Radiation oncology teaching provision and practice prior to and during the first wave of the COVID-19 pandemic in medical schools in the United Kingdom and the Republic of Ireland: a cross-sectional survey

Objectives:Radiotherapy is a key cancer treatment modality but is poorly understood by doctors. We sought to evaluate radiation oncology (RO) teaching in medical schools within the United Kingdom (UK) and Republic of Ireland (RoI), as well as any impacts on RO teaching delivery from the coronavirus disease 2019 (COVID-19) pandemic.Methods:A bespoke online survey instrument was developed, piloted and distributed to oncology teaching leads at all UK and RoI medical schools. Questions were designed to capture information on the structure, format, content and faculty for RO teaching, as well as both the actual and the predicted short- and long-term impacts of COVID-19.Results:Responses were received from 29/41 (71%) UK and 5/6 (83%) RoI medical schools. Pre-clinical and clinical oncology teaching was delivered over a median of 2 weeks (IQR 1–6), although only 9 (27%) of 34 responding medical schools had a standalone RO module. RO teaching was most commonly delivered in clinics or wards (n = 26 and 25 respectively). Few medical schools provided teaching on the biological basis for radiotherapy (n = 11) or the RO career pathway (n = 8), and few provide teaching delivered by non-medical RO multidisciplinary team members. There was evidence of short- and long-term disruption to RO teaching from COVID-19.Conclusions:RO teaching in the UK and RoI is limited with minimal coverage of relevant theoretical principles and little exposure to radiotherapy departments and their non-medical team members. The COVID-19 pandemic risks exacerbating trainee doctors’ already constrained exposure to radiotherapy.Advances in knowledge:This study provides the first analysis of radiotherapy-related teaching in the UK and RoI, and the first to explore the impact of the COVID-19 pandemic on radiationoncology teaching.     

脑肿瘤治疗后磁共振质子波谱评价

目的：评估脑肿瘤手术后、放疗后的多体素^1H MRS的临床应用价值。方法：21例脑肿瘤手术后、放疗后行多体素^1H MRS检查。结果：^1H MRS显示脑肿瘤内Cho升高5例，其中4例手术证实为肿瘤复发，1例为胶质增生。放射治疗后肿瘤生长抑制。^1H MRS表现为Cho降低，NAA、Cr明显下降。放射性坏死^1H MRS表现为肿瘤坏死区出现乳酸-脂质峰。结论：^1H MRS可评估脑肿瘤术后复发和监测肿瘤放疗后的病理变化，是一种有价值的检查方法。     

低剂量放疗在新型冠状病毒肺炎治疗中的应用

新型冠状病毒全球大流行,危重症新型冠状病毒肺炎患者合并细胞因子风暴成为临床亟待解决的难题.低剂量放疗曾短暂用于肺炎的治疗.过去数十年,研究者一直致力于阐明低剂量放疗的生物学机制.低剂量放疗具有炎症抑制作用,已在危重症新型冠状病毒肺炎中取得了初步的效果,受到了学术界和放疗界的重点关注.本文回顾了低剂量放疗在肺炎中的应用,...     

Analyzing changes in radiotherapy treatment planning error reporting during the COVID-19 pandemic

The 2019 coronavirus (COVID-19) pandemic has affected medical physics and radiation oncology departments and the delivery of radiation therapy. Among the changes implemented in response to the onset of the pandemic was a shift to remote treatment planning by health care institutions. The purpose of this study was to determine whether the overall frequency of errors changed after the implementation of remote radiation therapy treatment planning during the COVID-19 pandemic. Reported incidents were obtained from an incident reporting database operated by a multisite cancer care facility in the Northeast. Researchers compared the frequency of reported events in a period prior to the start of the pandemic (March 2019 to February 2020) with a period after the onset of the pandemic (March 2020 to February 2021). No significant increase in reported incidents was detected suggesting the efficiency and safety of remote radiotherapy treatment planning.     

