NEWSLETTER MARCH

NEWSLETTER MARCH - APRIL
ESTRO | EUROPEAN SOCIETY FOR RADIOTHERAPY & ONCOLOGY
CONFERENCES
3rd ESTRO Forum:
Education, Job Fair, Super Run, awards…
what to mark in your calendar
CLINICAL
First ESTRO patients’ workshop
BRACHYTHERAPY
Report on the 2nd GEC-ESTRO
workshop
RADIOBIOLOGY
Role of stem cells in radiation responses
N° 99 | BIMONTHLY | MARCH - APRIL 2015
CONTENTS
Editorial
Society Life
NEWSLETTER N° 99
MARCH - APRIL 2015
4
6
Clinical
10
Read it before your patients
16
Brachytherapy
44
Physics
61
RTT
70
Radiobiology
83
ESTRO School
91
Young ESTRO
108
Health Economics
Institutional Membership
118
122
National Societies
127
ESTRO Conferences
131
Calendar of events
172
Gaudi’s mosaics - Barcelone, Spain, where the 3rd ESTRO Forum will take place, 24-28 April 2015.
ESTRO | EUROPEAN SOCIETY FOR RADIOTHERAPY & ONCOLOGY
CLINICAL & TRANSLATIONAL MEETING
PHYSICS BIENNIAL MEETING
24 - 28 April 2015
Barcelona, Spain
GEC - ESTRO - ISIORT MEETING
PREVENT AND TARGET MEETING
RTT MEETING
WWW.ESTRO.ORG
EDITORIAL
“The governance
structure will
change, including
revision of some of
the roles of ESTRO
bodies”
Dear friends and colleagues,
Spring is on its way and so is the 3rd ESTRO
Forum. The congress is the place to meet and
network with colleagues from around the world,
with a superb scientific programme and one of
our largest technical exhibitions. I hope to see
you all in April in Barcelona to enjoy together the
magnificent congress we have organised for you.
The situation with ECCO and ESMO is slowly
evolving. I hope that I can bring some good news
to the ESTRO Forum. In the meantime, we have
finalised the scientific programme for the next
joint multidisciplinary ECCO-ESMO congress in
Vienna, from 25-29 September 2015.
I am happy to inform you all that the contract
between ESTRO and Elsevier for Radiotherapy
& Oncology, our beloved Green Journal, has been
signed. The contract is valid for the next two
years. The ESTRO Board will announce more
details at the 3rd ESTRO Forum General
Assembly on the Elsevier contract.
The ESTRO Board is working on the governance changes with Ernst & Young as consultants to finalise the decisions taken at the June
strategy review (JSR) meeting last year. As
already announced in the previous editorial,
the governance structure will change, including
revision of some of the roles of ESTRO bodies.
Following this, the statutes will be updated. All
these changes will be reported at the General
Assembly.
At the end of last year ESTRO signed a renewed
Memorandum of Understanding with the
American Society for Radiation Oncology (ASTRO) of which you can read more in the Society Life Corner.
I hope to see you all in Barcelona for the 3rd
ESTRO Forum.
Philip Poortmans
ESTRO President
SOCIETY LIFE
INTRODUCTION
ASTRO MOU
SOCIETY LIFE
“I hope to see all my
fellow members at our
general assembly”
The annual congress is not only a place for professionals to meet and
network with colleagues from around the world, but also for ESTRO full
members to assemble and find out about important developments in the
Society, as well as approve governance issues. I hope to see all my fellow
members at our general assembly.
One of ESTRO’s aims is to “take all reasonable measures to further develop
as the pre-eminent scientific society in radiotherapy and oncology, and
through this role, the Society will have a unique long-term strategic
responsibility for the future development of the clinical discipline of
radiation and clinical oncology within Europe and at a global level”. To
this end we continue to make strategic collaborations with other radiation
oncology societies worldwide. We are happy to announce our continued
collaboration with ASTRO.
PHILIP POORTMANS
Philip Poortmans
ESTRO President
GENERAL ASSEMBLY
The ESTRO General Assembly will be organised during the
3rd ESTRO Forum in Barcelona and takes place on Monday 27
April at 18.00-19.00 hrs in room 118/119 at the CCIB.
The agenda will be sent to all full members. Please note that
you need to have renewed your 2015 ESTRO membership by 22
April in order to attend. All 2015 members are welcome to join.
INTRODUCTION
ASTRO MOU
SOCIETY LIFE
ASTRO MOU
The American Society for Radiation Oncology (ASTRO) and ESTRO have been collaborating fruitfully
for years on joint symposia. On 16 December 2014 both societies signed a renewal of the Memorandum
of Understanding (MoU) confirming this valued collaboration for the next five years.
The MoU is valid until the end of 2020 and covers themes including joint symposia, possible “Best of”
sessions, guidelines and global initiatives. The joint ESTRO-ASTRO symposia will be held each year,
taking place at both the ESTRO and ASTRO congresses.
ESTRO looks forward to a successful and rewarding continuation of the collaboration with ASTRO.
ESTRO President Philip Poortmans is delighted with this outcome. He commented: “It is logical that we
share our knowledge and join forces to improve the quality of radiation oncology faster than we would
be able to do on our own. This is a good example of a “win-win” agreement, with patients being the main
beneficiaries.”
INTRODUCTION
ASTRO MOU
2015 ESTRO MEMBERSHIP
Join ESTRO and benefit from services specially designed
to support your career
FULL
Active Membership (95 EUR)
Supporting Ambassador (250 EUR)
ASSOCIATE
In Training Membership (75 EUR)
Affiliate (55 EUR)
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TAKE ADVANTAGE OF THE MANY BENEFITS THE ESTRO MEMBERSHIP HAS ON OFFER.
THESE BENEFITS ARE IN RELATION TO THE LEVEL OF INVOLVEMENT WITHIN THE SOCIETY.
Subscription to the Green Journal
Reduced fees for attending ESTRO conferences, teaching courses and joint events
Online access to scientific information through DOVE (events webcasts, delineation cases, etc.)
Eligibility for grants, awards, working groups, faculties and governance positions
And much more!
INSTITUTIONAL MEMBERSHIP
ESTRO offers European institutes the possibility to purchase several individual memberships in a batch
(minimum of five) for their members. Not only is this very economical, but it also offers several other
advantages. Please contact us at [email protected]
For more information on the available package deals and to download the application forms:
http://www.estro.org/members/institutional-membership/institutional-membership >
2015 MEMBERSHIP AVAILABLE ON WWW.ESTRO.ORG
CLINICAL
INTRODUCTION
ESTRO FIRST PATIENTS’
WORKSHOP
CLINICAL
“Every cancer patient in
Europe will have access
to state of the art radiation therapy, as part
of a multidisciplinary
approach where treatment is individualised
for the specific patient’s
cancer, taking account
of the patient’s personal
circumstances”
- ESTRO’s vision for 2020 -
After some delay, we finally managed to meet just
before Christmas in Brussels (despite a public strike
in Belgium) to have our workshop with European
patient representatives. Many thanks to them for
supporting ESTRO’s activities. On the following
pages we have a report on this workshop, written by
Chiara Gasparotto, ESTRO Public Affairs Manager.
I hope you enjoy reading it.
I am sure you have your own views and thoughts on
how to include patients and patient advocacy groups
in ESTRO activities to promote radiation oncology,
so please email me your comments: [email protected]
med.uni-tuebingen.de
DANIEL ZIPS
Daniel Zips
Chair of the Clincal Committee
ESTRO CLINICAL COMMITTEE
View the activities of the Clinical committee:
www.estro.org/about-us/governance-organisation/committees-activities/clinical-committee-activities >
View the members:
www.estro.org/about-us/governance-organisation/scientific-council/committees/clinical-committee >
The committee is contactable through Eralda Azizaj at the ESTRO office [email protected]
INTRODUCTION
ESTRO FIRST PATIENTS’
WORKSHOP
CLINICAL
ESTRO FIRST
PATIENTS’
WORKSHOP
ESTRO’s vision for 2020 puts the patient at the
very centre of everything we do, as follows: “Every
cancer patient in Europe will have access to state
of the art radiation therapy, as part of a multidisciplinary approach where treatment is individualised for the specific patient’s cancer, taking account
of the patient’s personal circumstances”.
CHIARA GASPAROTTO
INTRODUCTION
Keeping the central role of patients clearly in
mind, and observing the increasing amount of
patients receiving radiation therapy as part of
their cancer treatment, ESTRO is eager to develop
activities addressing the main stakeholders: the
patients. While raising awareness and conveying
a positive and safe image of radiation treatment,
ESTRO feels the need to be more inclusive and
develop a structured strategy towards patients.
The clinical committee is particularly interested
in the subject, and for this reason the development of a strategic view for patients has been
included in their three-year roadmap. Daniel Zips
and Joanna Kazmierska are responsible for this
new area within the clinical committee.
Our journey started during the ECCO conference
in September 2013 with a preliminary meeting
with Ian Banks, chair of the ECCO Patient
ESTRO FIRST PATIENTS’
WORKSHOP
Advisory Committee and president of the European Men’s Health Forum. The goal was to
establish a first, formal contact with patient representatives and to have some initial indications
on how to build a new bridge with them. The
meeting was very fruitful and left us with two
main messages: firstly, that the patients must
have a relevant voice within the Society, a main
stakeholder to collaborate with, especially with
regard to raising awareness of radiation oncology
and positioning of the discipline. Secondly, that
a good way to start could be the organisation of
a meeting with various patients’ representatives
to establish a link, understand their perception of
radiation oncology, and to brainstorm with them
on the format for this new collaboration.
meeting, in order to facilitate discussion and allow brainstorming easily.
Following this suggestion, the first ESTRO exploratory meeting with patients took place on
11 December at the ESTRO office. We wanted to
get inputs from patients’ representatives and to
understand their expectations, needs and wishes, with a two-fold outcome: to understand the
perception of radiotherapy from a patient’s point
of view; and to direct the ESTRO strategy by
using the inputs to draft a strategic document to
be submitted to the ESTRO Board, with recommendations on how best to include patients in
ESTRO.
After the introduction of the strategic background, the meeting was structured around
broad questions to be answered in relation to patients’ perception and awareness of radiotherapy,
and their needs, wishes and expectations concerning representation. The questions were very
useful for stimulating a lively discussion.
The patients reminded us of the importance of
the patient, their relationship with their doctors,
and the sense of responsibility that the inclusion
of patients in a society entails.
The meeting highlighted the fact that raising
awareness was an important area for collaboration with patient organisation, as the role of radiation oncology can be overlooked and its status
varies from country to country. General knowledge on radiation therapy, and how the treatment
is included in the patient journey, is often lacking.
Multidisciplinary cancer care remains problematic, as in many countries patients don’t get to
see or are not referred to a radiation oncologist.
There is a need for radiation oncology to be seen
as an equal partner on tumour boards. Multidisciplinary teams are key to enabling patients to
make an informed choice.
We tried to have a broad spectrum of patients’
representatives, from gender to age, to cancer
type and also to type of organisation. At the same
time, we wanted to have a small and informal
Another main point of discussion that was
brought up by all patients’ representatives was the
inequalities across Europe and the major differences in cancer care that a patient can encounter
There is a lack of knowledge concerning the
side-effects of radiation therapy and patients are
sometimes afraid to ask; moving towards safety
and highlighting the quality of treatment will
INTRODUCTION
The meeting started with an introduction to the
ESTRO Vision and the strategy underlying the
engagement of ESTRO with patients: the ESTRO
Vision puts the patients at its very centre and is
based on the three main pillars of ESTRO (science, education and profession). Therefore, the
ESTRO roadmap needs to be inclusive. Focusing
on patients, ESTRO should be the provider of
information and education and should enhance
the concept of multidisciplinary cancer care and
multidisciplinary teams, to allow patients to
make informed choices and ensure their access to
the best treatment option for them.
in Europe. There is a general call for improved
standards and the need to build common positions and strong statements from the European
scientific societies in order to fill those gaps.
Patients play a key role in identifying the problem, so that doctors and professional societies can
then tackle it. In this regard, European guidelines
are of paramount importance, drafted at European level and then implemented at national level. It
is important to ensure that the national perspective is aligned with the European one. National
societies are key players in ensuring this too, both
for dissemination of information and for tailoring it to individual national circumstances.
ESTRO FIRST PATIENTS’
WORKSHOP
help in dispelling misconceptions, negative myths
and the stigmas linked to cancer. This is where
the relationship with the doctor and the concept
of individualised treatment is of paramount importance; the side-effects should be communicated and the patient should be reassured. The
connection between radiation therapy and toxicity needs to be addressed, underlining safety and
focusing on risk management.
Board to draft a strategy and to pursue more regular cooperation with patients, in order to ensure
the continuity of this process.
Communication is central, without any doubt.
There was a firm agreement that the whole radiation therapy team has a role to play in this: RTTs,
physicists, doctors.
In collaboration with Daniel Zips and Joanna Kazmierska, chair and member of the ESTRO clinical
committee respectively.
Linked to communication, the patients reminded
us of the importance of having access to objective, trusted, certified information and recommendations that are evidence-based and that are
given by the Society that is the recognised expert
in radiation oncology. This would be a great help
to patients, families, and to future patients.
We warmly thank all the attendees for sharing
their experience with us and allowing us to have
such a clear overview of the different pathways we
can investigate further. Now we have many ideas
and, above all, very good collaborators to work
with in drafting a comprehensive strategy, focusing
on the main points of the discussion: communication, awareness, and positioning of the discipline.
The clinical committee will work closely with the
INTRODUCTION
Chiara Gasparotto
Public Affairs Manager
ESTRO office
Brussels, Belgium
PARTICIPANTS
ORGANISATIONS REPRESENTATIVES
Ian Banks
EMHF and Chair of PAC at ECCO
Louis Denis
Europa Uomo, responsible liaison EU / EAU
George Kapetanakis
ECPC
Ken Mastris
Europa Uomo, Chair of the Board
Mojca Miklavcic
Europa Donna, member of the Board, Slovenia
Edward David Naessens
Trinity College Dublin, Ireland
Vlad Voiculescu
ECPC Vice President and Treasurer
ESTRO REPRESENTATIVES
Alessandro Cortese
ESTRO CEO
Joanna Kazmierska
Great Poland Cancer Centre Poznan, Poland
Member of the ESTRO Clinical Committee
Daniel Zips
Universitätsklinik für Radio-Onkologie, Tübingen, Germany
Chair of the ESTRO Clinical Committee
Mary Coffey
TCD School of Radiation Therapy St. James’s
Hospital - Dublin, Ireland
Member of the RTT committee
Chiara Gasparotto
ESTRO Public Affairs Manager
Tanja Wolff
General Manager ESTRO Cancer Foundation
ESTRO FIRST PATIENTS’
WORKSHOP
DYNAMIC ONCOLOGY
VIRTUAL ESTRO
DOVE
THE ESTRO PLATFORM FOR SCIENTIFIC AND EDUCATIONAL DATA
DOVE is the e-library developed by ESTRO
giving you access to educational and scientific
material, produced and disseminated by the
Society: the Green Journal articles, conference
abstracts, webcasts, e-posters, slides, access to
FALCON (our delineation tool), guidelines, our
newsletter, etc.
HOW DOES IT WORK?
DOVE works as a search engine encompassing all kinds of data in radiation oncology. Just type in your
key words and then refine your search by ticking the boxes if you are looking for a particular type of
support (abstract, webcast, etc.). Or simply type a key word to see all the information available linked to
the topic.
HOW TO ACCESS DOVE?
Simply go to www.estro.org: DOVE appears on the welcome page. The level of free access to the content
you search will depend on your membership type.
WWW.ESTRO.ORG
READ IT BEFORE
YOUR PATIENTS
INTRODUCTION
BREAST
CERVIX
PROSTATE
HEAD AND NECK
RECTAL
LUNG
HODGKIN’S
LYMPHOMA
PAEDIATRICS
PALLIATION
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
Read the interview with Philip
Poortmans, chair of the clinical
and translational meeting, at
the 3rd ESTRO Forum, in the
Conference Corner on p137 >
INTRODUCTION
BREAST
CERVIX
HANS KAANDERS
PROSTATE
HEAD AND NECK
RECTAL
LUNG
HODGKIN’S
LYMPHOMA
PAEDIATRICS
PALLIATION
BACKGROUND
READ IT BEFORE
YOUR PATIENTS
BREAST
Radiotherapy or surgery of the
axilla after a positive sentinel
node in breast cancer (EORTC
10981-22023 AMAROS): a
randomised, multicentre, openlabel, phase 3 non-inferiority trial.
Mila Donker MD, Geertjan van Tienhoven MD, Marieke E
Straver MD, Philip Meijnen MD, Prof Cornelis J H van de Velde
MD, Prof Robert E Mansel MD, Prof Luigi Cataliotti MD, A
Helen Westenberg MD, Prof Jean H G Klinkenbijl MD, Lorenzo
Orzalesi MD, Willem H Bouma MD, Huub C J van der Mijle MD,
Grard A P Nieuwenhuijzen MD, Sanne C Veltkamp MD, Leen
Slaets PhD, Nicole J Duez MSc, Peter W de Graaf MD, Thijs
van Dalen MD, Andreas Marinelli MD, Herman Rijna MD, Prof
Marko Snoj MD, Prof Nigel J Bundred MD, Jos W S Merkus MD,
Prof Yazid Belkacemi MD, Prof Patrick Petignat MD, Dominic A X
Schinagl MD, Corneel Coens MSc, Carlo G M Messina MD, Jan
Bogaerts PhD, Prof Emiel J T Rutgers MD.
If treatment of the axilla is indicated in patients
with breast cancer who have a positive sentinel
node, axillary lymph node dissection is the
present standard. Although axillary lymph node
dissection provides excellent regional control, it
is associated with harmful side-effects. We aimed
to assess whether axillary radiotherapy provides
comparable regional control with fewer sideeffects.
METHODS
Patients with T1-2 primary breast cancer and no
palpable lymphadenopathy were enrolled in the
randomised, multicentre, open-label, phase III
non-inferiority EORTC 10981-22023 AMAROS
trial. Patients were randomly assigned (1:1) by
a computer-generated allocation schedule to
receive either axillary lymph node dissection or
axillary radiotherapy in case of a positive sentinel
node, stratified by institution. The primary
endpoint was non-inferiority of five-year axillary
recurrence, considered to be not more than 4%
for the axillary radiotherapy group compared
with an expected 2% in the axillary lymph node
dissection group. Analyses were by intention
to treat and per protocol. The AMAROS trial
is registered with ClinicalTrials.gov, number
NCT00014612.
Lancet Oncol. 2014;15(10): 1303–10
INTRODUCTION
BREAST
CERVIX
PROSTATE
HEAD AND NECK
RECTAL
FINDINGS
Between 19 February 2001 and 29 April 2010,
4,823 patients were enrolled at 34 centres from
nine European countries, of whom 4,806 were
eligible for randomisation. 2,402 patients were
randomly assigned to receive axillary lymph
node dissection and 2,404 to receive axillary
radiotherapy. Of the 1,425 patients with a positive
sentinel node, 744 had been randomly assigned
to axillary lymph node dissection and 681 to
axillary radiotherapy; these patients constituted
the intention-to-treat population. Median followup was 6.1 years (IQR 4.1—8.0) for the patients
with positive sentinel lymph nodes. In the axillary
lymph node dissection group, 220 (33%) of 672
patients who underwent axillary lymph node
dissection had additional positive nodes. Axillary
recurrence occurred in four of 744 patients in the
axillary lymph node dissection group and seven
of 681 in the axillary radiotherapy group. Fiveyear axillary recurrence was 0.43% (95% CI 0.00092) after axillary lymph node dissection versus
1.19% (0.31-2.08) after axillary radiotherapy. The
planned non-inferiority test was underpowered
because of the low number of events. The
one-sided 95% CI for the underpowered noninferiority test on the hazard ratio was 0.005.27, with a non-inferiority margin of two.
Lymphoedema in the ipsilateral arm was noted
significantly more often after axillary lymph node
dissection than after axillary radiotherapy at one
year, three years, and five years.
LUNG
HODGKIN’S
LYMPHOMA
PAEDIATRICS
PALLIATION
INTERPRETATION
Axillary lymph node dissection and axillary
radiotherapy after a positive sentinel node
provide excellent and comparable axillary
control for patients with T1-2 primary breast
cancer and no palpable lymphadenopathy.
Axillary radiotherapy results in significantly less
morbidity.
INTRODUCTION
BREAST
CERVIX
PROSTATE
HEAD AND NECK
RECTAL
LUNG
HODGKIN’S
LYMPHOMA
PAEDIATRICS
PALLIATION
BACKGROUND
READ IT BEFORE
YOUR PATIENTS
BREAST
Whole-breast irradiation
with or without a boost for
patients treated with breastconserving surgery for early
breast cancer: 20-year
follow-up of a randomised
phase III trial.
Bartelink H, Maingon P, Poortmans P, Weltens C,
Fourquet A, Jager J, Schinagl D, Oei B, Rodenhuis C,
Horiot JC, Struikmans H, Van Limbergen E, Kirova Y,
Elkhuizen P, Bongartz R, Miralbell R, Morgan D, Dubois
JB, Remouchamps V, Mirimanoff RO, Collette S, Collette
L; on behalf of the European Organisation for Research
and Treatment of Cancer Radiation Oncology and
Breast Cancer Groups.
Lancet Oncol. 2014 Dec 8. pii: S1470-2045(14)71156-8.
doi: 10.1016/S1470-2045(14)71156-8. [Epub ahead of print]
INTRODUCTION
BREAST
CERVIX
Since the introduction of breast-conserving
treatment, various radiation doses after
lumpectomy have been used. In a phase III
randomised controlled trial, we investigated the
effect of a radiation boost of 16 Gy on overall
survival, local control, and fibrosis for patients
with stage I and II breast cancer who underwent
breast-conserving treatment compared with
patients who received no boost. Here, we present
the 20-year follow-up results.
METHODS
Patients with microscopically complete
excision for invasive disease followed by wholebreast irradiation of 50 Gy in five weeks were
centrally randomised (1:1) with a minimisation
algorithm to receive 16 Gy boost or no boost,
with minimisation for age, menopausal status,
presence of extensive ductal carcinoma in situ,
clinical tumour size, nodal status, and institution.
Neither patients nor investigators were masked
to treatment allocation. The primary endpoint
was overall survival in the intention-totreat population. The trial is registered with
ClinicalTrials.gov, number NCT02295033.
FINDINGS
Between 24 May 1989 and 25 June 1996, 2,657
patients were randomly assigned to receive no
radiation boost and 2,661 patients randomly
assigned to receive a radiation boost. Median
PROSTATE
HEAD AND NECK
RECTAL
follow-up was 17.2 years (IQR 13.0-19.0).
Twenty-year overall survival was 59.7% (99%
CI 56.3-63.0) in the boost group versus 61.1%
(57.6-64.3) in the no boost group, hazard ratio
(HR) 1.05 (99% CI 0.92-1.19, p=0.323). Ipsilateral
breast tumour recurrence was the first treatment
failure for 354 patients (13%) in the no boost
group versus 237 patients (9%) in the boost
group, HR 0.65 (99% CI 0.52-0.81, p<0.0001).
The 20-year cumulative incidence of ipsilateral
breast tumour recurrence was 16.4% (99% CI
14.1-18.8) in the no boost group versus 12.0%
(9.8-14.4) in the boost group. Mastectomies
as first salvage treatment for ipsilateral breast
tumour recurrence occurred in 279 (79%) of
354 patients in the no boost group versus 178
(75%) of 237 in the boost group. The cumulative
incidence of severe fibrosis at 20 years was
1.8% (99% CI 1.1-2.5) in the no boost group
versus 5.2% (99% CI 3.9-6.4) in the boost group
(p<0.0001).
INTERPRETATION
A radiation boost after whole-breast irradiation
has no effect on long-term overall survival,
but can improve local control, with the largest
absolute benefit in young patients, although it
increases the risk of moderate to severe fibrosis.
The extra radiation dose can be avoided in most
patients older than age 60 years.
LUNG
HODGKIN’S
LYMPHOMA
PAEDIATRICS
PALLIATION
OBJECTIVE
READ IT BEFORE
YOUR PATIENTS
Conflicting results have been reported for adenoand adenosquamous carcinomas of the cervix
with respect to their response to therapy and
prognosis. The current study sought to evaluate
impact of adeno- and adenosquamous histology
in the randomised trials of primary cisplatinbased chemoradiation for locally advanced
cervical cancer.
CERVIX
Locally advanced
adenocarcinoma and
adenosquamous carcinomas
of the cervix compared to
squamous cell carcinomas
of the cervix in Gynecologic
Oncology Group trials
of cisplatin-based
chemoradiation.
Rose PG, Java JJ, Whitney CW, Stehman FB, Lanciano R,
Thomas GM.
Gynecol Oncol. 2014 Aug 23. pii: S0090-8258(14)012712. PMID:25152438. [Epub ahead of print]
INTRODUCTION
BREAST
CERVIX
METHODS
Patients with adeno- and adenosquamous
cervical carcinomas were retrospectively studied
and compared to squamous cell carcinomas in
GOG trials of chemoradiation.
of the cervix. However, when treated with
radiation therapy with concurrent cisplatin-based
chemotherapy, the 112 patients with adeno- and
adenosquamous carcinomas had a similar overall
survival (p=0.459) compared the 842 patients
with squamous cell carcinoma. Adverse effects to
treatment were similar across histologies.
CONCLUSION
Adeno- and adenosquamous carcinomas of
the cervix are associated with worse overall
survival when treated with radiation alone
but with similar progression-free and overall
survival compared to squamous cell carcinomas
of the cervix when treated with cisplatin-based
chemoradiation.
RESULTS
Among 1671 enrolled in clinical trials of
chemoradiation, 182 adeno- and adenosquamous
carcinomas were identified (10.9%). A higher
percentage of adeno- and adenosquamous
carcinomas were stage IB2 (27.5% versus 20.0%)
and fewer had stage IIIB (21.4% versus 28.6%).
The mean tumour size was larger for squamous
than adeno- and adenosquamous. Adeno- and
adenosquamous carcinomas were more often
poorly differentiated (46.2% versus 26.8%).
When treated with radiation therapy alone, the
70 patients with adeno- and adenosquamous
carcinoma of the cervix showed a statistically
poorer overall survival (p=0.0499) compared to
the 647 patients with squamous cell carcinoma
PROSTATE
HEAD AND NECK
RECTAL
LUNG
HODGKIN’S
LYMPHOMA
PAEDIATRICS
PALLIATION
READ IT BEFORE
YOUR PATIENTS
PROSTATE
Management of prostate
cancer in older patients:
updated recommendations
of a working group of the
International Society of
Geriatric Oncology.
In 2010, the International Society of Geriatric
Oncology (SIOG) developed treatment guidelines
for men with prostate cancer who are older than
70 years old. In 2013, a new multidisciplinary
SIOG working group was formed to update
these recommendations. The consensus of
the task force is that older men with prostate
cancer should be managed according to their
individual health status, not according to age.
On the basis of a validated rapid health status
screening instrument and simple assessment, the
task force recommends that patients are classed
into three groups for treatment: healthy or fit
patients who should have the same treatment
options as younger patients; vulnerable patients
with reversible impairment who should receive
standard treatment after medical intervention;
and frail patients with non-reversible impairment
who should receive adapted treatment.
Droz JP, Aapro M, Balducci L, Boyle H, Van den Broeck
T, Cathcart P, Dickinson L, Efstathiou E, Emberton M,
Fitzpatrick JM, Heidenreich A,Hughes S, Joniau S, Kattan
M, Mottet N, Oudard S, Payne H, Saad F, Sugihara T.
Lancet Oncol. 2014 Aug;15(9):e404-14. doi: 10.1016/
S1470-2045(14)70018-X.
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PURPOSE
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In a recent analysis of a large clinical database,
post-diagnosis aspirin use was associated with
57% lower prostate cancer–specific mortality
(PCSM) among men diagnosed with nonmetastatic prostate cancer. However, information
on this association remains limited. We assessed
the association between daily aspirin use and
PCSM in a large prospective cohort.
PROSTATE
Daily aspirin use and prostate
cancer-specific mortality in a
large cohort of men with nonmetastatic prostate cancer.
Jacobs EJ, Newton CC, Stevens VL, Campbell PT,
Freedland SJ, Gapstur SM.
J Clin Oncol. 2014 Nov 20;32(33):3716-22. doi: 10.1200/
JCO.2013.54.8875. Epub 2014 Oct 20.
