c.houweling@amc.uva.nl
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ESTRO SCHOOL
IMAGE-GUIDED CERVIX
CANCER RADIOTHERAPY –
WITH A SPECIAL FOCUS ON
ADAPTIVE BRACHYTHERAPY
4 – 6 April, 2016
Toronto, Canada
Course directors:
Richard Pötter, radiation oncologist, Medical University
Hospital, Vienna (Austria)
Kari Tanderup, physicist, University Hospital, Aarhus
(Denmark)
JENNIFER CROKE
INTRODUCTION
Cold spring temperatures and jet lag couldn’t
keep students or teachers away from the first
ever CARO-ESTRO course on “Image-guided
radiotherapy in gynaecological cancers” held in
April in Toronto, Canada. With 110 registrants
from all over the globe, encompassing a wide
range of experience and disciplines, this course
was a success from the start.
The course directors were Professor Richard
Pötter (Vienna) and Dr Kari Tanderup (Arhus).
There were five Canadian lecturers, three
radiation oncologists (Isreal Fortin - Montreal,
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Kathy Han - Toronto, Michael Milosevic Toronto), one gynaecologic oncology surgeon
(Taymaa May - Toronto) and one radiologist
(Kartik Jhaveri - Toronto) and three international
lecturers (Daniel Berger - Vienna, Umesh
Mahantshetty - Mumbai, Primoz Petric - Qatar).
This was the 17th edition of the course,
which typically spans four days. For the first
time, CARO and ESTRO joined forces and
this comprehensive and intense course was
condensed to 2.5 days. The programme focused
on introducing fundamental concepts such as
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anatomy, radiology, contouring, brachytherapy
techniques and treatment planning, as well as
demonstrating the key elements of implementing
image-guided brachytherapy through interactive
workshops and multiple choice questions.
Prior to the start of the course students were
asked to complete “homework”. Four cases were
provided and students were asked to contour
GTVB (gross tumour volume at brachytherapy),
HRCTV (high-risk clinical target volume),
IRCTV (intermediate-risk CTV) and various
organs at risk using the web-based platform
FALCON. The aggregate contouring data sets
were presented throughout the course for
teachers and students to discuss and reflect.
The course was extremely well organised. There
was a good balance of educational lectures
and applied learning. The morning sessions
consisted primarily of didactic lectures. The
INTRODUCTION
voting tool “Turning point” was an entertaining
and strategic method to promote discussion
during these sessions. In the afternoons, radiation
oncologists and medical physicists participated
in discipline-specific interactive workshops to
refine their skills in a hands-on forum. During
the radiation oncology interactive workshops,
students were able to re-contour the cases,
allowing them to apply the skills they learned
from the morning lectures. These workshops
permitted lots of opportunity for interaction
with the “experts” and other students, which was
well received. During the lunch-breaks videos
were shown demonstrating para-cervical blocks
and interstitial brachytherapy applications in the
operating room.
On the last day, attendees from various
geographic locations throughout Canada
presented their brachytherapy programmes.
It was very interesting to hear each centre’s
techniques and workflow processes. It was also
very exciting to learn that there is a lot of activity
in the area of image-guided brachytherapy in
Canada. Several programmes have enrolled
into EMBRACE 2 or are planning on doing so.
Afterwards, there was time for discussion to try
to create a pan-Canadian community practice
for MR-guided cervix cancer brachytherapy as
a means of increasing engagement, learning,
collaboration and research. The group made a
plan to meet at the CARO Annual Meeting this
September in Banff, Alberta (Canada), to discuss
future directions.
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The organising committee also arranged a
social evening. This very well-attended occasion
provided opportunities for conversations between
faculty and students over delicious food and
drink in a friendly, relaxed atmosphere.
I would like to take this opportunity to thank the
course coordinators, Melissa Vanderijst and Mary
Hooey, and the lecturers for their contributions.
I would also like to thank CARO and the GECESTRO for their support. Lastly, I am very
grateful to ESTRO for offering such important
educational programmes.
Dr Jennifer Croke MD FRCPC
Radiation oncologist, Radiation Medicine
Program, Princess Margaret Cancer Center
Assistant Professor, Department of Radiation
Oncology, University of Toronto
Toronto, Canada
Jennifer.croke@rmp.uhn.ca
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ESTRO SCHOOL
TARGET VOLUME
DETERMINATION – FROM
IMAGING TO MARGINS
10 – 13 April 2016
Barcelona, Spain
Course director: Gert de Meerleer, radiation oncologist,
UZ Leuven, Belgium
TAMARA CULIBRK
INTRODUCTION
When I started my fellowship in radiation
oncology, my more experienced colleagues
said that the only way to be a good radiation
oncologist is to know the basics and to update
your knowledge every day, because in a field as
dynamic as radiation oncology, what is common
practice today can be obsolete tomorrow. “But
how can you possibly analyse the enormous
amounts of up-to-date data or know what is
being done in other countries in Europe?” I
asked. The answer came back: “Go to conferences
or find an interactive course, in particular an
ESTRO course”. But which ESTRO course to
choose? I wanted a basic course that would
summarise all the guidelines, imaging techniques
and delineation volumes. That is how I settled
on the “Target volume determination – from
imaging to margins” course held in Barcelona
(my decision only made a little easier by the fact
that it was held in wonderful Barcelona).
The pre-course correspondence with Luis and
the ESTRO management was really easy and
efficient. The homework cases that we were
given were interesting and encouraged me to
read all the guidelines just to be sure that I had
determined the volumes correctly, and were
helpful preparation for the course topics. The
venue for the course was excellent, in one of the
most beautiful medical universities I have seen,
and the catering was really good. But what made
the course was the people and the atmosphere.
All the lecturers were good and available for
additional information and questions from
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the audience, which made the course more
dynamic. The course workshops where eyeopening, revealing how differently we treat the
same cases all over Europe, and to me, even
more astonishing was how the groups, with all
their differences, actually do a better job than
individuals alone. For those of us who came
alone and didn’t know anybody, the social event
was a great opportunity to relax, meet other
participants and have fun.
The course was much better than I could have
ever expected. I learned a lot and had fun doing
it. I have met some amazing colleagues from all
over the world and that made the experience even
more valuable. I would like to thank the lecturers
and the whole ESTRO team for a wonderful four
days in Barcelona and I hope to see them all at
other ESTRO courses in the future.
Tamara Ćulibrk
Fellow in radiation oncology
Institute for Pulmonary Diseases of Vojvodina
Serbia
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ESTRO SCHOOL
REPORT ON ESTRO
PARTICLE THERAPY
COURSE KRAKOW 2016
From 14 to 18 March about 110 physicists,
radiation therapists and oncologists gathered
with twelve teachers in Krakow for the ESTRO
Particle Therapy teaching course. I travelled
from New Zealand to attend, as this seemed a
unique chance to quickly bone up on the role of
protons in modern radiotherapy. New Zealand
is unlikely to have a proton facility in the near
future, but I am increasingly asked by colleagues
of other specialties about whether protons would
help their patients and I wanted to know when to
refer.
The course was held over five days at a very
comfortable hotel just outside the historic old
city, within walking distance of the Wawel
castle, the Market Square and the Jagiellonian
University. (At the University museum you can
see equipment Karol Olszewski used to produce
X-rays only weeks after Roentgen).
After the first day of teaching we had a tour
of the thousand-year-old Wieliczka salt mines,
with their beautiful underground chapels and
statues, before eating dinner in a restaurant 100m
below ground. This was a great opportunity to
get to know fellow students and teachers and to
establish future professional relationships. At
the end of day two, we visited the Bronowice
Cyclotron Centre. There we learnt about some of
the practical issues involved in proton treatment.
The didactic lectures covered radiobiology,
physical aspects of generating proton and
carbon ion beams and clinical aspects. A brief
introduction to general radiobiology was
followed by detailed accounts of the uncertainties
associated with the radiobiological effectiveness
of particles and how they can be modelled. This
was followed by a discussion of new insights into
the biology of hypofractionation.
As an oncologist, I found aspects of the physics
lectures harder to follow but benefitted from
the qualitative aspects, which gave me a better
appreciation of the physical challenges associated
with producing and modelling proton beams. A
number of the physics sessions were of practical
importance to clinicians, such as those on image
guidance, organ motion and uncertainties of dose
distribution.
The clinical sessions were of most interest to me.
These started with discussions about the reasons
for the traditional focus on the “historical niche”
indications for protons (skull base, paraspinal
IAIN WARD
INTRODUCTION
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and sacral chordomas and chondrosarcomas,
gliomas and paediatric tumours). Subsequent
sessions focused on paediatric tumours, head
and neck and CNS tumours, eye tumours, skull
base and paraspinal tumours, liver, lung and the
potential to use particles to treat pancreatic and
recurrent rectal cancer.
programme and to those, such as myself, who
want to learn more about when to refer.
Although most of the sessions were didactic,
frequent opportunities for questions and
discussion were scheduled. There was also
a journal club, at which participants were
nominated to present recent papers of interest, and also a choice discussion groups.
Unfortunately, I felt that we as participants failed
to take full advantage of these, but the faculty
was very good at raising issues to debate.
Iain Ward
Radiation Oncologist, Canterbury Regional
Cancer and Haematology Service,
Christchurch, New Zealand
Iain.Ward@cdhb.health.nz
The course finished with a stimulating debate
about how much we need to rely on randomized
controlled trials as opposed to other types of
evidence, before deciding how to utilize this
expensive technology.
ESTRO teaching courses are ideal ways to bring
one up to speed rapidly with specialized aspects
of radiation oncology. Five days away from the
day-to-day pressures of work allow focus on
the topic, in a pleasurable environment, with
like-minded students and international experts.
Having attended three such courses, I highly
recommend them. I recommend the Particle
Therapy course particularly to those who are
in the early stages of developing a treatment
INTRODUCTION
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ESTRO SCHOOL
WHO IS WHO?
Interview with
Yvette van der Linden and Peter Hoskin,
course directors
Palliative care and radiotherapy: A course on prognosis,
symptom control, re-irradiation, oligometastases
8 – 10 September 2016
Brussels, Belgium
INTRODUCTION
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ESTRO SCHOOL
WHO IS WHO?
Interview with
Yvette van der Linden and
Peter Hoskin, course directors
Palliative care and radiotherapy:
A course on prognosis, symptom
control, re-irradiation, oligometastases
8 – 10 September 2016
Brussels, Belgium
Why has this course been created?
Radiotherapy with a palliative intent is a major
component of our work. The positive impact
it has on symptom control and quality of life
underlines its importance for our patients.
Furthermore, the new concept of oligometastases,
which demands a different, more radical
approach to care, has emerged in recent years.
The technical and site-specific ESTRO courses
do not address readily the concept of symptom
palliation. Over a three-day programme, this
course will provide a comprehensive overview of
palliative oncology and the role of radiotherapy
across different tumour sites.
How long did it take to organise and
prepare the programme?