Brainstem stroke: A fatal thromboembolic event after new onset atrial fibrillation during covid-19 infection: A case report and literature review

Coronavirus disease (COVID-19) disease is a serious pandemic that put the world on an exceptional sanitary alert. It is a multifaceted disease, since it can affect the lung, the cardiovascular system and the central nervous system at the same time. A 66-year-old man, diabetic, hypertensive, admitted to the emergency room for medical management of acute dyspnea, diagnosed with COVID-19 infection. The evolution is marked by respiratory distress as well as new onset atrial fibrillation and a severe ischemic stroke of the brainstem. COVID-19 disease is associated with very serious thromboembolic complications of high incidence, and this is explained by the coagulopathy secondary to the alteration of the microcirculation after the hyper-inflammatory state. Ischemic stroke is one of these complications. The occurrence of new onset atrial fibrillation during COVID-19 infection makes the incidence of ischemic stroke very high and the prognosis more severe. The treatment is mainly based on antithrombotic therapy. Thromboembolic complications remain a real problem to manage in COVID-19 patients given the several mechanisms that promote this situation.     

Diagnostic accuracy of 11C-methionine PET for differentiation of recurrent brain tumors from radiation necrosis after radiotherapy.

We evaluated the diagnostic accuracy of PET with l-methyl-(11)C-methionine ((11)C-MET) for the differentiation of recurrent brain tumors from radiation necrosis. METHODS: Seventy-seven patients who had been previously treated with radiotherapy after primary treatment for metastatic brain tumor (n=51) or glioma (n=26) were studied to clarify the diagnostic performance of (11)C-MET PET in differentiating between recurrent brain tumors and radiation necrosis. A total of 88 PET scans with (11)C-MET were obtained; sometimes more than one scan was obtained when there was an indication of recurrent brain tumor or radiation necrosis. A definitive diagnosis was made on the basis of pathologic examination for recurrent brain tumors and on the basis of pathologic examination or clinical course for radiation necrosis. Several indices characterizing the lesions were determined; these included mean and maximum standardized uptake values (SUV(mean) and SUV(max), respectively) and the ratios of lesion uptake to contralateral normal frontal-lobe gray matter uptake corresponding to the SUV(mean) and the SUV(max) (L/N(mean) and L/N(max), respectively). Receiver-operating-characteristic (ROC) curve analysis was used to determine the optimal index of (11)C-MET PET and cutoff values for the differential diagnosis of tumor recurrence and radiation necrosis. RESULTS: The values of each index of (11)C-MET PET tended to be higher for tumor recurrence than for radiation necrosis. There were significant differences between tumor recurrence and radiation necrosis in all of the indices except for the L/N(max) for glioma. ROC analysis indicated that the L/N(mean) was the most informative index for differentiating between tumor recurrence and radiation necrosis. An L/N(mean) of greater than 1.41 provided the best sensitivity and specificity for metastatic brain tumor (79% and 75%, respectively), and an L/N(mean) of greater than 1.58 provided the best sensitivity and specificity for glioma (75% and 75%, respectively). CONCLUSION: (11)C-MET PET can provide quantitative values to aid in the differentiation of tumor recurrence from radiation necrosis, although these values do not appear to be absolute indicators. Quantitative analysis of (11)C-MET PET data may be helpful in managing irradiated brain tumors.     

18F-氟脱氧葡萄糖PET在放射性脑损伤诊断中的应用

随着放疗在脑部肿瘤治疗中的广泛应用,放射性脑损伤的诊断和治疗就显得尤为重要.18F-氟脱氧葡萄糖PET通过对脑组织细胞代谢功能的检测,能够早于形态学检查发现放射性脑损伤,并且在很大程度上能够鉴别放射性脑坏死与肿瘤复发,以指导临床治疗.     

Organization of a radiotherapy service during the COVID-19 epidemic: Experience of Regional Center of Oncology of Agadir,Morocco

This study proposes organization of the activity of a radiotherapy service during the pandemic COVID-19 period. Reliable circuits for staff as well as for patients are installed and treatment protocols are adapted to the current COVID-19 situation. Several scenarios are proposed to deal with any subsequent pandemic situation.     

Differentiation of radiation necrosis from tumor progression using proton magnetic resonance spectroscopy

We report on a young woman who was treated by stereotactic radiotherapy for recurrence of an initially resected low-grade astrocytoma. MRI follow-up examination 7 months after radiotherapy showed a gadolinium-DTPA-enhancing mass lesion indicative of high-grade tumor progression. This assumption was also supported by positron emission tomography with [2-18F]fluoro-2-deoxy-D-glucose (FDG-PET). In contrast, proton MR spectroscopy (1H-MRS) indicated radiation necrosis, which was confirmed histopathologically in surgical specimens. Subsequent follow-up examinations up to 19 months after surgery showed no evidence of tumor recurrence.     