PATIENTS AND METHODS
This analysis included men diagnosed with nonmetastatic prostate cancer between enrolment in
the Cancer Prevention Study-II Nutrition Cohort
in 1992 or 1993 and June 2009. Aspirin use was
reported at enrolment, in 1997, and every two
years thereafter. During follow-up through 2010,
there were 441 prostate cancer deaths among
8,427 prostate cancer cases with information on
pre-diagnosis aspirin use and 301 prostate cancer
deaths among 7,118 prostate cancer cases with
information on post-diagnosis aspirin use.
high-risk cancers (≥ T3 and/or Gleason score ≥
8), post-diagnosis daily aspirin use was associated
with lower PCSM (HR = 0.60; 95% CI, 0.37 to
0.97), with no clear difference by dose (low-dose,
typically 81 mg per day, HR = 0.50; 95% CI, 0.27
to 0.92, higher dose, HR = 0.73; 95% CI, 0.40 to
1.34).
CONCLUSION
A randomised trial of aspirin among men
diagnosed with non-metastatic prostate cancer
was recently funded. Our results suggest any
additional randomised trials addressing this
question should prioritise enrolling men with
high-risk cancers and need not use high doses.
RESULTS
Compared with no aspirin use, neither prediagnosis nor post-diagnosis daily aspirin use
were statistically significantly associated with
PCSM (pre-diagnosis use, multivariable-adjusted
hazard ratio (HR) = 0.92, 95% CI 0.72 to 1.17,
post-diagnosis use, HR = 0.98; 95% CI, 0.74 to
1.29). However, among men diagnosed with
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PURPOSE
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The role of adjuvant radiotherapy (aRT) in
treating patients with pN1 prostate cancer is
controversial. We tested the hypothesis that
the impact of aRT on cancer-specific mortality
(CSM) in these individuals is related to tumour
characteristics.
PROSTATE
Impact of adjuvant
radiotherapy on survival of
patients with node-positive
prostate cancer.
Abdollah F, Karnes RJ, Suardi N, Cozzarini C, Gandaglia
G, Fossati N, Vizziello D, Sun M, Karakiewicz PI, Menon
M, Montorsi F, Briganti A.
J Clin Oncol. 2014 Dec 10;32(35):3939-47. doi: 10.1200/
JCO.2013.54.7893. Epub 2014 Sep 22.
METHODS
We evaluated 1,107 patients with pN1 prostate
cancer treated with radical prostatectomy and
anatomically extended pelvic lymph node
dissection between 1988 and 2010 at two
tertiary care centres. All patients received
adjuvant hormonal therapy with or without
aRT. Regression tree analysis stratified patients
into risk groups on the basis of their tumour
characteristics and the corresponding CSM rate.
Cox regression analysis tested the relationship
between aRT and CSM rate, as well as overall
mortality (OM) rate in each risk group separately.
margins (HR, 0.30; P = .002); and (2) patients
with PLN count of 3 to 4 (HR, 0.21; P = .02),
regardless of other tumour characteristics. These
results were confirmed when OM was examined
as an end point.
CONCLUSION
The beneficial impact of aRT on survival in
patients with pN1 prostate cancer is highly
influenced by tumour characteristics. Men
with low-volume nodal disease (≤ two PLNs)
in the presence of intermediate- to high-grade,
non–specimen-confined disease and those with
intermediate-volume nodal disease (three to four
PLNs) represent the ideal candidates for aRT after
surgery.
RESULTS
Overall, 35% of patients received aRT. At
multivariable analysis, aRT was associated with
more favourable CSM rate (hazard ratio [HR],
0.37; P < .001). However, when patients were
stratified into risk groups, only two groups
of men benefited from aRT: (1) patients with
positive lymph node (PLN) count ≤ 2, Gleason
score 7 to 10, pT3b/pT4 stage, or positive surgical
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BACKGROUND
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We investigated whether 18 months of androgen
suppression plus radiotherapy, with or without 18
months of zoledronic acid, is more effective than
six months of neoadjuvant androgen suppression
plus radiotherapy with or without zoledronic
acid.
PROSTATE
Short-term androgen
suppression and radiotherapy
versus intermediate-term
androgen suppression and
radiotherapy, with or without
zoledronic acid, in men with
locally advanced prostate
cancer (TROG 03.04 RADAR):
an open-label, randomised,
phase 3 factorial trial.
Denham JW, Joseph D, Lamb DS, Spry NA, Duchesne G,
Matthews J, Atkinson C, Tai KH, Christie D, Kenny L, Turner
S, Gogna NK, Diamond T, Delahunt B, Oldmeadow C, Attia
J, Steigler A.
Lancet Oncol 2014;15(10):1076-89.
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METHODS
We did an open-label, randomised, 2 × 2 factorial
trial in men with locally advanced prostate cancer
(either T2a N0 M0 prostatic adenocarcinomas
with prostate-specific antigen [PSA] ≥10 μg/L
and a Gleason score of ≥7, or T2b-4 N0 M0
tumours regardless of PSA and Gleason score).
We randomly allocated patients by computergenerated minimisation – stratified by centre,
baseline PSA, tumour stage, Gleason score, and
use of a brachytherapy boost – to one of four
groups in a 1:1:1:1 ratio. Patients in the control
group were treated with neoadjuvant androgen
suppression with leuprorelin (22.5 mg every three
months, intramuscularly) for six months (shortterm) and radiotherapy alone (designated STAS);
this procedure was either followed by another 12
months of androgen suppression with leuprorelin
(intermediate-term; ITAS) or accompanied by
18 months of zoledronic acid (4 mg every three
months for 18 months, intravenously; STAS plus
zoledronic acid) or by both (ITAS plus zoledronic
acid). The primary endpoint was prostate cancerspecific mortality. This analysis represents the
first, pre-planned assessment of oncological
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endpoints, five years after treatment. Analysis was
by intention-to-treat. This trial is registered with
ClinicalTrials.gov, number NCT00193856.
FINDINGS
Between 20 October 2003 and 15 August 2007,
1,071 men were randomly assigned to STAS
(n=268), STAS plus zoledronic acid (n=268),
ITAS (n=268), and ITAS plus zoledronic acid
(n=267). Median follow-up was 7.4 years (IQR
6.5-8.4). Cumulative incidences of prostate
cancer-specific mortality were 4.1% (95% CI
2.2-7.0) in the STAS group, 7.8% (4.9-11.5) in
the STAS plus zoledronic acid group, 7.4% (4.611.0) in the ITAS group, and 4.3% (2.3-7.3) in
the ITAS plus zoledronic acid group. Cumulative
incidence of all-cause mortality was 17.0% (13.022.1), 18.9% (14.6-24.2), 19.4% (15.0-24.7), and
13.9% (10.3-18.8), respectively. Neither prostate
cancer-specific mortality nor all-cause mortality
differed between control and experimental
groups. Cumulative incidence of PSA progression
was 34.2% (28.6-39.9) in the STAS group, 39.6%
(33.6-45.5) in the STAS plus zoledronic acid
group, 29.2% (23.8-34.8) in the ITAS group, and
26.0% (20.8-31.4) in the ITAS plus zoledronic
acid group. Compared with STAS, no difference
was noted in PSA progression with ITAS or
STAS plus zoledronic acid; however, ITAS plus
zoledronic acid reduced PSA progression (subhazard ratio [SHR] 0.71, 95% CI 0.53-0.95;
p=0.021). Cumulative incidence of local
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progression was 4.1% (2.2-7.0) in the STAS
group, 6.1% (3.7-9.5) in the STAS plus zoledronic
acid group, 1.5% (0.5-3.7) in the ITAS group, and
3.4% (1.7-6.1) in the ITAS plus zoledronic acid
group; no differences were noted between groups.
Cumulative incidences of bone progression
were 7.5% (4.8-11.1), 14.6% (10.6-19.2), 8.4%
(5.5-12.2), and 7.6% (4.8-11.2), respectively.
Compared with STAS, STAS plus zoledronic
acid increased the risk of bone progression
(SHR 1.90, 95% CI 1.14-3.17; p=0.012), but no
differences were noted with the other two groups.
Cumulative incidence of distant progression
was 14.7% (10.7-19.2) in the STAS group, 17.3%
(13.0-22.1) in the STAS plus zoledronic acid
group, 14.2% (10.3-18.7) in the ITAS group, and
11.1% (7.6-15.2) in the ITAS plus zoledronic acid
group; no differences were recorded between
groups. Cumulative incidence of secondary
therapeutic intervention was 25.6% (20.5-30.9),
28.9% (23.5-34.5), 20.7% (16.1-25.9), and 15.3%
(11.3-20.0), respectively. Compared with STAS,
ITAS plus zoledronic acid reduced the need for
secondary therapeutic intervention (SHR 0.67,
95% CI 0.48-0.95; p=0.024); no differences were
noted with the other two groups. An interaction
between trial factors was recorded for Gleason
score; therefore, we did pairwise comparisons
between all groups. Post-hoc analyses suggested
that the reductions in PSA progression and
decreased need for secondary therapeutic
intervention with ITAS plus zoledronic acid
were restricted to tumours with a Gleason score
of 8-10, and that ITAS was better than STAS
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in tumours with a Gleason score of 7 or lower.
Long-term morbidity and quality-of-life scores
were not affected adversely by 18 months of
androgen suppression or zoledronic acid.
INTERPRETATION
Compared with STAS, ITAS plus zoledronic
acid was more effective for treatment of prostate
cancers with a Gleason score of 8-10, and ITAS
alone was effective for tumours with a Gleason
score of 7 or lower. Nevertheless, these findings
are based on secondary endpoint data and posthoc analyses and must be regarded cautiously.
Long-term follow-up is necessary, as is external
validation of the interaction between zoledronic
acid and Gleason score. STAS plus zoledronic
acid can be ruled out as a potential therapeutic
option.
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PURPOSE
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National Comprehensive Cancer Network
guidelines recommend patients with head and
neck cancer (HNC) receive treatment at centres
with expertise, but whether provider experience
affects survival is unknown.
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accrual volume and survival of
patients with head and neck
cancer.
Wuthrick EJ, Zhang Q, Machtay M, Rosenthal DI, Nguyen-Tan
PF, Fortin A, Silverman CL, Raben A, Kim HE, Horwitz EM,
Read NE, Harris J, Wu Q, Le QT, Gillison ML.
J Clin Oncol. 2014 Dec 8. pii: JCO.2014.56.5218. [Epub
ahead of print]
HHACs (18% v 6%; P < .001). When compared
with HHACs, patients at HLACs had worse OS
(5 years: 51.0% v 69.1%; P = .002). Treatment at
HLACs was associated with increased death risk of
91% (hazard ratio [HR], 1.91; 95% CI, 1.37 to 2.65)
after adjustment for prognostic factors and 72%
(HR, 1.72; 95% CI, 1.23 to 2.40) after radiotherapy
compliance adjustment.
PATIENTS AND METHODS
The effect of institutional experience on overall
survival (OS) in patients with stage III or IV HNC
was investigated within a randomised trial of
the Radiation Therapy Oncology Group (RTOG
0129), which compared cisplatin concurrent
with standard versus accelerated fractionation
radiotherapy. As a surrogate for experience,
institutions were classified as historically low(HLACs) or high-accruing centres (HHACs) based
on accrual to 21 RTOG HNC trials (1997 to 2002).
The effect of accrual volume on OS was estimated
by Cox proportional hazards models.
CONCLUSION
OS is worse for patients with HNC treated at
HLACs versus HHACs to cooperative group
trials after accounting for radiotherapy protocol
deviations. Institutional experience substantially
influences survival in locally advanced HNC.
Read the editorial in the Journal of
Clinical Oncology on this paper on the
next page >
RESULTS
Median RTOG accrual (1997 to 2002) at HLACs
was four versus 65 patients at HHACs. Analysis
included 471 patients in RTOG 0129 (2002 to
2005) with known human papillomavirus and
smoking status. Patients at HLACs versus HHACs
had better performance status (0: 62% v 52%; P
= .04) and lower T stage (T4: 26.5% v 35.3%; P =
.002) but were otherwise similar. Radiotherapy
protocol deviations were higher at HLACs versus
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The study reported by Wuthrick et al in the
article that accompanies this editorial provides
additional evidence that patients with advanced
head and neck cancer (HNC) should be treated
in high-volume HNC centres for optimal survival
outcomes.
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Impact of centre size and
experience on outcomes in
head and neck cancer.
Corry J, Peters LJ, Rischin D.
J Clin Oncol. 2014 Dec 8. pii: JCO.2014.58.2239. [Epub
ahead of print]
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This study was a retrospective subgroup analysis
of the impact of treatment centre expertise
on the overall survival (OS) of patients with
oropharyngeal cancer and known human
papillomavirus and smoking status who
were treated as part of the Radiation Therapy
Oncology Group (RTOG) 0129 randomised trial.
In this study, high patient accrual to previous
RTOG trials was used as a surrogate for HNC
expertise. There were a total of 471 patients: the
majority (321 patients) were treated at one of 88
historically low-accrual centres (HLACs), whereas
150 patients were treated at one of 13 historically
high-accrual centres (HHACs). Looking back
over a 15-year history of RTOG HNC trials,
the authors defined HHACs as the top tertile of
accrual centres, with an average of more than
42 patients accrued per centre. Patients treated
at HLACs had inferior outcomes, with five-year
locoregional failure rates of 36% compared with
21% for patients treated at HHACs, and five-year
OS rates of 51% compared with 69% for patients
treated at HHACs. There was a 91% increased
risk of death for patients treated at HLACs
after adjusting for age, T and N classification,
performance status, smoking, and human
papillomavirus status. Sensitivity analysis showed
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the results to be consistent when the cut-off for
high accrual was decreased from 42 patients (top
5% of centres) to 25 patients (top 10% of centres)
or when accrual was treated as a continuous
variable.
The authors showed that unacceptable
radiotherapy (RT) protocol non-compliance was
higher in HLACs compared with HHACs (11%
v 5%; P = .04), but in multivariable analysis, the
impact of this on OS was only approximately
20% of the total impact of accrual volume on OS.
This discrepancy likely reflects the requirement
for expertise across the gamut of diagnostic,
therapeutic, and support services to ensure
optimal patient outcomes. However, it is also
likely that RT quality could have contributed
more to the observed difference, given that
the quality assurance (RT QA) analysis was
limited to total dose, overall treatment time,
and field borders. There was no review of the
diagnostic imaging and accuracy of gross
tumour volume delineation, and no assessment
of radiation dosimetry to the gross tumour
volume or planning target volumes. There were
no significant differences between HLACs and
HHACs with respect to acute or late grade 3
to 5 treatment toxicities, but specific data on
treatment-related deaths would have been of
interest.
The overall message from this study is
remarkably similar to that from the Trans
Tasman Radiation Oncology Group (TROG)
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02.02 sub-study published in 2010 that
investigated the impact of radiation protocol
compliance and quality in a randomised trial
evaluating the addition of the hypoxic cytotoxin
tirapazamine to chemoradiotherapy. It was the
first HNC trial to include comprehensive RT QA
and was able to quantify the impact of major
RT protocol violations on patient outcomes. RT
was found to be protocol non-compliant in 208
of 820 patients (25%). A secondary review was
conducted of 206 of the 208 non-compliant plans,
with 97 of 206 (47%) predicted to have an adverse
impact on outcome. Indeed, these patients,
compared with patients with protocol-compliant
plans, had double the two-year locoregional
failure rate (46% v 22%) and an absolute
reduction in two-year OS of 20% (50% v 70%).
Importantly, the probability of receiving poorquality RT was most highly correlated with the
number of patients who were enrolled at centres.
The centres with the lowest accrual numbers (<
five patients) had a disproportionate number of
RT protocol violations compared with centres
with large accrual numbers (> 20 patients): 30%
versus 5% (P < .001).
mandible, and pharyngeal muscles), it can also
increase the risk of a geographic miss. This may
occur if there is inaccurate patient assessment
and/or tumour voluming, which is more likely
to result in a geographic miss than with previous
large-volume, treat-everything RT fields. Hence,
the potential for even greater disparity in HNC
outcomes in low-volume centres could be much
higher in the current IMRT era. The other factor
to note is that at least the RTOG HLACs were
enrolling some patients in clinical trials. There
is another layer of HNC work that is being
performed around the world in community
centres that rarely or never enrol their patients
onto clinical trials and rarely publish their
treatment outcomes. So these patients could quite
possibly have worse outcomes than the patients
in this study who were seen at HLACs. This lack
of data from such HNC centres contributes to
the difficulties in demonstrating what essentially
seems to be a prima facie case – the more you
practice, the better you get.
As Wuthrick et al have highlighted in their
article, the effect of centre experience and
expertise may be much greater with intensitymodulated RT (IMRT), which was not used in the
RTOG 0129 and TROG 02.02 studies but is now
the standard of care. Although the conformality
of IMRT provides many advantages, specifically,
the reduced dose to normal tissues (salivary,
There are retrospective studies that demonstrate
the value of being treated (both non-surgically
and surgically) in large-volume HNC centres.
Analyses of American national databases show
better survival for patients with laryngeal cancer
and cancer in other head and neck sites who
are treated in high-volume centres. Lassig et al
reviewed 388 patients with HNC who underwent
consultation at an academic institution,
including 145 patients who subsequently, for
unstated reasons, were treated at a community
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centre. They reported a 20% OS difference in
favour of the academic centre, although not
all significant prognostic factors were included
in the multivariable analysis. In contrast, a
Canadian study of laryngeal cancer across
Ontario, although finding significant differences
in treatment outcomes between centres, did not
find a correlation with centre patient volumes,
possibly because of the large variations seen
in treatment practice across the nine centres.
Overall, retrospective database analyses should be
seen as essentially hypothesis-generating because
they cannot account for the important issues
of patient selection and treatment bias. These
analyses generally do not include information
about all of the factors that can affect patient
outcomes, such as comorbidities, performance
status, tumour biomarkers, and smoking history,
nor do they include full treatment details or data
on treatment quality assurance.
A prospective study by Loevner et al showed
the considerable impact of diagnostic radiology
expertise in HNC. In this study, cross-sectional
imaging for 136 consecutive patients with HNC
who were referred to a high-volume tertiary
referral centre was reviewed. There was a change
in the interpretation of the imaging studies
in 56 of 136 patients (41%), which altered the
planned treatment in 55 of the 56 patients
(98%). Verification of the interpretative change
was confirmed by pathologic analysis (75%),
characteristic radiologic findings (18%), or
clinical and imaging follow-up (7%). A large
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network of support is required by patients with
HNC who are undergoing curative treatment.
This includes not only the diagnostic radiologists,
surgeons, and radiation oncologists, but also
HNC sub-specialty medical oncologists and
nursing staff and allied health and social workers.
This network of subspecialised support that is
the basis for comprehensive multidisciplinary
care cannot generally be replicated in centres that
treat only small numbers of patients with HNC.
The data that were collected prospectively from
this study by Wuthrick et al and the TROG 02.02
study suggest that we can improve outcomes
in HNC simply by centralising care at highvolume HNC treatment centres. The magnitude
of benefit, approximately 20% absolute
improvement in OS, far exceeds the postulated
benefit from any new treatment intervention that
we test in randomised trials in HNC. How should
we translate these findings into clinical practice?
The authors suggest ways to potentially improve
results from low-volume HNC centres: increased
use of contouring atlases, auto-contouring
software programs, and continuing medical
education that is focused on target delineation
and treatment planning for HNC. In addition,
there are many HHACs that have robust internal
RT QA programmes. Linking HLAC patients
into such RT QA programmes could be another
mechanism for potentially improving the
survival of patients with HNC treated at HLACs.
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However, we would argue that no matter how
much time and money is invested in trying to
improve HNC outcomes for patients in small
HNC centres, it is unrealistic to expect that
such centres can provide the necessary depth,
scope, and currency of expertise across the
whole multidisciplinary team that is required to
optimally manage patients with complex HNC. It
is likely that there is a minimum annual number
of patients with HNC that is required to establish
and maintain multidisciplinary expertise.
It must be stated that in both the study by
Wuthrick et al and in the TROG02.02 study,
there is an assumption that lower trial accrual
numbers equate to treatment of smaller numbers
of patients with HNC. It would be useful to
obtain the total number of patients with HNC
seen in HHACs, as opposed to those enrolled
onto trials, to enable a solid recommendation
to be made for the minimum annual number of
patients with HNC per centre that is required to
achieve these optimal HNC survival outcomes.
Notwithstanding these considerations, we
believe that the evidence is now compelling
to recommend that curative treatment of
patients with complex HNC be consolidated
at high-volume centres to achieve optimal
outcomes. A practical approach to achieve this
that also recognises the benefit to patients of
treatment close to home would be to link small
centres to high-volume centres in a network
arrangement. In this model, all patients with
HNC who potentially require multimodality
treatment would initially be assessed and have
a management plan formulated at a highvolume centre. A collaborative triage process
would then enable the less complex patient
cases to be directed back to the local centre for
treatment with appropriate support as required.
Other models, such as those involving videoconferencing, for instance, are also possible, but
irrespective of the model adopted, we believe that
the benefits of high-volume HNC expertise must
be made accessible to all patients with HNC for
optimal outcomes to be achieved.
We understand the reluctance of many patients to
travel beyond a local centre to receive treatment
at a more distant but larger cancer centre with
HNC experience and expertise. There may
be financial, physical, social, and emotional
impediments that need to be addressed. There
may also be an unwillingness on the part of many
small centres to acknowledge the limitations of
the services that they can reasonably provide.
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Externally validated HPVbased prognostic nomogram
for oropharyngeal carcinoma
patients yields more accurate
predictions than TNM staging.
Due to the established role of the human
papillomavirus (HPV), the optimal treatment
for oropharyngeal carcinoma is currently
under debate. We evaluated the most important
determinants of treatment outcome to develop
a multifactorial predictive model that could
provide individualised predictions of treatment
outcome in oropharyngeal carcinoma patients.
METHODS
Rios Velazquez E, Hoebers F, Aerts HJ, Rietbergen MM,
Brakenhoff RH, Leemans RC, Speel EJ, Straetmans J, Kremer B,
Lambin P.
We analysed the association between clinicopathological factors and overall and progressionfree survival in 168 OPSCC patients treated with
curative radiotherapy or concurrent chemoradiation. A multivariate model was validated in an
external dataset of 189 patients and compared to
the TNM staging system. This nomogram will be
made publicly available at www.predictcancer.org.
Radiother Oncol. 2014 Oct 24. pii: S0167-8140(14)003922. doi: 10.1016/j.radonc.2014.09.005. [Epub ahead of print]
RESULTS
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0.76-0.88), with a validation C-index of 0.67, (95%
CI, 0.59-0.74). Stratification of model estimated
probabilities showed statistically different
prognosis groups in both datasets (p<0.001).
CONCLUSION
This nomogram was superior to TNM
classification or HPV status alone in an
independent validation dataset for prediction of
overall and progression-free survival in OPSCC
patients, assigning patients to distinct prognosis
groups. These individualised predictions could
be used to stratify patients for treatment deescalation trials.
Predictors of unfavourable outcomes were negative
HPV-status, moderate to severe comorbidity,
T3-T4 classification, N2b-N3 stage, male gender,
lower haemoglobin levels and smoking history
of more than 30 pack years. Prediction of overall
survival using the multi-parameter model yielded
a C-index of 0.82 (95% CI, 0.76-0.88). Validation
in an independent dataset yielded a C-index of
0.73 (95% CI, 0.66-0.79. For progression-free
survival, the model’s C-index was 0.80 (95% CI,
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Randomised phase III trial of
concurrent accelerated radiation plus cisplatin with or without cetuximab for stage III to
IV head and neck carcinoma:
RTOG 0522.
Ang KK, Zhang Q, Rosenthal DI, Nguyen-Tan PF, Sherman EJ,
Weber RS, Galvin JM, Bonner JA, Harris J, El-Naggar AK, Gillison ML, Jordan RC, Konski AA, Thorstad WL, Trotti A, Beitler
JJ, Garden AS, Spanos WJ, Yom SS, Axelrod RS.
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PATIENTS AND METHODS
Eligible patients with stage III or IV HNC
were randomly assigned to receive radiation
and cisplatin without (arm A) or with (arm B)
cetuximab. Acute and late reactions were scored
using Common Terminology Criteria for Adverse
Events (version 3). Outcomes were correlated with
patient and tumour features and markers.
CONCLUSION
Adding cetuximab to radiation-cisplatin did
not improve outcome and hence should not be
prescribed routinely. PFS and OS were higher in
patients with p16-positive OPC, but outcomes
did not differ by EGFR expression.
RESULTS
Of 891 analysed patients, 630 were alive at analysis
(median follow-up, 3.8 years). Cetuximab plus
cisplatin-radiation, versus cisplatin-radiation
alone, resulted in more frequent interruptions in
radiation therapy (26.9% v 15.1%, respectively);
similar cisplatin delivery (mean, 185.7 mg/m2 v
191.1 mg/m2, respectively); and more grade 3 to 4
radiation mucositis (43.2% v 33.3%, respectively),
rash, fatigue, anorexia, and hypokalaemia, but
not more late toxicity. No differences were found
J Clin Oncol. 2014;32(27):2940-50.
INTRODUCTION
Combining cisplatin or cetuximab with radiation
improves overall survival (OS) of patients with
stage III or IV head and neck carcinoma (HNC).
Cetuximab plus platinum regimens also increase
OS in metastatic HNC. The Radiation Therapy
Oncology Group launched a phase III trial
to test the hypothesis that adding cetuximab
to the radiation-cisplatin platform improves
progression-free survival (PFS).
between arms A and B in 30-day mortality (1.8% v
2.0%, respectively; P = .81), three-year PFS (61.2%
v 58.9%, respectively; P = .76), three -year OS
(72.9% v 75.8%, respectively; P = .32), locoregional
failure (19.9% v 25.9%, respectively; P = .97), or
distant metastasis (13.0% v 9.7%, respectively; P
= .08). Patients with p16-positive oropharyngeal
carcinoma (OPC), compared with patients
with p16-negative OPC, had better three-year
probability of PFS (72.8% v 49.2%, respectively; P
< .001) and OS (85.6% v 60.1%, respectively; P <
.001), but tumour epidermal growth factor receptor
(EGFR) expression did not distinguish outcome.
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We tested the efficacy and toxicity of cisplatin
plus accelerated fractionation with a concomitant
boost (AFX-C) versus standard fractionation
(SFX) in locally advanced head and neck
carcinoma (LA-HNC).
HEAD AND NECK
Randomised phase III trial to
test accelerated versus standard
fractionation in combination
with concurrent cisplatin for
head and neck carcinomas in the
Radiation Therapy Oncology
Group 0129 Trial: long-term
report of efficacy and toxicity.
Nguyen-Tan PF, Zhang Q, Ang KK, Weber RS, Rosenthal DI,
Soulieres D, Kim H, Silverman C, Raben A, Galloway TJ, Fortin A,
Gore E, Westra WH, Chung CH, Jordan RC, Gillison ML, List M,
Le QT.
J Clin Oncol. 2014;32(34):3858-67.
PATIENTS AND METHODS
Patients had stage III to IV carcinoma of the oral
cavity, oropharynx, hypopharynx, or larynx.
Radiation therapy schedules were 70 Gy in 35
fractions over seven weeks (SFX) or 72 Gy in
42 fractions over six weeks (AFX-C). Cisplatin
doses were 100 mg/m(2) once every three weeks
for two (AFX-C) or three (SFX) cycles. Toxicities
were scored by using National Cancer Institute
Common Toxicity Criteria 2.0 and the Radiation
Therapy Oncology Group/European Organisation
for Research and Treatment of Cancer criteria.
Overall survival (OS) and progression-free survival
(PFS) rates were estimated by using the KaplanMeier method and were compared by using the
one-sided log-rank test. Locoregional failure (LRF)
and distant metastasis (DM) rates were estimated
by using the cumulative incidence method and
Gray’s test.
patients, no differences were observed in OS
(hazard ratio [HR], 0.96; 95% CI, 0.79 to 1.18; P
= .37; eight-year survival, 48% v 48%), PFS (HR,
1.02; 95% CI, 0.84 to 1.24; P = .52; eight-year
estimate, 42% v 41%), LRF (HR, 1.08; 95% CI, 0.84
to 1.38; P = .78; eight-year estimate, 37% v 39%), or
DM (HR, 0.83; 95% CI, 0.56 to 1.24; P = .16; eightyear estimate, 15% v 13%). For oropharyngeal
cancer, p16-positive patients had better OS than
p16-negative patients (HR, 0.30; 95% CI, 0.21 to
0.42; P < .001; eight-year survival, 70.9% v 30.2%).
