Put yourself in their shoes … the vulnerability of children and their families when attending for radiotherapy treatment: The role of the specialist paediatric radiotherapy radiographer

Childhood cancer is rare; only 1 in 600 children under the age of 15 years develop a cancer. The treatment of childhood cancers is usually a multimodality approach and can involve surgery, chemotherapy and radiotherapy. Radiotherapy is used in the management of tumours of the central nervous system, solid tumours, leukaemia's and Hodgkin's Lymphoma in the paediatric setting. Paediatric patients make up just 1% of the workload in radiotherapy departments, therefore they tend to be very adult orientated environments and treating children can be complex and challenging for staff. As healthcare professionals we must acknowledge the vulnerability of children and their families when they are coming for radiotherapy treatment. The role of the specialist paediatric radiographer has evolved to work alongside the children and their families to alleviate some of the families and staff anxieties, acting as an advocate, a key point of contact and resource. The very nature of radiotherapy treatment means parents will be separated from their children whilst the treatment is delivered. As radiographers we must ensure we put ourselves in their shoes and acknowledge how difficult this is for children and their parents. The key to every interaction with families is excellent communication and this is not just between professionals, the children and families but also between colleagues to ensure care is co-ordinated. Radiographers working with paediatric patients must have refined communication skills, be able to build rapports, offer support and comfort to children and their parents to ensure they receive the best possible care that is tailored to the individual families holistic needs. The specialist paediatric radiotherapy radiographer is in a unique position to deliver this expert care and support.     

Reducing cardiac dose in post-operative irradiation of breast cancer patients: the relative importance of patient positioning and CT scan planning

Left-sided post-operative radiotherapy fields for the treatment of breast cancer inevitably encompass the heart within the treatment volume, resulting in late mortality which may negate the cause-specific survival advantage of the therapy. The effect of positioning was studied in 11 patients with left-sided tumours and five with right-sided tumours receiving routine post-operative radiotherapy to the breast or chest wall as part of primary therapy for breast cancer. Using the same arrangement of glancing fields for each patient treatment position, the optimum patient positioning resulted in a reduction in cardiac dose compared to our standard patient treatment position. On the left side the reduction in mean cardiac dose was 60% (p < 0.001) and the reduction in maximum dose was 32% (p < 0.001); on the right it was 17% and 31%, respectively. The volume of cardiac tissue irradiated was also reduced for all patients. Using this optimum treatment position, cardiac dose was investigated in a further 10 patients with left-sided tumours and our standard glancing field set-up was compared with 3-dimensional planning. A further reduction of 12% in the mean cardiac dose was achieved. 5 of 10 patients had a further small reduction of 4.6% in the maximum dose and one patient had a further reduction in maximum dose of 58%. In conclusion, sophisticated radiotherapy planning can reduce cardiac doses, but optimum patient positioning is of greater importance. The general application of such relatively simple measures could have a significant positive effect on overall survival from breast cancer.     

Solitary extramedullary plasmacytoma of the premaxilla

Solitary extramedullary plasmacytoma is a rare tumour with radiotherapy playing an important role in its management. This report describes the case history of a man with a solitary extramedullary plasmacytoma at an extremely rare site, the premaxilla, that posed certain diagnostic and therapeutic dilemmas. The patient underwent surgery followed by postoperative radiotherapy. The use of two modalities of treatment for this localized tumour has been justified by briefly reviewing the literature and defining the various prognostic factors. These prognostic factors in turn should guide the treatment of these uncommon tumours.     

Evaluation of the role of computed tomography in radiotherapy treatment planning

The role of computed tomography (CT) in radiotherapy treatment planning was assessed in a series of 231 patients in whom treatment was planned with radical intent. For each patient, a treatment plan was produced by the best conventional techniques in use at the Middlesex Hospital. Each patient then underwent a CT scan in which the treatment conditions were closely simulated. As a result of the CT scan images, alteration was made to the planned treatment in 47% of 198 assessable patients. Large differences were seen in the usefulness of CT treatment planning for tumours in different sites, with the greatest contribution made to treatment of tumours of the sinuses and nasopharynx and of the bladder. Although its unit cost is high, computed tomography can be a very useful tool in radiotherapy treatment planning and can contribute uniquely to improved patient management for adequately selected patients.     