Porphyrie und Radiotherapie: doch eine Risikokonstellation?

BACKGROUND: Little is known concerning the relation of porphyrias to radiation treatment for cancer. The recent literature does not report negative outcomes at least in single cases of breast cancer, bladder cancer or in a patient with lymphoma. Theoretically, there is a risk for radiation treatment in cases of porphyrias. CASE REPORT: Two patients with porphyria are described who underwent radiotherapy for glioblastoma multiforme. Case histories, radiation treatment data and the proof of porphyria are given in detail. The patients received a concomitant radiochemotherapy with infusions of ACNU [1-(4-amino-2-methyl-5-pyrimidinyl)-methyl-(2-chloroethyl)-3-nitrosourea] every 6 weeks. The total radiation doses at the ICRU point were 60 and 38 Gy, respectively, given in single daily fractions of 2 Gy. RESULTS: Both patients responded well as far as objective tumor regression is concerned but died early after 7 and 1.5 months following diagnosis. The first patient experienced a large brain necrosis and deterioration of her porphyria. The second patient died of cardiopulmonary insufficiency still during radiotherapy with persistent or even increased signs of porphyria. The tumor showed extensive necrosis already after 38 Gy. CONCLUSION: In view of annotations in the literature and this case report, caution is advised as for irradiation of brain or nervous tissues in case of porphyrias. Molecular biology data seems to support this warning to some extent.     

Acute ischemic stroke after first dose of inactivated COVID-19 vaccine: A case report

The acute cerebral ischemia induced by the COVID-19 vaccine is one of the side effects. We report the first case of a patient who suffered from a neurological deficit mimicking a stroke after receiving his 1st dose of the inactivated COVID-19 vaccine BIBP (Sinopharm) and who mainly developed cerebral venous thrombosis. Our reported case is a 36-year-old man who was admitted to our intensive care unit 2 days after his first injection dose of the inactivated COVID-19 vaccine BIBP (Sinopharm). He presented a numbness in his left arm and legs with headaches 24 hours after the vaccine injection. In the second day, he had asymmetry of the face which was aggravated by the installation of disturbance of consciousness and a state of agitation. His vital signs were normal. A brain CT scan without injection was done showing a right deep parietal ischemic stroke. The treatment was initiated by aspirin. cerebral MRI showed a very extensive stroke ischemic in the superficial and deep right parietal territory with the onset of hemorrhagic rearrangement of the right basal ganglia, magnetic resonance imaging angiography of the supra-aortic trunks was normal. The patient gradually improved and was discharged after 15 days of his stay in the intensive care unit. The installation of ischemic stroke reported in our young patient after receiving his first dose of inactivated COVID-19 vaccine BIBP; could be a new immune response to the vaccine.     

低剂量放疗治疗重型/危重型新冠肺炎:获益还是风险？

新型冠状病毒肺炎(COVID-19)患者一旦发展成重型/危重型, 肺部炎症因子风暴导致的呼吸衰竭就会成为患者的主要死亡原因。重型/危重型患者现有治疗方法疗效有限, 低剂量放疗(LDRT)治疗重型/危重型COVID-19的临床应用在国外多个医学中心陆续开展, 显示出良好的可行性和有效性, 但其作用机制和最佳剂量尚未完全清楚。本文对LDRT治疗重型/危重型COVID-19的放射生物学机制、有效性、不良反应、治疗剂量等热点问题进行综述, 以期更好地认识其临床获益和不良反应。     