There were no statistically significant differences in
the grade 3 to 5 acute or late toxicities between the
two arms and p-16 status.
CONCLUSION
When combined with cisplatin, AFX-C neither
improved outcome nor increased late toxicity in
patients with LA-HNC. Long-term high survival
rates in p16-positive patients with oropharyngeal
cancer support the ongoing efforts to explore deintensification.
RESULTS
In all, 721 of 743 patients were analysable (361,
SFX; 360, AFX-C). At a median follow-up of 7.9
years (range, 0.3 to 10.1 years) for 355 surviving
INTRODUCTION
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Physical inactivity has been associated with
higher mortality risk among survivors of
colorectal cancer (CRC), but the independent
effects of pre- versus post-diagnosis activity are
unclear, and the association between watching
television (TV) and mortality in survivors of
CRC is previously undefined.
COLORECTAL
Pre- and postdiagnosis physical
activity, television viewing, and
mortality among patients with
colorectal cancer in the
National Institutes of HealthAARP Diet and Health study.
Arem H, Pfeiffer RM, Engels EA, Alfano CM, Hollenbeck A,
Park Y, Matthews CE.
J Clin Oncol. 2014 Dec 8. pii: JCO.2014.58.1355. [Epub
ahead of print]
INTRODUCTION
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METHODS
We analysed the associations between prediagnosis (n = 3,797) and post-diagnosis (n =
1,759) leisure time physical activity (LTPA) and
TV watching and overall and disease-specific
mortality among patients with CRC. We used
Cox proportional hazards regression to estimate
hazard ratios (HRs) and 95% CIs, adjusting for
known mortality risk factors.
a 22% increased all-cause mortality risk (HR, 1.22;
95% CI, 1.06 to 1.41; P trend = .002), and more
post-diagnosis TV watching was associated with a
non-significant 25% increase in all-cause mortality
risk (HR, 1.25; 95% CI, 0.93 to 1.67; P for trend =
.126).
CONCLUSION
LTPA was inversely associated with all-cause
mortality, whereas more TV watching was
associated with increased mortality risk. For both
LTPA and TV watching, post-diagnosis measures
independently explained the association with
mortality. Clinicians should promote both
minimising TV time and increasing physical
activity for longevity among survivors of CRC,
regardless of previous behaviours.
RESULTS
Comparing survivors of CRC reporting more than
seven hours per week (h/wk) of pre-diagnosis LTPA
with those reporting no LTPA, we found a 20%
lower risk of all-cause mortality (HR, 0.80; 95%
CI, 0.68 to 0.95; P for trend = .021). Post-diagnosis
LTPA of ≥ 7 h/wk, compared with none, was
associated with a 31% lower all-cause mortality risk
(HR, 0.69; 95% CI, 0.49 to 0.98; P for trend = .006),
independent of pre-diagnosis activity. Compared
with 0-2 TV hours per day (h/d) before diagnosis,
those reporting ≥ 5 h/d of TV before diagnosis had
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This study investigated the long-term probability
of developing a second cancer in a large pooled
cohort of patients treated with surgery with or
without radiotherapy (RT).
RECTAL/
ENDOMETRIAL
PATIENTS AND METHODS
No increased risk of second
cancer after radiotherapy in
patients treated for rectal or
endometrial cancer in the
randomised TME, PORTEC-1,
and PORTEC-2 trials.
Wiltink LM, Nout RA, Fiocco M, Meershoek-Klein Kranenbarg
E, Jürgenliemk-Schulz IM, Jobsen JJ, Nagtegaal ID, Rutten HJ, van
de Velde CJ,Creutzberg CL, Marijnen CA.
J Clin Oncol. 2014 Dec 22. pii: JCO.2014.58.6693. [Epub
ahead of print]
INTRODUCTION
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All second cancers diagnosed in patients included
in the TME, PORTEC-1, and PORTEC-2 trials
were analysed. In the TME trial, patients with
rectal cancer (n = 1,530) were randomly allocated
to preoperative external-beam RT (EBRT; 25 Gy
in five fractions) or no RT. In the PORTEC trials,
patients with endometrial cancer were randomly
assigned to postoperative EBRT (46 Gy in 2-Gy
fractions) versus no RT (PORTEC-1; n = 714)
or EBRT versus vaginal brachytherapy (VBT;
PORTEC-2; n = 427).
matched general population. The standardised
incidence ratio for any second cancer was 2.98 (95%
CI, 2.82 to 3.14).
CONCLUSION
In this pooled trial cohort of > 2,500 patients
with pelvic cancers, those who underwent EBRT
or VBT had no higher probability of developing
a second cancer than patients who were treated
with surgery alone. However, patients with
rectal or endometrial cancer had an increased
probability of developing a second cancer
compared with the general population.
RESULTS
A total of 2,554 patients were analysed (median
follow-up, 13 years; range 1.8 to 21.2 years). No
differences were found in second cancer probability
between patients who were treated without RT (10and 15-year rates, 15.8% and 26.5%, respectively)
and those treated with EBRT (10- and 15-year rates,
15.4% and 25.6%, respectively) or VBT (10-year
rate, 14.9%). In the individual trials, no significant
differences were found between treatment arms.
All cancer survivors had a higher risk of developing
a second cancer compared with an age- and sex-
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The optimal chemotherapy regimen to use
with radiotherapy in stage III non-small-cell
lung cancer is unknown. Here, we compare the
outcome of patents treated within the Veterans
Health Administration with either etoposidecisplatin (EP) or carboplatin-paclitaxel (CP).
LUNG
Cisplatin and etoposide versus
carboplatin and paclitaxel with
concurrent radiotherapy for
stage III non-small-cell lung
cancer: an analysis of Veterans
Health Administration Data.
METHODS
The authors identified patients treated with EP
and CP with concurrent radiotherapy from 2001
to 2010. Survival rates were compared using
Cox proportional hazards regression models
with adjustments for confounding provided by
propensity score methods and an instrumental
variables analysis. Co-morbidities and treatment
complications were identified through
administrative data.
with centres where EP was used in less than 10%
of the patients (HR, 1.07; 95% CI, 0.90 to 1.26).
Patients treated with EP, compared with patients
treated with CP, had more hospitalisations (2.4
v 1.7 hospitalisations, respectively; P < .001),
outpatient visits (17.6 v 12.6 visits, respectively; P
< .001), infectious complications (47.3% v 39.4%,
respectively; P = .0022), acute kidney disease/
dehydration (30.5% v 21.2%, respectively; P <
.001), and mucositis/oesophagitis (18.6% v 14.4%,
respectively; P = .0246).
CONCLUSION
After accounting for prognostic variables,
patients treated with EP versus CP had similar
overall survival, but EP was associated with
increased morbidity.
Santana-Davila R, Devisetty K, Szabo A, Sparapani R, Arce-Lara
C, Gore EM, Moran A, Williams CD, Kelley MJ, Whittle J.
J Clin Oncol. 2014 Nov 24. pii: JCO.2014.56.2587. [Epub
ahead of print]
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RESULTS
A total of 1,842 patients were included; EP was
used in 27% (n = 499). Treatment with EP was
not associated with a survival advantage in a
Cox proportional hazards model (hazard ratio
[HR], 0.97; 95% CI, 0.85 to 1.10), a propensity
score matched cohort (HR, 1.07; 95% CI, 0.91 to
1.24), or a propensity score adjusted model (HR,
0.97; 95% CI, 0.85 to 1.10). In an instrumental
variables analysis, there was no survival
advantage for patients treated in centres where EP
was used more than 50% of the time as compared
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LUNG
In vivo quantification of
hypoxic and metabolic status
of NSCLC tumours using [18F]
HX4 and [18F]FDG-PET/CT
imaging.
Zegers CM, van Elmpt W, Reymen B, Even AJ, Troost EG,
Ollers MC, Hoebers FJ, Houben RM, Eriksson J, Windhorst
AD, Mottaghy FM, De Ruysscher D, Lambin P.
Clin Cancer Res. 2014 Dec 15;20(24):6389-97.
Increased tumour metabolism and hypoxia
are related to poor prognosis in solid tumours,
including non-small cell lung cancer (NSCLC).
PET imaging is a non-invasive technique that is
frequently used to visualise and quantify tumour
metabolism and hypoxia. The aim of this study
was to perform an extensive comparison of
tumour metabolism using 2[18F]fluoro-2-deoxyd-glucose (FDG)-PET and hypoxia using HX4PET imaging.
EXPERIMENTAL DESIGN
FDG- and HX4-PET/CT images of 25 patients
with NSCLC were co-registered. At a global
tumour level, HX4 and FDG parameters were
extracted from the gross tumour volume (GTV).
The HX4 high-fraction (HX4-HF) and HX4
high-volume (HX4-HV) were defined using a
tumour-to-blood ratio > 1.4. For FDG highfraction (FDG-HF) and FDG high-volume
(FDG-HV), a standardised uptake value (SUV)
> 50% of SUVmax was used. We evaluated the
spatial correlation between HX4 and FDG uptake
within the tumour, to quantify the (mis)match
between volumes with a high FDG and high HX4
uptake.
For the primary GTV, the HX4-HF was three
times smaller compared with the FDG-HF. In
53% of the primary lesions, less than 1 cm3 of the
HX4-HV was outside the FDG-HV; for 37%, this
volume was 1.9 to 12 cm3. Remarkably, a distinct
uptake pattern was observed in 11%, with large
hypoxic volumes localised outside the FDG-HV.
CONCLUSION
Hypoxic tumour volumes are smaller than
metabolic active volumes. Approximately half
of the lesions showed a good spatial correlation
between the PET tracers. In the other cases, a
(partial) mismatch was observed. The addition
of HX4-PET imaging has the potential to
individualise patient treatment.
RESULTS
At a tumour level, significant correlations were
observed between FDG and HX4 parameters.
INTRODUCTION
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A prospective study comparing
the predictions of doctors versus
models for treatment outcome
of lung cancer patients: a step
toward individualised care and
shared decision-making.
Oberije C, Nalbantov G, Dekker A, Boersma L, Borger J, Reymen
B, van Baardwijk A, Wanders R, De Ruysscher D, Steyerberg E,
Dingemans AM, Lambin P.
Radiother Oncol. 2014 Jul;112(1):37-43. doi: 10.1016/j.radonc.2014.04.012. Epub 2014 May 17.
Decision Support Systems, based on statistical
prediction models, have the potential to change
the way medicine is being practised, but their
application is currently hampered by the
astonishing lack of impact studies. Showing
the theoretical benefit of using these models
could stimulate conductance of such studies. In
addition, it would pave the way for developing
more advanced models, based on genomics,
proteomics and imaging information, to further
improve the performance of the models.
PURPOSE
In this prospective single-centre study, previously
developed and validated statistical models
were used to predict the two-year survival
(2yrS), dyspnoea (DPN), and dysphagia (DPH)
outcomes for lung cancer patients treated
with chemo-radiation. These predictions were
compared to probabilities provided by doctors
and guideline-based recommendations currently
used. We hypothesised that model predictions
would significantly outperform predictions from
doctors.
Differences in the performances of doctors and
models were assessed using Area Under the
Curve (AUC) analysis.
RESULTS
A total number of 155 patients were included. At
timepoint #1 the differences in AUCs between the
ROs and the models were 0.15, 0.17, and 0.20 (for
2yrS, DPN, and DPH, respectively), with p-values
of 0.02, 0.07, and 0.03. Comparable differences at
timepoint #2 were not statistically significant due
to the limited number of patients. Comparison to
guideline-based recommendations also favoured
the models.
CONCLUSION
The models substantially outperformed
ROs’ predictions and guideline-based
recommendations currently used in clinical
practice. Identification of risk groups on the basis
of the models facilitates individualised treatment,
and should be further investigated in clinical
impact studies.
MATERIALS AND METHODS
Experienced radiation oncologists (ROs)
predicted all outcomes at two timepoints: (1)
after the first consultation of the patient, and
(2) after the radiation treatment plan was made.
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BACKGROUND
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The role of bleomycin and dacarbazine in the
ABVD regimen (i.e. doxorubicin, bleomycin,
vinblastine, and dacarbazine) has been
questioned, especially for treatment of early-stage
favourable Hodgkin’s lymphoma, because of the
drugs’ toxicity. We aimed to investigate whether
omission of either bleomycin or dacarbazine, or
both, from ABVD reduced the efficacy of this
regimen in treatment of Hodgkin’s lymphoma.
HODGKIN’S
LYMPHOMA
Omission of dacarbazine or
bleomycin, or both, from the
ABVD regimen in treatment of
early-stage favourable Hodgkin’s
lymphoma (GHSG HD13): an
open-label, randomised, noninferiority trial.
Behringer K, Goergen H, Hitz F, Zijlstra JM, Greil R, Markova J, Sasse S,
Fuchs M, Topp MS, Soekler M, Mathas S, Meissner J, Wilhelm M, Koch
P, Lindemann H, Schalk E, Semrau R, Kriz J, Vieler T, Bentz M, Lange
E, Mahlberg R, Hassler A, Vogelhuber M, Hahn D, Mezger J, Krause
SW, Skoetz N, Böll B, von Tresckow B, Diehl V, Hallek M, Borchmann
P, Stein H, Eich H, Engert A; on behalf of the German Hodgkin Study
Group; the Swiss Group for Clinical Cancer Research; the Österreichische Arbeitsgemeinschaft für Klinische Pharmakologie und Therapie.
Lancet. 2014 Dec 19. pii: S0140-6736(14)61469-0. doi:
10.1016/S0140-6736(14)61469-0. [Epub ahead of print]
INTRODUCTION
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FINDINGS
METHODS
In this open-label, randomised, multicentre trial
(HD13) we compared two cycles of ABVD with
two cycles of the reduced-intensity regimen
variants ABV (doxorubicin, bleomycin, and
vinblastine), AVD (doxorubicin, vinblastine,
and dacarbazine), and AV (doxorubicin and
vinblastine), in patients with newly diagnosed,
histologically proven, classic or nodular,
lymphocyte predominant Hodgkin’s lymphoma.
In each treatment group, 30 Gy involved-field
radiotherapy (IFRT) was given after both cycles
of chemotherapy were completed. From 28
January 2003, patients were centrally randomly
assigned (1:1:1:1) with a minimisation method
to the four groups. Because of high event rates,
assignment to the AV and ABV groups stopped
early, on 30 September 2005 and 10 February
2006; assignment to ABVD and AVD continued
(1:1) until 30 September 2009. Our primary
objective was to show non-inferiority of the
PROSTATE
experimental variants compared with ABVD in
terms of freedom from treatment failure (FFTF),
by excluding a difference of 6% after five years
corresponding to a hazard ratio (HR) of 1.72,
via a 95% CI. Analyses reported here include
qualified patients only, and between-group
comparisons include only patients recruited
during the same period. The trial was registered,
number ISRCTN63474366.
HEAD AND NECK
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Of 1,502 qualified patients, 566, 198, 571, and
167 were randomly assigned to receive ABVD,
ABV, AVD, or AV, respectively. Five-year FFTF
was 93.1%, 81.4%, 89.2%, and 77.1% with ABVD,
ABV, AVD, and AV, respectively. Compared with
ABVD, inferiority of the dacarbazine-deleted
variants was detected with five-year differences
of -11.5% (95% CI -18.3 to -4.7; HR 2.06 [1.21
to 3.52]) for ABV and -15.2% (-23.0 to -7.4; HR
2.57 [1.51 to 4.40]) for AV. Non-inferiority of
AVD compared with ABVD could also not be
detected (five-year difference -3.9%, -7.7 to -0.1;
HR 1.50, 1.00 to 2.26). 178 (33%) of 544 patients
given ABVD had WHO grade III or IV toxicity,
compared with 53 (28%) of 187 given ABV, 142
(26%) of 539 given AVD, and 40 (26%) of 151
given AV. Leucopoenia was the most common
event, and highest in the groups given bleomycin.
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INTERPRETATION
Dacarbazine cannot be omitted from ABVD
without a substantial loss of efficacy. With
respect to our predefined non-inferiority margin,
bleomycin cannot be safely omitted either, and
the standard of care for patients with early-stage
favourable Hodgkin’s lymphoma should remain
ABVD followed by IFRT.
INTRODUCTION
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This prospective phase II study was designed
to assess disease control and to describe
acute and late adverse effects of treatment
with proton radiotherapy in children with
rhabdomyosarcoma (RMS).
PAEDIATRICS
CONCLUSION
PATIENTS AND METHODS
Preliminary results of a phase II
trial of proton radiotherapy for
paediatric rhabdomyosarcoma.
Ladra MM, Szymonifka JD, Mahajan A, Friedmann AM, Yong
Yeap B, Goebel CP, MacDonald SM, Grosshans DR, Rodriguez-Galindo C, Marcus KJ,Tarbell NJ1 Yock TI.
J Clin Oncol. 2014 Nov 20;32(33):3762-70. doi: 10.1200/
JCO.2014.56.1548. Epub 2014 Oct 20.
LC by risk group was 93% for low-risk and 77%
for intermediate-risk disease. There were 13
patients with grade 3 acute toxicity and three
patients with grade 3 late toxicity. There were no
acute or late toxicities higher than grade 3.
Fifty-seven patients with localised RMS (age
21 years or younger) or metastatic embryonal
RMS (age 2-10 years) were enrolled between
February 2005 and August 2012. All patients
were treated with chemotherapy based on either
vincristine, actinomycin, and cyclophosphamide
or vincristine, actinomycin, and ifosfamide–
based chemotherapy and proton radiation.
Surgical resection was based on tumour site and
accessibility. Common Terminology Criteria
for Adverse Events, Version 3.0, was used to
assess and grade adverse effects of treatment.
Concurrent enrolment onto Children’s Oncology
Group or European Paediatric Sarcoma Study
Group protocols was allowed. All pathology and
imaging were reviewed at the treating institution.
Five-year LC, EFS, and OS rates were similar to
those observed in comparable trials that used
photon radiation. Acute and late toxicity rates
were favourable. Proton radiation appears to
represent a safe and effective radiation modality
for paediatric RMS.
RESULTS
Median follow-up was 47 months (range: 14
to 102 months) for survivors. Five-year eventfree survival (EFS), overall survival (OS), and
local control (LC) were 69%, 78%, and 81%,
respectively, for the entire cohort. The five-year
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PALLIATION
Impact of reirradiation of painful
osseous metastases on quality of
life and function: a secondary
analysis of the NCIC CTG
SC.20 randomised trial.
Chow E, Meyer RM, Chen BE, van der Linden YM, Roos D,
Hartsell WF, Hoskin P, Wu JS, Nabid A, Tissing-Tan CJ, Oei B,
Babington S, Demas WF, Wilson CF, Wong RK, Brundage M.
J Clin Oncol. 2014 Oct 27. pii: JCO.2014.57.6264. [Epub
ahead of print]
PURPOSE
The authors previously demonstrated that 48% of
patients with pain at sites of previously irradiated
bone metastases benefit from reirradiation. It is
unknown whether alleviating pain also improves
patient perception of quality of life (QOL).
and improved QOL, as determined by scores
on the EORTC QLQ-C30 scales of physical,
role, emotional and social functioning, global
QOL, fatigue, pain, and appetite. Similar results
were obtained using the BPI-PS; observed
improvements were typically of lesser magnitude.
PATIENTS AND METHODS
CONCLUSION
The investigators used the database of a
randomised trial comparing radiation treatment
dose fractionation schedules to evaluate whether
response, determined using the International
Consensus Endpoint (ICE) and Brief Pain
Inventory pain score (BPI-PS), is associated
with patient perception of benefit, as measured
using the European Organisation for Research
and Treatment of Cancer (EORTC) Quality of
Life Questionnaire Core 30 (QLQ-C30) and
functional interference scale of the BPI (BPI-FI).
Evaluable patients completed baseline and twomonth follow-up assessments.
Patients responding to reirradiation of painful
bone metastases experience superior QOL scores
and less functional interference associated with
pain. Patients should be offered re-treatment for
painful bone metastases in the hope of reducing
pain severity as well as improving QOL and pain
interference. RESULTS
Among 850 randomly assigned patients, 528
were evaluable for response using the ICE
and 605 using the BPI-PS. Using the ICE, 253
patients experienced a response and 275 did
not. Responding patients had superior scores
on all items of the BPI-FI (i.e. general activity,
mood, walking ability, normal work, relations
with other people, sleep, and enjoyment of life)
INTRODUCTION
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LYMPHOMA
PAEDIATRICS
PALLIATION
PURPOSE
READ IT BEFORE
YOUR PATIENTS
PALLIATION
Preservation of memory with
conformal avoidance of the
hippocampal neural stem-cell
compartment during wholebrain radiotherapy for brain
metastases (RTOG 0933): a
phase II multi-institutional trial.
Gondi V, Pugh SL, Tome WA, Caine C, Corn B, Kanner A,
Rowley H, Kundapur V, DeNittis A, Greenspoon JN, Konski AA,
Bauman GS, Shah S, Shi W, Wendland M, Kachnic L, Mehta MP.
J Clin Oncol. 2014 Dec 1;32(34):3810-6. PMID:25349290
[PubMed - in process]
Hippocampal neural stem-cell injury during
whole-brain radiotherapy (WBRT) may play a
role in memory decline. Intensity-modulated
radiotherapy can be used to avoid conformally
the hippocampal neural stem-cell compartment
during WBRT (HA-WBRT). RTOG 0933 was a
single-arm phase II study of HA-WBRT for brain
metastases with pre-specified comparison with a
historical control of patients treated with WBRT
without hippocampal avoidance.
PATIENTS AND METHODS
analysable at four months. Mean relative decline
in HVLT-R DR from baseline to four months
was 7.0% (95% CI, -4.7% to 18.7%), significantly
lower in comparison with the historical control
(P < .001). No decline in QOL scores was
observed. Two grade 3 toxicities and no grade 4
to 5 toxicities were reported. Median survival was
6.8 months.
CONCLUSION
Conformal avoidance of the hippocampus during
WBRT is associated with preservation of memory
and QOL as compared with historical series.
Eligible adult patients with brain metastases
received HA-WBRT to 30 Gy in 10 fractions.
Standardised cognitive function and qualityof-life (QOL) assessments were performed at
baseline and two, four and six months. The
primary end point was the Hopkins Verbal
Learning Test-Revised Delayed Recall (HVLT-R
DR) at four months. The historical control
demonstrated a 30% mean relative decline in
HVLT-R DR from baseline to four months. To
detect a mean relative decline ≤ 15% in HVLT-R
DR after HA-WBRT, 51 analysable patients were
required to ensure 80% statistical power with α =
0.05.
RESULTS
Of 113 patients accrued from March 2011
through to November 2012, 42 patients were
INTRODUCTION
BREAST
CERVIX
PROSTATE
HEAD AND NECK
RECTAL
LUNG
HODGKIN’S
LYMPHOMA
PAEDIATRICS
PALLIATION
BRACHYTHERAPY
INTRODUCTION
GEC-ESTRO MEETINGS
EDITORS’ PICKS
THE GEC-ESTRO HANDBOOK
OF BRACHYTHERAPY
Welcome to the Brachytherapy Corner.
BRACHYTHERAPY
“The Corner concludes
with the announcement
of the 2nd edition of the
GEC-ESTRO handbook
of brachytherapy”
GEC-ESTRO ASSEMBLY
Sunday 26 April 2015
at the 3rd ESTRO Forum, Barcelona
Room 122/123 from 13:30 - 14:30
INTRODUCTION
In this Corner you can read about the well-attended and
successful 2nd GEC-ESTRO workshop in Brussels. Simon
Buus summarises this one day event by highlighting the
main topics. The day after the 2nd GEC-ESTRO workshop,
an in vivo dosimetry seminar was held in Brussels and
Alexandra Rink reports on the day’s activities. Dr Juli
Jamnasi from Vina Cancer Center in Indonesia visited
Universitätklinikum Schleswig-Holstein in Lübeck
and also took the opportunity to visit the 2nd GECESTRO workshop. This Corner carries an account of his
experiences during his short stay in Europe.
As usual, we have the editors’ pick of brachytherapy
papers. María del Carmen Pujades tells us about a study
on air-kerma evaluation at the entrance of HDR facilities.
Michael Zelefsky discusses a paper about the bladder neck
dose as a predictive factor for toxicity in LDR prostate
brachytherapy. This is an important study that can
contribute to the sparse data on dosimetry and toxicity.
The Corner concludes with the announcement of the 2nd
edition of the GEC-ESTRO handbook of brachytherapy
under the editorship of Erik Van Limbergen, Richard
Pötter, Peter Hoskin and Dimos Baltas. This edition will be
an online version and some chapters are already online; it
will be completed gradually with the addition of the other
chapters.
PETER HOSKIN
BRADLEY PIETERS
KARI TANDERUP
Peter Hoskin, Bradley Pieters and Kari Tanderup
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BRACHYTHERAPY
4 - 5 December 2014 - Brussels , Belgium
GEC-ESTRO workshop
State of the art brachytherapy to maximise the
therapeutic window
Simon Buus
Focusing on multidisciplinary approaches in
brachytherapy
Dr Julijamnasi
In vivo dosimetry seminar
Alexandra Rink
INTRODUCTION
GEC-ESTRO MEETINGS
EDITORS’ PICKS
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OF BRACHYTHERAPY
GEC-ESTRO MEETINGS
BRACHYTHERAPY
4 - 5 December 2014 - Brussels , Belgium
GEC-ESTRO WORKSHOP
State of the art brachytherapy
to maximise the therapeutic
window
Simon Buus
Department of Oncology
Aarhus University Hospital
Denmark
2nd GEC-ESTRO workshop in session
SIMON BUUS
INTRODUCTION
The 2nd GEC-ESTRO workshop was held in
Brussels on 4 December 2014. The workshop
followed in the steps of last year’s successful 1st
GEC-ESTRO workshop. About 200 people participated in this year’s event, but the number could
have been even higher, as there was an upper
limit for participants. At the time of writing, a
3rd GEC-ESTRO workshop is being planned on
19 November 2015, and we have to consider the
GEC-ESTRO MEETINGS
optimal venue for the next workshop, so that no
one is rejected.
Brussels is, in many ways, the perfect location
for a meeting held in December with all the
Christmas trees and lights. Add a few traditional
Belgian Christmas beers, a happy mix of oncologists and physicists, and you have the recipe for a
good and very dynamic workshop.
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Alex Rijnders on the impact of improvements in dosimetry on the therapeutic window
Good news was announced about the much awaited update of the GEC-ESTRO handbook (2002),
which is getting off the ground. The second edition is launched with three chapters covering
dosimetry, radioprotection, and prostate cancer,
and the handbook will be updated continuously
to contain a planned 37 chapters. The GEC-ESTRO handbook is available on the DOVE platform
at www.estro.org/about-us/governance-organisation/committees-activities/gec-estro-hand-
INTRODUCTION
book-of-brachytherapy, but you need to log in with
your ESTRO username and password.
The overall topic of the workshop was “State of
the art brachytherapy to maximise the therapeutic window”. In my opinion, the different working
groups successfully addressed this.
The BRAPHYQS group explained about their
ongoing work to reduce the uncertainties of do-
GEC-ESTRO MEETINGS
simetry, imaging, and dose delivery. The ANORECTAL group presented an update of their
results in rectal cancer, and informed us about
the planned randomised OPERA trial examining the organ preserving effect of a 90/3 Gy HDR
boost added to standard chemoradiotherapy. The
gynae group showed updated results in cervical
cancer on their very fruitful retroEMBRACE and
EMBRACE – benchmarking studies to establish
evidence-based dose recommendations to target
volumes and constraints to organs at risk. Based
on these results, the gynae group will continue their research in the proposed EMBRACE
II study, which intends to reduce dose to small
tumours and improve target coverage in larger
tumours using MRI-guided radiotherapy. The
head and neck group explained about their efforts
to establish a database within the COBRA database frame, and showed examples of visual preserving ENT brachytherapy. The BREAST group
proposed guidelines for conformal target delineation in breast brachytherapy. The URO-GEC
presented an update on the results of brachytherapy boost in bladder cancer, and presented the
early results of laparoscopic and robotic assisted
bladder implants – impressive pioneering work
that may change our current practice in bladder
cancer. Finally, an overview of prostate cancer
brachytherapy was presented – showing the
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4 - 5 December 2014 - Brussels , Belgium
rapid development from whole gland boost to
focal salvage brachytherapy.