Glomus tumour in a child

Glomus tumours are uncommon neoplasms. Very rarely do they present in the paediatric age group. We describe a case of bilateral glomus tumours in a 13-year-old girl that were successfully treated with radiotherapy. The patient remains well 8 years after completion of treatment.     

Music therapy as a non-pharmacological anxiolytic for paediatric radiotherapy patients

Outpatient radiotherapy treatment in the paediatric cancer patient can be a traumatic and an anxiety-provoking experience for both the patient and the family. Music therapy has been widely reported to have psychosocial, educational and physical benefits for the paediatric cancer patient. Using individual case reports, this paper shows the successful use of music therapy as a non-pharmacological anxiolytic in the paediatric radiotherapy, outpatient waiting room setting, by providing the patient and the family with a means of communication, self-expression and creativity.     

Epidermal growth factor receptor and its inhibition in radiotherapy: in vivo findings

Increasing evidence shows that dysregulated epidermal growth factor receptor (EGFR) signalling plays an important part in neoplasia. When over expressed or mutated, EGFR is frequently associated with more aggressive tumour growth, poor patient prognosis and resistance of tumours to cytotoxic agents, including radiation. The present studies with murine carcinomas showed that there is an inverse correlation between the level of EGFR and tumour radiocurability. Likewise, the present clinical study in patients with head and neck cancer shows that EGFR over expression correlates with poorer tumour response to radiotherapy. Adding EGFR to tumour cells in vitro protected cells against the cytotoxic action of radiation, whereas blocking EGFR with anti‐EGFR antibodies enhanced cell radiosensitivity. A casual relationship between EGFR and increased cellular resistance to radiation was established by transferring the EGFR gene into low EGFR‐expressing radiosensitive tumour cells, which then become radioresistant. Radiation activated EGFR and its downstream signalling pathways in radioresistant but not in radiosensitive tumours, and this effect was associated with increased resistance to radiation, and enhanced repopulation in irradiated tumours. Increasing evidence shows that blockage of EGFR or interference with any of the steps in its signal transduction cascade can counteract negative outcomes of EGFR signalling, which has recently been explored as a therapeutic strategy in cancer treatment. The present findings demonstrate that treatment of human tumour xenografts with C225, an anti‐EGFR monoclonal antibody, dramatically enhanced tumour response to radiation. Overall, the findings show that over expression of EGFR may serve as a predictor of tumour treatment outcome by radiotherapy and as a therapeutic target to enhance the efficacy of radiotherapy.     

ALARA and paediatric imaging in radiation therapy: A survey of Canadian paediatric imaging practice

PurposeThere is little discussion in the literature regarding paediatric imaging dose reduction with respect to conventional imaging carried out in radiotherapy departments. This is in contrast to diagnostic radiography where dose optimization when imaging children is a very current topic. For this reason Canadian radiotherapy clinics were surveyed to look at paediatric imaging practice, knowledge and perspectives with respect to imaging dose reduction.MethodAs this was an exploratory study, a questionnaire was developed and sent to radiation therapy clinics across Canada, via email, to assess knowledge of paediatric imaging and dose reduction initiatives. The questionnaire focus was CT simulation and treatment verification imaging of children.ResultsPractice and knowledge of paediatric imaging varied across Canada. Forty percent of clinics reported using paediatric specific protocols for CT simulation and 20% of clinics reported using paediatric specific protocols for treatment verification imaging. There was variation in imaging practices among the clinics that reported treating the most children. The survey results show that while some measures are being taken to reduce paediatric imaging dose in radiation therapy, 46.7% of the respondents felt more could be done.ConclusionThe survey demonstrates interest in dose reduction in radiation therapy imaging as well as differences in current practice and knowledge across Canada. Paediatric imaging dose reduction would appear to be an area of practice that would benefit from more study and development of standards of practice.     