YVETTE
VAN DER LINDEN
INTRODUCTION
PETER HOSKIN
the ESTRO School encouraged us to develop the
course, which will be held for the first time this
year.
What will be the main learning
outcomes?
We will offer a comprehensive programme
addressing the pathophysiology and treatment of
the common manifestations of metastatic cancer,
in particular bone, central nervous system (CNS),
liver and lung disease. We will discuss the use
of prognostic models on survival and treatment
outcomes to inform our patients and to help
them choose treatment. Treatment with systemic
anti-cancer drugs, radiation and other supportive
measures will be presented.
We first began discussing the idea of this course
around two years ago and were delighted when
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How did you select the teachers?
We sought out the best people in the field.
We have specialist radiation oncologists in
palliative radiotherapy, who also contribute to
palliative consultation teams. Two of them are
also palliative care physicians to provide a more
holistic view of the specialty.
Who is the course aimed at?
The course will be useful for all health care
professionals who deal with patients who have
advanced malignant disease; in particular,
radiation oncologists, those in training, and
radiation therapists (RTTs). The course will
also be of interest to palliative care physicians
and specialist nurses working in cancer centres
or on palliative wards. Their input will give the
course a broad palliative base to discuss palliative
topics. A basic understanding of the principles
of metastatic cancer, analgesics and radiotherapy
will be helpful for those attending.
INTRODUCTION
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2016
MULTIMODAL
CANCER
TREATMENT
HAEMATOLOGICAL MALIGNANCIES
IN COLLABORATION WITH ILROG (INTERNATIONAL LYMPHOMA RADIATION ONCOLOGY GROUP)
31 August-03 September, 2016 | Vienna, Austria
TARGET GROUP
Radiation oncologists involved in the treatment of haematological
malignancies.
COURSE AIM
The aim of this course is to:
• Enable radiation oncologists to participate in the multidisciplinary
management of haematological malignancies
• Administer radiotherapy to these diseases according to modern principles,
using up-to-date technology to achieve maximum cure rates while at the
same time minimising the risk of long-term complications.
LEARNING OUTCOMES
By the end of this course participants should be able to:
• Design strategies for the multimodality treatment of haematological
malignancies
• Apply modern principles for radiotherapy in the multimodality setting
• Define target volumes and prescribe radiation doses and fractionation
schedules appropriate for different haematological malignancies
• Apply and evaluate different treatment techniques depending on disease
localisations and risks of normal tissue complications.
EARLY REGISTRATION DEADLINE ON 1 JUNE 2016
4TH ESO-ESTRO MASTERCLASS IN
RADIATION ONCOLOGY
2016
RESEARCH
19-23 November 2016 | Prague, Czech Republic
AIMS AND EXPECTED LEARNING
OUTCOMES OF THE MASTERCLASS
The major course aims of the Masterclass of
radiation oncology are two-fold:
• To provide an overview on state of the art advances in current research in the different fields
of radiation and multidisciplinary oncology,
including technology and biology oriented research
• To provide practical skills for active participation in the various fields of radiation and
multidisciplinary oncology research and development.
In order to reach these course aims the Masterclass is divided in two parts:
• Interactive group sessions (50%) are dedicated
to open discussions of research project proposals presented by the junior participants.
The performance of these sessions (two hours)
has to be dynamic (participative), structured
(agenda of interventions), critical (in respect to
free hypothetical thinking based on scientific
evidence) and they are moderated by advanced
juniors and facilitated by seniors
• Expert lectures (50%) are devoted to update
interdisciplinary science in radiation oncology
by experts.
Plenary discussions are coordinated to extend
into a summarised format the debate of the research projects re-developed from the discussion
in small working groups for all participants.
Expected learning outcomes can be summarised as follows.
By the end of this Masterclass the participant
should:
• Know about the current research scenarios in
clinical radiation oncology, in technology oriented research, in biology and translational related research and in multidisciplinary research
• Have improved skills in the definition of research endpoints and their assessment
• Have improved skills to identify appropriate
research methodologies for different research
questions
• Be able to design and develop a research proposal in one of the major fields of radiation and
multidisciplinary oncology
• Be able to critically assess research proposals in
his/her major field of interest.
DEADLINE FOR APPLICATION: 14 MAY 2016
More information on the programme and on
how to apply: www.estro.org
Further reading in the ESTRO guide 2016,
page 98.
2016
PHYSICS FOR MODERN RADIOTHERAPY
(JOINT COURSE FOR CLINICIANS AND PHYSICISTS)
RADIOTHERAPY
TREATMENT
PLANNING AND
DELIVERY
11-15 September, 2016 | Athens, Greece
TARGET GROUP
The course is primarily aimed at:
• Trainees in radiation oncology or radiation physics
• Radiation oncologists and medical physicists early in their career.
The course may also be useful for:
• Clinicians and physicists who are eager to update their knowledge on
physics and technical aspects of radiotherapy after a period of relative lack of
access to education on modern technology and techniques.
• Dosimetrists and radiation therapists (RTTs) having a strong interest in the
application of physics and technology in radiotherapy
• PhD students in radiation therapy or physics, as this course can broaden
their knowledge.
COURSE AIM
The lectures aim to:
• Provide physics knowledge relevant to clinical radiotherapy
• Provide comprehensive overviews of imaging and volume concepts in
radiotherapy
• Discuss modern dose delivery techniques, such as IMRT, rotational therapy
(VMAT, helical tomotherapy), S(B)RT, IGRT, adaptive therapy (ART), and
brachytherapy
• Discuss safety issues in lectures on commissioning and QA/QC, radiation
protection, in vivo dosimetry and induction of secondary tumours.
Complimentary to the lectures, this course has clinical case discussions as
an important component, discussing planned homework submitted by the
participants (see below for details) regarding selected treatment techniques,
planning solutions, constraints and objectives, choice of margins, protocols
for image guidance, QA, etc.
YOUNG ESTRO
INTRODUCTION
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YOUNG ESTRO
Welcome to the May-June issue of the Young
Corner.
We present an exciting
opportunity for young
researchers working in the field
of low dose ionising radiation:
the Multudisciplinary
European Low Dose Initiative
(MELODI) Award
ESTRO 35, which was held in Turin, Italy has just
passed. We hope you had a satisfying congress,
and enjoyed the very interesting scientific and
educational programme.
We will have some reflection on ESTRO 35 in the
July-August issue of the Newsletter, reason enough
for you to look forward to the next corner.
In this issue of the ESTRO newsletter, Natalia
Arteaga Marrero at the Department of Radiation
Sciences and Radiation Physics at Umeå University,
Sweden, offers an interesting perspective on the
radiation oncology field, reporting back from the
3rd International Conference on Translational
Research in Radio-Oncology and Physics for Health
in Europe (ICTR-PHE), which was held in Geneva,
Switzerland, in February 2016.
In addition, Pierfrancesco Franco, from the
Department of Oncology at the University of
Turin, Italy, provides some highlights from the
1st Assisi Think Tank Meeting, held in Assisi,
Italy, in February 2016, including an overview of a
brainstorming session on the most current topics in
the combined modality treatment of breast cancer
and several trial proposals.
KATHRINE RØE
REDALEN
INTRODUCTION
Our Corner also features two mobility reports.
The first is from Surendra Kumar Saini from
the M.P. Shah Medical College and Associated
Government Hospital in Jamnagar (Gujarat),
India, who visited the Department of Oncology at
Aarhus University Hospital in Aarhus, Denmark,
to learn about stereotactic body radiation therapy.
The second is from Jesús Manuel Blanco Suárez
from the Department of Radiation Oncology at
Doctor Negrin University Hospital in Las Palmas
de Gran Canaria, Spain, who visited the Innovative
Cancer Institute in Miami, Florida, to learn about
innovative techniques being used in radiosurgery.
Finally, we present an exciting opportunity for
young researchers working in the field of low dose
ionising radiation: the Multudisciplinary European
Low Dose Initiative (MELODI) Award. Read on to
find out more.
We hope that you enjoy this issue of the Young
Corner and we wish you well both professionally
and personally in the coming months.
Warm regards,
Kathrine Røe Redalen and Pierfrancesco Franco
PIERFRANCESCO
FRANCO
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Report from the
International Conference
on Translational
Research in RadioOncology and Physics for
Health in Europe (ICTRPHE) 2016
15–19 February 2016
Geneva, Switzerland
NATALIA ARTEAGA
MARRERO
INTRODUCTION
The 3rd International Conference on Translational Research in Radio-Oncology and Physics for Health in Europe (ICTR-PHE)
was held in Geneva, Switzerland
This was the third International Conference on
Translational Research in Radio-Oncology and
Physics for Health in Europe (ICTR-PHE), which
is held every other year in Geneva, Switzerland.
The underpinning philosophy of the conference is
to support the provision of effective translational
research by bringing different disciplines together.
As such, it is an ideal event for a newcomer in the
field, or someone working at the interface between
disciplines such as myself, to get a clear perspective
on the challenges and issues in different areas
within the radiation oncology field.
In addition to the science, I was interested in
experiencing the conference from the perspective of
a young researcher. My initial impressions were that
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a large number of young researchers were present,
which was confirmed by the organising committee
during the conference’s closing remarks: of 442
participants, more than 80 were young researchers.
The organisers acknowledged the effort made by
the corresponding institutions to send such a large
representation. It was particularly exciting to see
young researchers, both male and female, giving
plenary talks. In order to provide some statistics,
I tried to keep track of the speakers in the sessions
that I attended. Around 40% of the speakers were
young researchers, and among those, approximately
34% were female.
Regarding the science, there were many talks
focused on the relative biological effectiveness
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and the beam range assessment issues in particle
radiotherapy, handling of big data and creating
automatised software using multi-centre databases.
We learned about radiomics as well as other ‘omics’
approaches, and novel biomarkers. The ESTROfunded lecture was delivered by Eric Deutsch from
the Gustave Roussy Cancer Campus Grand Paris,
who presented some outstanding work. I found the
new technologies session in which Jan Lagendijk
introduced the MR-Linac experimental clinical
prototype, which is being tested in UMC Utrecht
particularly interesting. You can read a more
extended and detailed overview of the conference
at: https://ictr-phe16.web.cern.ch/content/
conference-blog.
The next ICTR-PHE will be in 2018 and I encourage
young researchers to attend.
Natalia Arteaga Marrero
Postdoctoral researcher
Department of Radiation Sciences, Radiation Physics
Umeå University
Umeå, Sweden
Natalia presenting at an oral session.
In terms of my contribution to the conference,
I have had the pleasure of attending all three
meetings, and this was the second time that I
have been given the opportunity to present my
work in an oral presentation at a parallel session.
Unfortunately, in parallel sessions you are often in
competition with other interesting sessions, and
the audience at my session was relatively small.