Inspired by the time of Christmas, I asked the
three wise men from GEC-ESTRO what they believed to be the most important issue/event at the
workshop.
Jacob Lindegaard (GEC-ESTRO, present chair)
“That the GEC-ESTRO handbook has been
launched in a new format and on a new platform
that provides very interesting perspectives in terms
of interactivity between the GEC-ESTRO working
groups, the ESTRO brachytherapy courses and the
GEC-ESTRO members.” Being modest about the
suggested wisdom, Jacob stated: “I’m surely not
one of the three wise men, who were as you know
Kasper, Melchior, and Balthasar. Perhaps Dimos
Baltas is the closest we get in the GEC community.”
Peter Hoskin (GEC-ESTRO, past chair),
referring to Christian’s comment:
“This was also a feature for me, with several people
telling me how valuable it was for them to have the
opportunity to meet in that way, which they had
not been able to achieve in the main ESTRO meeting.”
Simon Buus
Department of Oncology
Aarhus University Hospital
Denmark
Christian Kirisits (GEC-ESTRO, chair-elect)
“I am definitely not wise... but what I really liked
about the workshop is that I met so many colleagues from the different fields of brachytherapy
again – most of them I did not meet during the big
ESTRO meeting in Vienna last year.”
INTRODUCTION
GEC-ESTRO MEETINGS
Read the interview with Jacob
Lindegaard, chair of the GECESTRO-ISIORT meeting at the
3rd ESTRO Forum, in the Conference Corner on p 141 >
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GEC-ESTRO MEETINGS
BRACHYTHERAPY
4 - 5 December 2014 - Brussels , Belgium
GEC-ESTRO WORKSHOP
Focusing on multidisciplinary
approaches in brachytherapy
Dr Julijamnasi
Vina Cancer Center, Murni Teguh Memorial Hospital
Medan, Indonesia
After reading an email from ESTRO, it only took
me a few minutes before I decided to join the 2nd
GEC-ESTRO workshop on 4 December 2014 in
Brussels, Belgium. For most Indonesian young
oncologists, it is not easy (or cheap) to travel to
Europe, but I believe this meeting is of the highest standard.
DR JULIJAMNASI
INTRODUCTION
Fortunately, my request to join a four-week training course in brachytherapy was approved by
Professor Georgy Kovács at Universitätklinikum
Schleswig-Holstein (UKSH) Lubeck, Germany.
GEC-ESTRO MEETINGS
He urged me to join the GEC-ESTRO meeting
and another ESTRO-endorsed “Interdisciplinary
Teaching Course in Head and Neck Cancers
Brachytherapy” (ITCHNB) in Rome, which was
held just a week before the 2nd GEC-ESTRO
meeting.
The ITCHNB was marvellous. The faculty managed to provide hands-on implantation training
on some models, creatively made to represent a
human head and neck. This three-day course discussed almost everything about head and neck
EDITORS’ PICKS
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GEC-ESTRO MEETINGS
4 - 5 December 2014 - Brussels , Belgium
ESTRO website online: www.estro.org/about-us/
governance-organisation/committees-activities/
gec-estro-handbook-of-brachytherapy. This handbook contains a chapter on dosimetry. It discusses
both TG-43 and the new model-based algorithms.
While therapeutic benefits versus complication
burdens are yet to be carefully measured with
modern image-guided techniques, the brachytherapists attending the meeting were optimistic.
György Kovács on the interdisciplinary cooperation
resulting in visual acuity preservation in ENT cancers.
brachytherapy, including physics, the American
Brachytherapy Society and GEC-ESTRO protocols, techniques, and the long-term experiences of
using low dose rate versus high dose rate versus
pulse dose rate. There was a strong emphasis on
multidisciplinary collaboration and I believe this
biennial site-specific course is a “must” for anyone who is interested in head and neck cases.
The GEC-ESTRO workshop was orchestrated superbly. It started by introducing the new GECESTRO handbook, which can be accessed on the
INTRODUCTION
26-hour journey time from Medan, Indonesia, to
come to Europe. Bravo ESTRO!
Dr Julijamnasi
Vina Cancer Center,
Murni Teguh Memorial Hospital
Medan, Indonesia
Another interesting topic was the COBRA project, which is now undergoing feasibility testing
before being launched in the next few months.
This project may expand on the opportunities to
explore more about brachytherapy applications in
most solid tumours.
THE GEC-ESTRO COMMITTEE
WISHES TO THANK:
Elekta Brachytherapy, Eckert & Ziegler
BEBIG and Varian Medical Systems for
their support of this workshop as exhibitors;Elekta Brachytherapy for their support
of this workshop as sponsors.
I was greatly impressed with all the topics at the
GEC-ESTRO meeting. It paid off my strenuous
GEC-ESTRO COMMITTEE
View the activities of the GEC-ESTRO committee: www.estro.org/about-us/governanceorganisation/committees-activities/gec-estro-brachytherapy-committee-activities >
View the members: www.estro.org/about-us/governance-organisation/scientific-council/
committees/gec-estro-brachytherapy-committee >
The committee is contactable through Evelyn Chimfwembe [email protected] at the ESTRO office.
GEC-ESTRO MEETINGS
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OF BRACHYTHERAPY
GEC-ESTRO MEETINGS
BRACHYTHERAPY
4 - 5 December 2014 - Brussels , Belgium
IN VIVO DOSIMETRY
SEMINAR
Alexandra Rink
Medical physicist
Princess Margaret Hospital
Assistant Professor,
Department of Radiation Oncology,
University of Toronto
Toronto, Canada
Dr Luc Beaulieu presenting “Development of multiple-points PSD for in vivo dosimetry”
ALEXANDRA RINK
INTRODUCTION
The inaugural Braphyqs & GEC-ESTRO Seminar
on On-line treatment verification could not have
come soon enough. Held in beautiful Brussels,
Belgium, at the beginning of December, it attracted the attention of oncologists, post-doctoral
fellows, medical physicists and industry alike.
One of the key organisers, Dr Kari Tanderup,
provided arguments for on-line dosimetry in
brachytherapy in a recent publication (K. Tanderup et al, Med Phys 40: 2013). She concluded that
GEC-ESTRO MEETINGS
there was a need for further development and the
establishment of a robust method for the independent verification of dose delivery. This, I believe, is recognised by many in the brachytherapy
field. Perhaps that is why this first meeting was
attended by 85 participants from 21 countries,
and representatives from several main industry
players, including Elekta, Varian Medical Systems
and Eckert & Ziegler BEBIG.
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Dr Joanna Cygler presenting “MOSFET applications in
brachytherapy”
Dr Sam Beddar presenting “In vivo dosimetry with PSDs to monitor the rectal dose during EBRT and the prospects for
HDR brachytherapy”
The meeting started with the greeting from Dr
Tanderup herself, who pointed out that when you
search for “in vivo dosimetry in radiotherapy”
there are just over 1,500 hits in total, providing a
small glimpse into the types of errors that occur.
Not a large number to start, but what is noteworthy is that only 133 of them are for brachytherapy.
This is not surprising, since only a quarter of centres do any in vivo dosimetry in brachytherapy,
and most are not on-line. In one of the first talks
of the day, Dr Gustavo Kertzscher argued for
the necessity of real-time feedback. He provided
an example of a simulated treatment with two
swapped transfer tubes, showing no difference in
total delivered dose at a point used by a cumulative dosimeter, despite an error being made. The
only way to have caught this error during treatment, he concluded, would have been by using a
system with real-time capabilities.
INTRODUCTION
GEC-ESTRO MEETINGS
The talks throughout the day covered a variety
of on-line dose verification strategies. Advances
in dosimetry techniques using MOSFETs and
MOSkins, as well as fibre-optic probes using
scintillators, radiochromic thin films, doped
silica, and radioluminescent aluminum crystals,
were presented by a number of speakers. Some
illustrated the use of these systems in rectum
and bladder during treatment delivery. There
was even a presentation by Dr Rien Moerland on
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Presentation slide, courtesy of Dr Francois TherriaultProulx
verifying position of Ir192 source with respect to
patient anatomy by treating and simultaneously
imaging within an MRI, an endeavour requiring a modified MR-safe afterloader, with a much
longer source cable and transfer tubes.
The day was not without a little controversy. Dr
Francois Therriault-Proulx proposed an opensource approach. Armed with historical successes
of this strategy in other industries, he pleaded
INTRODUCTION
with the group to join forces in order to expedite
and improve the development of in vivo real-time
dosimetry systems and their testing platforms.
While not all in the audience agreed with the feasibility of this approach, it started an interesting
discussion that continued into the evening, with
several people brainstorming ideas over pints of
beer at a local university pub. Another feather
ruffling moment came when I shared my view of
an ideal dosimetry system implementation, where
irradiating the probes beforehand to measure
their calibration factors for subsequent use is no
longer required. If rigorous QA/QC is done at the
manufacturer end, something we as end-users
can pressure the industry for, an optical verification of calibration factor in certain fibre-optic
dosimetry systems is sufficient at the user end.
This approach would eventually significantly reduce physics involvement, and therefore increase
the probability of in vivo dosimetry implementation within centres. However, given several faux
pas committed by dosimeter manufacturers in
the not-too-distant past, Dr Joanna Cygler and
several others objected to my line of thinking.
At this point, it appears that we cannot trust the
manufacturers to do the calibration and documentation correctly, but I hope that can change
in the near future. I am happy to report that no
tomatoes were thrown at this point.
GEC-ESTRO MEETINGS
At the end of the day, everybody was hoping
for an off-the-shelf solution appropriate for
brachytherapy, as voiced multiple times by Dr
Dimos Baltas. However, it is hard to imagine this
without serious involvement and support from
industry. In order to facilitate ease of use in a
clinic and interpretation of measurements, the
dosimetry system should be integrated with the
treatment planning and delivery systems. Therefore, it seems obvious that the market leaders
mentioned above should get involved, and do it
soon.
By the end of the meeting, it was clear that this
was really only the beginning – the first of more
events yet to come. We were all excited about
meeting again with an even larger group of participants, perhaps at the next Brachytherapy
World Congress to be held in San Francisco, California in 2016, and sharing our progress.
Alexandra Rink
Medical physicist
Princess Margaret Hospital
Assistant Professor,
Department of Radiation Oncology,
University of Toronto
Toronto, Canada
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Highlight Brachytherapy Papers
Air-kerma evaluation at the maze entrance of
high dose rate brachytherapy facilities
María del Carmen Pujades
J Radiol Prot. 2014 Sep 15;34(4):741-753. [Epub ahead of print]
Dose to the bladder neck is the most important
predictor for acute and late toxicity after lowdose-rate prostate brachytherapy: implications
for establishing new dose constraints for
treatment planning
Michael J. Zelefsky
Int J Radiat Oncol Biol Phys. 2014 Oct 1;90(2):312-9. doi:
10.1016/j.ijrobp.2014.06.031.
INTRODUCTION
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Highlight Brachytherapy Papers
Air-kerma evaluation at the
maze entrance of high dose rate
brachytherapy facilities
M.C. Pujades, D. Granero, J. Vijande, F. Ballester, J. PerezCalatayud, P. Papagiannis and F. A. Siebert
J Radiol Prot. 2014 Sep 15;34(4):741-753. [Epub ahead of print]
Corresponding author:
María del Carmen Pujades
Centro Nacional de Dosimetría (CND)
Valencia, Spain
[email protected]
What was your motivation for initiating
this study?
There are not specific recommendations to evaluate the air kerma rate at the door of high dose rate
(HDR) brachytherapy facilities. So, the motivation
for initiating this study was to propose an adaptation of the National Council on Radiation Protection and Measurements (NCRP) 151 methodology
for this task.
Such methodology is checked against Monte Carlo
calculations. We had previously studied a conventional 192Ir bunker, i.e. similar to those for megavoltage units with the door at the end of the maze.
The next step was to apply the methodology to
60
Co facilities and to study less conventional design
bunkers.
Five different facility designs were studied for 192Ir
and 60Co HDR applications to account for several
different bunker layouts.
What were the main challenges during
the work?
MARÍA DEL CARMEN
PUJADES
INTRODUCTION
Some real bunkers present complicated geometries, often because they were not originally
designed for HDR. In these cases, adapting the
methodology of NCRP 151 may require interpre-
GEC-ESTRO MEETINGS
tations. Accurate radiation protection calculations are of interest especially in such instances.
The most challenging task in this study was trying to separate the MC results in the equivalent
NCRP 151 components of the scatter radiation, to
see if they worked well separately. It resulted in a
task that was not straightforward. We have divided the scatter components in MC calculation into
ones that resemble those defined by the NCRP
151.
What are the most important findings of
your study?
The photon spectrums at the door entrance of
the facilities were obtained with MC calculations.
One of the most interesting things we found is
that all the spectra were similar independently
of the bunker design and radionuclide, with an
average energy of about 110 keV for 192Ir facilities
and 130 keV for 60Co facilities. The impact on
door lead shielding estimation using the photon
spectrum at the door instead of the one for 192Ir or
60
Co was evaluated comparing transmission data
for both spectra. We concluded that the use of
transmission data for the real spectra at the door
instead of the ones emitted by source would
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Highlight Brachytherapy Papers
reduce the lead thickness by a factor of five for
192
Ir and ten for 60Co.
What are the implications of this research?
The adaptation of the NCRP 151 methodology
proposed in this study works well for conventional bunkers with a door at the end of the maze
but fails for bunkers of unusual design. For those
facilities, a specific Monte Carlo study is in order
for reasons of safety and cost-effectiveness.
Since the beam that reaches the door is softer
than the primary source beam, the use of transmission data for the real spectra at the door
instead of the ones emitted by the source will
significantly lighten the door and hence simplify
construction and operating requirements for all
bunkers.
INTRODUCTION
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Highlight Brachytherapy Papers
Dose to the bladder neck is the most
important predictor for acute and
late toxicity after low-dose-rate
prostate brachytherapy: implications
for establishing new dose constraints
for treatment planning
Hathout L, Folkert MR, Kollmeier MA, Yamada Y, Cohen GN,
Zelefsky MJ.
Int J Radiat Oncol Biol Phys. 2014 Oct 1;90(2):312-9. doi:
10.1016/j.ijrobp.2014.06.031.
Corresponding author:
Michael J. Zelefsky
Memorial Sloan-Kettering Cancer Center,
Weill-Cornell Medical School
New York, USA
MICHAEL J. ZELEFSKY
INTRODUCTION
What was your motivation for initiating
this study?
Our motivation for this study was to attempt to
identify an anatomic region or zone of normal
tissue, which, after exposure to radiation, may be
most associated with urinary-related symptoms
commonly observed after prostate brachytherapy.
The specific normal tissue responsible for urinary
toxicity after brachytherapy has been elusive. Some
have focused attention on the prostatic urethra
and others on the bladder. We were interested in
studying the dose to the bladder neck, which is
important in micturition function to see if higher
doses to this region were associated with increased
urinary toxicities.
What were the main challenges during
the work?
For this study we updated the toxicity in a cohort of 927 patients and retrospectively one of the
co-authors contoured the bladder neck region in
all cases, which we defined as the 5mm region
around the urethra between the catheter balloon
and the prostatic urethra. These structures were
re-confirmed by a second investigator to further
ensure accuracy. The bladder neck doses were then
recalculated in all cases and various dose-volume
parameters were then analysed.
GEC-ESTRO MEETINGS
What are the most important findings of
your study?
We found that the bladder neck dose was an important predictor of acute and late urinary symptoms, after prostate brachytherapy. Specifically
we noted that the bladder neck D2cc >50% was
the strongest predictor for grade ≥2 acute urinary
retention and lower urinary tract symptoms in patients treated with low dose rate brachytherapy.
What are the implications of this research?
These findings are important as they demonstrate
that symptoms after brachytherapy may be more
related to bladder neck and detrusor muscle dysfunction rather than prostatic urethra swelling
alone. In addition, our data suggest that bladder
neck dose rather than simply overall bladder dose
should be measured as part of the routine dosimetric evaluation performed after prostate brachytherapy. Efforts to reduce bladder neck dose with
brachytherapy may result in reduced treatment related toxicities for patients treated with this modality. These data are also consistent with prior reports
from our institution and others that the bladder
neck or trigone region may represent a critical anatomic sub-unit of normal tissue where higher doses
to this region could be associated with increased
urinary toxicities after prostate radiotherapy.
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The first edition of the GEC-ESTRO Handbook of
Brachytherapy was released in 2002. In the meantime major new developments have taken place in
the field of radiation oncology and brachytherapy
and have been integrated into the growing educational activities of the ESTRO School.
BRACHYTHERAPY
THE GEC-ESTRO
HANDBOOK OF
BRACHYTHERAPY
2nd edition
The GEC-ESTRO Handbook is publicly available. To access the table of contents visit www.
estro.org/about-us/governance-organisation/committees-activities/gec-estro-handbook-of-brachytherapy
From here select the chapter you would like to
view. You will be prompted to login into DOVE
using your ESTRO account details. Access is
free.
INTRODUCTION
Furthermore, many recommendations have been designed
and published by GEC-ESTRO
working groups during the
last decade reflecting various
aspects of the developing field
of brachytherapy, particularly
for prostate, cervix, breast and
head and neck brachytherapy. Such new insights have
demanded the complete revision of the old edition of the
GEC-ESTRO Handbook of
Brachytherapy (2002), which
is now partly outdated. As this
task has turned out to be huge,
a new template was finally chosen by the editors
in agreement with ESTRO and the GEC-ESTRO
Committee, taking into account emerging forms
of book production and publication. This template also reflects the growing complexity and the
continuously changing situation in the field of
brachytherapy in general with much diversification, and also the growth of educational activities
within the ESTRO School. There are at present
four teaching courses dedicated to brachytherapy and there is even wider representation of
GEC-ESTRO MEETINGS
brachytherapy in other educational activities of
the ESTRO School and beyond.
Continuous online publication of the book, chapter by chapter, was therefore chosen to allow rapid
publication and general availability of the chapter
contents, keeping within the overall
frame of the GEC-ESTRO Handbook. This internet GEC-ESTRO
Handbook of Brachytherapy will
grow with time and will become
both comprehensive and up to date.
This is possible through the DOVE
(Dynamic Oncology Virtual ESTRO) platform which was implemented on the new homepage of
ESTRO in 2014. Chapters that are
considered ready for publication
are made available in DOVE.
An overview of all planned chapters is provided in the “Table of
Contents” which is continuously
available in DOVE. Published chapters are in
bold letters with the publication date indicated.
They are directly accessible through the “Table of
Contents”.
Editors
Erik Van Limbergen
Richard Pötter
Peter Hoskin
Dimos Baltas
EDITORS’ PICKS
THE GEC-ESTRO HANDBOOK
OF BRACHYTHERAPY
2015
ESTRO SCHOOL
LIVE COURSE
TOPICS
• Sources used in brachytherapy
• Physics and dose calculation
• Clinical radiobiology in brachytherapy:
general principles and practical examples
• Radioprotection and afterloaders
• Optimisation of stepping source
brachytherapy
• Eye plaque brachytherapy
• Permanent seed and HDR prostate implants
• Radiobiology of permanent implants
• Interstitial brachytherapy
• Place of intracavitary brachytherapy in
cervix, endometrium and vaginal cancer
• Place of endoluminal brachytherapy in
oesophageal and bronchus carcinoma
• Recommendations for recording and reporting in interstitial, intracavitary and
endolumina brachytherapy
MODERN BRACHYTHERAPY TECHNIQUES
15-18 March, 2015 | Limassol, Cyprus
WWW.ESTRO.ORG
RADIOTHERAPY
TREATMENT
PLANNING
AND DELIVERY
PHYSICS
INTRODUCTION
PREDICTIVE MODELS
OF TOXICITY
EDITORS’ PICKS
PHYSICS
“With the publication
of the QUANTEC
reports the work on
dose effect models
does not end, but is
just at the beginning”
Dear colleagues,
This edition of the Physics Corner features a very nice
contribution from Claudio Fiorino on the past, present and
future of predictive models of toxicity. Claudio points out clearly
that with the publication of the QUANTEC reports the work on
dose effect models does not end, but is just at the beginning. The
challenges ahead include the distribution of dose inside organs,
the integration of dose into multi-variable models and the use of
big data.
The editor’s pick section features two papers from the United
Kingdom. Catharine Clark explains the results of a multiinstitutional dosimetry audit of rotational intensity-modulated
radiotherapy and Evangelia Kaza explains how an active
breathing coordinator can be used during the acquisition of
magnetic resonance images.
Mischa Hoogeman ([email protected])
Ludvig Muren ([email protected]),
Frank Van den Heuvel ([email protected]),
PHYSICS MEMBERS ASSEMBLY
Saturday 25 April 2015 at the 3rd ESTRO
Forum, Barcelona
Room 122/123 at lunchtime
INTRODUCTION
MISCHA HOOGEMAN
Read the interview with Robin
Garcia, chair of the biennial
physics meeting at the 3rd
ESTRO Forum, in the Conference Corner on p139 >
PREDICTIVE MODELS
OF TOXICITY
LUDVIG MUREN
FRANK
VAN DEN HEUVEL
EDITORS’ PICKS
PHYSICS
PREDICTIVE MODELS
OF TOXICITY: AN
ALWAYS YOUNG
(AND NEW) OLD
STORY
Claudio Fiorino
Medical physics
San Raffaele Scientific institute
Milano, Italy
CLAUDIO FIORINO
INTRODUCTION
Some history: the impact of the “Emami
& Burman” paper
More than 20 years ago the milestone publication
by Emami et al. [1] dealt with the first attempt at
a systematic quantification of dose-volume effects
of organs at risk in fractionated radiotherapy.
This work was accomplished within the American Task Group of 3D conformal radiation therapy (3DCRT), which generated an important
report regarding the emerging (at that time) field
of 3DCRT. The huge merits of the Emami work
and of its companion paper dealing with the first
NTCP fit estimates for most organs [2] largely
outweighed the evident limitations.
The authors tried to quantify with a simple
scheme (i.e. assessing the TD5/50 for whole, two/
thirds, one/thirds organ irradiation) the behaviour of most organs when considering the most
relevant toxicity end-points.
We cannot understand the revolutionary impact
of these courageous works if we don’t recall what
radiotherapy was in the late 1980s: CT-planning
was not universally available and was often dedicated to selected categories of patients. Massive
contouring on CT and BEV-based 3DCRT optimisation started to appear in only a few large
academic centres in both the USA and in Europe.
These experiences helped to inspire the authors
to offer a guide for implementing 3DCRT that
was seen as visionary and as the “new” radiotherapy paradigm for the 1990s. Also thanks to this
document, and probably more to the dramati-
PREDICTIVE MODELS
OF TOXICITY
cally growing field of computer science, medical
imaging, and to the evolution of delivery systems (MLC became a reality during those years),
3DCRT quickly became the standard, preparing
the way for the next step of intensity-modulated
and image-guided radiotherapy.
In particular, the work of Burman et al. introduced the idea that the risk of an adverse effect could be quantified starting from the 3D
dose-volume information of the organ. This
NTCP concept was revolutionary and attractive;
however, it was clear, as the same authors underlined, that the published curves fitting “clinical” data with an error-function (the so-called
Lyman-Kutcher-Burman, LKB, model[3]) were
affected by large uncertainties that related to the
“clinical” data being roughly derived by the experience of a very skilled radiation oncologist and
not by quantitative, reliable data (i.e. DVH-based
information of single patients within a large cohort of patients, carefully scored).
The long road to QUANTEC
More than 20 years later, a lot remains to be
explored, although the situation is drastically
different. The easy availability of 3D individual
dose-volume information offered the possibility
to model the dose-volume effect of many organs
on large cohorts of patients. The growing number
of publications concerning dose-volume relationships reflects more and more the absolute need to
continuously improve and refine our
EDITORS’ PICKS
knowledge in the field of quantitative modelling
of normal tissue effects. Still more, in the era
of inverse planning, optimisation is driven by
numbers that directly reflect our knowledge (and
often our ignorance) around the quantitative assessment of dose-volume effects. In this context,
the QUANTEC group and its report [4] tried to
summarise this growing amount of information
in a relatively short and usable guide.
QUANTEC differed from the Emami work in
its recommendations, as it tried to report in a
cautious manner what we knew at that moment
in time. The document gave clear and exhaustive recommendations only in the few situations
where consistent results had been published (for
instance, parotids, lungs, spinal cord, rectum). In
the case of controversial results or, still more, of
lack of results, the document simply discussed in
a critical manner the controversial points, often
suggesting urgent lines of research (for instance
bladder and heart) without avoiding giving some
suggestions, but with clear warnings about the
uncertainty of the suggested recommendations.
New challenges…part I: looking at the
3D dose distributions
The organ-based DVH approach to describe
quantitatively the relationship between dose and
toxicities is clearly a difficult constraint. First,
symptoms cannot be linked always to the irradiation of a single organ without looking what
happens in the surrounding volume. Second, and
INTRODUCTION
maybe more importantly, approximating the organs as “homogenous entities” from the point of
view of their response to radiation is very useful
but it is not true: organs are composed of a complexity of sub-structures and different tissues that
are not considered by DVHs. Due to this, much
research is oriented to implement methods that
try to integrate the spatial information included
in the 3D dose distributions to the specific local
reactions. Imaging is a good candidate to measure local radiation-induced changes and correlate
them to the insurgence of toxicities [5,6]. Another
important field concerns the development and
the refinement of methods that may permit a
direct comparison of the 3D dose distribution in
patients with or without toxicities by advanced
similarity tests [7,8] with the potential to detect
more sensitive regions/organs and de facto overcome the organ-based approach.
in most patients. On one hand, the application of
dose-volume constraints reduces the incidence
and severity of toxicities; on the other hand, it
enhances the impact of the individual sensitivity
factors.
New challenges…part II: integrating the
dose into multi-variable models
New challenges…part III: the large data-base story: hopes and pitfalls
In the hypothetical case that two patients receive
the same dose distribution, the development of
a toxicity is always modulated by the individual.
The fact that dose is not all is clear from the early
days of radiobiology and has received stronger
support in the current “omics” era [9]; the availability of any individual information characterising the patients and potentially influencing their
reaction to radiation is more and more mandatory, especially nowadays in the era of image-guided IMRT in which organs are spared effectively
PREDICTIVE MODELS
OF TOXICITY
This implies the need to have access to data, including individually assessed clinical, biological
and genetic information. This means that our
approach has to become more and more “phenomenological” [10] with the development of
robust methods for selecting the most predictive
variables (including both dosimetric and non-dosimetric ones) and condensing the information
in robust, user-friendly predictive models. The
adaptation of statistical methods for data-mining
and robust variable selection is a pivotal point
of the story that will be written in the next few
years.
The access to information, previously unknown,
is rapidly changing the field of predictive modelling of radiotherapy effects. Platforms that are
able to connect large networks of institutes quickly and safely are becoming a reality and it is likely
that in the next few years a significant proportion
of European centres will be included in these
networks. This is also a cultural process, shifting
from a “doctor/institutional data” culture to a
“pooling data” culture [11].
EDITORS’ PICKS
It is likely that this process will be accompanied
by a greater radical automation of the processes
of data collection, permitting the sharing of data
with much less effort compared to now [12].
Although the huge possibilities of this visionary
(and more and more real) path to toxicity modelling are more than evident, we should not forget
that the possibility of creating large databases
is not the aim but is a (powerful) tool. In other
words, the outcome of the process in terms of robustness and reliability of the models will depend
not only on the numbers (a highly important
component) but also, and maybe more importantly, on the quality of data. In contrast to the
“easy” measure of the success of a therapy (the
patient is dead or alive, is under control or not),
toxicity is a much more complex and demanding
problem that deserves attention and the prospective and careful collection of patient-reported
and physician-reported information for years.
Well-assessed, prospective, observational studies focused on specific toxicities seem to be the
best choice; this kind of study may largely benefit
from the possibilities of advanced data-sharing
tools to permit the participation of a larger number of centres.
Predicting is a medical physics peculiarity
Is there still space for medical physicists to contribute to these challenging developments as
they have done over past decades? The question
INTRODUCTION
is provocative and the answer is obvious since
the prediction of what may happen, given some
“boundary conditions”, is an innate interest of
physicists and, specifically, of medical physicists.