Epidermal growth factor receptor and its inhibition in radiotherapy: in vivo findings

Increasing evidence shows that dysregulated epidermal growth factor receptor (EGFR) signalling plays an important part in neoplasia. When over expressed or mutated, EGFR is frequently associated with more aggressive tumour growth, poor patient prognosis and resistance of tumours to cytotoxic agents, including radiation. The present studies with murine carcinomas showed that there is an inverse correlation between the level of EGFR and tumour radiocurability. Likewise, the present clinical study in patients with head and neck cancer shows that EGFR over expression correlates with poorer tumour response to radiotherapy. Adding EGFR to tumour cells in vitro protected cells against the cytotoxic action of radiation, whereas blocking EGFR with anti-EGFR antibodies enhanced cell radiosensitivity. A casual relationship between EGFR and increased cellular resistance to radiation was established by transferring the EGFR gene into low EGFR-expressing radiosensitive tumour cells, which then become radioresistant. Radiation activated EGFR and its downstream signalling pathways in radioresistant but not in radiosensitive tumours, and this effect was associated with increased resistance to radiation, and enhanced repopulation in irradiated tumours. Increasing evidence shows that blockage of EGFR or interference with any of the steps in its signal transduction cascade can counteract negative outcomes of EGFR signalling, which has recently been explored as a therapeutic strategy in cancer treatment. The present findings demonstrate that treatment of human tumour xenografts with C225, an anti-EGFR monoclonal antibody, dramatically enhanced tumour response to radiation. Overall, the findings show that over expression of EGFR may serve as a predictor of tumour treatment outcome by radiotherapy and as a therapeutic target to enhance the efficacy of radiotherapy.     

Optical tracking technology in stereotactic radiation therapy.

The last decade has seen the introduction of advanced technologies that have enabled much more precise application of therapeutic radiation. These relatively new technologies include multileaf collimators, 3-dimensional conformal radiotherapy planning, and intensity modulated radiotherapy in radiotherapy. Therapeutic dose distributions have become more conformal to volumes of disease, sometimes utilizing sharp dose gradients to deliver high doses to target volumes while sparing nearby radiosensitive structures. Thus, accurate patient positioning has become even more important, so that the treatment delivered to the patient matches the virtual treatment plan in the computer treatment planning system. Optical and image-guided radiation therapy systems offer the potential to improve the precision of patient treatment by providing a more robust fiducial system than is typically used in conventional radiotherapy. The ability to accurately position internal targets relative to the linac isocenter and to provide real-time patient tracking theoretically enables significant reductions in the amount of normal tissue irradiated. This report reviews the concepts, technology, and clinical applications of optical tracking systems currently in use for stereotactic radiation therapy. Applications of radiotherapy optical tracking technology to respiratory gating and the monitoring of implanted fiducial markers are also discussed.     

Chest CT in infants and children

Computed tomography (CT) is a powerful and irreplaceable imaging technique in the evaluation of thoracic disease in infants and children. Recent advances in CT technology, with multi-detector equipment now widely available in most institutions, allowing a highly detailed evaluation of the chest in a short time period has resulted in expanding indications of chest CT in paediatric patients. Its improved diagnostic yield along with a widespread availability has also resulted in an increased number of CT examinations in children, not always with beneficial impact on patient management and outcome. Accordingly with the ALARA concept, a judicious and correct use of CT is strongly advisable in order to reduce unnecessary high dose radiation exposure. The objective of this paper is to review the use of chest CT in paediatric patients focused mainly on basic technical aspects and clinical applications in the evaluation of the lungs, mediastinum and chest wall.     

Kaposi's sarcoma in AIDS: the role of radiation therapy

Radiotherapy can provide good palliation for AIDS patients with symptomatic Kaposi's sarcoma. We have retrospectively reviewed the treatment of 13 lesions in 5 patients. All treated tumours demonstrated significant regression with moderate doses of radiation. Side effects were acceptable and treatment provided good pain relief, functional improvement, and restoration of cosmesis. Our experience confirms that radiotherapy has a meaningful role in the management of AIDS-related Kaposi's sarcoma.     