In general, regardless of your public speaking
experience, presenting your work to an audience
of experts is a daunting process. In this regard,
the role of the chairperson is often crucial, and I
really appreciated the great job done by the chair in
creating a comfortable environment that promoted
the free exchange of ideas. The experience was
fruitful, educational, and rewarding.
INTRODUCTION
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Report from the 1st Assisi
Think Tank Meeting
(ATTM)
5–7 February 2016
Assisi, Italy
PIERFRANCESCO
FRANCO
INTRODUCTION
The audience at the 2016 Assisi Think Tank Meeting
Professor Cynthia Aristei opening the 2016 Assisi Think Tank
Meeting
The Assisi Think Tank Meeting on Research
Challenges in Breast Cancer was held at Casa
Leonori in Assisi, Italy, in February this year.
The scientific organisers were Professors Cynthia
Aristei, Philip Poortmans and Vincenzo Valentini.
The aim of the three-day meeting was to identify
the most debated issues in the combined modality
treatment of breast cancer in order to promote
possible trial designs to reduce the uncertainty
on clinical choices in daily practice, and to share
this with the scientific community and potential
public sponsors. The organisers brought together an
international board of radiation oncologists actively
involved in research on breast cancer. Three specific
clinical contexts were examined in depth:
by Charlotte Coles and Vincenzo Valentini; trial
proposal leader: Meritxell Arenas);
1) the role of radiation therapy in treating regional
lymph nodes after primary systemic therapy,
with or without axillary node dissection (chaired
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2) the role and timing of post-mastectomy radiation
therapy in the breast reconstruction scenario
after mastectomy (chaired by Philip Poortmans
and Cynthia Aristei; trial proposal leaders: Celine
Bourgier and Orit Kaidar-Person);
3) the role of radiation therapy in treating regional
lymph nodes, with or without axillary node
dissection (chaired by Birgitte Offersen and Cynthia
Aristei; trial proposal leaders: Giovanni Frezza and
Maria Cristina Leonardi).
Before the meeting, three clinical cases illustrating
the contexts being examined were sent out for a
survey on the possible clinical choices relating to
the different treatment approaches proposed. The
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results of this survey were submitted for discussion
to the panel of experts involved. On the first day
of the meeting all participants received a report of
the preferences in the different clinical situations
in order to identify the ‘grey zone’ – any clinical
situation in which there was no preferred choice
endorsed by at least 70% of the participants. Those
situations were then selected for thinking about
possible trials that could help to find evidence to
reduce these uncertainties. After searching for
ongoing trials, the three working groups (one for
each clinical case) gathered together to discuss
and develop suitable new trial designs. On the
second day, which was open to a wider range of
participants, the surveyed and discussed clinical
settings were presented. Following this, the trial
proposals were outlined and opened up for wider
discussion. The feasibility, inclusiveness and
generalisability of the study proposals were also
considered by the audience, providing immediate
and useful feedback on the proposed trials. The
third day, as with the first, was reserved for the
expert board members, and involved reflection on
the feedback of the clinicians attending the previous
day, and re-assessing the feasibility and design
of the trial proposals in light of their comments.
The Assisi Think Tank Meeting finished with all
participants intending to return to their national
societies and breast collaborative groups to share
and discuss the trial proposals in order to find
opportunities for collaboration and to assess
levels of interest in participation. In this way, the
main goal of the 2016 Assisi Think Tank Meeting,
‘coming back home with a trial proposal in the
INTRODUCTION
pocket’, was achieved. The beautiful setting of the
Umbrian hill town of Assisi, with its spiritual and
meditative roots, also contributed to the success of
this meeting.
Pierfrancesco Franco, MD
Department of Oncology-Radiation Oncology
University of Turin
Turin, Italy
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Professors Vincenzo Valentini, Philip Poortmans and Birgitte
Offersen discussing the timing of radiation therapy in the
context of breast reconstruction after mastectomy
Doctors Charlotte Coles and Meritxell Arenas discussing a
trial design examining the role of regional radiation therapy
after primary systemic therapy in breast cancer
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Stereotactic body radiation therapy
Radiosurgery training with innovative techniques
Surendra Kumar Saini
Jesús Manuel Blanco Suárez
INTRODUCTION
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Stereotactic body
radiation therapy
Figure 2. The motion of the liver during calypso-gated
treatment recorded by the Calypso system. Vertical red lines
show when we had to adjust for baseline-shifts by moving the
couch. Grey areas show when the beam delivery was going on
(gating breaks not shown).
Surendra Kumar Saini
HOST INSTITUTE:
Department of Oncology
Aarhus University Hospital, Aarhus, Denmak
4 - 24 November 2015
SURENDRA
KUMAR SAINI
INTRODUCTION
Figure 1. A standard non-coplanar seven-field liver SBRT
photon plan.
I would like to thank ESTRO for enriching my
professional experience with a mobility grant
that enabled me to learn about stereotactic
body radiation therapy (SBRT), a high-precision
radiotherapy technique that can be used with a
variety of indications.
Dr Morten Høyer, who supervised my visit,
designed a schedule that devoted suitable time
to every aspect of SBRT, from patient interaction
and decision-making regarding radiation
treatment to immobilisation and treatment
delivery. I was introduced to the team of
clinicians, medical physicists and other staff who
plan and deliver radiation treatment.
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I observed routine machine quality assurance and
patient-specific quality assurance for different
treatments. It was extremely useful for me to
discuss with physicists the quality assurance
carried out routinely on radiotherapy machines
and on individual patient plans. I discussed with
clinicians the indications for stereotactic ablative
radiotherapy (SABR), acute and late toxicities
and follow-up schedules. The team shared their
experiences of managing toxicities, and the
difficulties of interpreting imaging following
SABR. I also observed treatment planning and
delivery of linac-based SBRT, a range of intensity
modulated radiation therapy (IMRT), conformal
3D radiation therapy planning and high-dose rate
(HDR) brachytherapy.
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I was fortunate enough to also see calypso-based
gated radiation delivery, which was part of a
research project at the department. Although
proton therapy treatment is not yet available in
Aarhus, they still calculate comparative photonand proton-treatment plans as part of routine
academic practice in order to select the best
treatment plan for patients with brain tumours.
The department used their full range of treatment
platforms for SABR, including volumetric
modulated arc therapy (VMAT), taking into
account both tumour motion and machine
capacity. This flexibility has come through years
of experience.
I attended daily meetings with clinicians, where
new patients were discussed, providing excellent
exposure to a wide range of diagnoses, images
and radiotherapy plans for trainees. The clinical
teams in the department are based around
tumour sites, giving clinicians an opportunity to
develop expertise in a particular tumour site.
The opportunity to see SABR used in various
emerging indications, and to obtain protocols
that the hospital has developed and published,
has been invaluable in preparing me for the
introduction of these treatments in India. It gave
me the opportunity to spend time planning on
Varian Treatment Planning Software and iPlan
RT by Brainlab, and my confidence in using and
understanding IMRT and SABR planning on
different treatment platforms has grown, which
will help me strive for excellence when treating
INTRODUCTION
patients at my home centre. Learning alongside
physicists during treatment planning and
optimisation gave me a thorough understanding
of the planning processes and enabled me to
see beyond the clinician’s perspective, which is
invaluable for multidisciplinary team working
and patient care.
In conclusion, visiting Aarhus University
Hospital was a great opportunity for personal
development as a clinician and it helped me to
connect with a network of knowledgeable people
in radiation oncology, which will help me to excel
further in this field of improving cancer care.
I would like to thank Drs Per Poulsen, Morten
Høyer, Jørgen B Petersen and Esben Worm for
the images in this report.
Surendra Kumar Saini, MD, DPH
Assistant Professor
Department of Radiotherapy & Oncology
M.P. Shah Medical College and Associated Guru
Gobindsingh Government Hospital
Jamnagar (Gujarat), India
drsurensaini@gmail.com
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Figure 3. Six-field non-coplanar photon plan versus three-field
coplanar proton plan for a brain tumour. Both 95% and 10%
level isodose colourwash is shown. The 10% image shows how
the protons spare the normal tissue.
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YOUNG ESTRO
Radiosurgery training
with innovative
techniques
Jesús Manuel Blanco Suárez
HOST INSTITUTE:
Innovative Cancer Institute
Miami, Florida
January – May 2015
JESÚS MANUEL
BLANCO SUÁREZ
INTRODUCTION
undergoing radiosurgery treatment is quite high,
allowing me to gain extensive experience in a
relatively short period of time.
Dr Jesús Manuel Blanco Suárez together with the radiation
oncology team working at the Innovative Cancer Institute in
Miami
I am a doctor in training at the Department
of Radiation Oncology at the Doctor Negrin
University Hospital located in Las Palmas de
Gran Canaria, Spain. For the last year of my
residency, I decided to focus my training on
radiosurgery techniques, such as stereotactic
radiosurgery (SRS) and stereotactic body
radiation therapy (SBRT), an area where I am
able to continue my work due to innovative
technology offered in my home centre.
We are experiencing an increasing number
of patients who may benefit from this type of
treatment regime, as well as others who may be
candidates for re-irradiation. With an aim to
obtain quality training and to provide the best
possible treatment for our patients, I chose to do
my rotation in an international reference centre
– the Innovative Cancer Institute (ICI) in Miami,
Florida, USA. At ICI the volume of patients
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The centre is headed by Dr Beatriz Amendola, an
internationally leading radiation oncologist and
member of prominent international societies such
as ESTRO, ASTRO and SEOR. Dr Amendola
introduced me to all the members of her team
so that I could carry out various projects during
my stay. I was given access to clinical research,
stereotactic radiotherapy techniques, and was
involved in every step of the process, starting
from the most appropriate and convenient
therapeutic scheme for the patient, to treatment
planning and to contouring volumes (target and
risk organs structures). In addition, I was allowed
to give approval of dosimetry and monitoring
during treatment delivery. The treatment systems
used for radiosurgery procedures were Trilogy
and EDGE Linac (Varian Systems), Gammaknife
(Elekta) and Cyberknife (Accuray).
Dr Amendola attended consultations with me,
where we explained to patients in detail what
their best therapeutic scheme could be, as well
as the characteristics of the treatment and its
possible side effects. Particularly valuable for my
education were the ‘chart round’ meetings held
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several times during the week. In these meetings
we discussed patients, diagnosis and treatments,
as well as monitoring of patients during
treatment.
I also had the opportunity to attend a number
of lectures given by Dr Amendola, both in
universities and hospitals, and at other scientific
events, allowing me to participate at all times
and to increase my knowledge in a wide range of
oncology subjects.
Jesús Manuel Blanco Suárez
Department of Radiation Oncology
Doctor Negrin University Hospital
Las Palmas de Gran Canaria, Spain
blancosuar@hotmail.com
The Center for Innovative Medicine in Miami, Florida
Dr Amendola shared her contacts with ARRO
members (ASTRO) so that the links between
those based in Europe and the USA can develop.
I was also allowed to participate in clinical
research projects and publications that were
already underway when I arrived. The results
from these projects have been published or
are accepted for publication in peer-reviewed
journals.