Maybe the right question is how much will medical physics contribute? It is hard to answer this
question. Personally, I believe that this exciting
field of research is a big challenge for medical
physicists nowadays and is full of amazing opportunities. We are living in rapidly changing
time, in which we are requested to interact more
and more, not only with clinicians and radiation
biologists, but also with other people outside the
field, including those who work in engineering,
informatics, mathematics, biology and also other
areas of physics.
It is certainly a challenge worth meeting!
[4] Marks LB, Yorke ED, Jackson A et al. Use of normal
tissue complication probability models in the clinic. Int J
Radiat Oncol Biol Phy. 2010;76 (Suppl 1):S10-S19.
[5] Nijkamp J, Rossi M, Lebesque J et al. Relating acute
esophagitis to radiotherapy dose using FDG-PET in
concurrent chemo-radiotherapy for locally advanced
non-small cell lung cancer. Radiother Oncol. 106:118-123,
2013
[6] Fiorino C, Rizzo G, Scalco E et al. Density variation
of parotid glands during IMRT for head–neck cancer:
Correlation with treatment and anatomical parameters.
Radiother Oncol. 2012;104:224-229.
[7] Acosta O, Drean G, Ospina J. et al. Voxel-based
population analysis for correlating local dose and rectal
toxicity in prostate cancer radiotherapy. Phys Med Biol.
2013;58:2581-95.
[8] Witte MG, Heemsbergen WD, Bohoslavsky R et al.
Relating dose outside the prostate with freedom from
failure in the Dutch trial 68Gy vs. 78Gy. Int J Radiat Oncol Biol Phys. 2010;77:131-8.
[9] Bentzen SM. Preventing or reducing late side effects
of radiation therapy: radiobiology meets molecular pathology. Nature Rev Cancer. 2006;6:702-713
REFERENCES
[1] Emami B, Lyman J, Brown A et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol
Biol Phy. 1991;21:109-122.
[2] Burman C, Kutcher GJ, Emami B, Goitein M. Fitting
of normal tissue tolerance data to an analytic function.
Int J Radiat Oncol Biol Phy. 1991;21:123-135.
[3] Kutcher GJ, Burman C. Calculation of complication
probability factors for non-uniform normal tissue irradiation: The effective volume method. Int J Radiat Oncol
Biol Phy. 1989;16:1623-1630.
PREDICTIVE MODELS
OF TOXICITY
[10] van der Schaaf A, Langendijk JA, Fiorino C, Rancati
T. Embracing phenomenological approaches to NTCP
modeling: a question of method. Int J Radiat Oncol Biol
Phys. 91:468-471,2015
[11] Deasy JO, Bentzen SM, Jackson A et al. Improving
normal tissue complication probability models: the need
to adopt a “data-pooling” culture. Int J Radiat Oncol Biol
Phys. 2010; 76 (Suppl 1):S151-S154
[12] Skripcac T, Belka C, Bosch W. Creating a data exchange strategy for radiotherapy research: toward federated databases and anonymised public datasets. Radiother Oncol. 2014; 113:303-309
EDITORS’ PICKS
EDITORS’ PICKS
PHYSICS
Highlight Radiotherapy Physics Papers
First MRI application of an active breathing
coordinator
A multi-institutional dosimetry audit of
rotational intensity-modulated radiotherapy
Evangelia Kaza
Phys. Med. Biol. 60 (2015) 1681-1696
Catharine Clark
Radiotherapy and Oncology 113 (2014) 272–278
INTRODUCTION
PREDICTIVE MODELS
OF TOXICITY
EDITORS’ PICKS
EDITORS’ PICKS
Highlight Radiotherapy Physics Papers
PHYSICS
First MRI application of an
active breathing coordinator
Kaza E, Symonds-Tayler R, Collins DJ, McDonald F,
McNair HA, Scurr E, Koh D-M, Leach MO.
Phys. Med. Biol. 60 (2015) 1681-1696
CORRESPONDING AUTHOR:
Evangelia Kaza
CR UK Cancer Imaging Centre, Institute of Cancer
Research, London, and Royal Marsden Hospital
London, UK
[email protected]
What was your motivation for initiating
this study?
An Active Breathing Coordinator (ABC, Elekta) is a respiratory control apparatus routinely
employed during lung, liver or breast radiotherapy to reduce motion and treatment margins by
holding respiration at a specified level for a preset
duration. We adapted such a device for MR applications, to acquire MR images with the same
patient positioning and lung volume used during
conventional treatment planning and radiotherapy, in order to aid planning and treatment response assessment.
What where the challenges during the
work?
EVANGELIA KAZA
INTRODUCTION
Our intention was to perform minimal technical
alterations for successful ABC operation, whilst
preserving the main commercial components,
software and operational mode and maintaining the patient positioning used in radiotherapy planning. We had to evaluate and take into
account the impact of any modifications. As an
improvement to the original system, we built a
triggering circuit achieving automatic and simultaneous MR acquisition with ABC-controlled
breath holds. Moreover, we developed a comprehensive MR-ABC examination protocol compris-
PREDICTIVE MODELS
OF TOXICITY
ing morphological (T1, T2) and functional (diffusion-weighted) sequences with a minimal number
and duration of breath holds, applicable on lung
cancer patients.
What is the most important finding of
your study?
Volunteer Diffusion-Weighted-MRI (DWI) in
ABC-controlled breath holds delivered better
image quality than self-sustained breath holding
and precise abdominal intra-session organ position reproducibility. Lung cancer patient MRI
demonstrated not only very good intra-session
tumour and thorax position reproducibility under ABC, but also very good MR-CT inter-modality registration. DWI presented increased
contrast and detail in the tumour region, which
may reflect structural and biological differences.
What are the implications of this research?
Reproducing breath holds at a predefined lung
volume became possible for MRI, as practiced in
radiotherapy. Using identical ABC settings MRI
can match CT. The combination of variously
weighted MR images can provide a wide range
of contrast mechanisms and thus additional
diagnostic information compared to CT, which
should aid radiotherapy planning.
EDITORS’ PICKS
EDITORS’ PICKS
Highlight Radiotherapy Physics Papers
PHYSICS
A multi-institutional dosimetry
audit of rotational intensitymodulated radiotherapy
Catharine H. Clark, Mohammad Hussein, Yatman Tsang,
Russell Thomas, Dean Wilkinson, Graham Bass, Julia Snaith,
Clare Gouldstone, Steve Bolton, Rebecca Nutbrown, Karen
Venables, Andrew Nisbet
Radiotherapy and Oncology 113 (2014) 272–278
CORRESPONDING AUTHOR:
Catharine Clark
Royal Surrey County Hospital
Guildford, UK
and the National Physical Laboratory
Teddington, UK
CATHARINE CLARK
INTRODUCTION
What was your motivation for initiating
this study?
There has been a rapid uptake of volumetric modulated arc radiotherapy (VMAT) and tomotherapy in the UK since it was introduced commercially, such that by 2010 around 30% of centres
were already using it for treatment. This uptake
was much quicker than the implementation of
intensity modulated radiotherapy (IMRT) and
it was felt there was a need for an independent
audit to verify the implementation, investigate the
capability of the planning and delivery systems
and assess whether each planning and delivery
system had been optimised uniformly across each
institution.
What where the challenges during the
work?
First of all we had to undertake a pilot study to
ascertain that the proposed detector array would
be suitable to use for an audit. We visited ten
centres and made measurements, both with the
array and with the standard audit equipment of
ion chambers, film and alanine pellets. The correlation of the results was excellent and this gave
us the confidence to carry out the whole audit
using only the array. Whilst conducting the audit,
the main challenges we faced were the practical-
PREDICTIVE MODELS
OF TOXICITY
ities of visiting 34 centres in the UK and driving
round the whole country. The team managed to
visit five centres in five days in Scotland, which
was amazing!
What is the most important finding of
your study?
The main finding is that the majority of the centres have done an excellent job in implementing
rotational IMRT. However, we also found some
interesting issues, in particular to do with the
ability of the treatment planning system (TPS)
to model the presence of the couch in the beam,
that the minimum leaf gap can have a significant
effect on the ability of the TPS to model what the
machine actually does, that too high modulation
leads to very high monitor units, and also that
these are more difficult plans to verify correctly
at the machine. We found that the systems where
the planning and delivery technology came from
the same manufacturer tended to deliver the plan
more closely to the planned one.
What are the implications of this research?
Most of the centres were credentialed to join
a clinical trial using their rotational IMRT
technique. We have been able to identify some
EDITORS’ PICKS
EDITORS’ PICKS
Highlight Radiotherapy Physics Papers
of the issues with the different systems and
give the centres quantitative information as to
whether they have got the best from the planning
and delivery systems. We hope that this will
help them, and also allow them to feed back to
the manufacturers as to improvements that they
would like to see made.
ESTRO PHYSICS COMMITTEE
View the activities of the Physics Committee:
http://www.estro.org/about-us/governance-organisation/committees-activities/
physics-committee-activities >
View the members:
http://www.estro.org/about-us/governance-organisation/scientific-council/
committees/physics-committee >
The committee is contactable through Evelyn Chimfwembe [email protected] at the
ESTRO office.
RESEARCH MASTERCLASS IN RADIOTHERAPY
3-6 September 2015
Prague, Czech Republic
PHYSICS
Submit your application form by 1 June 2015
Download the application form:
http://www.estro.org/binaries/content/assets/estro/school/2015-general-docs/research-masterclass-in-rp-application-form-2015.pdf >
More information:
http://www.estro.org/school/items---list-courses-school-main-pages/2015-prague-master-class-physicists >
INTRODUCTION
PREDICTIVE MODELS
OF TOXICITY
EDITORS’ PICKS
RTT
INTRODUCTION
PAPER REVIEWS
CASE REPORT
INTERVIEW WITH
YOLANDE LIEVENS
RTT
“RTTs have submitted a very large
number of abstracts
for this conference:
197, which is twice
as many as for the
2nd ESTRO Forum
in 2013!”
We welcome you to the second RTT Corner of 2015.
This seems to be a really interesting year for the RTT world. Multiple
courses are organised for radiation therapists in a discipline specific or an
interdisciplinary manner. For us, the peak of 2015 will be the 3rd ESTRO
Forum. RTTs have submitted a very large number of abstracts for this
conference: 197, which is twice as many as for the 2nd ESTRO Forum in
2013! Another way to be inspired is, of course, by reading the RTT Corner.
This time we have three interesting papers to present. First, Philipp Scherer, co-editor of the RTT Corner, will discuss in the paper review some
recently submitted articles that are of importance to the RTT community.
Second, there is the case report, which is well worth reading, by RTT committee member, Velimir Karadza.
Last but not least, Bruno Speleers has interviewed Professor Yolande
Lievens, the President-elect of ESTRO. They discussed recent developments in the position of the RTT in the world of radiotherapy. Since there
was so much to be discussed, the interview will be published in two parts.
For the second part you will have to wait another two months, but we can
assure you it’s well worth it.
PHILIPP SCHERER
MARTIJN KAMPHUIS
We hope you will enjoy reading the RTT Corner. If you want to contribute
or have ideas for future inclusions in this Corner or the ESTRO newsletter,
please don't hesitate to contact us at [email protected] or
[email protected] – every input is welcomed.
Philipp Scherer and Martijn Kamphuis
INTRODUCTION
PAPER REVIEWS
CASE REPORT
INTERVIEW WITH
YOLANDE LIEVENS
PAPER REVIEWS
RTT
Absorbable hydrogel spacer use in men
undergoing prostate cancer radiotherapy: 12month toxicity and proctoscopy results of a
prospective multicentre phase II trial
A comparison of patient position displacement
from body surface scanning and cone beam CT
bone registrations for radiotherapy of pelvic
targets
Matthias Uhl, Klaus Herfarth, Michael Eble, Michael Pinkawa, Baukelien van
Triest, Robin Kalisvaart, Damien C Weber, Raymond Mirabell, Danny Y Song,
and Theodore L DeWeese
Kenneth Wikström, Kristina Nilsson, Ulf Isacsson, and Anders Ahnesjö
Acta Oncologica 2014 53: 268-277
Radiation Oncology 2014, 9:96
INTRODUCTION
PAPER REVIEWS
CASE REPORT
INTERVIEW WITH
YOLANDE LIEVENS
PAPER REVIEWS
RTT
BACKGROUND
Absorbable hydrogel spacer
use in men undergoing prostate
cancer radiotherapy: 12-month
toxicity and proctoscopy results
of a prospective multicentre
phase II trial
Matthias Uhl, Klaus Herfarth, Michael Eble, Michael Pinkawa,
Baukelien van Triest, Robin Kalisvaart, Damien C Weber,
Raymond Mirabell, Danny Y Song, and Theodore L DeWeese
Rectal toxicity is one of the limiting side-effects
mentioned whenever the topic of dose escalation
for prostate cancer radiotherapy is discussed.
Due to the anatomical situation, achieving a low
dose at the rectum as organ at risk, especially at
the anterior wall of the rectum is hardly possible. Even the variety of image-guided or adaptive
therapy possibilities developed in the last years
could not solve this problem. The authors of this
article investigate the use of a spacer positioned
between rectum and prostate – in this case a
polyethylene glycol (PEG) hydrogel-spacer – to
reduce the dose delivered to the rectum.
Radiation Oncology 2014, 9:96
METHODS
In this multi-centre, non-randomised, single arm
study the toxicity scores of 52 patients treated
with IMRT to a dose of 78 Gy (in 2 Gy fractions
with five fractions per week) for localised prostate cancer, who received a PEG hydrogel-spacer
(injected transperinal prior to treatment planning), were evaluated. A planning CT-scan was
generated, somewhat before and after injection
of the spacer, and the plans were compared to
analyse the dosimetric impact of the spacer. Gastrointestinal (GI) and genitourinary (GU) toxicity
INTRODUCTION
PAPER REVIEWS
were documented using the RTOG/EORTC grading and recorded weekly during treatment and
three, six and 12 months after radiation therapy.
Furthermore, Vienna Rectoscopy Scale (VRS)
was used to document proctoscopy findings 12
months after irradiation.
FINDINGS
The comparison of the treatment plans was only
mentioned briefly – reduction of the rectal V70
by ≥ 25% in 96% of the patients, with a mean
reduction of 8 Gy – because a separate report on
the dosimetric comparison was published previously by the same group (Song et al. 2013). In this
most recent publication of the trial – preliminary
clinical outcomes were published 2013 (Uhl et al.
2013) – the authors concentrate on the acute and
late GI and GU toxicity. Grade one or worse GI
toxicity scores were 52.1 % acute toxicities and
4.3% late toxicities, and GU toxicities were 79.2%
and 19.1 % respectively. This included some patients that were Grade 1 and one Grade 2 at baseline. In the absence of a control arm the authors
compared the results with other published data
and RTOG/EORTC Grade 2 or more GI toxicity
was substantially lower than in other trials. Similarly, a comparison of the VRS with published
data showed lower toxicity in the patients
CASE REPORT
INTERVIEW WITH
YOLANDE LIEVENS
PAPER REVIEWS
treated with a spacer. Comparison with a control
arm would have allowed a more rigorous judgement, but nevertheless, it can be concluded that,
despite the higher radiation dose, the treatment
of the patients with a spacer resulted in a considerably lower rectal toxicity.
RELEVANCE TO RADIATION THERAPISTS (RTTS)
The implementation of a method to enlarge the
space between the prostate and rectum allows
the introduction of dose escalation or a change
of fractionation with a lower risk of additional
toxicity at the rectum and, therefore, influencing
the time needed to manage these side-effects.
Additionally, this could have an impact on our
workload in the treatment units if the number of
fractions of one of our biggest patient groups is
changed.
INTRODUCTION
PAPER REVIEWS
REFERENCES
A multi-institutional clinical trial of rectal dose reduction via injected polyethylene-glycol hydrogel during intensity modulated radiation therapy for prostate cancer:
analysis of dosimetric outcomes.
Song DY, Herfarth K, Uhl M, Elbe MJ, Pinkawa M, van
Triest B, Kalisvaart R, Weber DC, Miralbell R, De Weese
TL, Ford EC
Int J Radiat Oncol Biol Phys 2013, 87:81-87
Low rectal toxicity after dose escalated IMRT treatment
of prostate cancer using an absorbable hydrogel for
increasing and maintaining space between the rectum
and prostate: results of a multi-institutional phase II trial.
Uhl M, van Triest B, Eble MJ, Weber DC, Herfarth K, De
Weese TL
Radiother Oncol 2013, 106:215-219
CASE REPORT
INTERVIEW WITH
YOLANDE LIEVENS
PAPER REVIEWS
RTT
BACKGROUND
A comparison of patient position
displacement from body surface
scanning and cone beam CT bone
registrations for radiotherapy of
pelvic targets
Kenneth Wikström, Kristina Nilsson, Ulf Isacsson, and Anders
Ahnesjö
Acta Oncologica 2014 53: 268-277
In the last few years several optical surface detection devices evolved as a method for image-guided radiotherapy without administering an additional imaging dose. These methods for optical
surface scanning offer prosperous features for the
verification of patient set-up, but also for monitoring, gating, and patient positioning. In this
article the authors evaluate the accuracy of one
of these methods, body surface laser scanning
(BSLS). They try to achieve this by comparing the
set-up errors recorded by the BSLS to displacements recorded using a cone beam computed
tomography (CBCT) with bony alignment, in the
pelvis region.
METHODS
Registrations of the set-up for 40 patients were
compared, resulting in a total of 170 analysed setups. Surface scans were compared to a reference
scan obtained at the first fraction (with the CBCT
corrections applied), while CBCT was registered
directly to the planning CT. The patient outline
derived from the planning CT was used as an
additional reference to register the BSLS to. The
patients were positioned using a skin mask and
the set-up errors evaluated using BSLS and CBCT
for the analysis.
INTRODUCTION
PAPER REVIEWS
FINDINGS
The authors were able to demonstrate that the
surface scan allowed a significantly better setup, especially if a restricted volume (pelvis only,
omitting legs and stomach) was used for surface
registration. Significantly better meaning that
the radial difference was closer to the results of
CBCT with 0.26cm (0.24-0.29cm 95%CI) compared to 0.38 (0.34-0.42cm 95%CI) when using
skin marks only. Interestingly, these improvements could only be shown when using the reference scan from the first fraction and not the
outline derived from the planning CT, which
could be due to the surface data derived from different systems or a reduction of a small systematic error that is corrected due to using the CBCT
corrections of the first fraction. Adding some
information from other publications, the authors
conclude, that BSLS offers additional benefits, i.e.
detecting changes of body contour due to weight
change or tumour pro-/regression, or verifying
pose and position, hence a correction of, for example, leg position is possible before acquiring
CBCT.
CASE REPORT
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PAPER REVIEWS
RELEVANCE TO RADIATION THERAPISTS (RTTS)
The introduction of surface scanners into radiotherapy offers several possibilities that could
change the workflow of RTTs, especially at the
treatment machines. A surface scan could help
position the patient or decide whether additional
IGRT-procedures are needed for the actual fraction if a set-up error above a certain threshold is
detected. Following the currently used lines of
argument, the results published, and the technical possibilities of such devices, surface scanning
even has the potential to supplant skin marks.
INTRODUCTION
PAPER REVIEWS
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YOLANDE LIEVENS
INTRODUCTION AND BACKGROUND
RTT
CASE REPORT
Treatment verification and
dose distribution in irradiation
of chondrosarcoma of cervical
spine
Velimir Karadza, Timor Grego, Kristijan Galic
Radiotherapy Unit, Department of Oncology
University Hospital Centre Zagreb, Croatia
ACKNOWLEDGEMENTS:
Tonko Herceg
Radiation Oncologist
Department of Oncology
University Hospital Centre Zagreb, Croatia
VELIMIR KARADZA
INTRODUCTION
TIMOR GREGO
KRISTIJAN GALIC
IMRT was recommended, but both IMRT and
3DCRT plans were considered.
Treatment verification using Megavoltage Portal
Imaging and/or Megavoltage CBCT sometimes
can contribute significantly to overall dose delivered to the patient and the planning target
volume (PTV). This is usually not the case, or at
least not something of a greater significance when
treatment verification is used on a weekly basis,
every fifth treatment. On the other hand, if verification needs to be done every day prior to treatment, due to geometric uncertainties or OARs
that are very close to the PTV, the dose given to
the patient during treatment may have a greater
impact that needs to be considered carefully.
CASE
A 22-year-old male patient, diagnosed with chondrosarcoma grade II of the cervical vertebrae
causing spinal compression, underwent surgery
in December 2013. His status was: laminectomia C5/6, partim C4 and C7, tumour ressection
– chondrosarcoma grade II, spinal cord decompression, residual tumour part in the C6 level.
Insertion of vertebral prosthesis Harm’s was
performed in January 2014. A postoperative CT
performed in April 2014 showed a total resection
of the bony component of the tumour, except for
a small residual part in the level of C6 vertebrae,
where the vertebral prosthesis was placed.
The radiation oncologist decided that radiotherapy of the residual process was indicated, and
PAPER REVIEWS
TREATMENT PLAN
Medical physicists composed two radiotherapy
treatment plans: an IMRT and a 3DCRT plan. The
IMRT was calculated with seven fields with step
and shoot method. The 3DCRT plan consisted of
four oblique wedged fields, with more weight on
posterior oblique fields (fig.1). Treatment planning
was conducted on an XiO treatment planning
system. Dose constraints were D90%>64 Gy and
D5%<70.62 Gy for target volumes and for OAR-s
QUANTEC(2010.) guidelines were used. DVH
comparison of these plans was performed (fig. 2).
Although the IMRT plan showed better PTV coverage, OAR sparring (spinal cord and larynx) was
better for the 3DCRT plan.
The problem with the delivery of these RT plans
was the proximity of the spinal cord to PTV (2
mm on some slices). This suggested that a very
careful and precisely controlled treatment delivery should be performed, and it implied the usage
of CBCTs or portal imaging every day prior to
irradiation. kV-imaging was still not available in
our department at that time. Therefore, all the
imaging had to be done by either Cone Beam or
EPID using MV exposure, which, in this case,
was considered as an undesired dose contribution. Due to availability of “Port During” option,
the choice was made for the 3DCRT plan.
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Figure 1: Beam arrangement for 3DCRT plan
Figure 2: DVH comparison between 3DCRT and IMRT plan. 3DCRT plan: solid line,
IMRT: dashed line
One more thing led to implementation of a “Port
During” verification of the patient's position:
the fact that the PTV/beam was shaped accordingly to the vertebral prosthesis where the residual tumour was placed. This indicated good visibility and a reliable marker for a position check of
the field and the spinal cord.
TREATMENT DELIVERY
Radiotherapy treatment was delivered on Siemens
Primus Plus with 82 MLC. The dose was delivered using the 3DCRT plan and a protocol for
INTRODUCTION
treatment verification was established. Set up correction was performed with eNAL protocol. “Port
During” was performed at every fraction, so that
it was possible to check the position of treatment
field in accordance to the spinal cord (fig. 3 & 4).
This option allows us to use the treatment fields
while irradiating the patient for creating Portal
images with EPID. In this way, it was possible to
maintain continuous control of patient position
using the MUs from treatment field, therefore
minimising the dose contribution from treatment
verification imaging.
PAPER REVIEWS
Portal images were analysed on a daily basis and
even though they occasionally showed smaller
shifts, the overall control of the patient position
and dose delivered to the spinal cord was in
agreement with the initial plan.
SUMMARY
In the case presented here, a patient diagnosed
with chondrosarcoma, radiotherapy treatment
of the residual tumour in the cervical spine was
prescribed. The original intention was to treat the
patient with an IMRT plan. In the process of
CASE REPORT
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YOLANDE LIEVENS
comparison of IMRT and 3DCRT plans, proximity of spinal cord and patient set-up correction
were taken into account. Due to absence of kV
imaging it was concluded that treatment verification on a daily basis with “Port During” option
would better fit the need to keep the minimum
dose on the spinal cord. 3DCRT plan was chosen
for these reasons, as the overall OAR sparing was
better. This example shows us that sometimes
less complex treatment plans with conventional
portal imaging can give quite satisfactory results.
However, in this case usage of portal images derived from treatment fields with MV energy gave
enough information, because there was a very
good reference structure for image registration
- the vertebral prosthesis. Otherwise, decisions
about the precise position of the field using “Port
During” would have probably been very difficult.
Figure 3: DRR from treatment field
INTRODUCTION
Please note: this work has not been peer reviewed
Figure 4: Port during
PAPER REVIEWS
CASE REPORT
INTERVIEW WITH
YOLANDE LIEVENS
Yolande Lievens is the President-elect of ESTRO. Just like Philip
Poortmans, ESTRO’s current President, she has agreed to share
with us her vision on the position of the RTTs within the interdisciplinary team and beyond.
RTT
The second part of the interview will be featured in the next
issue of the newsletter in this Corner.
Interview with
YOLANDE LIEVENS
President-elect of
ESTRO
By Bruno Speleers
Member of the ESTRO RTT committee
BRUNO SPELEERS
INTRODUCTION
How did you start your involvement
within ESTRO?
My career in radiation oncology started about 20
years ago. I was trained in the radiation oncology
department of the University Hospital of Leuven.
You may remember that one of the co-founders of
ESTRO, Emmanuel van der Schueren, was chairman in Leuven at that time. Moreover, ESTRO’s
administration was hosted by the Leuven radiotherapy department. As a consequence I came in
contact with ESTRO at a very early stage in my
career.
My active participation started as author of the
“Radiotherapy in Public Health Policy” section
in the ESTRO newsletter, a column, now the
“Health Economics Corner”, where I share the
task with Madelon Pijls-Johannesma and Peter
Dunscombe. I have been a teacher on the target
volume delineation course for a few years and a
member of the clinical committee and the professional and memberships council. In 2010 ESTRO
launched the HERO (Health Economics in Ra-
PAPER REVIEWS
diation Oncology) project, which I co-chair with
Cai Grau. Last but not least, I have had the great
honour to be elected ESTRO President as of April
2016.
In the previous interview, Philip Poortmans talked about the many differences in the role of the RTTs between The
Netherlands and Belgium in the past. Is
this still the case?
It is a bit difficult to picture clearly how RTTs
function in The Netherlands because I am not
working there myself. But the difference in educational background between RTTs in The Netherlands and nurses in Belgium is bound to have
an impact on their involvement in daily radiotherapy practice. In The Netherlands they are
specifically trained to master the skills of an RTT.
Radiotherapy is included from the beginning of
their education and during a clinical placement
they learn how to deal with the more technical
issues such as planning and the image-guided
CASE REPORT
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YOLANDE LIEVENS
approach to radiotherapy. Belgium is one of the
few countries in Europe where the professionals
working on the radiotherapy treatment machines
are nurses. They are trained with a focus on bedside care and only get involved in radiotherapy
once they start working in a radiotherapy department. This defers the actual training in radiation
oncology to the time they start to work in the
radiotherapy department, which, in the context
of our rapidly evolving discipline, is quite challenging.
Apart from the specific example of Belgium and The Netherlands, it is a fact
that there is a large difference in background knowledge of RTTs among the
different European countries. What
would you advise in order to support
optimal patient care?
Within the HERO project, for which we have now
finalised the first work package, we have made
an evaluation of radiotherapy staffing in Europe.
For RTTs, as for all radiotherapy professionals
for that matter, we observed large variations in
the key parameters related to availability of personnel and their workload. One of the dominant
factors in that respect is the variability in roles
and responsibilities, which are certainly, to some
extent, related to the background knowledge they
acquired during training. Additionally, there are
different national rules and regulations so that
their tasks may be determined by the tasks that
INTRODUCTION
other radiotherapy professionals – radiation oncologists, medical physicists, dosimetrists – perform.
Adequate education and training is the first prerequisite to optimise the care delivered by the
RTTs. An enormous body of work has already
been done in that respect by ESTRO in defining
the core curriculum. The next phase in improving standardised education is to implement the
core curriculum throughout Europe. But in our
vision to build a common platform of knowledge
we should not overlook the necessity to take into
account the needs of each individual country. Regarding this point we are still lacking important
information: ideally we should first come up with
a better definition of the staffing requirements
based on cancer incidence and population mix,
and on the level of technology already implemented in a given country. Only then will we be
able to correctly forecast the needs and, in turn,
align training and education to meet both the
knowledge and clinical need requirements.
How has the role of the RTT developed
within the interdisciplinary team from
the start of your career up to today?