Child Proton Beam Therapy: A qualitative study of parental views on treatment and information sources

IntroductionProton Beam Therapy (PBT) is often described as an advanced mode of radiotherapy. Whilst PBT offers an equivalent chance of cure to conventional radiotherapy, it is said to offer a theoretical reduction in long term side effects. NHS patients have had access to PBT since 2008 and approximately 65% of the 1144 approved referrals have been for paediatric cases. Yet, there is little research on how parents in these paediatric cases perceive their child's PBT and the information sources they encounter.MethodsThis is a qualitative inquiry informed by in-depth interviews carried out with 27 parents of children treated with PBT.ResultsParents primarily frame PBT as a form of radiation but one which is better than alternatives. Whilst medical professionals do play a role, wider sources of information – such as other families and the internet – are important to both initial decision-making and treatment/recovery experiences.ConclusionParents are faced with the challenge of a ‘fragmented expertise’ which comes with the ‘novelty’ of the radiation therapy, the ‘rare’ nature of the tumours and the remote location of clinical specialists.Implications for practiceThis article will prove useful for practitioners dealing with parents and care givers of children undergoing proton therapy, and is especially valuable and timely for practitioners based in the newly installed proton centres in the UK. Two high energy proton centres are expected to become fully operational in the UK by the end of 2020. Understanding parents’ experiences and perspectives can help avoid undue anxiety and lead to service improvements and overall satisfaction.     

Induction of solid tumors by ionizing radiation

Secondary malignancies are a rare complication after irradiation. 31 observations of such tumours are described, which appeared 4 to 56 years after radiotherapy. The NSD values varied between 400 and 3500 ret. 19 patients developed sarcomas and 12 others carcinomas. The hypotheses of radiation induced tumours and their clinical relevance are discussed. Three patient groups at risk may be distinguished: 1. children, 2. patients who received several treatment series, 3. patients who received combined radio- and chemotherapy.     

Personalized radiotherapy: concepts,biomarkers and trial design

In the past decade, and pointing onwards to the immediate future, clinical radiotherapy has undergone considerable developments, essentially including technological advances to sculpt radiation delivery, the demonstration of the benefit of adding concomitant cytotoxic agents to radiotherapy for a range of tumour types and, intriguingly, the increasing integration of targeted therapeutics for biological optimization of radiation effects. Recent molecular and imaging insights into radiobiology will provide a unique opportunity for rational patient treatment, enabling the parallel design of next-generation trials that formally examine the therapeutic outcome of adding targeted drugs to radiation, together with the critically important assessment of radiation volume and dose-limiting treatment toxicities. In considering the use of systemic agents with presumed radiosensitizing activity, this may also include the identification of molecular, metabolic and imaging markers of treatment response and tolerability, and will need particular attention on patient eligibility. In addition to providing an overview of clinical biomarker studies relevant for personalized radiotherapy, this communication will highlight principles in addressing clinical evaluation of combined-modality-targeted therapeutics and radiation. The increasing number of translational studies that bridge large-scale omics sciences with quality-assured phenomics end points—given the imperative development of open-source data repositories to allow investigators the access to the complex data sets—will enable radiation oncology to continue to position itself with the highest level of evidence within existing clinical practice.     