I would like to express my gratitude to Dr
Amendola and her entire team for their attention
and involvement in my training, for making my
stay as productive as possible and for treating me
as part of their team from day one.
Dr Jesús Manuel Blanco Suárez together with Dr Beatriz
Amendola, Head of the Innovative Cancer Institute
I would also like to thank Dr Pedro C. Lara
Jimenez, current president of SEOR (Spanish
Society for Radiation Oncology) and Head of
Service of the Department of Radiation Oncology
at Doctor Negrin University Hospital for giving
me the opportunity to undertake this placement.
INTRODUCTION
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Announcement
and rules for
administration of a
MELODI Award
Call 2016
The Board of the MELODI (Multidisciplinary
European Low Dose Initiative) Association has
decided to reward annually a young researcher
by offering a MELODI Award, to be officially
announced at the annual MELODI Workshop.
MELODI is a European Platform dedicated to
low dose radiation risk research.
OBJECTIVES
The MELODI Board wants to reward each year
one young researcher, active in the domains
covered by the activities of the MELODI
Association, in order to raise more attention for
research in the domain of low doses of ionising
radiation in a broader sense, and to encourage
young researchers to be active and to publish in
this domain of activities.
THE MELODI AWARD
The Award will be €4,000 (an amount fixed
annually by the MELODI Board). This amount
will, in part, fund the presentation of the work
(which formed the basis of the MELODI Award
application) at an international conference to be
convened between the Board and the winner of
the Award; the remainder of the Award can be
spent at the winner’s discretion.
INTRODUCTION
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MODALITIES AND CONDITIONS
As regard to the candidate
▶ The candidate should be not older than 35
years of age and should have shown his/her
excellence in research on the effects of low
dose ionising radiation, with experience in
at least one of the major scientific disciplines
of relevance for low dose research of at least
three years, illustrated by at least one major
publication in an internationally known peerreviewed scientific journal;
▶ The candidate should personally have played a
key role in the research presented.
As regard to the research
▶ The research topic should be in line with
the Strategic Research Agenda (SRA) of
the MELODI Association and contribute
considerably to progress in understanding or in
developing at least one aspect of the SRA;
▶ The research should be original and innovative;
▶ The research results should have been
published in international, peer-reviewed
literature or should be in press. The impact
factor of the journal will be taken into account
during the selection;
▶ The research has been performed mainly
within the European Union and its Associated
Countries (i.e. with science and technology
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cooperation agreements that involved
contributing to the European Commission 7th
Framework Programme Budget, http://cordis.
europa.eu/fp7/who_en.html).
Selection of the candidate
▶ Th
e Scientific Committee of the MELODI
Association will review the applications
according to the criteria of the MELODI Award
and in accordance to peer reviewing standards.
The Scientific Committee will recommend the
winner of the MELODI Award to the MELODI
Board of Directors that takes the final decision.
Normally only ONE Award will be attributed
annually, but an equal first is not excluded. The
Award Ceremony will be part of the annual
MELODI Workshop
▶ Th
e following criteria will be used in the
assessment:
•C
V of the candidate (to verify agreement
with conditions mentioned above)
• For the scientific work:
- Scientific excellence and respect of
scientific methodology
- Creativity and originality, innovation
- Pertinence for the MELODI Association
- Value for the SRA and potential to
enlarge the research for the next years to
come
- Compatibility with the general conditions
mentioned above
- A multi-disciplinary approach shows
added value
INTRODUCTION
- Relevant publications in peer-reviewed
scientific journals.
Research performed in a context of cooperation
between various institutes shows an added
value. This includes research conducted with
international institutes outside of the EU.
PRACTICALITIES
▶ The candidates should send their application
to the MELODI Secretariat via melodi.
secretariat@sckcen.be before the deadline
mentioned on the MELODI website; the
deadline will be strictly applied;
▶ The application should be written in English,
and should include:
1) A
motivation letter in which the applicant
indicates why he/she considers him/herself
eligible
2) A short CV of the candidate of maximum
two pages
3) A list of scientific publications and
presentations
4) A
letter of support of the scientific
supervisor
5) A short description of the research context,
the innovative aspects, the link to the SRA
6) A
copy of at least one publication in an
international peer reviewed journal, or the
text of a publication accepted for publication
(proof needed) in an international peer
reviewed journal
7) I f applicable: an electronic version of the
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PhD or a more extensive report on the
work performed (if postdoctoral or multidisciplinary research project)
- The above-mentioned documents
should be combined into one pdf file
when submitting them to the MELODI
Secretariat, containing the above
mentioned chapters which have to be
numbered 1-7.
▶ Th
e MELODI Secretariat will check the
completeness of the application and provide the
applicants with a confirmation of receipt and
ask for supplementary information if needed.
▶ Th
e winner will be informed in advance and
is requested to confirm his/her presence at the
forthcoming MELODI Workshop to guarantee
his/her presence at the Awarding Ceremony
during the MELODI Workshop. He/she is
also requested to prepare a short scientific
presentation of 15 minutes to be presented at
the Workshop at the occasion of the Awarding
Ceremony.
▶ Th
e winner of the MELODI Award will be
allowed to mention this Award in all her/his
forthcoming activities where this is relevant,
provided that a link to the MELODI website is
added. Alternatively, the MELODI Association
has the right to freely publish a summary of
the winning text and/or material for publicity
purposes on any MELODI related carrier if
considered useful without written consent from
the winner.
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THE MELODI AWARD
To promote research in the domain of low dose ionising radiation, and to encourage young
researchers to be active and to publish in this area, the MELODI Board wants to reward a
young researcher working in this field.
The Award is €4,000 (an amount fixed annually by the MELODI Board).
AWARD 2016 time schedule:
Application deadline: 15 June 2016
The candidates will be informed about the selection procedure in mid-August 2016
The winner will be invited to the MELODI Workshop in Oxford, UK (19-23 September,
2016), to present his/her scientific work and receive the award.
About MELODI see:
WWW.MELODI-ONLINE.EU
INTRODUCTION
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HEALTH
ECONOMICS
INTRODUCTION
PROTON THERAPY: THE RIGHT TREATMENT? IT DEPENDS…
HEALTH
ECONOMICS
“In this Corner a
recently published
review of the costeffectiveness of protons
is discussed”
Most experts agree that proton therapy can
be more effective than conventional radiation
for treating certain cancers. However, there
is still a debate about the cost-effectiveness of
proton therapy as compared to conventional
radiotherapy with photons. In this Corner a
recently published review of the cost-effectiveness
of protons is discussed, as well as possible
solutions to tackling some obstinate bottlenecks
in defining its cost-effectiveness.
YOLANDE LIEVENS
PETER DUNSCOMBE
MADELON JOHANNESMA
INTRODUCTION
PROTON THERAPY: THE RIGHT TREATMENT? IT DEPENDS…
HEALTH
ECONOMICS
PROTON THERAPY:
THE RIGHT
TREATMENT? IT
DEPENDS…
Given its favourable dose distribution, proton
therapy is expected to be less toxic and more
effective than photon therapy in many cases. This
has led to a massive growth in the development
of proton centres worldwide in the last decade.
However, its cost-effectiveness compared to
conventional photon radiotherapy is not yet clear.
A recent publication by Verma et al [1] presents
the results of a comprehensive review of all
available data regarding the cost-effectiveness
of proton beam therapy (PBT). This systematic
review was conducted using the Preferred
Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines. Eligibility
criteria included work published in English
between 2000 and 2015 evaluating the costeffectiveness of proton radiation therapy. Data
were retrieved from electronic databases and
included abstracts from relevant oncology
meetings. Predefined selection criteria resulted
in 563 eligible articles / abstracts being identified
for further study. After excluding duplicates
and articles outside the scope of the review, 18
original investigations (three abstracts and 15
articles) were identified. These data gave insight
on the current evidence of the cost-effectiveness
of proton therapy for eight cancer indications:
prostate, breast, non-small cell lung cancer, head
and neck, paediatrics, oesophageal, skull base and
uveal melanoma.
Tabel 1 Included articles
1thauthor
Lundkvist
Konski
Peeters
Aizer
Yu
Goyal
Taghian
Ovalle
Grutters
Lievens
Ramaekers
Mailhot-Vega
Hirano
Mailhot-Vega
Moriarty
pubyear
2005
2007
2010
2015
2013
2012
2006
2014
2010
2013
2013
2013
2014
2015
2015
method
markov
markov
review
medicare/seer
medicare
medicare/seer
medicare
medicare
markov
markov*
markov
montecarlo
markov
markov
markov
total
MADELON JOHANNESMA
INTRODUCTION
prostate
1
1
1
1
1
1
breast
1
nsclc
h&n
1
1
pediatric
1
esophageal
skullbase
uveal
1
1
1
1
1
1
1
1
1
1
1
6
3
3
3
4
0
1
1
*datawerenotretreivedfromamarkovmodelbutfromareviewoftheliterature
PROTON THERAPY: THE RIGHT TREATMENT? IT DEPENDS…
Results showed that PBT was the most costeffective option for several paediatric brain
tumours. PBT costs for breast cancer, although
higher than for photon external beam therapy,
were favourable for appropriately selected
patients with left-sided cancers at high risk of
cardiac toxicity and also favourable compared
with brachytherapy for accelerated partial breast
irradiation. For non-small cell lung cancer
(NSCLC), the greatest cost-effectiveness benefits
using PBT were observed for loco-regionally
advanced – but not early stage – tumours. PBT
offered superior cost-effectiveness in selected
head / neck cancer patients at higher risk of acute
mucosal toxicities. Similar cost-effectiveness
was observed for PBT, enucleation, and plaque
brachytherapy in patients with uveal melanoma.
to hospitals and other healthcare providers.
In combination with SEER data, estimates on
(cost-)effectiveness can be made. However, these
reimbursement rates may be different from the
costs actually incurred by the providers and,
depending on the perspective of the analyses,
these estimates may need to be adjusted to reflect
this [2]. On the other hand, comparing results
of Markov models should also be done with
caution. The impact of the variables included in
a model – patient and tumour characteristics,
assumed impact of the treatment on outcome,
treatment costs – need to be taken into account
when assessing the final result of the analysis [3].
Therefore, comparing results of Markov model
analyses where different variables are used doesn’t
necessarily make sense.
It was concluded that although the data are
limited, PBT offers promising cost-effectiveness
for paediatric brain tumours, well-selected breast
cancers, loco-regionally advanced NSCLC, and
high-risk head / neck cancers. Until now, it has
not been demonstrated that PBT is cost-effective
for prostate cancer or early stage NSCLC.
Taking the above into consideration, it seems
hard, or even impossible, to estimate the costeffectiveness of proton therapy based on the
published literature. Of course, more and better
data will result in better outcomes and more
robust conclusions. However, this lack of data
was already obvious ten years ago [4]; we might
wonder if an adequate dataset will ever be
available.