There are certainly differences, which is not surprising given the important technological evolution that has taken place in radiotherapy over the
last decade. In the past RTTs were almost solely
involved with daily treatment delivery and simu-
PAPER REVIEWS
lation, whereas now they are often also involved
in the more technical aspects like planning. As
a consequence of the introduction of more hightech treatment machines with on-board imaging
capabilities, RTTs have become a driving force in
patient-specific quality assurance through online
imaging. Moreover, in some departments in Belgium, RTTs have taken up the global role of quality assurance as quality managers. As a matter
of fact, about a year ago a Quality Management
Board of Experts was installed in Belgium, and it
is interesting and pleasing to see how many RTTs
are part of this group.
What do you consider to be the
strengths of RTTs in the interdisciplinary
team?
RTTs have the advantage of being able to follow
the patient more closely during their entire process. Hence, contrary to the other radiotherapy
professionals, they have a more global overview
of the patient, his/her physical and psychological
evolution and needs during treatments, whereas
radiation oncologists, physicists and dosimetrists
have a more scattered patient contact. This daily
contact is certainly an enormous advantage for
the RTTs.
And within ESTRO?
Apart from the more technical and quality-related aspects that RTTs are involved with, it is
CASE REPORT
INTERVIEW WITH
YOLANDE LIEVENS
specifically this close interaction between the
RTTs and the patient that gives them the possibility to better understand and observe what the patients really need. We are exploring how we can
involve patients more closely in our Society, and
RTTs will certainly be able to bring us important
additional information in that respect.
Do you see weaknesses that should be
improved?
We have already extensively discussed the educational challenges, which are certainly the first
important issue to tackle.
ESTRO RTT COMMITTEE
View the activities of the ESTRO RTT Committee:
www.estro.org/about-us/governance-organisation/committees-activities/
rtt-committee-activities >
View the members:
www.estro.org/about-us/governance-organisation/scientific-council/committees/rtt-committee >
The committee is contactable through Viviane Van Egten [email protected] at the ESTRO
office.
It is, moreover, an understatement that in most
countries, and Belgium does not form an exception to that general observation, RTTs are infrequently involved in research. That this is, however, perfectly possible is demonstrated for example
by Ireland, where research forms an integrated
part of the training of RTTs.
Finally, I feel that RTTs are not yet adequately
involved in the professional aspects of radiotherapy, be it in organisations at the national or international level. The active participation of RTTs in
ESTRO, for example, deserves further endorsement.
INTRODUCTION
PAPER REVIEWS
Read the interview with Martijn
Kamphuis, chair of the RTT
meeting at the 3rd ESTRO Forum,
in the Conference Corner on p143 >
CASE REPORT
INTERVIEW WITH
YOLANDE LIEVENS
RADIOBIOLOGY
INTRODUCTION
SPOTLIGHT
RECENT NEWS FROM
THE STEM CELL FIELD
RADIOBIOLOGY
“In this edition of the
Radiobiology Corner
we put the spotlight on
Professor Dr Rob P.
Coppes, whose group is
dedicated to elucidating
the role of stem cells in
the radiation responses
of tissues and organs”
Read the interview with Brad
Wouters, chair of the PREVENT
and TARGET meetings at the
3rd ESTRO Forum, in the
Conference Corner on p144 >
INTRODUCTION
The loss of dividing cells and its detrimental
effect on tissue homeostasis has long been
known to be an important mechanism by
which normal tissue damage can develop,
resulting in complications after radiotherapy.
In this edition of the Radiobiology Corner
we put the spotlight on Professor Dr Rob P.
PETER VAN LUIJK
Coppes, whose group is dedicated to elucidating the role of stem cells in the radiation
responses of tissues and organs in order to find novel approaches
to predict, prevent and treat radiotherapy side-effects. In addition,
members of his group discuss four recent publications on this topic. Taken together, these publications highlight the maturation of
the field in terms of solving technical issues and a paradigm-shift
from “a single type of cell does all” towards the notion that other
cell types and processes also contribute to the fate of an organ after
irradiation.
ANNE KILTIE
MARTIN PRUSCHY
Peter van Luijk
Dept Radiation Oncology
University Medical Centre Groningen
University of Groningen
Groningen, The Netherlands
CONCHITA VENS
As usual we encourage you to contact Anne Kiltie, Martin
Pruschy and Conchita Vens, with comments (good or bad) at our
“electronic” mail address [email protected]
SPOTLIGHT
RECENT NEWS FROM
THE STEM CELL FIELD
RADIOBIOLOGY
SPOTLIGHT
Professor Dr Rob P Coppes
Departments of Radiation Oncology and Cell Biology
Cancer Research Centre Groningen
University Medical Centre Groningen
University of Groningen
Groningen, The Netherlands
ROB COPPES
INTRODUCTION
Rob Coppes is a professor of radiation oncology
with a special focus on the radiation biology of
normal tissues. His group at the Cancer Research
Centre at the University Medical Centre Groningen is currently composed of two assistant professors, two post-docs, four PhD students and five
technicians.
Rob obtained an MSc degree in Animal Physiology and a PhD on the pre-synaptic regulation of
noradrenergic neurotransmission in molecular
pharmacology at the University of Groningen.
This phenomenon is very closely related to the
secretion of granules from the salivary gland.
It was the topic of his first post-doc position at
the department of radiobiology of the UMCG.
Here he studied the pharmacological removal of
enzyme-containing granules from the salivary
glands, which were thought to release their enzymes in the cells, causing cell death after irradiation. Although many of the tested degranulating
drugs protected the salivary glands, no relation
was found with the number of remaining granules and radiation response. Instead he found
that these drugs induced stem/progenitor cells
to proliferate and regenerate the radiation-damaged gland faster. Here, his interest in stem cells
was raised. Moreover, the collaboration with
Professor Albert van der Kogel and Dr Peter van
Luijk on proton irradiation of the spinal cord
and the hypothesis that small fields were repaired by (stem) cells from outside the radiation
field further stimulated his curiosity. Finally, the
movement of the radiobiology lab to a new fa-
SPOTLIGHT
cility, where the department of stem cell biology
of Professor Gerald de Haan was located as well,
facilitated this process and soon the idea of developing a stem cell therapy to prevent radiotherapy-induced toxicity was born.
Together with several other normal tissue radiobiologist and stem cell biologists, he applied for
and coordinated the EU-funded integrated project FIRST (Further improvement of radiotherapy
of cancer through side-effect reduction by application of stem cell transplantation). Now, 10 years
and several grants later, his group has developed
a protocol for adult stem cells therapy for radiation-induced hyposalivation and consequential
xerostomia for which a phase I/II clinical trial is
planned from 2017-2018. Meanwhile his interest
in particle therapy was stimulated. The accurate
irradiation possible with protons revealed many
novel insights, such as the interaction between
organs (heart/lung) and the uneven distribution
of stem cells within organs, with the potential for
stem cell sparing radiotherapy.
Currently, the possibility of growing adult tissue stem cells as tissue resembling organoids, as
developed in the laboratories of Professor Hans
Clevers (Hubrecht Institute, Utrecht) and Coppes,
opens novel avenues for the study of radiation
effects on normal tissue and tumours. The potential of this methodology in the development
of personalised medicine and the prediction of
response is unprecedented and indicates that exciting times lie ahead of us.
RECENT NEWS FROM
THE STEM CELL FIELD
RADIOBIOLOGY
RECENT NEWS FROM THE STEM CELL FIELD
By various members of Professor Rob Coppes’s group
Survival of neural stem cells undergoing DNA
damage-induced astrocytic differentiation in selfrenewal-promoting conditions in vitro
Lgr5+ stem cells are indispensable for radiationinduced intestinal regeneration
Review of Metcalfe et al., Cell Stem Cell. 2014;14:149-59
by Martti Maimets
Review of Schneider, PLOS One 2014;9:e87228
by Peter Nagle
Transient activation of hedgehog pathway
rescued radiation-induced hyposalivation by
preserving stem/progenitor cells and
parasympathetic innervation
Long-term culture of genome-stable bipotent
stem cells from adult human liver
Review of Hai et al., Clinical Cancer Research 2014;20:140-150
by Sarah Pringle
Review of Huch et al. Cell 2014;160:299–312
by Cecilia Rocchi
INTRODUCTION
SPOTLIGHT
RECENT NEWS FROM
THE STEM CELL FIELD
RECENT NEWS FROM THE STEM CELL FIELD
RADIOBIOLOGY
Lgr5+ stem cells are
indispensable for radiationinduced intestinal regeneration
Review of Metcalfe et al.,
Cell Stem Cell. 2014;14:149-59
Paper review by
Martti Maimets
PhD student
University Medical Centre Groningen
Groningen, The Netherlands
INTRODUCTION
By various members of Professor Rob Coppes’s group
Intestinal epithelial cells undergo continual
self-renewal, which depends on intestinal stem
cell (ISC) activity. At least three crypt cell types
have been identified to contain ISCs. These, however, have distinct expression of specific molecular
markers, proliferation kinetics and sensitivity to
ionising radiation. Lgr5+ columnar cells residing
at the crypt base are mitotically active and, therefore, thought to be the “work-horse” stem cell
population responsible for intestinal homeostasis. Upon ablation of these Lgr5+ cells, a second
population of stem cells (“ position four cells” or
“Chris Potten cells”) assumes total ISC function
and quickly produces new Lgr5+ ISCs. Additional intestinal populations, including progenitor
cells generated by these ISCs, have been shown to
acquire plasticity in regards to injury-mediated
responses.
to the sensitivity to ionising radiation of the “reserve” Lgr5− stem cells. This indicates that, even
though stem cell plasticity exists, not all of the
distinct stem cell populations are necessarily involved in the radiation response of a tissue.
However, recent expression profiling of these distinct ISC populations has demonstrated a robust
position four-cell gene expression in Lgr5+ cells,
which challenges the current understanding of
intestinal homeostasis and post-injury response.
In a recent issue of Cell Stem Cell, Metcalfe et al.
show that Lrg5+ ISCs are crucial for intestinal
regeneration following irradiation but are not
required for hyperplastic responses. This is due
SPOTLIGHT
RECENT NEWS FROM
THE STEM CELL FIELD
RECENT NEWS FROM THE STEM CELL FIELD
RADIOBIOLOGY
Transient activation of
hedgehog pathway rescued
radiation-induced hyposalivation by preserving stem/progenitor cells and parasympathetic
innervation
Review of Hai et al.,
Clinical Cancer Research 2014;20:140-150
Paper review by
Sarah Pringle
Post-doc
University Medical Centre Groningen
Groningen, The Netherlands
INTRODUCTION
By various members of Professor Rob Coppes’s group
Hyposalivation and consequential xerostomia are
deleterious sequelae of salivary gland (SG) damage commonly occurring after radiotherapy for
head and neck cancers. In the absence of a durable
treatment for this condition, recent efforts have
focused on the manipulation of resident stem/progenitor cells within the SG, before, during or after
radiotherapy treatment, to prevent hyposalivation.
In a recently published study, Hai et al. suggest
that homeostasis of radiation-damaged SGs can
be recovered by manipulation of the Hedgehog
signalling pathway. This pathway has long been
implicated in the behaviour of many other stem/
progenitor cell pathways. In a transgenic mouse,
transient Hedgehog pathway activation led to
functional rescue from radiation-induced hyposalivation, including saliva production and
increased expression of the water-channel associated protein AQP-5. Mechanistically, Hai et al.
also demonstrate that the stem/progenitor cell
pool of the SG, characterised by sca-1+ and c-Kit+
cells, was increased following Hedgehog pathway
stimulation. Moreover, functionally more salispheres (floating cultures of SG stem/progenitor
cells) were generated from SGs exposed to Hedgehog activation compared to control counterparts.
Further exploration showed that stimulation of
SPOTLIGHT
the Hedgehog pathway exerted the observed effect on SG stem/progenitor cells by boosting or
preserving the function of the parasympathetic
innervation pathway, represented by measurement
of neurotrophic factors bdnf, ngf and nrtn, and
the receptor for such factors, Chrm1. As such, this
is the first report to link augmentation of parasympathetic innervation to the preservation of the
stem/progenitor cell pool and furthermore to the
rescue of irradiation damaged SGs from hyposalivation.
RECENT NEWS FROM
THE STEM CELL FIELD
RECENT NEWS FROM THE STEM CELL FIELD
RADIOBIOLOGY
Survival of neural stem cells
undergoing DNA damageinduced astrocytic differentiation in self-renewal-promoting
conditions in vitro
Review of Schneider,
PLOS One 2014;9:e87228
Paper review by
Peter Nagle
PhD student
University Medical Centre Groningen
Groningen, The Netherlands
INTRODUCTION
By various members of Professor Rob Coppes’s group
DNA double strand breaks pose a major threat to
cells and are potentially lethal if they are not
repaired by the DNA damage response. Previous
studies from these authors indicated that ionising radiation causes neural stem cells (NSCs) to
differentiate. However, although these cells were
capable of repairing DNA damage, the transcription of some vital DNA damage response genes
was down.
Recently, Schneider demonstrated that NSCs that
have been irradiated undergo delayed apoptosis, which is caspase-dependent and p53-independent under self-renewal-promoting culturing
conditions. Next, by over-expressing BCL2 to
inhibit apoptosis, the authors showed that NSCs
are pushed towards astrocytic differentiation
in response to irradiation, while differentiation
towards other cell fates was not detected. To investigate the effect of culturing conditions on
apoptosis in NSCs, the cells were seeded in different conditions post-irradiation. Conditions
that promote neuronal differentiation resulted in
increased levels of apoptosis. However, conditions
that induce astrocytic differentiation (addition
of BMP2 or FCS to self-renewal media) showed a
decrease in apoptosis compared to normal self-renewal media.
SPOTLIGHT
From this, Schneider concludes that DNA damage
itself is not the cause of ionising radiation induced
apoptosis in NSCs, but it is, in fact, the post-irradiation culture conditions that are important in
terms of apoptosis proneness. If this is indeed
true, this paper also raises further questions for
stem cell radiation research. For instance, it would
be interesting to investigate whether this holds
true for other stem cell types and/or for the apoptotic response of stem cells to other forms of irradiation.
RECENT NEWS FROM
THE STEM CELL FIELD
RECENT NEWS FROM THE STEM CELL FIELD
RADIOBIOLOGY
Long-term culture of
genome-stable bipotent stem
cells from adult human liver
Review of Huch et al.,
Cell 2014;160:299–312
By various members of Professor Rob Coppes’s group
Therapy based on adult stem cells could offer a
unique opportunity to rescue the functionality of
damaged tissue, both in terms of cell replacement
and trophic support to the surrounding tissue.
Beside the difficulties of characterising the most
potent stem/progenitor cell population, safety
issues regarding the risk of genetic and epigenetic
aberration during long-term in vitro expansion
are a primary concern for the use of cell therapy
in regenerative medicine.
In a recent study, Huch et al. described the optimisation of a long-term human liver stem cell
culture system. They show that Wnt signalling,
cAMP activation and inhibition of the Tgf-β
pathway are fundamental to assuring the longterm self-renewal (more than six months) of
human Lgr5+ liver cells in vitro. Under these
conditions, cells expanded in culture maintain
the ability to differentiate into functional hepat-
ocytes in vitro as well as upon in vivo transplantation into a damaged liver. Moreover, an important feature of this 3D organoid culture is the
long-term maintenance of their genomic stability.
In fact, the authors observed that the number of
base substitutions acquired over the three months
of culture was ten-fold lower than that which has
been reported previously in cultures derived from
induced pluripotent stem (iPS) cells. In addition,
when analysed for structural aberration, only two
copy number variants were found in the longterm expanded cells, also indicating a higher
chromosomal stability during expansion when
compared to iPS cells.
Taken together these results open up the possibility of using the therapeutic potential of autologous adult stem cells transplantation for treating
the adverse side-effects associated with radiation
treatment.
ESTRO RADIOBIOLOGY COMMITTEE
Paper review by
Cecilia Rocchi
PhD student
University Medical Centre Groningen
Groningen, The Netherlands
INTRODUCTION
View the activities of the Radiobiology Committee:
www.estro.org/about-us/governance-organisation/committees-activities/radiobiology-committee-activities >
View the members:
www.estro.org/about-us/governance-organisation/scientific-council/committees/radiobiology-committee >
The committee is contactable through Viviane Van Egten [email protected] at the ESTRO office.
SPOTLIGHT
RECENT NEWS FROM
THE STEM CELL FIELD
ESTRO SCHOOL
INTRODUCTION
E-CONTOURING
COURSE REPORTS
WHO’S WHO?
UPDATES ON THE EDUCATIONAL
TRAINING COMMITTEE
ESTRO SCHOOL
“The next examination
for ESTRO Fellow
candidates will take
place during the
Barcelona meeting
on 24 April”
The new calendar year for the ESTRO School has now started.
There is a full programme of 35 live courses, covering the core curricula for radiation oncologists, radiation physicists and RTTs, plus
seven online delineation workshops.
A new development currently being worked on is the concept of
blended learning, with a mix of online and live teaching. Several
such courses are planned for the coming years.
The 3rd ESTRO Forum will offer many educational opportunities,
including five pre-meeting courses and four separate online contouring workshops on 24 April. During the main meeting, each
day begins with teaching lectures and there are multi-disciplinary
tumour board sessions, as well as FALCON contouring workshops.
There will also be a “teachers’ retreat” on 23 April, bringing together many of the dedicated people who are involved in teaching activities in the ESTRO School on the 35 ESTRO courses. This will offer
the opportunity to discuss common problems and future possibilities and the day will end with an entertaining social event.
The next examination for ESTRO Fellow candidates will take place
during the Barcelona meeting on 24 April. If you are interested in
applying, check out the information under the “Careers & Grants”
tab at the top of the website estro.org/careers-grants/estro-fellow/
index.
FIONA STEWART
Core member, Education
and Training Committee
CHRISTINE VERFAILLIE
ESTRO Chief Operating
Officer
We are looking forward to seeing you all in Barcelona.
Find out about education at
the 3rd ESTRO Forum on
www.estro.org and in the
Conference Corner on p150 >
INTRODUCTION
E-CONTOURING
Richard Pötter, Christine Verfaillie and Fiona Stewart
RICHARD PÖTTER
Chairman, Education
and Training Committee
COURSE REPORTS
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E-CONTOURING
FALCON* is ESTRO’s web-based contouring platform that offers you the opportunity to practice your
delineation skills online and to compare them with those made by delineation experts and with the
ESTRO guidelines.
With FALCON you can:
• practise by yourself online anytime you wish on a database of contouring cases accessible at
www.estro.org: head and neck, lymphoma and gynaecological cancer. FALCON cases are freely accessible to ESTRO members.
• join a virtual workshop: below is the programme for the coming months. Please note that some of
them are in Sydney time (AEDT).
* Fellowship in Anatomic deLineation and CONtouring
FALCON
Fellowship in Anatomic deLineation & CONtouring
INTRODUCTION
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UPDATES ON THE EDUCATIONAL
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2015 FALCON ONLINE SCHEDULE
Workshop Topic
Breast cancer
Gynaecological cancer
External Beam RT
Prostate cancer
Gynaecological cancer
Brachytherapy
Paediatric cancer
Head and neck cancer
Head and neck cancer
Dates
25 February 2015
5 March 2015
11 March 2015
1 April 2015
10 April 2015
17 April 2015
14 September 2015
21 September 2015
28 September 2015
September-October*
15 October 2015
22 October 2015
29 October 2015
19 October 2015
26 October 2015
2 November 2015
7 December 2015
14 December 2015
21 December 2015
Time CET
18.00-19.00 hrs
18.00-20.00 hrs
18.00-19.30 hrs
09.00-10.00 (18.00 hrs AEDT)
10.00-12.00 (18.00 hrs AEDT)
10.00-11.30 (18.00 hrs AEDT)
18.00-19.00 hrs
18.00-20.00 hrs
18.00-19.30 hrs
18.00-19.00 hrs
18.00-20.00 hrs
18.00-19.30 hrs
09.00-10.00 hrs (17.00 hrs AEDT)
09.00-11.00 hrs (17.00 hrs AEDT)
09.00-10.30 hrs (18.00 hrs AEDT)
18.00-19.00 hrs
18.00-20.00 hrs
18.00-19.30 hrs
10.00-11.00 hrs (18.00 hrs AEDT)
10.00-12.00 hrs (18.00 hrs AEDT)
10.00-11.30 hrs (18.00 hrs AEDT)
Faculty
Workshop director: Birgitte Offersen
Cancer specialist: Philip Poortmans
Workshop director: Ina Jurgenliemk-Schulz
Cancer specialist: Umesh Mahantshetty
Workshop director: Carl Salembier
Cancer specialist: Alberto Bossi
Workshop director: Ina Jurgenliemk-Schulz
Cancer specialist: Umesh Mahantshetty
Workshop director: Umberto Ricardi
Cancer specialist: Rolf-Dieter Kortmann
Workshop director: Jesper Eriksen
Cancer specialist: Vincent Grégoire
Workshop director: Jesper Eriksen
Cancer specialist: Vincent Gregoire
*Dates to be announced
CONTOURING SESSIONS AT THE 3RD ESTRO FORUM
Eight contouring sessions will take place between 24-28 April in Barcelona (oesophagus, lymphoma, prostate
and OAR). Have a look at the programme in the Conferences Corner and on www.estro.org. Also, don’t miss
the free FALCON demos on the ESTRO booth in the exhibition area (booth #2000).
INTRODUCTION
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ESTRO SCHOOL
ESO/ESTRO 3rd masterclass in radiation
oncology
Quantitative methods in radiation oncology:
models, trials and clinical outcomes
8 - 12 November 2014 | Cascais, Portugal
7 - 10 December 2014 | Vienna, Austria
Target Volume Determination - from imaging to
margins
9 - 13 November 2014 | Vienna, Austria
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ESTRO SCHOOL
ESO/ESTRO 3RD
MASTERCLASS IN
RADIATION ONCOLOGY
8 - 12 November 2014
Cascais, Portugal
CHAIRMEN:
Michael Baumann
Jacques Bernier
Roberto Orecchia
Richard Pötter
It is a great pleasure to be able to share the wonderful experience we all had at this unforgettable
course. The selection process to be able to attend
was thorough. I found this really exciting, because I hoped to be able to meet colleagues with
different backgrounds, from all over the world,
but with the same great interest in research. And
I am happy to say that this masterclass greatly
exceeded my expectations.
ELEONOR RIVIN DEL
CAMPO
INTRODUCTION
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The first thing that attracted me about this masterclass was that it covered all aspects of research
in radiation oncology, from biology, imaging,
technology, multidisciplinarity, without forgetting such important basic aspects such as methodology and statistics. All of the sessions were
very well structured. Each day we would focus on
a main topic and listen to the lectures from the
brilliant faculty such as Daniel Zips, Daniela
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Thorwarth, Jose Belderbos, Felipe Calvo, Sören
Bentzen and our chairs: Richard Pötter, Roberto
Orecchia and Jacques Bernier. And after these
extensive overviews of the topics, the following
morning we presented our own research proposals for that topic. This schedule allowed us to
understand the topic better, especially those that
were not our main area of research, which helped
us interpret our colleagues’ research proposals on
the next day. This gave way to very stimulating
discussions during the small group workshops
where we presented our proposals, which continued and were even more interactive in the general session where we presented some of the most
noteworthy proposals.
Not only were we able to learn from and interact with such an amazing faculty board, but also
with the other colleagues. It was incredible to
have such close contact with the faculty. They
were very open and eager to get to know us, and
even discuss our projects with us directly during
coffee breaks or meals. This was an extremely
valuable input, which I am sure will help many of
us when developing our research projects. On the
other hand, we were also able to share the success
and the pitfalls of our still short experience in the
research field, for most of us, with other young
radiation oncologists/physicists from around the
INTRODUCTION
E-CONTOURING
world. This was very enriching because we all
have had different experiences, depending on
our background and access to grants, technology, mentors, etc. However we all have the same
eagerness to discover more about our specialty
by trying to answer those research questions that
still elude us. Many of us have certain research
interests in common, and hopefully will be able
to work on projects together in the future. These
connections are key in the research field where it
is so important to share our knowledge so as to
help each other to improve and advance. This is
especially true in the era of internet, which allows
us to collaborate even though we are miles away.
This masterclass is highly recommended, and one
of a kind.
Eleonor Rivin del Campo
Specialist in radiation oncology
Gustave Roussy Cancer Campus
Villejuif, France
[email protected]
And last, but definitely not least, the organisation
was splendid, thanks to ESO and ESTRO. The
venue was outstanding. The ocean views from the
breakfast/lunch room, and even from our own
rooms, allowed us to completely disconnect from
our daily, stressful routine, and focus on learning
and interacting during the course. In addition, it
was so pleasant that it allowed the group to get to
know each other on a personal as well as a professional level. Some colleagues were able to share
runs along the beach, and we all went on evening
walks where we would compare our day-to-day
professional lives, as well as discussing research.
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ESTRO SCHOOL
TARGET VOLUME
DETERMINATION - FROM
IMAGING TO MARGINS
9 - 13 November 2014
Vienna, Austria
COURSE DIRECTOR:
Gert De Meerleer
Radiation oncologist
Ghent University Hospital
Gent, Belgium
As a trainee in radiation oncology I was looking
for a course covering the scope of radiation oncology from image registration to the delineation
process. This course titled “Target Volume Delineation - From imaging to margins” suited that
purpose very well, so I travelled to the beautiful
city of Vienna to enjoy a fruitful course.
ROBIN WIJSMAN
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The confirmation letter mentioned the “highly
interactive character” of this course, which was
true as we started the first day with useful group
discussions upon the homework exercises: the
delineation of a brain, a lung and a head and
neck tumour. With these discussions, the need
for a course like this became quite clear, as it was
sometimes hard to find consensus upon the
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delineation of the target volumes. This introduction formed the basis of the course, since the different, scheduled topics worked towards solving
the cases.
By the use of different imaging modalities such
as computed tomography and positron emission
tomography, every tumour site (from CNS to
prostate) was separately discussed, starting with a
review of the anatomical structures involved. We
discussed the strengths and weaknesses of every
imaging modality, together with the pitfalls in
image registration and position verification. Subsequently, the evidence for target volume delineation practices was discussed, leading to useful
recommendations concerning, for example, target
volume margins and elective lymph node irradiation. Finally, we discussed the consensus-based
delineations of the target volumes of the cases
and compared the group results with those of the
teachers.
dence-based) principles of target volume delineation of the most common tumour sites.
Robin Wijsman
Resident in radiation oncology
Radboud UMC afdeling Radiotherapie
Nijmegen
The Netherlands
During the course there was plenty of time for
interesting discussions supported by the very
enthusiastic teaching staff, even during the coffee
and lunch breaks (while enjoying the tasty food).
I would highly recommend this well organised
course for those who want to learn the basic (evi-
INTRODUCTION
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ESTRO SCHOOL
QUANTITATIVE METHODS
IN RADIATION ONCOLOGY:
MODELS, TRIALS AND
CLINICAL OUTCOMES
7 - 10 December 2014
Vienna, Austria
COURSE DIRECTOR:
Sören Bentzen
Biologist
University of Maryland School of Medicine
Baltimore, USA
It was my pleasure to attend the recent ESTRO
teaching course on “Quantitative methods in radiation oncology: Models, trials and clinical outcomes” held in Vienna. The excellent faculty was
lead by Sören Bentzen and the meeting organised
most efficiently by Gabriella Axelsson. The title
was rather daunting but the course was in fact a
quick, wide-ranging introduction to many are-
MICHAEL JACKSON
INTRODUCTION
E-CONTOURING
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as of numerical data analysis. The participants
included medical physicists and radiation oncologists covering a broad range of experience and
location. The schedule was quite intense over
four days, and arriving from Australia at 9.30pm
Saturday evening to start work at 8.00am Sunday
morning was stressful, but the interesting programme kept us all awake and involved. Sören
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Bentzen, in particular, was very stimulating and
the largely Dutch and Danish faculty members,
Francesca Buffa, Philippe Lambin, Johannes Langendijk, Peter van Luijk and Ivan Vogelius were
all good speakers. Richard Pötter and Dietmar
Georg from the Medical University of Vienna
came as guest speakers.
The programme began with an introduction to
statistics and clinical trials and went on to cover
much else, including the selection of endpoints,
meta-analyses, modelling and technology assessment. The clinical examples were a general
overview of hot topics in radiation oncology and
beyond. My favourite topic, proton therapy, was
mentioned several times, although not always favourably given the cost and lack of evidence. The
fragile rationale for several other expensive treatments and diagnostic tests was also exposed.