A novel use for routine CBCT imaging during radiotherapy to detect COVID-19

IntroductionThoracic CT is a useful tool in the early diagnosis of patients with COVID-19. Typical appearances include patchy ground glass shadowing. Thoracic radiotherapy uses daily cone beam CT imaging (CBCT) to check for changes in patient positioning and anatomy prior to treatment through a qualitative assessment of lung appearance by radiographers. Observation of changes related to COVID-19 infection during this process may facilitate earlier testing improving patient management and staff protection.MethodsA tool was developed to create overview reports for all CBCTs for each patient throughout their treatment. Reports contain coronal maximum intensity projection (MIP's) of all CBCTs and plots of lung density over time. A single therapeutic radiographer undertook a blinded off-line audit that reviewed 150 patient datasets for tool optimisation in which medical notes were compared to image findings. This cohort included 75 patients treated during the pandemic and 75 patients treated between 2014 and 2017. The process was repeated retrospectively on a subset of the 285 thoracic radiotherapy patients treated between January–June 2020 to assess the efficiency of the tool and process.ResultsThree patients in the n = 150 optimisation cohort had confirmed COVID-19 infections during their radiotherapy. Two of these were detected by the reported image assessment process. The third case was not detected on CBCT due to minimal density changes in the visible part of the lungs.Within the retrospective cohort four patients had confirmed COVID-19 based on RT-PCR tests, three of which were retrospectively detected by the reported process.ConclusionThe preliminary results indicate that the presence of COVID-19 can be detected on CBCT by therapeutic radiographers.Implications for practiceThis process has now been extended to clinical service with daily assessments of all thoracic CBCTs. Changes noted are referred for oncologist review.     

Clinical role of technetium-99m sestamibi single-photon emission tomography in evaluating pretreated patients with brain tumours

One of the main problems regarding the follow-up of patients with brain tumours treated with radiotherapy is the distinction between radiation necrosis and tumour relapse. In many cases computed tomography (CT) scan is unable to distinguish between the two. We assessed the usefulness of brain single-photon emission tomography (SPET) with technetium-99m-sestamibi in cases where CT scan was not conclusive. The absence of tracer uptake in normal brain, the sharp uptake in neoplastic tissue, and the favourable physical properties of technetium make the scintigraphic method particularly accurate. We therefore propose the association of CT scan with^99mTc-sestamibi brain SPET in the follow-up of patients in whom a distinction between radiation necrosis and active disease is needed for an adequate therapeutic decision.Preliminary results were presented at the 6th World Nuclear Medicine and Biology Congress (Sydney, October 1994) and at the 42nd Annual Meeting of the Society of Nuclear Medicine (Minneapolis, June 1995).     

Multiple cranial nerve palsies revealing blast crisis in patient with chronic myeloid leukemia in the accelerated phase under nilotinib during severe infection with SARS-COV-19 virus: Case report and review of literature

Since the introduction of tyrosine kinase inhibitors as primary therapy for patients with chronic myeloid leukemia (CML), the prognosis of these patients has improved significantly, and the number of patients who progress to the blast phase has decreased considerably. We report the case of a 35 year-old CML patient in accelerated phase treated with nilotinib, who presents a severe COVID-19 infection requiring non-invasive ventilation, and who subsequently presents a multiple cranial nerve palsy revealing a blast crisis of his CML. Multiple cranial nerve palsy is a sign of neurological involvement of CML in its blast phase. The blast crisis represents a real challenge for the clinician, especially during COVID-19 infection. The treatment remains the association of a tyrosine kinase inhibitors with a chemotherapy protocol, as well as the administration of methotrexate and cytarabine by intrathecal and intravenous infusion in high doses. Despite the importance of the association of CML with COVID-19 infection, there is not yet enough data to know the true impact of this infection on the evolution of this hemopathy.     

Case study thoracic radiotherapy in an elderly patient with pacemaker: The issue of pacing leads

To assess clinical outcome of patients with pacemaker treated with thoracic radiation therapy for T8-T9 paravertebral chloroma. A 92-year-old male patient with chloroma presenting as paravertebral painful and compressive (T8-T9) mass was referred for radiotherapy in the Department of Radiation Oncology, Institut Curie. The patient presented with cardiac dysfunction and a permanent pacemaker that had been implanted prior. The decision of Multidisciplinary Meeting was to deliver 30 Gy in 10 fractions for reducing the symptoms and controlling the tumor growth. The patient received a total dose of 30 Gy in 10 fractions using 4-field conformal radiotherapy with 20-MV photons. The dose to pacemaker was 0.1 Gy but a part of the pacing leads was in the irradiation fields. The patient was treated the first time in the presence of his radiation oncologist and an intensive care unit doctor. Moreover, the function of his pacemaker was monitored during the entire radiotherapy course. No change in pacemaker function was observed during any of the radiotherapy fractions. The radiotherapy was very well tolerated without any side effects. The function of the pacemaker was checked before and after the radiotherapy treatment by the cardiologist and no pacemaker dysfunction was observed. Although updated guidelines are needed with acceptable dose criteria for implantable cardiac devices, it is possible to treat patients with these devices and parts encroaching on the radiation field. This case report shows we were able to safely treat our patient through a multidisciplinary approach, monitoring the patient during each step of the treatment.     