The studies examined by Verma et al used
different methods to retrieve data for their costeffectiveness analysis. Some used Markov models
while others used estimations from Medicare
/ SEER (Surveillance, Epidemiology, and End
Results) data. Centres for Medicare and Medicaid
Services (CMS), is the largest public payer in
the USA: they publish rates of reimbursement
INTRODUCTION
Additionally, it is possible to quantitatively
assess the effectiveness of proton therapy for
individual patients, comparing photon and
proton treatments on dose metrics, toxicity and
cost-effectiveness levels, retrieved from a decision
support system [6].
Gathering good clinical and cost data remains
essential in defining the cost-effectiveness of new
technologies, such as proton therapy. Because it
is evident that protons will not be cost-effective
for all patients, but could be effective for subsets of patients, we shouldn’t look at the whole
population anymore, but instead at the individual
patient level. Well-designed decision support
systems will play an important role here. Whether
or not proton therapy is the right treatment
will ultimately depend on individual patient
characteristics.
Madelon Johannesma
Epidemiologist
MAASTRO clinic
Maastricht, The netherlands
Health insurance company CZ
Tilburg, The Netherlands
A model-based approach could be the solution
based on sub-groups or on individual patients.
Applying NTCP models could generate evidence
regarding the value of proton therapy, and
help to identify enriched cohorts of patients
who are likely to benefit from protons [5].
PROTON THERAPY: THE RIGHT TREATMENT? IT DEPENDS…
REFERENCES
[1] Verma V, Mishra MV, Mehta MP. A systematic review of
the cost and cost-effectiveness studies of proton radiotherapy.
Cancer. 2016 Feb 1
[2] Sorenson C, Drummond M, Burns LR. Evolving reimbursement and pricing policies for devices in Europe and
the United States should encourage greater value. Health Aff
(Millwood). 2013 Apr;32(4):788-96.
[3] Lievens Y, Pijls-Johannesma M. Health economic controversy and cost-effectiveness of proton therapy. Semin Radiat
Oncol. 2013 Apr;23(2):134-41.
Review.
[4] Lodge M, Pijls-Johannesma M, Stirk L, Munro AJ, De
Ruysscher D, Jefferson T. Asystematic literature review of the
clinical and cost-effectiveness of hadron therapy in cancer.
Radiother Oncol. 2007 May;83(2):110-22. Epub 2007 May 14.
Review.
[5] Widder J, van der Schaaf A, Lambin P, Marijnen CA,
Pignol JP, Rasch CR,Slotman BJ, Verheij M, Langendijk JA.
The Quest for Evidence for Proton Therapy: Model-Based Approach and Precision Medicine. Int J Radiat Oncol Biol Phys.
2015
[6] Cheng Q, Roelofs E, Ramaekers BL, Eekers D, van Soest J,
Lustberg T, Hendriks T, Hoebers F, van der Laan HP, Korevaar
EW, Dekker A, Langendijk JA, Lambin P. Development and
evaluation of an online three-level proton vs photon decision
support prototype for head and neck cancer - Comparison of
dose, toxicity and cost-effectiveness. Radiother Oncol. 2016
Feb;118(2):281-5.
INTRODUCTION
PROTON THERAPY: THE RIGHT TREATMENT? IT DEPENDS…
PROJECTS
& RESEARCH
THE ANDANTE PROJECT
The ANDANTE project is finished:
what was achieved?
PROJECTS
& RESEARCH
THE ANDANTE PROJECT
Multidisciplinary evaluation of the cancer risk from neutrons
relative to photons using stem cells and the analysis of second
malignant neoplasms following paediatric radiation therapy
Andrea Ottolenghi, Klaus Trott, Vere Smyth
ANDREA
OTTOLENGHI
THE ANDANTE PROJECT
KLAUS
TROTT
VERE
SMYTH
The ANDANTE project has now completed its
four years. The final meeting was held in the
historic buildings of the University of Pavia in
Italy on 30 November and 1 December 2015. It
was a time to review what had been achieved and
to look forward to where the results could lead.
The purpose of the project was to shed light
on the apparent increase by about an order of
magnitude in the relative biological effectiveness
(RBE) of neutrons with an energy in the region
of 1MeV, as suggested by the accepted radiation
weighting factors used for risk estimation by
the International Commission on Radiological
Protection (ICRP). In particular, the project was
designed to provide new insight into the risks
of breast cancer and thyroid cancer following
exposure to low doses of neutrons during
paediatric proton therapy compared to the second
cancer risks following conventional radiotherapy.
This depends, amongst other things, on the
neutrons’ RBE. The project combined radiation
physics (characterisation of radiation exposure
conditions and modelling DNA damage from
neutron beams), radiobiology (investigating
biological markers following irradiation of organspecific stem cells in neutron and photon beams),
and epidemiology (formulation of a prospective
study to validate the project results).
It is quite possible that the relative biological
effectiveness between neutrons and photons
is specific to the tissues irradiated and to the
damage endpoint, so in order to simulate the
conditions leading to second cancers following
proton therapy, stem cells were isolated from
the salivary gland, thyroid gland, and breast
tissue. The stem cells were irradiated with either
photons or neutrons, and the relative magnitudes
of indicators of possible carcinogenesis were
investigated. The irradiation beams and initial
interactions with DNA were modelled in order
to look for corresponding relative effects. The
results were combined to generate a risk model
for second cancers to be tested in a prospective
epidemiological study.
The reference photon radiation used for
calculating RBE was a 220kV X-ray beam,
generated by Xstrahl-200 machines at the
University Medical Centre, Groningen, The
Netherlands, and the University of Rostock
in Germany. Neutron irradiations were done
at Physikalisch-Technische Bundesanstalt
(PTB), Braunschweig, Germany, using a broad
spectrum high-dose-rate neutron beam to
determine overall stem cell response to neutrons
and also quasi-monoenergetic beams in order
to determine the dependence of response on
neutron energy. A neutron spectrum similar
to that of the scattered neutrons generated in
proton therapy was produced using the proton
generator at KVI Centre for Advanced Radiation
Technology, Groningen. Each of the experimental
beams was modelled using the PHITS (Particle
and Heavy Ion Transport code System) Monte
Carlo (MC) code in order to optimise the design
of stem cell holder, and to simulate the secondary
charged particles produced to be used as input
to the track structure simulations for calculating
RBE.
The MC code PARTRAC (PARticle TRACKs)
was used to simulate biomolecular damage,
using protons and heavier fragments, with
energies acquired through recoil following a
neutron scattering, as generated by the PHITS
simulations. The PARTRAC code, besides the
physical and physico-chemical processes related
to energy deposition, also includes an accurate
representation of chromatin and can be used
to get results on the radiation-induced DNA
fragmentation. In particular, double-strand
breaks (DSBs) and complex lesions (CLs, defined
as the presence of two or more DSBs within 30
base pairs, and which are thought to play a key
role in determining late cellular consequences)
were scored as a function of energy for p, C, N
and O fragments. The results from neutrons
and 220 kV x-rays allowed the calculation of the
DSB-cluster RBE. Significantly, the values are
generally in between the international (ICRP)
and the USA (NRC) standards (see Figure 1).
To our knowledge, this activity has led to the
establishment of the first neutron RBE model for
DNA damage induction, purely based on first
principle calculations.
THE ANDANTE PROJECT
Methods for the isolation of mouse salivary and
thyroid gland stem cells and human breast tissue
stem cells were successfully developed, based
on the formation of spheroids (multicellular
3D structures), which can be obtained in
non-adherent cultivation of cell suspensions.
Following irradiation by neutrons and photons in
the dose range of 0.1 to 2.0 Gy, the stem cells were
subjected to a number of in vitro tests for markers
indicating radiation damage and possible cancer
induction. Results showed a clear dose-response
relationship for clonogenic cell survival and
γH2AX assays, but equivocal results for other
markers. The results were combined with the
track-structure studies to derive a functional
relationship of RBE with neutron energy.
Irradiated stem cells were also transplanted into
mice to investigate the formation of radiationinduced tumours, but it was not possible to
demonstrate a carcinogenic response to radiation
during the project.
The GEANT4 (for GEometry ANd Tracking)
MC simulation toolkit was used to model the
neutron fields generated by the actively scanned
proton beams used for radiotherapy at the Paul
Scherrer Institute, Switzerland. The simulations
were validated against measurements taken
using liquid scintillator detectors. Measurements
were also taken at Northwestern Medicine,
Chicago, USA, on both actively scanned and
passively modulated proton therapy beams, for
comparison with the MCNPX (Monte Carlo
N-Particle Transport) code. These two different
types of beam are both used for proton therapy,
and generate different scattered neutron fields.
Comparison between the simulations and
measurements showed that MC simulation can
be used to calculate the neutron doses and energy
spectra with sufficient accuracy for estimating
neutron-induced second cancer risks in proton
therapy patients. A model for analytical neutron
dose reconstruction was developed, based on the
MC calculations.
The neutron dose calculation method and
the RBE values produced by the project were
combined to give a method for estimating the
risk from clinical data of a second cancer being
caused in a patient by exposure to scattered
neutrons during proton therapy. The method was
tested using sample-anonymised patient data in
preparation for a prospective epidemiological
study to compare second cancer rates following
paediatric proton therapy with conventional
radiotherapy to test for consistency with the RBE
values generated by the project. A dialogue has
been initiated with the National Cancer Institute
(USA) and the International Agency for Research
on Cancer, Lyon, France (WHO-IARC), towards
formulation of a proposal for a prospective study,
and initial plans developed for an international
multi-centre database of radiotherapy treatments
and outcomes. Expressions of interest have been
positive, and possible funding streams for the
study are being investigated. A power calculation
on cohort size and timescale has indicated that it
is likely to take several decades of epidemiological
follow-up time to demonstrate an effect of the
neutrons on the secondary cancer rates. However,
the setting up of an international registry of
childhood cancers has the potential to shed light
on the link between radiation exposure to proton
(and photon) therapy and the subsequent risk of
second cancers linked to such treatments.
PARTICIPANT
Università degli Studi di Pavia
(Coordinator)
Bundesamt für Strahlenschutz
COUNTRY
LEAD SCIENTIST
Italy
Andrea Ottolenghi
Germany
Linda Walsh
Technische Universitaet Wien*
Sweden
Lembit Sihver
ESTRO
Belgium
Evelyn Chimfwembe
Loma Linda University Medical Center USA
Reinhard Schulte
Paul Scherrer Institute, Villigen
Tony Lomax
Switzerland
University Medical Centre, Groningen The Netherlands Rob Coppes
Universitaet Rostock
Germany
Guido Hildebrandt
Fig. 1: Trend of calculated RBE for DNA cluster damage as a function of
neutron energy, compared with ICRP 103 and US NRC Wrs (details in Baiocco
et al, to be published).