I found the sessions on NTCP models and alternatives to conventional RCTs for technology
assessment particularly helpful. Monte Carlo
methods, which are familiar to most in treatment
planning, were extended to several other interesting applications. A noble attempt was made to explain bootstrapping but I am still rather unclear
on the details and will stick to slip-on shoes to
avoid tripping up. More on health economics and
INTRODUCTION
E-CONTOURING
Bayesian methods may be included in the future.
I suspect it was a difficult course to run because
of the wide range of audience experience but the
discussion was well moderated by Sören Bentzen
who always has a good anecdote to stimulate discussion. Participants, and especially the faculty,
were challenged to defend their positions. Having
more pre-course reading material might have
been useful to give a more even knowledge base
but the course slides were excellent.
and the whole faculty were always approachable
at other times.
Dr Michael Jackson
Radiation oncologist
Prince of Wales Hospital
Sydney, Australia
[email protected]
Vienna is a wonderful city, even in winter, and
the dinner on the first night helped everyone to
get to know one another. The venue was a small
hotel on the edge of the city centre but easy to
access by public transport.
I can confidently recommend this course to
young oncologists, physicists, RTTs and others
who want to learn more about quantitative methods and controversies in radiation oncology and
also as a refreshing overview for the more experienced. Mathematical ability is not required. It
will not equip you for a career as a statistician but
will help you understand papers and to ask tricky
questions at Journal Clubs and other meetings.
For those wanting advice on a particular project,
the meet-the-professor sessions were very useful
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Sofia Rivera
BIOGRAPHY
Head of radiation oncology breast unit
at the Gustave Roussy institute,
Villejuif, France
Sofia Rivera studied medicine in Paris and Madrid. She undertook a specialisation in radiation
oncology in Dijon and her doctoral degree in
2008 was on the evaluation of quality insurance
procedure by dummy run in phase III trials.
During her training she was charmed by the
multidisciplinary nature of radiation oncology
and the enormous potential for innovation within this field. In addition to her clinical work, she
undertook a masters degree in science in radiobiology and is currently working on her PhD on
a translational topic evaluating the combination
of HDAC inhibitors and radiation in preclinical
NSCLC models at Gustave Roussy radiobiology
laboratory (INSERM1030 unit).
Following her studies, she worked as an assistant
professor in radiation oncology at the Hôpital
Saint-Louis in Paris where she became senior
radiation oncologist. She was then approached
by the Gustave Roussy cancer centre to take over
the position of head of the breast cancer radiation
unit.
SOFIA RIVERA
INTRODUCTION
In this new section of the ESTRO School Corner, we will highlight in every issue a person who is very
active in education at ESTRO. For this first time, we have invited Sofia Rivera, a radiation oncologist at Gustave Roussy Institute, Villejuif, France, since January 2013. At only 38 years old, she has
already accumulated several years of experience and involvement with ESTRO: she joined the young
group in 2006, she is a teacher for the ESTRO course on advanced skills in modern radiotherapy,
she is co-chair of FALCON workshops and has been a member of the ETC (Education and Training
Committee) for six years, just to name a few of her activities within the Society…
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Currently her areas of focus are:
∙ Breast cancer where, as principal investigator,
she is involved in various clinical trials including preoperative radiotherapy and accelerated
hypo-fractionated partial breast irradiation.
∙ Combination of new drugs with radiotherapy,
which is strongly linked to her PhD research
topic, her involvement in phase I trials and her
position as co-chair of the Synergy for Targeted
Agents and Radiotherapy (STAR) group in the
EORTC Radiation Oncology Group (ROG).
Her heart is in research, patient care and training
and she strongly believes that in these three fields
the room for improvement in radiation oncology
can only be filled in by sharing and spreading our
expertise, knowledge and interrogations. That is
why at a local, national and international level she
is involved in training programmes for radiation
oncology residents, RTTs and physicists.
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INTERVIEW
What is your current role within the
ESTRO School?
I’m a member of the core Educational and Training Committee (ETC) where we discuss pedagogical, strategic, organisational and financial
aspects of education in ESTRO, namely within
the ESTRO School.
I’m a member of the core FALCON group where
we work on pedagogical, strategic, organisational
and financial aspects of the contouring tool and
activities developed in ESTRO for pedagogical
and scientific purposes. Besides that I’m the cochair of the FALCON online workshops group in
which we have an exponentially growing activity
developing online contouring workshops for radiation oncologists, RTTs, and every professional
involved in contouring all over the world [1].
I am a teacher of “advanced skills in modern
radiotherapy” [2], which is an annual ESTRO
course that started in 2014. I’ve been teaching in
two pre-meeting courses (one on contouring and
one in radiobiology) and in live contouring workshops on thoracic organs at risk in ESTRO meetings for two years now.
Last but not least I’m part of the evaluation group
for the ESTRO mobility grants [3] where twice a
year we assess, score and discuss the applications
from RTTs, biologists, physicists and radiation
oncologists.
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How and when did you enter the ESTRO
School?
I didn’t realise it because time is running so fast
and being part of the ESTRO School is so interesting that you don’t count, but in fact I entered
the ETC six years ago. At that time I was the
co-chair of the young scientific committee for
the ESTRO meeting and Professor Guy Kantor
approached me saying he would retire soon from
the ETC and he thought it would be great to be
replaced by a young ESTRO member. Soon after,
I was invited by Professor Richard Pötter, chair
of the ETC to attend an ETC meeting. I came to a
few meetings with Prof Kantor and got involved
in ETC activities, so I took over his position
smoothly when he left the ETC.
What was your previous ESTRO involvement before becoming a course teacher?
My first ESTRO involvement was in the young
ESTRO group in 2006-2007. Supported by the
ESTRO Board, the scientific committee of the
ESTRO meeting and the ETC, we reinitiated a
young scientific session at ESTRO meetings and
that was a fantastic experience. Then I was involved in the young ESTRO group up to 2013
and in the ETC up to now with various activities,
among which two of the most exiting were being an editor of the Young Corner of the ESTRO
newsletter and launching FALCON within the
core FALCON group.
COURSE REPORTS
We imagine that you are very busy with
your position at the Institute. What are
your motivations for taking on additional responsibility with the ESTRO School
and what gives you most satisfaction?
ESTRO has clearly broadened my vision of radiation oncology and has brought me valuable
professional, scientific and human experiences
that confirmed for me that I had made the right
choice by choosing radiation oncology as a specialty. Being involved in ESTRO activities in close
contact with brilliant and highly motivated people willing to openly share their experience and
knowledge has been a source of motivation and
energy. I strongly believe the progress we need
in radiation oncology for our patients can only
come from sharing and spreading our expertise,
knowledge and interrogations. Joining forces in
our community across specialties is essential to
me. In ESTRO and in the ESTRO School I’ve
found a spirit that goes completely along with
that and makes me feel part of this Society. I
sincerely think that teaching and being taught
within the ESTRO School brought as much
knowledge as satisfaction, and it’s clearly one of
the most fantastic experiences of my professional
life that I’m willing to continue even with the increasing burden and responsibilities of my position at the Institute.
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LINKS
ESTRO EDUCATION AND TRAINING COMMITTEE
[1] Online worshops:
http://estro.org/school/articles/onlineworkshops/2015-online-workshops
View the members:
www.estro.org/about-us/governance-organisation/scientific-council/committees/education-and-training-committee >
[2] ESTRO teaching course on
Advanced skills in modern radiotherapy,
28 June - 2 July 2015
Copenhagen, Denmark
http://estro.org/school/items---list-courses-school-main-pages/2015-copenhagen--advanced-skills-in-modern-radiotherapy
The committee is contactable through Christine Verfaillie [email protected] and Viviane Van
Egten [email protected] at the ESTRO office.
[3] ESTRO mobility grants
Next dealine on 30 April 2015
http://estro.org/school/articles/grants/
estro-mobility-grants
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UPDATES ON THE EDUCATIONAL
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ESTRO SCHOOL
UPDATES ON THE
EDUCATIONAL
TRAINING
COMMITTEE
RESTRUCTURING OF THE
EDUCATION AND TRAINING
COMMITTEE
At the June strategy review it was agreed that the
Core Education Committee would become a full
ESTRO Council, with direct links to the Board.
The new Council will become effective at the 3rd
ESTRO Forum in April in Barcelona.
The Educational Council will:
• Define the strategy for education within the
framework of the overall ESTRO strategy
• Delegate tasks to implement this strategy to
Task Forces within the broader Education and
Training Committee or other Standing Committees and Task Forces
• Follow up on the implementation of these tasks
• Oversee the daily management of the School by
the ESTRO staff
• Monitor the budget of the School
• Facilitate relations with other oncology (related)
societies regarding education
• Approve appointments related to the implementation of the educational strategy (e.g. course
directors).
Composition of the Educational Council:
The Council will consist of an Educational Executive (Chair/School Director, Administrative Director, Presidential Representative), plus approximately nine other members who will be selected
to represent all subspecialties and to link to all
ESTRO committees and Task Forces. The Board
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will appoint the Chair of the Council, based on
open solicitation and selection of the most appropriate candidates. The Board will appoint other
Council members, based on recommendations
by Standing Committees and existing Council
members.
INTERNAL REVIEW OF ESTRO
SCHOOL
An internal review of the ESTRO School is currently underway, based on the guidelines for
postgraduate medical education models developed by the World Federation for Medical Education (WFME). The existing structure and
performance of the School scored very well on
the majority of important issues. However, a few
areas for improvement have been identified and
are currently being investigated:
• Support for teachers and faculties
• Mechanism for robust evaluation of the efficacy
of educational programmes
• Professional and pedagogical expertise
• Trainee representation on educational programmes
• Administrative structure of the School to support programme implementation
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ESTRO SCHOOL
OF RADIOTHERAPY AND ONCOLOGY
2015
WWW.ESTRO.ORG
COMPREHENSIVE QUALITY
MANAGEMENT IN RADIOTHERAPY:
QUALITY ASSESSMENT
AND IMPROVEMENT
CANCER SURVIVORSHIP
1 - 4 February 2015 | Turin, Italy
16 - 19 May 2015 | Manila, The Philippines
ESTRO/EANM COURSE ON
MOLECULAR IMAGING AND
RADIATION ONCOLOGY
BIOLOGICAL BASIS OF PERSONALISED
RADIATION ONCOLOGY
14 - 16 May 2015 | Brussels, Belgium
ADVANCED TREATMENT PLANNING
NEW!
22 - 25 February 2015 | Madrid, Spain
BASIC CLINICAL RADIOBIOLOGY
7 - 11 March 2015 | Brussels, Belgium
30 August - 3 September 2015 | Dublin, Ireland
22 - 24 May 2015 | Seoul, South Korea
8 - 12 March 2015 | Paris, France
TARGET VOLUME DETERMINATION:
FROM IMAGING TO MARGINS
13 - 16 March 2015 | Amman, Jordan (postponed)
MODERN BRACHYTHERAPY
TECHNIQUES
15 - 18 March 2015 | Limassol, Cyprus
DOSE MODELLING AND VERIFICATION
FOR EXTERNAL BEAM RADIOTHERAPY
14 - 17 June 2015 | Beijing, China
PHYSICS FOR MODERN RADIOTHERAPY
EVIDENCE BASED RADIATION
ONCOLOGY
15 - 19 March 2015 | Barcelona, Spain
A CLINICAL REFRESHER COURSE
WITH A METHODOLOGICAL BASIS
21 - 25 June 2015 | Moscow, Russia
3rd ESTRO FORUM
PRE-MEETING COURSES
BRACHYTHERAPY FOR
PROSTATE CANCER
24 April 2015 | Barcelona, Spain
28 - 30 June 2015 | Vienna, Austria
IMAGE-GUIDED RADIOTHERAPY IN
CLINICAL PRACTICE
ADVANCED SKILLS IN MODERN
RADIOTHERAPY
10 - 14 May 2015 | Prague, Czech Republic
28 June - 2 July 2015 | Copenhagen, Denmark
RADIOTHERAPY TREATMENT PLANNING AND DELIVERY
BIOLOGY
3 - 5 September 2015
London, United Kindgom
NEW!
ESTRO/ESOR MULTIDISCIPLINARY
APPROACH OF CANCER IMAGING
15 - 17 October 2015 | Brussels, Belgium
BEST PRACTICE IN RADIATION
ONCOLOGY
A FOUR PHASE PROJECT TO TRAIN RTT
TRAINERS IN COLLABORATION WITH THE IAEA
19 - 21 October 2015 | Vienna, Austria
IMAGING FOR PHYSICISTS
IMAGE-GUIDED RADIOTHERAPY AND
CHEMOTHERAPY IN GYNAECOLOGICAL CANCER: FOCUS ON ADAPTIVE
BRACHYTHERAPY
13 - 17 September 2015 | Leiden, The Netherlands
1 - 5 November 2015 | Utrecht, The Netherlands
BASIC TREATMENT PLANNING
COMBINED DRUG-RADIATION
TREATMENT: BIOLOGICAL BASIS,
CURRENT APPLICATIONS AND
PERSPECTIVES
NEW!
3 - 6 September 2015 | Prague, Czech Republic
8 - 11 June 2015 | Florence, Italy
A JOINT COURSE FOR CLINICIANS
AND PHYSICISTS
14 - 18 June 2015 | Ljubljana, Slovenia
HAEMATOLOGICAL MALIGNANCIES
RESEARCH MASTERCLASS IN
RADIOTHERAPY PHYSICS
MULTIDISCIPLINARY MANAGEMENT
OF BREAST CANCER
MULTIDISCIPLINARY MANAGEMENT
OF HEAD AND NECK ONCOLOGY
PARTICLE THERAPY
MULTIMODAL CANCER TREATMENT
CLINICAL PRACTICE AND
IMPLEMENTATION OF IMAGE-GUIDED
STEREOTACTIC BODY RADIOTHERAPY
13 - 17 September 2015 | Lisbon, Portugal
ADVANCED TREATMENT PLANNING
18 - 22 September 2015 | Lisbon, Portugal
MULTIDISCIPLINARY MANAGEMENT
OF BRAIN TUMOURS
4 - 6 October 2015 | Turin, Italy
IMRT AND OTHER CONFORMAL
TECHNIQUES IN PRACTICE
4 - 8 October 2015 | Brussels, Belgium
15 - 18 November 2015 | Vienna, Austria
PAEDIATRIC RADIATION ONCOLOGY
19 - 21 November 2015 | Izmir, Turkey
BASIC CLINICAL RADIOBIOLOGY
ENDORSED BY ESTRO
21 - 24 November 2015 | Brisbane, Australia
4 - 8 October 2015 | Budapest, Hungary
QUANTITATIVE METHODS IN
RADIATION ONCOLOGY: MODELS,
TRIALS AND CLINICAL OUTCOMES
MULTIDISCIPLINARY MANAGEMENT
OF LUNG CANCER
ADVANCED TECHNOLOGIES
TARGET VOLUME DETERMINATION FROM IMAGING TO MARGINS
15 - 17 October 2015 | Athens, Greece
IMAGING
BEST PRACTICE
6 - 9 December 2015 | Brussels, Belgium
6 - 10 December 2015 | India
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WHO’S WHO?
UPDATES ON THE EDUCATIONAL
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YOUNG ESTRO
INTRODUCTION
YESTRO
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YOUNG ESTRO
“The young task force
has officially become a
standing committee in
ESTRO”
We have some great news to share with you:
the young task force has officially become a
standing committee in ESTRO. It will allow us to
support the needs and create initiatives for young
members, provide the structure for continued
input, organisation and network for young
activities already in place and to have a structure
to launch new ideas with proper consistency and
efficiency.
CATHARINE CLARK
In this issue, we publish two mobility reports.
Lucas Persoon from The Netherlands wrote the
first one after he visited the Aarhus University
Hospital in Denmark. Dr Sayan Paul from India
wrote the second mobility report in this issue
after he visited Vienna General Hospital to learn
more about brachytherapy techniques.
Don’t forget to renew your membership for
2015 and to register for ESTRO’s 3rd Forum
in Barcelona. We have added at the end of this
Corner the young programme that the scientific
advisory group of young ESTRO members has
prepared for you. We look forward to meeting
you in Barcelona!
JEAN-EMMANUEL
BIBAULT
Catharine Clark and Jean-Emmanuel Bibault
Read the interview with Laura
Mullaney and Kasper Rouschop,
chairs of the young programme
at the 3rd ESTRO Forum, in the
Conference Corner on p145 >
INTRODUCTION
YESTRO
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YOUNG ESTRO
THE YOUNG TASK
FORCE HAS BECOME
A STANDING
COMMITTEE
The young task force (YTF) has the pleasure
to inform you that ESTRO now has a standing
committee to represent the young. The ESTRO
Board approved the creation of this new committee, yESTRO, at their meeting on 17 November
2014. The committee will officially start at the
3rd ESTRO Forum, although work continues on
all fronts on the issues started by the YTF, while
articulating the activities the new committee
should tackle.
activities and supporting young members. The
first task given by the Board to the committee is
to investigate and come up with a way to involve
young national societies more in ESTRO.
Come and toast a glass to the new committee at
the Young reception at the 3rd Forum on Monday
27 April at 16.45-17.45 hrs.
This has been a long process for the young members in ESTRO. Everything began in 2011 at the
ESTRO 30th Anniversary congress when the first
YTF was formed based on efforts of few young
ESTRO members who started to lobby for a
specific young element in ESTRO in early 2009.
These pioneers created and managed the young
track and the young Corner in the newsletter
between 2009-2011 until the YTF took over these
activities.
We thank them for their innovation and persistency and are proud that their ultimate goal has
finally been realised, with the creation of the
yESTRO. This committee will be an integral
part of the ESTRO governance, contributing to
INTRODUCTION
YESTRO
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YOUNG ESTRO
Adaptive radiotherapy using portal dosimetry for
clinical decision-making
Lucas C.G.G. Persoon
Image based gynaecological brachytherapy,
the ultimate dose painting: treat the disease
you see
Paul Sayan
INTRODUCTION
YESTRO
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Adaptive radiotherapy using
portal dosimetry for clinical
decision-making
Lucas C.G.G. Persoon
HOST INSTITUTE:
Aarhus University Hospital
Aarhus University
Aarhus, Denmark
DATE OF VISIT:
31 August 2014 – 19 September 2014
LUCAS PERSOON
INTRODUCTION
The aim of the visit was to familiarise myself with
clinical procedures developed for adaptive radiotherapy developed at Aarhus University Hospital
(AUH). Secondly, we wanted to set up a collaboration between our institutes to share knowledge
to analyse large groups of patients and develop
adaptive radiotherapy decision-support aids for
informed decision-making. AUH has a long track
record in applying adaptive radiotherapy strategies for several treatment sites and, therefore, was
an excellent choice to learn more about the strategies so that we can combine this with our EPID
dosimetry method to apply adaptive radiotherapy
in a better way.
During the visit we focused mainly on three
treatment sites: head and neck, lung and bladder
cancer, where AUH has a lot of experience with
adaptive radiotherapy. In lung cancer treatments
AUH has considerable experience and they have
analysed a large patient group. They observed in
a study published in ESTRO’s Green Journal that
in approximately 20% of the patients, a clinical
relevant anatomy change emerged during treatment. In this study reduction of lung atelectasis,
tumour regression and base-line shifts of the tumour frequently occurred. During the visit they
showed how they apply this procedure and the
way they can adapt a treatment within one day.
YESTRO
For head and neck the focus was on contour
propagation. Contour propagation is necessary
for an accurate assessment of the dose based on
dose recalculations using Cone Beam CT (CBCT)
images. One of the main disadvantages is that
re-delineations are necessary in order to get accurate Dose Volume Histogram (DVH) results,
especially for head and neck re-delineations,
which are time-consuming. AUH has explored
some methods to perform contour propagation
and dose accumulation.
Besides the methods developed for lung and head
and neck, AUH uses an adaptive radiotherapy
protocol for bladder cancer patients with a planof-the-day where, based on the CBCT, a plan is
selected according to the bladder filling when the
patients come for treatment. I had the opportunity to follow the entire treatment adaptation process at the treatment machine.
Furthermore AUH has a lot of experience in motion assessment and tracking while MAASTRO
clinic has a lot experience with time-resolved
EPID dosimetry, and this was one of the topics
where our two institutes plan to collaborate for
radiotherapy treatments.
During the two-week visit I was also introduced
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to many of the other research areas AUH is working on and I happened to see their new facilities
at the Skejby location. The visit surpassed my
expectations and I learned a lot and was able to
set up a collaboration project.
Finally, I would like to thank ESTRO for providing the opportunity to visit AUH. From AUH I
would like to thank Professor Ludvig Paul Muren
and his whole team for arranging the visit and
the hospitality. I also would like to thank Lone
Hoffmann, PhD; Ulrik Vindelev Elstrøm, PhD
and Anne Vestergaard, MSc for the very pleasant
discussions and collaborations we have set up.
Lucas C.G.G. Persoon, Msc
Computer scientist and PhD student
MAASTRO clinic
Maastricht, The Netherlands
[email protected]
INTRODUCTION
YESTRO
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Image based gynaecological
brachytherapy, the ultimate
dose painting: treat the disease
you see
Paul Sayan
HOST INSTITUTE:
AKH, Vienna General Hospital
Medical University
Vienna. Austria
Dr Sayan Paul and Mrs Kanan with Prof Richard Pötter, the pioneer in image based gynaecological brachytherapy, in AKH, Vienna
DATE OF VISIT:
13 - 23 October 2014
AIM OF THE VISIT
PAUL SAYAN
INTRODUCTION
Brachytherapy plays an integral role in treatment
of gynaecological cancers. There has been much
development in image-based technology for external beam radiation and these technologies are
available in most of the radiotherapy centres, but
the skill and training needed for image-based
brachytherapy are still lacking even in many advanced radiotherapy facilities. In spite of having
equal importance in treatment of gynaecological
cancers, most of the centres are still using con-
YESTRO
ventional treatment planning in brachytherapy
for this reason. Being a state-of-the-art radiotherapy facility in India, where cervical cancer is the
leading cancer in females, we planned to start image-based brachytherapy in our centre. In order
to get trained we visited AKH, Vienna, which has
been the pioneer in this field and where Professor
Richard Pötter has been teaching and guiding
the radiotherapy fraternity of the world this technique for more than a decade.
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DETAILS OF THE SCIENTIFIC CONTENT OF THE VISIT
There was extensive preplanning by the host
institute for our visit. A detailed schedule was
prepared taking a holistic approach to train us
not only in the technique but also in patient
care as a whole. There was balanced allocation
of time for clinical exposure, technical training,
physics training, research work and didactic
lectures. There regular morning meeting and
tumour boards were organised in English for our
better understanding. Lectures on image-based
brachytherapy technique, clinical results and
trial outcomes were delivered. Various cases with
imaging and pathology were also discussed in
these meetings. The most useful and exciting part
of the training was Prof Pötter’s personal involvement in teaching the technique we had gone to
learn about. Starting from the pre-planning he
explained the imaging clinical findings, desired
plan of treatment, prescription dose to various
target areas, expected outcome and toxicities
and also how to reduce toxicities and enhance
gain. In the operation room we were shown the
application of compatible brachytherapy applicators (Vienna 1 and 2 applicators) and the tricks
and areas of caution during application and post
application care. A detailed training on image
INTRODUCTION
acquisition and hands-on training on contouring
and planning were the most useful part of this
whole exercise. We were allowed to contour and
plan real time and were checked and corrected by
Prof Pötter himself and their excellent physicist,
Dr Daniel Berger. Their friendly nature never allowed this technically demanding task to become
boring for a second. The team explained their
meticulous plan evaluation and we witnessed the
plan’s execution as well. It was our good luck that
there were a good number of patients and applications during our visit. The rest of our time was
devoted to exposure to clinical research.
We attended the EMBRACE trial meetings and
learned the trial data collection, data evaluation,
screening and analysis methods. The joyful and
cooperative environment of the department made
this whole learning process exciting and enjoyable. We had good times with other international fellows from different parts of the world and
making a few new friends among them was the
icing on the cake.
in the process of implementing image-based techniques, this visit gave us immense confidence on
this subject. The skill we acquired will be of great
use in our day-to-day practice. Our successful
implementation of this technique has the potential to change the pattern of practice in this part
of the world where it can yield best results.
Lastly we express our heartiest thanks and gratitude to ESTRO, Mrs Viviane van Egten, Prof Pötter, Dr Berger and the whole AKH team for this
wonderful training, which has not only enriched
us but also will benefit millions of gynaecological
cancer patients in south east Asia.
Dr Sayan Paul
Radiation Oncologist
Fortis Memorial Research Institute
Gurgaon, Haryana, India
[email protected]
RESULTS FROM THE VISIT
Being a tertiary referral centre in India we get
a good number of patients with gynaecological
malignancies who need brachytherapy. As we are
YESTRO
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YOUNG
PROGRAMME
3rd ESTRO Forum
Monday 27 April 2014
08.00 - 08.40 | ROOM 114
TEACHING LECTURE
Co-chair: S. Rivera (FR)
Initiating and maintaining meaningful collaborations: A requirement for good sciences! – A
guide for dummies
Chair: P. Kelly (IE)
Speaker: P. Lambin (NL)
Learning Objectives: This session will look at
what are the important factors to consider when
initiating collaborations with more experienced
colleagues and once these collaborations have
been formed how to ensure that they remain active and mutually beneficial.
08.45 - 10.00 | ROOM 114
SYMPOSIUM
Integrating health economics in research
Chair: L. Fokdal (DK)
INTRODUCTION
YESTRO
> Why health economics matters in radiation
oncology research
Y. Lievens (BE)
> How to incorporate cost calculation into our
research?
N. Defourny (BE)
> How to calculate cost-effectiveness?
J. Grutters (NL)
10.30 - 11.30 | ROOM 114
MOVING POSTER SESSION I AND II
> Head and neck cancer
> Lung cancer
> Breast cancer
> Gynaecological cancer
> Dosimetry and dose measurements
> Treatment planning calculation, optimisation,
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radiobiological planning, predictive models of
outcome
> Radiobiology imaging and physics imaging
> Intrafraction motion management
> RTT Pre-treatment imaging; adaptive radiotherapy; geometric uncertainties and margins
14.45 - 16.15 | ROOM 114
SYMPOSIUM
Chair: K. Rouschop (NL)
Working smarter to create ‘my dream career’
Learning Objectives: In this symposium a report
on the current and ongoing young ESTRO activities will be provided, including experiences of
ESTRO fellows and exchange programmes. This
session will promote engagement in the young
ESTRO community and the exchange of ideas on
future activities.
Chair: L. Fog (DK)
Co-chair: W. Van Elmpt (NL)
> Physicist: K. Tanderup (DK)
13.15 - 14.15
BROWN BAG LUNCH: MEET THE
PROFESSORS - YOUNG ESTRO
MEMBERS
Radiation Oncology: D. de Ruysscher (BE), D.
Zips (DE)
Chair: J-E Bibault (France)
Physics: D. Low (US), L. Muren (DK)
Chair: D. Thorwarth (DE)
RTT: M. Coffey (IE), H. McNair (GB)
Chair: E. Forde (IE)
Radiobiology: F. Stewart (NL), B. Wouters (CA)
Chair: K. Røe (NO)
Learning Objectives: This session is designed to
provide an opportunity for young ESTRO members to meet a number of preselected professors/
experts over lunch to ask questions and generate
discussion, putting some of the teaching lecture
lessons into practice.
> Clinician: S. Combs (DE)
> Radiobiologist: M. Koritzinsky (CA)
> RTT: M. Leech (IE)
Learning Objectives: In this session, four outstanding young researchers will explore the steps
they consider key to building the career of their
dreams.
Our expert panel, which boasts a biophysicist,
a radiation therapist, a doctor and a physicist,
will explore goal-setting, branding, creating and
exploiting opportunities, the usefulness of networking inside and outside your own institution,
finding your place within your team and the role
of mentorship. We hope to leave you inspired,
enthused and well-equipped to build your dream
career.
16.45 - 17.45
SYMPOSIUM
Report from the Young Task Force and Young
reception
Chair: V. Valentini (IT)
INTRODUCTION
Feedback / brainstorm from audience for YTF
YESTRO
YOUNG RECEPTION AT THE 3RD
FORUM
Monday 27 April at 16.45-17.45 hrs
Room 114
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HEALTH
ECONOMICS
INTRODUCTION
STEREOTACTIC BODY RADIOTHERAPY:
WHAT DOES IT REALLY COST?