MR弥散、灌注成像及1H-MRS在判断脑肿瘤放疗后坏死与肿瘤复发诊断中的应用

目的 :试探讨弥散、灌注成像及1H MRS在放射性坏死与脑肿瘤复发鉴别诊断中的作用。材料和方法 :对象 :肿瘤复发和放射性坏死的脑肿瘤患者 2 8例 ,男 17例 ,女 11例。年龄 12～ 6 6岁。检查方法 :MR弥散、灌注成像和1H MRS检查。结果 :脑肿瘤复发 16例 ,放射性坏死 12例。影像表现 :脑肿瘤复发 :弥散成像信号多样 ;灌注成像 :局部高信号 ;1H MRS :Cho上升 ,NAA下降 ,以Lip Lac波升高。放射性坏死 :弥散成像信号多样 ;灌注成像低信号 ;1H MRS :Cho、NAA、Cr均较低。结论 :MRI弥散、灌注成像及1H MRS对判断脑肿瘤放疗后坏死还是肿瘤复发有意义。     

Contribution of PET in the follow-up of cerebral metastases in non-small cell lung cancer. A clinical case valuation

We report a clinical case of a male 44 years old with lung adenocarcinoma with a single brain metastases treated with surgery and radiotherapy. The different PET studies performed during the evolution of the disease were very useful and crucial, firstly in the detection of radiation necrosis and after that when cerebral metastases recurrent appeared twice. The radiographic technique (Brain MRI) and the histopathology after the surgical removal confirmed the PET results. PET imaging is helpful in selected patients with brain metastases in lung cancer.     

MR Gd-DTPA enhancement of radiation brain injury.

MR examinations of 104 patients who had undergone radiotherapy to the brain were reviewed. Thirty-six patients received Gd-DTPA enhanced study during the course of MR evaluation and six of the patients showed enhancing radiation necrosis. Histopathological confirmations were obtained in three patients. Gd-DTPA enhancing radiation lesions were multiple and patchy in three patients, multiple and patchy with cyst formation in two and ring shaped in one. In terms of their distribution, enhancing lesions in four patients were seen only in the white matter within the irradiated field and these patients had undergone radiotherapy within five years. The interval after radiotherapy was more than eight years in two patients and their enhanced lesions were observed in both the white and gray matter. Histopathological findings of Gd-DTPA enhancing radiation necrosis were gliosis and coalescing vacuoles of the neural tissue. None of these enhanced radiation lesions showed significant mass effects. Patterns of the enhancement were not specific. It was considered to be difficult to differentiate tumor recurrence from radiation necrosis with conventional Gd-DTPA enhanced MR examinations. In one patient, delayed MR images after Gd-DTPA administration showed increases in the size and number of radiation enhanced lesions. Dynamic and delayed MR study might add more information to conventional imaging after Gd-DTPA. Further studies are necessary to differentiate radiation lesions from tumor recurrences.     

Radiation necrosis vs high-grade recurrent glioma: differentiation by using dual-isotope SPECT with 201TI and 99mTc-HMPAO.

Conventional imaging techniques are often unreliable in distinguishing between radiation necrosis and recurrent glioma in patients who are symptomatic after high-dose radiotherapy. We performed dual-isotope single-photon emission computed tomography (SPECT) with the use of thallium-201 (201TI) and the perfusion agent 99mTc-hexamethyl-propyleneamine oxime (HMPAO) to aid in this differentiation in 15 patients with glioma prior to biopsy. We found that dual-isotope SPECT scanning correlated with the pathologic findings in 14 of the 15 cases. All patients with high 201TI uptake in their treated tumor beds had local tumor recurrence, and all patients with low 201TI uptake showed only radiation changes without evidence of solid tumor. In patients with an intermediate level of 201TI concentration in their tumor bed, 99mTc-HMPAO uptake differentiated those patients with active tumor from those without; three of four patients with preserved or increased perfusion had pathologic evidence of solid tumor, whereas none of the four patients with decreased perfusion to the tumor bed had evidence of local recurrence. We believe that dual-isotope SPECT with 201TI and 99mTc-HMPAO may be useful in differentiating sites of likely tumor growth from nonspecific radiation changes in patients treated for malignant glioma.