MANAGEMENT AND COORDINATION GROUP
Andrea Ottolenghi
Klaus Trott
Vere Smyth
SCIENTIFIC ADVISORS
Albrecht Kellerer
Werner Rühm
Herman Suit
Project website: www.andanteproject.eu >
* Responsibilities taken over from Chalmers University of Technology in the final 12 months
ANDANTE contract number 295970, is a EURATOM
funded project under FP7 programme
THE ANDANTE PROJECT
RESEARCH INTO COMBINATION
THERAPY FOR PATIENTS WITH
COMPLEX LUNG CANCER
Prestigious European grant for development of
lung cancer therapy
Professor Philippe Lambin of Maastricht UMC+
and the Maastro Clinic has been awarded a
prestigious Advanced Grant by the European
Research Council (ERC). Lambin and his team
will use the subsidy of approximately 2.5 million
euro to conduct research into an innovative
method of treating patients with metastatic
lung cancer. The new treatment is based on a
combination of immunotherapy, stereotactic
radiotherapy and a special medication targeting
tumour hypoxia. In particular, the new
treatment would benefit patients suffering from
metastatic lung cancer.
More information >
http://www.mumc.nl/en/actueel/nieuws/
prestigious-european-grant-development-lungcancer-therapy
PHILIPPE LAMBIN
INSTITUTIONAL
MEMBERSHIP
INTRODUCTION
RADBOUD UNIVERSITY MEDICAL CENTRE
INSTITUTIONAL
MEMBERSHIP
INSTITUTIONAL ESTRO MEMBERSHIP
BECOME AN INSTITUTIONAL
MEMBER
As an institutional member you can sign
up groups of five people for institutional
membership, saving you money while
providing all the benefits of regular
membership as well as some additional
advantages created just for your institute.
The packages include various membership
types and a minimum of three disciplines
need to be represented. For more
information visit: www.estro.org
The Institutional membership category has been especially designed for European hospitals, clinics
or other institutions that seek to continuously develop and support their radiotherapy and oncology
professionals. In this Corner we invite our institutional members to provide some feedback on their
experiences and their institute. Radboud University Medical Centre, Nijmegen, The Netherland, is
featured in this issue.
Contact: institutional-membership@estro.org
INTRODUCTION
RADBOUD UNIVERSITY MEDICAL CENTRE
INSTITUTIONAL
MEMBERSHIP
Radboud University
Medical Centre
Nijmegen, The Netherlands
© William Moore
Spokesperson: Professor Philip Poortmans (MD, PhD)
Number of ESTRO institutional members: 100
www.radboudumc.nl/zorg/afdelingen/radiotherapie
Radboud University Medical Centre staff
Please describe the radiotherapy
department at your institute
PHILIP POORTMANS
INTRODUCTION
Radboud University Medical Centre is a leading
academic centre for patient care, education and
research, whose mission is to ‘have a significant
impact on healthcare’. Our activities help to
improve healthcare and consequently the health
of both individuals and society. We believe we
can achieve this by providing high-quality,
participatory and personalised healthcare,
operational excellence and by working together
in sustainable networks. The 150 professionals
based in the Department of Radiation Oncology
fully align with this mission and vision. The 15
radiation oncologists, six medical physicists, 55
radiation therapists and more than 35 researchers
work closely together with the other members
of our team working in patient care, training
(ten residents in radiation oncology and three
in medical physics) and education and scientific
research ranging from fundamental studies
through to clinical trials. The department is part
of the Radboudumc Centre for Oncology, which
works to optimise multidisciplinary care within
our hospital, as well as in the region working
with other hospitals.
RADBOUD UNIVERSITY MEDICAL CENTRE
What are the main areas of
specialisation in your department?
While the department is known for its
progressive work in the field of head and neck
cancer (ARCON), prostate (rectal balloon),
Hodgkin lymphoma (EORTC trials), lung and
breast cancer, it is perhaps best known as a
leader in translational radiobiological research.
Our ambition to maintain and expand this line
of research was recently strengthened with the
integration of a research team from the Radboud
Tumour Immunology Lab into the research
laboratory of the Department of Radiation
Oncology, more than doubling its size. This opens
new doors to benchmarking research on the
interaction between radiation and the immune
system in the tumour microenvironment
and the consequences for local and systemic
tumour regression or progression. In addition,
understanding these fundamental immunological
and radiobiological mechanisms will allow us to
develop innovative combined approaches to be
tested in future clinical trials.
One of the strengths of our radiobiology/
immunology research facility is its location in the
centre of the outpatient clinic, which encourages
interaction and collaboration between basic,
translational and clinical researchers. We use the
facilities of PRIME (Preclinical Imaging Centre)
for pre-clinical imaging of experiments involving
animals. The state-of-the-art techniques available,
INTRODUCTION
include: PET/CT, SPECT/CT, MRI optical
imaging system; multi-photon fluorescence
microscopy, as well as behaviour and cognition
facilities.
What are your main achievements so far
and the main challenges?
Most recently we brought all technical aspects
of our protocols up-to-date, expanding the
indications for the use of respiratory control,
volumetric IMRT and stereotactic treatments.
Together with contemporary imaging, including
PET-CT and MRI for planning and evaluation,
we further optimised treatment delivery with
IGRT and are gradually introducing adaptive
radiation therapy. We recently introduced
automated treatment planning for prostate
cancer, and will be implementing a plan-ofthe-day approach for cervical cancer this year
– another approach that will greatly benefit from
automated planning. An additional novelty is
the introduction of 3D printing for the creation
of bolus material, used for the treatment of skin
cancer with electron-beam radiation therapy.
Our current challenge is to improve our work
processes further, for which we have set up the
‘durable improvement’ project. Our ambition for
the future is that we will optimise our workflow
so that patients who are referred to us can start
their radiation therapy the first working day after
their initial consultation. We do not necessarily
want to apply this approach in all cases, but we
would like our processes to be so efficient that it
becomes possible.
Later in 2016 we will start our complex brachytherapy applications (mainly for cervical cancer)
using the brand-new infrastructure of MITeC
(Medical Innovation & Technology expert
Centre), which offers an MRI in the operating
theatre to verify and adapt/optimise the
applicators and needles.
Is your department currently
undertaking some studies or clinical
trials that you would like to share with
the ESTRO community?
We directly and indirectly participate in several
clinical trials and other research projects. These
include: RACOST (evaluating stereotactic
treatment of vertebral metastases); IRMA
(evaluating external-beam APBI); arthrosis
trials for hands and knees; EORTC-1219 /
DAHANCA-29 (evaluating the use of nimorazole
in head and neck cancer); UPGRADE_RT
(PET/CT driven dose de-escalation for elective
neck treatment on head and neck cancer);
COOPERATION (Dutch randomised multicentre
trial COmparing twO PalliativE RAdiaTION
schemes for incurable head and neck cancer).
We also collaborate, in a more technical
field, with MAASTRO Clinic in the DuCAT
project (Dutch Network of Computer Assisted
RADBOUD UNIVERSITY MEDICAL CENTRE
Theragnostics) that aims to develop decisionsupporting software. As part of this project, one
of our researchers developed a patient-centred
decision-aid tool for the treatment of prostate
cancer, working in close collaboration with the
Department of Urology.
Why is it important for your institute
that its staff members are part of
ESTRO?
We consider ESTRO as a preferred partner for
long-term development of our specialities in an
international context. By involving a broad range
of our collaborators via institutional membership,
we facilitate the transferral of important
information throughout the department. As
transfer of knowledge and skills is the key to
faster and durable progress, the institutional
membership offers a great opportunity to join
and subsequently strengthen the entire ESTRO
community, of which our department now forms
an integral part.
Is there anything particular about your
institute that you would like to share
with the ESTRO community?
The Radboud multidisciplinary approach excels
in the field of head and neck cancer, and is often
considered as a showpiece and benchmark for
other national and international teams. Please feel
welcome to contact us if you see opportunities for
common research projects or if you would like to
share and exchange knowledge and skills.
What additional benefits would be
useful as part of the institutional
membership?
Well, easy access is an indispensable tool for
feeling part of the community. The current
website already offers great options, though we
hope that this will further develop in the coming
years to a truly interactive companion in science
and education.
INTRODUCTION
RADBOUD UNIVERSITY MEDICAL CENTRE
FACT FILE
Radboud University Medical Centre, department of radiation
oncology, Nijmegen, The Netherlands
Description of your institution:
Academic radiation oncology department with a regional function. The enthusiastic
interdisciplinary team works closely together in the field of patient care, training and education.
Research forms an integral part of the department and is transferred from bench to bedside.
Areas of specialisation:
We focus on excellent quality for all working processes, actually involve the patients via
participatory and personalised healthcare and optimise our operational processes, all this by
working together in sustainable multidisciplinary networks. Radiobiology, now combined
with immunological research, forms an integrated part of our department.
Equipment used in the radiation oncology department:
We have six state-of-the-art Elekta linear accelerators, three at the Radboudumc, two in the
nearby Canisius Wilhelmina Hospital and one at the Maasziekenhuis Pantein in Boxmeer.
One older linac is used for a limited number of indications and we have an agreement with
Elekta for a second modern linac in Boxmeer.
We have one wide-bore planning-CT-scan in our department and broad access to MRI and
PET-CT in the Department of Medical Imaging.
Our brachytherapy equipment consists of a Flexitron remote afterloader including peripheral
equipment.
INTRODUCTION
RADBOUD UNIVERSITY MEDICAL CENTRE
CONFERENCES
INTRODUCTION
2016 ICTR-PHE CONFERENCE
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
CONFERENCES
We shall have reports on
the discipline tracks of the
congress in the relevant
Corners of the next
newsletter
We hope you all enjoyed meeting colleagues and friends, who you
usually get to meet only once a year, at ESTRO 35 in beautiful Turin.
We shall have reports on the discipline tracks of the congress in the
relevant Corners of the next newsletter. Two weeks or so after Turin you
will get a chance to read the ESTRO 35 congress report, highlighting
reports on selected abstracts presented at the congress as well as on
the award lectures. Don’t miss out on the chance to learn about some
sessions you might have missed.
In this issue you can read about the third biennial ICTR-PHE
(International Conference on Translational Research in Radio-Oncology
| Physics for Health in Europe) conference, held in February in Geneva,
Switzerland, and also the European Congress of Radiology (ECR)
meeting held in March in Vienna, Austria.
AGOSTINO BARRASSO
ESTRO Congress manager
ERALDA AZIZAJ
ESTRO Programme manager
We take this opportunity to remind you to save the date of the upcoming
6th ICHNO (International Conference on Innovative Approaches in
Head and Neck Oncology), which will take place 16-18 March 2017, in
Barcelona, Spain.
It was a pleasure seeing you all in Turin.
Agostino Barrasso and Eralda Azizaj
INTRODUCTION
2016 ICTR-PHE CONFERENCE
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
6TH ICHNO
International Conference
on innovative approaches in
HEAD & NECK
ONCOLOGY
16-18 March 2017
Barcelona, Spain
The 6th International Conference on Innovative Approaches in Head and Neck Oncology (ICHNO) will be
held from 16 to 18 March 2017 in Barcelona, Spain.