Spinal deformity after intra-operative radiotherapy for paediatric patients

The purpose of this study was to clarify the incidence and characteristics of late-onset complications of the spine in children who underwent intra-operative radiation therapy (IORT) for common paediatric malignant tumours. 12 children with more than 4 years of follow-up after IORT were included and, in 11 of these, thoracic and/or lumbar spines were irradiated. To compare doses of irradiation to the spine with the resulting deformities, dose simulations of IORT were carried out on two selected cases using a radiation treatment planning system with a pencil-beam algorithm. The mean follow-up period was 135 months (range, 53–234 months). Radiographic reviews found spinal deformity in six patients. Only one patient was symptomatic and the spinal deformity was severe (Grade 3), whereas spinal deformity was mild in the remaining five patients without clinical symptoms (Grade 1). In all of the six patients, anterior wedge-shaped deformity was dominant, and scoliosis was found in only two patients. In one particular case with nephrectomy, irradiation had penetrated much deeper than usual at the site of nephrectomy, and dose distribution was asymmetric, causing clinically significant spinal deformity with scoliosis. In conclusion, specific deformities of the spine observed after IORT can be explained on the basis of dose distribution of the electron beam to the spine.Identification of late morbidity of paediatric cancer therapy has become increasingly important, as recent therapeutic developments have improved the survival rate of affected children. Radiation-induced bone injury is one of the hazardous problems: a high dose of radiation therapy impairs bone growth and gives rise to physical disabilities in affected children. Late complications following skeletal irradiation for childhood tumours have been reported previously [1–6].Intra-operative radiation therapy (IORT) is a technical refinement of radiation therapy that allows sparing of the dose-limiting tissues adjoining the target region. Following gross tumour removal, surgical displacement of critical organs or shielding of adjacent structures is carried out to minimise the radiation damage to the normal structure, and at the same time to deliver an effective irradiation dose to the therapeutic target in a single session. A high dose of electron beam irradiation with the proper acceleration energy can be delivered to residual tumours at the surgical site and neighbouring areas at high risk for microscopic disease. Combined with intensive chemotherapy, IORT has been applied successfully to paediatric malignant tumours [7–15]. In general, IORT has fewer and less severe adverse effects than conventional radiation therapy (external beam radiation therapy (EBRT)). However, the prevalence of arterial and ureteral stenosis following IORT has attracted particular attention recently [16]. The reason that IORT and EBRT are associated with different patterns of complications may result from differences in dose fractionation and distribution between electron beams and high-energy X-ray beams. Moreover, electron beams have a shorter range in bony tissue than X-ray beams and therefore present very different dose distribution patterns to X-rays. This suggests that the biological effects of IORT may be particularly unpredictable in the paraspinal region of patients. The purpose of this study was to clarify the incidence and characteristics of late-onset complications of the spine in children who underwent IORT for common paediatric malignant tumours (mostly for neuroblastoma). We focused on serial radiological changes and reviewed the medical records of long-term survivors retrospectively.     

Pleomorphic adenoma of the parotid gland.

A case of pleomorphic adenoma arising from the deep lobe of the parotid gland is presented. Controversy often surrounds the management of a parotid lump, and many investigations are of little help. The first operation cures most salivary tumours and the patient usually has no residual disability. There is no place for the use of radiotherapy, in the treatment of pleomorphic adenoma.     

Implications of the uptake of 131I-radiolabelled meta-iodobenzylguanidine (mIBG) for the targeted radiotherapy of neuroblastoma

Selective uptake of radiolabelled meta-iodobenzylguanidine (mIBG) in neuroblastoma provides a possible approach to biologically targeted radiotherapy of this disease. A mathematical model was used to predict absorbed doses to tumours of varying size from therapeutic 131I-mIBG, based on measurements of 125I-mIBG uptake in surgically excised tumours from six patients. Two size categories of tumour target were considered: bulk tumour and microscopic disease. The predicted absorbed doses were compared with doses calculated to achieve a 50% probability of tumour cure. The analysis shows that the probability of tumour cure depends strongly on mIBG uptake, effective half-life of mIBG in tumour and tumour diameter. Small microtumours may be relatively resistant to mIBG treatment owing to the limited absorption of 131I beta-energy. The product of patient mass and percentage uptake per unit mass of tumour may be a useful indicator of therapeutic outcome when targeted radiotherapy is used for the treatment of paediatric tumours.     

Grounded theory for radiotherapy practitioners: Informing clinical practice

Radiotherapy practitioners may be best placed to undertake qualitative research within the context of cancer, due to specialist knowledge of radiation treatment and sensitivity to radiotherapy patient’s needs. The grounded theory approach to data collection and analysis is a unique method of identifying a theory directly based on data collected within a clinical context. Research for radiotherapy practitioners is integral to role expansion within the government’s directive for evidence-based practice. Due to the paucity of information on qualitative research undertaken by radiotherapy radiographers, this article aims to assess the potential impact of qualitative research on radiotherapy patient and service outcomes.