The European SocieTy for Radiotherapy and Oncology
(ESTRO), the European Head and Neck Society (EHNS)
and the European Society of Medical Oncology (ESMO)
have the pleasure to invite you to participate in this conference.
This biennial conference promises once again to provide
a unique platform for the dissemination of the most
relevant and cutting edge science and innovation in the
field of head and neck oncology. This conference has been
shaping up to be a major international event in promoting
multidisciplinarity in head and neck oncology.
With major emphasis on head and neck, this meeting will
specifically cover the main following topics:
• New insights in the epidemiology and prevention of
cancer
• Oncogenesis, HPV related cancers, immunology and
vaccination
• Updated results of practice changing randomised
trials
• Multidisciplinary management of cancers
• Molecular targeted therapies and molecular imaging
• Novel radiation and surgical treatments
• Towards individualised management of cancer
• Robotic and minimally invasive surgery
• Reconstructive and salvage surgery
• Elderly patients, co-morbidities and their impact on
management
• New insight in systemic treatments of cancers
• Thyroid, nasopharynx cancers and rare cancers
• Quality of life, supportive care and management of
treatment side effects.
The format of the meeting will include prestigious invited
‘state of the art lectures’; lectures on the latest innovative
approaches; proffered papers and poster presentations
of new data in the field of head and neck oncology. The
programme will be enriched by pro and contra debates
and interactive tumour board sessions where the audience will have the possibility to participate and share their
input via an electronic voting system. There will be also a
special focus on presentations of new data from practice
changing randomised trials. Ample time will be given
for discussions to allow in-depth interaction among the
various disciplines and the participants.
To stimulate multidisciplinary interactions among the
various specialists, all the lectures, debates, tumour
boards and proferred papers will be given in the same
conference room.
It is hoped that the mix of a rich and challenging scientific programme coupled with the enticing atmosphere
of the city of Barcelona will convince you to attend this
6th International Conference on Innovative Approaches
in Head and Neck Oncology.
Hans Langendijk, ESTRO
C. René Leemans, EHNS
Jean-Pascal Machiels, ESMO
Chairpersons of the 6th ICHNO conference
CONFERENCES
In scientific collaboration
with ESTRO
15 - 19 February 2016
Geneva, Switzerland
MANJIT
DISANJH
INTRODUCTION
JACQUES
BERNIER
In their opening addresses on Monday 15
February, Eckhard Elsen, CERN’s Director for
Research and Computing, and the conference
chairs, CERN’s Manjit Dosanjh and Jacques
Bernier from Clinique de Genolier, welcomed
the participants and discussed the aims of the
conference.
The words that best summarise this meeting were
Jacques Bernier’s: “The primary mission of the
ICTR-PHE conference is to bridge gaps between
all disciplines involved in translational research
in order to boost advances in biophysics and
enhance the quality of their transfer into clinical
practice.” Indeed, already on that first day, experts
in detector technologies, particle accelerators
and nuclear medicine, as well as radiochemists,
biologists and IT professionals were exchanging
ideas and sharing their knowledge.
© Salvatore Fiore
2016 ICTR-PHE CONFERENCE
International Conference on
Translational Research in
Radio-Oncology | Physics for
Health in Europe
The third biennial ICTR-PHE medical conference
concluded on Friday 19 February 2016, once
again on a very successful note. More than 440
participants from all over the world met over five
days and then returned to their home institutes
with new ideas, new collaboration prospects and
optimistic visions of the future of cancer therapy.
From left to right: Jacques Bernier, Eckhard Elsen and
Manjit Dosanjh
The conference got into full swing immediately
after the opening addresses, with its first session
on radiobiology. Among the various topics
discussed, the presentation by Michael Story,
from the University of Texas Southwestern
Medical Center (USA), intrigued the audience.
He discussed novel potential biomarkers and,
in particular, miR 551a and 551b-3p, two micro
RNA (small non-coding RNA molecules) that
were found to be statistically associated with
disease phenotype. The talk by Ahmed Mansoor,
from the US National Cancer Institute, confirmed
how important it is for radiation biology to
partner with immunology. New clinical trials
have recently proven that when radiation therapy
ANAÏS
SCHAEFFER
2016 ICTR-PHE CONFERENCE
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
© Salvatore Fiore
© Salvatore Fiore
The development and the clinical use of prompt
gamma camera was then presented in detail
by Christian Richter from Oncoray, Dresden
(Germany).
The main auditorium
During the coffee break…
is combined with immune modulating agents it
is possible to obtain a higher progression survival
with respect to just immunotherapy.
attention on an issue that is very critical for
hadron-therapy effectiveness: beam spatial
control. The biggest advantage of particle beam
therapy, which is the finite range of the beam, can
be a double-edged sword, because the over- or
under-shoot of the beam requires extra margins,
but this can compromise the dose distribution
and the efficacy of the therapy. That is why much
effort is being put in to developing imaging
techniques for beam range assessment. A number
of possibilities are being studied, but according
to Bortfeld, at the moment prompt gamma
imaging appears to be the most promising; it
is based on the detection of secondary gamma
radiation emitted from nuclear reactions of
protons with tissue. It would allow detecting
in real time the position of the beam in the
body of the patient (during treatment) with an
accuracy of about 1mm. With such precision
the range margins could be reduced, resulting in
significant improvements of treatment quality.
The second day, Tuesday 16 February, continued
with the second part of the discussion on nuclear
medicine that had started on Monday evening.
Michael Lassmann, from the University of
Wurzburg (Germany), took the stage to give an
overview of ‘theranostics’ in nuclear medicine.
This is a very active field of research, with
many new radiopharmaceuticals now available
for imaging and molecular radiotherapy.
Nevertheless, it is still a challenge to establish
reliable dose-response relationships.
The second part of Tuesday morning was
dedicated to detectors and imaging. The session
started with a plenary talk by Thomas Bortfeld,
from the Massachusetts General Hospital and
Harvard Medical School (USA), who focused
INTRODUCTION
2016 ICTR-PHE CONFERENCE
New technologies are key potential weapons
in the fight against cancer and several sessions
of the conference covered this field with highlevel presentations and speakers. Among them,
Jan Lagendijk, from the Universitair Medisch
Centrum Utrecht (The Netherlands), focused his
presentation on Tuesday afternoon on the use of
magnetic resonance imaging for external beam
radiotherapy guidance. Lagendijk explained that
although for certain tumours it is possible to have
a good visualisation of the cancerous structures
with cone beam CT-linac radiotherapy systems,
that’s not the case for all tumours. Indeed, for
most other tumour locations, such as rectum,
oesophagus, pancreas, kidney or individual
lymph nodes, the limited visualisation using cone
beam CT and the lack of dynamic information
hinder a better targeting.
Klaus Maier-Hein, from the University of
Heidelberg (Germany), then showed that
radiomics – the extraction and analysis of large
amounts of advanced quantitative imaging
features with high throughput – can be used for
image-based personalised medicine. Maier-Hein
captivated the audience with a very interesting
example on computing models: together with
his team, he developed a method to anticipate
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
the development and progression of tumours – a
work still in progress but already very promising.
The afternoon concluded in music with a public
lecture of Domenico Vicinanza and Genevieve
Williams, from the Anglia Ruskin University
(UK), on sound as tool for scientific investigation
(you can watch it here).
Thursday 18 February started with a very
interesting programme, which kicked off with a
talk from Søren Bentzen, from the University of
Maryland (USA), who discussed the necessity to
combine precise medicine with multimodality
treatment (surgery, radiotherapy, chemotherapy,
etc.) in order to offer the patient a tailored
therapy.
Deutsch gave an overview of the new concepts
that impact the understanding of the basic
mechanics of oncology, leading to a new
perception of the biological response to
radiotherapy. Nowadays, direct radiation-induced
cell kill of tumour clonogens has to be integrated
within the concept of microenvironment: this
concept implies the consideration of several
cellular compartments, which are shown to
contribute to both tumour response and the
generation of normal tissue damage. These
findings have paved the way for an emerging
new generation of combined clinical trials that,
we hope, will be presented at the ICTR-PHE
conference.
After this very interesting talk, Philippe Lambin,
from the University Medical Centre of Maastricht
(The Netherlands), came on stage to show how
distributed learning can be the solution for rapid
INTRODUCTION
© Salvatore Fiore
On Wednesday 17 February, the morning started
early in front of an already packed room with
the lecture supported by ESTRO and given by
Eric Deutsch, from the Gustave Roussy Cancer
Campus Grand Paris (France).
Eric Deutsch receives the ESTRO award from Yolande
Lievens, chair of the scientific programme committee for
ESTRO 35
learning health care. Lambin described ‘rapid
learning’ as the use of data routinely generated
through patient care and clinical research to
feed an ever-growing database. Thanks to this
database, Lambin hopes to be able to develop
mathematical models – following the example
of weather models – capable of “predicting the
future”. Indeed, as Klaus Maier-Hein showed
earlier, simulation models really are a promising
way to greatly improve cancer treatment and
research. But to achieve that, computing scientists
need huge amounts of data – data they are
eager to collect all over the world through the
Euregional Computer Assisted Theragnostics
project (EuroCAT).
2016 ICTR-PHE CONFERENCE
Later, an overview of the state of clinical trials
for particle therapy in different countries was
given in a well-attended session. James Cox, from
MD Anderson Cancer Centre in Texas (USA),
presented the current situation in the USA,
where 17 particle facilities operate delivering
protons, while no centre yet performs carbon
ions treatment. Clinical trials, which have to
follow precise protocols, are necessary in order to
demonstrate that proton therapy can be a more
effective treatment than photons in terms of
tumour control, patient survival, and treatment
toxicity. According to Cox, clinical trials for
particle therapy can not be effectively conducted
in the USA, due to a number of structural biases,
such as: cost (influencing the age and the social
status of the patients); subjectivity in scoring
acute and sub/acute effects; patient acceptance; as
well as expertise of the investigators. Moreover,
most of the studies don’t take into account late
effects, which are very important in order to
assess treatment toxicity.
Norman Coleman, senior scientific advisor to
the International Cancer Expert Corps (ICEC)
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
© Salvatore Fiore
From left to right: Manjit Dosanjh, Mattia Donzelli,
Grischa Klimpki, Olga Sokol, Brent Huisman, Pankaj
Chaudhary and Jacques Bernier
and member of the US National Cancer Institute,
took the floor on Thursday afternoon. He gave
a very interesting and engaged presentation on
the history and mission of the non-governmental
organisation ICEC. Coleman highlighted that
today, 30 African and Asian countries still don’t
have access to interventions to prevent and
treat cancer and its symptoms, and there is still
a shortfall of 5,000 radiotherapy machines in
the developing world. The mission of the ICEC
is to implement a global force to address this
problem, through a mentoring network of cancer
professionals who work with local and regional
in-country groups to develop and sustain
expertise for better cancer care.
On Friday 19 February in the afternoon, the
youngest researchers of the 2016 ICTR-PHE
conference took the floor. Indeed, on the first
INTRODUCTION
day of the conference, more than 100 of them
arrived with the posters presenting their latest
research carefully rolled in their bag. One by
one pinned on the main conference hall panels,
the posters raised a lot of interest and triggered
many discussions during the whole week of the
conference.
The presentation of the six winning posters
that afternoon was a highlight of the whole
conference. At the special session, chaired
by Manjit Dosanjh and Jacques Bernier,
many people gathered to listen to the young
researchers who will play an important part in
the future of the medical imaging and cancer
field. The winners were: Emanuele Scifoni (GSI
Helmholtzzentrum für Schwerionenforschung,
Darmstadt, Germany); Mattia Donzelli
(European Synchrotron Radiation Facility
of Grenoble, France); Grischa Klimpki (Paul
Scherrer Institute, Switzerland); Karol Brzezinski
(Universitat de València, Spain, and University of
Groningen, The Netherlands); Pankaj Chaudhary
(University of Belfast, Northern Ireland); Brent
Huisman (Université de Lyon, France).
This session and this very successful ICTRPHE conference concluded with a word
from the chairs. “It’s really important that
young researchers have access to these sorts
of conferences, where they can talk to senior
scientists and have their work exposed,” explained
Manjit Dosanjh. “We’ve seen that everybody now
2016 ICTR-PHE CONFERENCE
is talking about personalised medicine – even the
healthcare companies are looking forward to the
development of these precise treatments, because
they should result in being more cost effective as
well as being more specific to the patient. In the
next few years, funds will go towards this new
medicine, and it is now the challenge we have
to meet. Let’s see if, in future conferences, we’ll
come up with solutions.”
Jacques Bernier added: “We can say we’ve met
the objective of this conference, which is to
create interactions between physics, biology
and medicine. From the first to the last day, I’ve
seen constructive exchanges not only in the
conference rooms, but also in the corridors,
where discussions are often more open. I’ve been
impressed by many wonderful lectures, which
promise great progress in the future.”
Manjit Dosanjh concluded: “We were very
happy to receive the positive feedback about
the scientific programme and the stimulating
atmosphere from so many of the participants.”
Manjit Disanjh and Jacques Bernier
Conference organisers
Anaïs Schaeffer, CERN blogger
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
CONFERENCES
Magnetic resonance imaging
(MRI) and magnetic resonance
/ position emission tomography
(MR-PET) in radiation
treatment planning – challenges
and opportunities
ESTRO - EFR joint session
At the European Congress of
Radiology (ECR) meeting
2 - 6 March 2016, Vienna, Austria
UULKE
VAN DER HEIDE
INTRODUCTION
At the ECR meeting in Vienna in March, ESTRO
and the European Society of Radiology held a
joint session on the topic “MRI and MR-PET
in radiation treatment planning – challenges
and opportunities”. Speakers from the radiation
oncology and diagnostic imaging community
covered the exciting new developments in the
use of MRI in radiation oncology, exploring both
the potential benefits and challenges of using
integrated MR-PET devices.
Uulke van der Heide, medical physicist in
the radiation oncology department of the
Netherlands Cancer Institute in Amsterdam,
discussed the issue of geometrical fidelity
of MR images for radiotherapy treatment
planning. In particular, he said that for
stereotactic applications it is critical that MRI
sequences are optimised for this purpose,
as regular diagnostic sequences often show
distortions of several millimetres. He also
discussed the use of functional MRI techniques
to aid tumour delineation. The substantial
contouring variation that is found reflects a
high degree of heterogeneity in pathology. A
probabilistic approach to target definition may
be more appropriate for modern radiotherapy,
where sophisticated dose distributions can be
delivered based on tumour load and tumour
characteristics.
Nicola Dinapoli, radiation oncologist from
Catholic University Gemelli Hospital in Rome,
Italy, talked about the integration of MR imaging
in radiotherapy execution as a method for
monitoring patient positioning and tumour
location fraction by fraction. The discussion
started from the current standard in radiotherapy,
which does not allow you to strictly monitor the
“on-line” execution of the treatment, because it
uses the cone beam CT or other kinds of “static”
imaging techniques for verifying the patient’s
positioning and tumour location. The most
important advantages of MRI are connected to
the possibility of achieving cinematic and highcontrast images that can offer a new perspective
for adapting and tailoring the radiation treatment
during the treatment course itself.
Ursula Nestle, radiation oncologist and nuclear
medicine physician from the University Hospital
in Freiburg, Germany, showed the potential
of integrated MR-PET systems for radiation
oncology. A clear advantage is expected for target
volumes that are poorly visible on computed
tomography (CT). Also, information about
NICOLA DINAPOLI
2016 ICTR-PHE CONFERENCE
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
motion can be derived from both PET and
MRI, to be used in radiotherapy treatment
planning. The exciting new prospect lies in
the simultaneous acquisition of molecular and
functional imaging techniques by PET and MRI.
Further studies, in combination with clinical
trials are necessary to investigate new target
volume concepts and methods for treatment
planning and plan adaptation.
Elna-Marie Larsson, neuro-radiologist at
Uppsala University in Sweden, discussed some
of the challenges that need to be overcome for
successfully adopting imaging techniques taken
from MRI and PET. The boundary and shape of a
tumour may appear differently on anatomical and
functional MRI sequences. The PET images may
show yet again a different shape. To use these
sources of information for tumour delineation
requires a better understanding of the biological
implications. She also addressed the technical
challenges of dealing with geometrical distortions
in MRI. For radiotherapy, it is imperative
that patients are scanned in their treatment
position, which can be challenging for head and
neck cancer patients. Here, dedicated MR coil
configurations are developed that allow MRI
scanning of patients in a mask.
that close interaction between radiologists,
nuclear medicine physicians, radiation
oncologists and medical physicists is essential
to make optimal use of MRI and MR-PET in
radiation oncology.
Uulke van der Heide,
Medical physicist
Radiation Oncology Department
Netherlands Cancer Institute
Amsterdam, The Netherlands
Nicola Dinapoli,
Radiation oncologist
Catholic University Gemelli Hospital
Rome, Italy
Larsson concluded with the statement that
successful integration of MR-PET into radiation
treatment planning requires multidisciplinary
collaboration. Indeed, the entire session showed
INTRODUCTION
2016 ICTR-PHE CONFERENCE
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
2016 ICTR-PHE CONFERENCE
MAGNETIC RESONANCE IMAGING AND MAGNETIC RESONANCE / POSITION
EMISSION TOMOGRAPHY IN RADIATION TREATMENT PLANNING
CALENDAR
OF EVENTS
MAY 2016
6 - 7 MAY 2016 | SANTIAGO DE CHILE, CHILE
1st International ecancer Symposium on Radiotherapy
18-20 MAY, 2016 | DRESDEN, THE NETHERLANDS
Biomarkers for radiation oncology event
ESTRO
RECOMMENDED
EVENT
ESTRO
RECOMMENDED
EVENT
20 MAY 2016 | DUBLIN, IRELAND
4th Beacon Hospital International Stereotactic Radiosurgery and Stereotactic Ablative
Radiotherapy Symposium
ESTRO
ENDORSED EVENT
More information: www.beaconhospital.ie/symposium2016
JUNE 2016
3 JUNE 2016 | BUCHAREST ROMANIA
Integration of new technologies in the clinical practice in radiation oncology
13 - 17 JUNE 2016 | BARCELONA, SPAIN
Updated Oncology 2016 State of the Art News and Challenging Topics event
18 - 19 JUNE 2016 | ANN ARBOR, MI, USA
ESTRO
RECOMMENDED
EVENT
ESTRO
RECOMMENDED
EVENT
ESTRO
RECOMMENDED
EVENT
4th MR in RT event
More information: www.med.umich.edu/radonc/MRinRT2016
27 - 29 JUNE 2016 | SAN FRANCISCO, USA
6th World Congress of Brachytherapy
ESTRO
JOINT EVENT
More information: www.estro.org/congresses-meetings/items/wcb-2016
SEPTEMBER 2016
15-17 SEPTEMBER 2016 | LUGANO, SWITZERLAND
ESO-EANO masterclass in neuro-oncology, challenges in radiotherapy for patients with
brain glioma
ESTRO
ENDORSED EVENT
15 - 16 SEPTEMBER 2016 | ROME, ITALY
II International Congress on Re-irradiation
22 - 24 SEPTEMBER 2016 | PARIS, FRANCE
International conference on immunotherapy-radiotherapy combinations
29 SEPTEMBER - 01 OCTOBER 2016 | PADUA, ITALY
12th Meet the Professor Advanced International Breast Cancer Course (AIBCC) event
ESTRO
ENDORSED EVENT
ESTRO
RECOMMENDED
EVENT
OCTOBER 2016
05-07 OCTOBER 2016 | MAASTRICHT, THE NETHERLANDS
Monte Carlo methods in radiation therapy event
13 - 14 OCTOBER 2016 2016 | ROME, ITALY
Fourth Annual UPMC International Symposium on SRS/SBRT
ESTRO
RECOMMENDED
EVENT
ESTRO
ENDORSED EVENT
NOVEMBER 2016
2 - 3 NOVEMBER 2016 | POZNAN, POLAND
4th GEC-ESTRO Workshop - Techniques, trials and technologies for Brachytherapy Patients
More information: http://www.estro.org
ESTRO
RECOMMENDED
EVENT
24 - 27 NOVEMBER 2016 | MILAN, ITALY
8th European Multidisciplinary Meeting on Urological Cancers (EMUC)
More information: http://emuc16.org
JOINT ESTRO,
ESMO, EAU
DECEMBER 2016
7 - 11 DECEMBER 2016 | OBERGURGL, AUSTRIA
Cancer Stem Cells (CSCs): Impact on Treatment 2016
More information: http://transidee-conference.uibk.ac.at/CSC2016
SCIENTIFIC
COLLABORATION
CREDITS
ESTRO
Bimonthly newsletter
N° 106 | May - June 2016
European Society for
Radiotherapy & Oncology
DEADLINES FOR SUBMISSION
OF ARTICLES IN 2016
July/August 2016 Issue > 2 May 2016
September/October 2016 > 27 June 2016
OFFICERS
President: Philip Poortmans
President-elect: Yolande Lievens
Past-president: Vincenzo Valentini
November/December 2016 > 1 September 2016
For permission to reprint articles please
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EDITOR
If you want to submit articles for
publication, please contact the editor:
cecile.hardon@estro.org
EDITORIAL ADVISERS
For advertising, please contact:
valerie.cremades@estro.org
Cécile Hardon-Villard
Emma Mason
Nick Sarson
GRAPHIC DESIGN
Daneel Bogaerts
Sophie Nelis
Published every two months and distributed
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