HEALTH
ECONOMICS
“Stereotactic body
radiotherapy: what
does it really cost?”
Before being able to launch their product on
the market, manufacturers of new radiotherapy
equipment only have to prove that their product
does what it is designed to do: to deliver radiation, and to do it safely. But health care payers
want evidence that goes beyond this requirement.
They want evidence that innovative treatments
are of clinical benefit to patients, and that these
treatments deliver sufficient additional value
for the typically higher cost. Unfortunately, this
evidence is not always readily available, and research often needs to be performed after novel
equipment has been purchased by the health care
provider. This shifts the financial risk from the
health care payer to the provider, often delays
reimbursement, and, as a consequence, may result in a situation where innovations disseminate
slowly into general practice due to financial disincentives. Coverage with evidence development
(CED) has been proposed as a means to overcome
this potential barrier, as is described in a paper
on the cost of stereotactic body radiotherapy
(SBRT) for early stage non-small cell lung cancer
(ES-NSCLC) [1].
YOLANDE LIEVENS
PETER DUNSCOMBE
Yolande Lievens, Peter Dunscombe and Madelon
Pijls
MADELON PIJLS
INTRODUCTION
STEREOTACTIC BODY RADIOTHERAPY:
WHAT DOES IT REALLY COST?
HEALTH
ECONOMICS
STEREOTACTIC
BODY RADIOTHERAPY: WHAT
DOES IT REALLY
COST?
YOLANDE LIEVENS
INTRODUCTION
As level 1 evidence for (lung) SBRT is lacking, the
Belgian obligatory health care insurance organisation has, to date, not agreed to endorse reimbursement. However, in order not to withhold
this promising treatment modality from patients,
a CED programme has been launched for SBRT
in well-defined clinical indications. In return for
the financing, health care providers have to commit themselves to collect effectiveness data that
are gathered in a central database, monitored by
the Belgian cancer registry and the health care
insurance organisation.
To provide input for this cost-based coverage
programme, a comprehensive cost calculation
study of standard and innovative radiotherapy
was performed in ten Belgian radiotherapy centres, representative of all 25 centres in Belgium.
The choice for the costing methodology was
time-driven activity-based costing (TD-ABC).
This method has been described previously and
was selected for its usefulness in the context of
situations where high treatment complexity goes
hand in hand with a rapidly evolving technology, as is the case in radiotherapy. In short, ABC
tackles the problem of resources that cannot be
directly traced to a single product (so-called indirect costs, such as equipment or personnel) in a
stepwise approach: resource costs are first allocated to activities using “resource drivers”, and the
calculated activity costs are further assigned to
the products (services or treatments) through “activity drivers”. The product cost is calculated by
simply adding together all costs assigned to that
product. Whereas the original ABC-methodology
typically required a large number of diverse cost
drivers, TD-ABC reduces the necessary parameters at each process step to only two: the cost,
per time unit, of each of the resources used in
the process and the time spent by each resource.
We will not focus on the specificity of this model’s parameters; the interested reader will find it
in much detail in the paper, as well as in the full
report of the Belgian Knowledge Centre, which is
available online [2].
The analysis in the paper focuses on the cost of
SBRT for ES-NSCLC, put in the context of curative intent treatments for lung cancer. In the
ten participating departments, the overall yearly
number of lung radiotherapy treatments delivered with curative intent varied from 46 to 252,
the lung SBRT treatments from 7 to 73 (mean
40). The average cost (in 2011 in Euros) of lung
SBRT was computed at €6,221, with an average
by centre ranging between €3,104 and €12,649;
compared to a cost of €5,919 (€4,557-€6,564) for
standard fractionated 3D-CRT and of €7,379
(€5,054-€8,733) for IMRT. This shows that in spite
of fewer fractions, the average lung SBRT cost is
close to that of standard fractionated radiotherapy, due to the high demand on machine and
personnel time per fraction.
On the contrary, the cost of SBRT treatments
decreased with a decreasing number of fractions.
Similar conclusions hold true for more standard
treatment techniques, where, in line with the
STEREOTACTIC BODY RADIOTHERAPY:
WHAT DOES IT REALLY COST?
lower resource needs, the costs of hypofractionated schedules came out about 30-35% lower than
those of standard fractionated schedules.
new treatment to the patient at an early stage of
technology development.
Lastly, as can also be deduced from the figures
above, the average cost amongst the different centres varies more for SBRT than for conventional
radiotherapy techniques, with 3D-CRT having
the smallest variability in cost. This reflects the
impact of differences in the equipment and technologies used, in stages of the learning curve and
related personnel demands, in the utilisation of
the various resources, and, by extension, in a lack
of clear guidance and planning in this field.
Yolande Lievens
Ghent University Hospital
Ghent, Belgium
REFERENCES
[1] Lievens Y, Obyn C, Mertens A-S et al. “Stereotactic
body radiotherapy for lung cancer: what does it really
cost?” J Thorac Oncol. 2014 Nov 7. [Epub ahead of print].
[2] Hulstaert F, Mertens A-S, Obyn C, et al. “Innovative radiotherapy techniques: a multicentre time-driven
activity-based costing study.” Health Technology Assessment (HTA) Brussels: Belgian Health Care Knowledge
Centre (KCE) KCE Reports. Brussels: Belgian Health
Care Knowledge.
One should be aware that the costs presented
above might not be entirely generalisable to other
jurisdictions, as the input figures, in terms of resource costs and use, may diverge from one country to another. However, this study does demonstrate that it is feasible to compute resource costs
with TD-ABC in a multicentre context, resulting
in real-life cost data that can support reimbursement negotiations. As a matter of fact, based on
these computations, the Belgian obligatory health
insurance organisation initiated a CED project
with provisional financing for innovative radiotherapy, including SBRT amongst others, for
ES-NSCLC. The ultimate goal is to make a blueprint of the Belgian SBRT landscape, showing the
national distribution of indications, techniques
and practice patterns, and their evolution over
time. Thanks to the financial coverage, it allows
health care providers to deliver this promising
INTRODUCTION
STEREOTACTIC BODY RADIOTHERAPY:
WHAT DOES IT REALLY COST?
INSTITUTIONAL
MEMBERSHIP
INTRODUCTION
UZ BRUSSEL
INSTITUTIONAL
MEMBERSHIP
INSTITUTIONAL ESTRO MEMBERSHIP
BECOME AN INSTITUTIONAL
MEMBER
The possibility of signing up groups of
five people represents a very interesting
economical opportunity, whilst benefitting
from all regular membership advantages
as well as a few extra advantages created
just for your institute. The packages include
various membership types and a minimum
of three disciplines need to be represented.
Detailed information can be found on the
website: 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. UZ Brussel is featured in this issue.
Contact: [email protected]
INTRODUCTION
UZ BRUSSEL
INSTITUTIONAL
MEMBERSHIP
UZ BRUSSEL,
VRIJE UNIVERSITEIT
BRUSSEL (VUB)
Brussels, Belgium
Number of ESTRO institutional members: 27
Spokesperson: Professor Mark De Ridder,
Head of the radiation oncology department
www.uzbrussel.be/u/view/nl/127896-Radiotherapie.
html
The radiation oncology department at UZ Brussel
How would you describe the radiation
oncology department of your institute?
MARK DE RIDDER
INTRODUCTION
From the launch of the Vrije Universiteit Brussel,
the need was identified for a proprietary hospital. Its foundations have remained relevant to
this day as they relate to the university’s mission
not only to provide a platform for the education
of students in the (para)medical professions, the
development of new medical techniques or innovative treatments, but also for the best possi-
ble accessible medicine governed by the right of
self-determination. In view of its location in the
Brussels region, the VUB has also taken it upon
itself to provide an answer to the failed language
policy in Brussels’ public hospitals.
The radiation oncology department of the UZ
Brussel treats approximately 1,500 patients per
year. Our staff consist of 12 radiotherapists (of
which three are physicians in training), 29
UZ BRUSSEL
nurses and technologists, two social nurses, a
dietician, a psychologist, two logisticians, seven
clinical physicists, two dosimetrists, five service
engineers, two radiobiologists, a lab technician, a
team of six administrative staff, a data manager,
four post-doc scientists and six PhD students.
Our mission is “to offer the optimal and most
efficient radiation therapy tailored to the individual patient, through development and clinical
implementation of novel irradiation techniques
and radiobiological concepts”. The department is
on two sites, applying a multi-vendor philosophy
with dedicated technology to optimise an individualised treatment approach.
What are the main areas of specialisation in your department?
The UZ Brussel’s clinical research programme is
currently built around four strategic clusters: a)
diagnosis and treatment of colorectal cancer, b)
treatment of oligometastasis, c) frameless stereotactic radiosurgery, and d) biological modulated
radiotherapy with special emphasis on the tumour microenvironment.
Research activities are largely focused on safe
implementation of 3D conformal radiation therapy in all its aspects, more particularly Intensity-Modulated Radiation Therapy (IMRT) and
Image-Guided Radiation Therapy (IGRT). From
the start, research has been based on the concept
INTRODUCTION
that conformal radiotherapy requires real-time
and accurate knowledge of the patient’s anatomy
during dose delivery. As such, the UZ Brussel
has always advocated the need for real-time image-guidance to warrant safe administration of
dose when applying sophisticated dose delivery
techniques. In 1992 the centre was one of the
first centres worldwide to report on on-line patient set-up procedures using an electronic portal imaging device mounted to the gantry of the
linac combined with a tele-controlled treatment
couch. These developments gradually evolved in
the combination of a real-time infrared tracking
device with stereoscopic X-ray imaging and a (6
degrees-of-freedom) robotic treatment couch for
high precision localisation of tumours prior to,
and during treatment, such as respiratory gated delivery of irradiation (in use clinically since
2006). In 2009, this expertise emanated in the
exploration of real-time tumour tracking with
the co-development and clinical implementation
of the VERO-system for stereotactic body radiotherapy.
In parallel to the development of IGRT, the UZ
Brussel recognised the need for rotational irradiation in combination with intensity-modulation
and was the first European centre to introduce
IMRT by means of sequential tomotherapy into
the clinic in 1995. Research in this field focuses
on volumetric approaches in arc therapy to increase efficiency in dose delivery, and it resulted
in the clinical introduction of two units for helical tomotherapy in 2005 and 2006, and VMAT in
2011. In addition, the UZ Brussel has been active
in the validation of both frame-based and frameless linac-based stereotactic radiosurgery using
dynamic arc therapy with circular cones or micro-multileaf collimators since 1992.
In addition, these technological developments
aim at integrating research in high precision
radiotherapy with radiobiology. The radiobiological research unit of the department is focused on
hypoxic tumour cell radiosensitisation and the
role of the pro-inflammatory tumour infiltrate in
radioresponse. Clinical trials on this synergy are
currently on-going.
Special programmes for patient safety and treatment quality are continuously adapted and implemented to monitor and improve the care programme within the department.
What are the main achievements so far
and the main challenges on your daily
work and for the future?
Our focus is the translation, integration and clinical implementation of new biological concepts
and innovative radiation techniques in phase I/
II clinical trials. We implemented IMRT/IGRT
in the pre-operative treatment of rectal cancer
and dynamic tumour tracking by the Vero SBRT
system in oligometastatic and lung cancer.
The implementation of biological imaging
UZ BRUSSEL
modalities for patient individualised treatment
strategies is our future challenge.
Is your department currently undertaking some studies or clinical trials that
you would like to share with the ESTRO
community?
The radiotherapy department of the UZ Brussel
offers high quality and academic-based patient
care. The department acts as the principal or
participating investigator in several clinical studies. The focus of our research is on radiobiology,
colorectal cancer, oligometastatic cancer and
stereotactic radiosurgery.
We would like to invite the ESTRO community
to join the RECTUMSIB trial, evaluating a simultaneous integrated radiation boost as an alternative to concomitant chemotherapy in pre-operative radiation treatment of rectal cancer (NCT
01224392).
What attracted you to apply for an institutional membership and why is it
important for your institute that its staff
members are part of ESTRO?
The main feature of the concept “institutional
membership” is the obvious answer, in that it
mirrors the department’s philosophy of multidisciplinary team-work. Promoting ESTRO from
within the institute, as opposed to individual
initiatives, lowers the threshold for attending
INTRODUCTION
courses and meetings. As such, we see ESTRO
as an additional and important contribution to
the educational programme of the department.
Moreover, an institutional approach opens doors
for benchmarking, networking and collaboration
on different levels.
the entire team. We encourage people interested
in visiting the department for a medium or long
term visiting project to contact us any time at
[email protected]
In your opinion, what additional benefits
would be useful as part of the institutional membership package?
Tools to facilitate inter-departmental collaborations and exchanges of not only researchers but
also clinical personnel might help to strengthen the ESTRO network with a view to creating
a uniform, high quality radiotherapy service
throughout Europe.
Is there anything particular about your
institute that you would like to promote
and share with the ESTRO community?
We organise weekly seminars, doctoral school
and clinical training programmes for residents
in radiation oncology, medical physics and RTTs
within certified academic programmes. The
department has an open-house policy in that
it accepts external visitors and fellows from all
disciplines related to radiation oncology (radiation oncologists, medical physicists and RTTs)
on a regular basis. Exchange of experience with
trainees and visiting experts is considered to be
mutually fruitful and is highly appreciated by
UZ BRUSSEL
NATIONAL
SOCIETIES
INTRODUCTION
TURKISH SOCIETY FOR
RADIATION ONCOLOGY
NATIONAL
SOCIETIES
“This edition of the
Corner hosts TROD,
the Turkish Society for
Radiation Oncology”
Welcome to the National Societies Committee (NSC) Corner.
Continuing to offer national societies the opportunity to present their views on
issues of general interest (such as education, mobility and expectations towards
ESTRO), this edition of the Corner hosts TROD, the Turkish Society for Radiation
Oncology. TROD representatives introduce their society, report on its approach to
continuous medical education and update us on the current state of the national
radiation oncology services field. The conclusion of this concise, yet informative
interview serves as a reminder to the NSC of its main responsibility: to promote the
open discussion on radiation therapy in the broader European area as a means of
highlighting issues requiring concerted action and promoting inclusive approaches
drafted from the synthesis of views.
PANAGIOTIS
PAPAGIANNIS
It is in this regard that we’d like to remind you of our next meeting on 24 April at
the 3rd ESTRO Forum in Barcelona. We are looking forward to your active participation, recommendations, experience sharing, as well as comments and criticism
regarding our progress on further promoting the role of ESTRO as a melting pot of
national societies and their concerns.
Panagiotis Papagiannis
Member of the ESTRO national societies committee
Medical School, University of Athens
Athens, Greece
National societies half-day meetings at the
3rd ESTRO Forum:
• National Associations Day Joint Meeting
for ALATRO, SEOR, SPRO: 24 April
• National Associations Day, Polish Society
of Radiation Oncology: 24 April
View the full programmes in the
Conference Corner on p153 >
INTRODUCTION
ESTRO NATIONAL SOCIETIES COMMITTEE
View the members and the activities:
www.estro.org/about-us/governance-organisation/professional--membership-council/committees/national-societies-committee-nsc >
The committee is contactable through Chiara Gasparotto [email protected] at the ESTRO
office.
TURKISH SOCIETY FOR
RADIATION ONCOLOGY
NATIONAL
SOCIETIES
TURKISH SOCIETY
FOR RADIATION
ONCOLOGY
Interview with
Professor Yavuz Anacak,
Representative of TROD to ESTRO
and Professor Serdar Özkök,
President of TROD
Ege University Hospital,
Izmir, Turkey
When was your society founded, and
how many members does it have at
present?
The history of radiotherapy in Turkey goes
back to beginning of 20th century, when the
first documented radiotherapy applications
were published in 1904 (1). Radiotherapy was
a branch of radiology until 1987 when it was
accepted as a separate medical specialty and
referred to as “radiation oncology” in Turkish
law. The Turkish Society for Radiation Oncology
(TROD) was founded in Istanbul in 1993, spread
out to the whole country quickly and became
a national society within a few years. TROD
is the only society for radiation oncologists in
Turkey; all radiation oncologists and radiation
oncology residents are considered to be natural
members. Medical physicists are also eligible for
membership by application. Currently TROD has
more than 700 members, including 450 radiation
oncologists, 200 medical physicists and 50
radiation oncology residents.
What would you refer to as the major
strength of your national society?
SERDAR ÖZKÖK
INTRODUCTION
YAVUZ ANACAK
The aim of the TROD is to enhance capacity
and standards of knowledge among Turkish
radiation oncologists by organising regional
and national meetings and training courses,
developing certification standards and executing
board exams, developing national guidelines for
radiotherapy applications, providing fellowships
abroad and grants for ESTRO school courses.
TROD has several working groups which organise
coordinated clinical research projects to enhance
the science of radiation oncology in Turkey.
TROD represents Turkish radiation oncologists at
various levels on governmental issues, including
lobbying for the rights of radiation oncologists,
advising on manpower and infrastructure
planning, and contributing to national cancer
control plans and health policies.
How does your society work towards
addressing the need for continuous
professional development of its
members?
As we all know radiation oncology is a rapidly
evolving medical speciality, which means there
need to be frequent updates of individuals’
knowledge.
TROD has organised the National Radiation
Oncology Congress (UROK) biennially since
1994. The last meeting was held in 2014 with
more than 700 participants. Almost all topics and
issues related to radiation oncology are usually
discussed at UROK. TROD also organises a
National Cancer Congress (UKK) jointly with
the Turkish Medical Oncology Society and the
Turkish Paediatric Oncology Society.
Several training courses are organised annually
by TROD in different Turkish towns. These
courses range from basic radiation physics and
radiobiology to hands-on training for advanced
contouring, or they are specific to certain
TURKISH SOCIETY FOR
RADIATION ONCOLOGY
situations such as sarcomas, head and neck, and
secondary cancers. In 2015, 250-300 people are
expected to participate in these courses. Every
year TROD provides fellowships abroad lasting
for three months to one year for three young
members, and also supports the participation
of its members in the ESTRO School courses by
covering the expenses of 25-30 participants each
year. Other activities of the Society include grants
for research projects, awards for the three papers
each year with the highest impact, and awards for
the best presentations at the meetings.
Since 2008, TROD has organised two-step board
exams. The first step is a multiple choice text
exam, where the questions are selected from an
online question bank provided by university
professors. Those who are successful in the
written exam are required to participate in an
Objective Structured Clinical Examination
(OSCE) to test their clinical skills. The OSCE
takes place in a clinical skills lab where the
participants should complete 10 tasks, including
target definition, contouring, DVH evaluation,
patient communication etc. Currently 160
members are board certified. Re-certification
exams are planned every 10 years.
What is the situation with health
professional mobility in Turkey and how
would you comment on the national
training/accreditation programme in
your specialty with regard to professional
INTRODUCTION
mobility as a sending/receiving country?
Radiation oncology is booming in Turkey. Until
recently there were few public radiotherapy
centres located in the country’s main towns.
However, in the last decade we have witnessed
a huge amount of investment in radiotherapy,
both from public and private sectors. Currently
there are around 120 radiotherapy centres in the
country, which require a well-trained workforce
at all levels; thus, the employment rate is very
high within Turkey and, to the best of our
knowledge, currently fewer than ten colleagues
are working abroad. Almost all radiotherapy
professionals studied and received their diplomas
and certificates from Turkish institutions, while
many colleagues visited centers in North America
and Western Europe for fellowships of variable
durations. Given its population and the above
mentioned investment increase, Turkey has the
largest radiotherapy infrastructure in its broader
region, attracting cancer patients and students
from abroad. Many colleagues from Turkic
countries of the Caucasus and Central Asia, and
neighboring Middle Eastern countries received
full academic training in Turkish institutions, and
many get additional training provided by IAEA
fellowships and bilateral agreements.
Is there a particular topic that you think
the NS committee should target in the
future?
Although ESTRO represents the whole of Europe,
there is much heterogeneity between regions and
countries, including infrastructure and manpower, education and training, laws and legal issues
and practices of radiotherapy. As a middle-income country Turkey has a number of problems
in the development of a nationwide radiotherapy
infrastructure that would be easily accessible by
all cancer patients in the country. We think ESTRO did a very good job in establishing the National Societies Committee, which brings together
the member societies and provides a common
ground to share and discuss the issues and problems within countries, regions and the whole continent. We hope the National Societies Committee
will continue working to document and define the
strong and weak points of European radiotherapy, propose and execute solutions to enhance the
radiotherapy capacity in Europe and help to close
the gap between East and West, North and South.
REFERENCE
(1) (Rasih Emin: “Le Cancer et les rayons X à l’Hôpital
Hamidie”, Hamidiye Etfal Hastahane-i Âlisinin İstatistik Mecmua-i Tıbbiyesi, 113-114, 1904)
If your national societies would like to share
views on topics of common interest, please
contact the National Societies Committee via
Chiara Gasparotto: [email protected]
TURKISH SOCIETY FOR
RADIATION ONCOLOGY
CONFERENCES
INTRODUCTION
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“Together we’ll show
that quality of life can
be maintained during
and after treatment
and we count on you
to help us spread this
positive message”
It’s always a special time of year at ESTRO: spring seems to be on its way
and buds are slowly emerging after a cold winter… However, in the
ESTRO office the atmosphere is far from bucolic; we are on the starting
blocks to make our annual congress the best European platform for radiation oncology.
As this is the newsletter you will receive just before the congress, we have
gathered here all the practical details you will need onsite. However, don’t
panic if you don’t have your newsletter with you in Barcelona: we will
launch an app shortly before the congress. It will provide you with information on all the sessions, floor plans, maps, access to social media, etc.
You will find details in the following pages.
AGOSTINO BARRASSO
ESTRO Congress manager
The ESTRO Forum is the place to share science and knowledge between
disciplines. The chairs of the five meetings have reviewed all the abstracts
and here they tell us about some of the science that will be presented.
Besides top science, we have created some new events, which we recommend you don’t miss. These include the ESTRO Job Fair, where participants will have the opportunity to meet companies and institutes for job
interviews, and the Super Run. ESTRO is encouraging all Forum participants and also patients, former patients and their families to join us for
a five-kilometre run on the Barcelona beach. Together we’ll show that
quality of life can be maintained during and after treatment and we count
on you to help us spread this positive message.
ERALDA AZIZAJ
ESTRO Programme manager
We look forward to meeting you in sunny Barcelona for an outstanding
scientific meeting that can definitely compete with Barcelona’s sun. Despite the beautiful weather we can expect, we are confident that no sunscreen will be needed!
Agostino Barrasso and Eralda Azizaj
INTRODUCTION
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WORLD CONGRESS ON
LARYNX CANCER
3RD ESTRO FORUM
24 - 28 April 2015
Barcelona, Spain
26 - 30 July 2015
Cairns, Queensland, Australia
EUROPEAN CANCER
CONGRESS
25 - 29 September 2015
Vienna, Austria
INTRODUCTION
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CLINICAL
24 - 28 April 2015
Barcelona, Spain
PHYSICS
BRACHYTHERAPY
RADIOBIOLOGY
RTT
INTRODUCTION
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INTRODUCTION
MARK YOUR CALENDAR
By Philip Poortmans, ESTRO President
Clinical and translational meeting - Philip Poortmans >
Physics Biennial meeting - Robin Garcia >
GEC-ESTRO-ISIORT meeting - Jacob Lindegaard >
RTT meeting - Martijn Kamphuis >
PREVENT and TARGET meetings - Brad Wouters >
Social activities >
Young programme >
Rendez-vous with colleagues >
Education >
Awards >
Exhibition >
Wifi >
Luncheons and refreshments >
YOUNG TRACK OF THE 3RD ESTRO FORUM
NATIONAL SOCIETIES HALF-DAY MEETINGS
Interview with Laura Mullaney and Kasper Rouschop,
Chairs of the Young programme
KEYNOTE LECTURE
3RD ESTRO FORUM IN FIGURES
ESTRO JOB FAIR
FREE 3RD ESTRO FORUM APP
THE SUPER RUN
INTERVIEWS WITH THE CHAIRS
LOCAL ORGANISING COMMITTEE
Interview with Ismael Sancho, Chair
INTRODUCTION
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CONFERENCES
Dear colleagues,
INTRODUCTION
Philip Poortmans
ESTRO President
The 3rd ESTRO Forum is now just around the
corner and I’m very pleased to announce that we
have received a lot of abstracts for the congress.
And a big increase on the previous Forum: in
2013 we received 1,175 abstracts and this year it
has risen to 1,637 abstracts. The Physics Biennial
meeting got the record number of submitted abstracts (630), followed by the Clinical and translational meeting with 594. I would also like to
underline that the number of abstracts submitted
for the RTT meeting have almost doubled from
99 in 2013 to 197 in 2015.
Although the Forum is a young event, the overall
number of abstracts received is only eight percent
below that of our numbered meetings like
ESTRO 33. This growth definitely suggests a
promising future for the ESTRO fora to come.
Forum is growing thanks to the mosaic of different profiles, skills, knowledge and competencies
of radiation oncology professionals. In an area
where it’s always difficult to fit our professions
into boxes labelled such as “radiation oncologist”
or “RTT”, the success of the Forum relies on this
diversity, which fosters an exchange of our experience and knowledge. This is why I recommend
you warmly to join us in the interdisciplinary
track, in addition to the sessions for your own
discipline.
I look forward to welcoming you in Barcelona to
share knowledge and to develop networks for the
benefit of our patients.
With warm regards,
Philip Poortmans
ESTRO President
On the following pages all the chairs of the various meetings unveil a bit more about the top
science to be presented onsite and especially in
their meetings: clinical and translational, the
physics biennial meeting, GEC-ESTRO-ISIORT,
RTT, PREVENT and TARGET meetings.
PHILIP POORTMANS
INTRODUCTION
Finally, I would like to say that the ESTRO
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CONFERENCES
CLINICAL AND
TRANSLATIONAL MEETING
Interview with Philip
Poortmans, Chair
Which topics attracted the largest number of abstracts and why do you think
these subjects are so well represented?
Among the 594 abstracts that were submitted to
the clinical and interdisciplinary tracks, breast,
gastrointestinal, genitourinary, head and neck
and lung have definitely been the most popular
topics. That could be explained simply by the fact
that there is currently a lot of research going on
in these radiation oncology topics, as well as from
the interdisciplinary perspective. Moreover, these
tumour sites are an important area in daily practice for all of us.
Are there any dominant emerging trends
that are expressed in these abstracts?
PHILIP POORTMANS
INTRODUCTION
gramme consisting of teaching lectures, scientific
symposia, oral presentations and debates.
What about international collaboration
at the ESTRO Forum?
A lot of partners are participating in the programme. I want to underline the very visible
presence of the International Atomic Energy
Agency (IAEA) who submitted seven very good
abstracts (see text box next page) that will be
presented altogether in a dedicated proffered
paper session; the Forum is also the platform for
international joint activities with ASTRO, CARO,
JASTRO… just to name a few who are part of the
scientific programme again this year.
The submitted abstracts reflect the complexity
of our discipline, the tremendous continuous
development in the field of research as well as
inter- and multidisciplinary aspects of oncology as a whole. Many current efforts focus on the
optimisation of treatment, building as much on
technical developments specific to imaging and
radiation therapy, as on optimising combined
modality approaches and on quality of life. Our
knowledge of tumour biology continues to evolve
tremendously. All of these aspects, and several more, will be covered by the scientific pro-
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RANDOMISED TRIALS
Several randomised trials are part of the scientific programme and Professor Philip Poortmans highlights some of them:
IAEA randomised trials
number of common indications that are highly
relevant for daily practice.
In this session, we included two IAEA-supported studies on the availability and utilisation of
radiation oncology as well.
The IAEA submitted seven abstracts, to which
we have dedicated a separate session. They focus
on various topics:
• Nimorazole with accelerated radiotherapy in
head and neck squamous cell carcinomas (report of an incomplete trial);
• Optimisation of treatment of locally advanced
non-small cell lung cancer using radiotherapy
and chemotherapy;
• Irradiation of the supraclavicular nodal region
in post-mastectomy radiotherapy;
• Short-course radiotherapy for locally advanced
rectal cancer;
• Optimal single dose radiotherapy in the treatment of painful bone metastases.
• Current radiotherapy capacity in post-Soviet
countries;
• Optimal radiotherapy utilisation rate in developing countries.
These show that developing countries, with the
help of the IAEA, can contribute significantly to
increasing the level of evidence and they underline the contribution of radiation oncology for a
The same trial shows interesting survival results (LDR Brachytherapy is Superior to 78 Gy
of EBRT for Unfavourable Risk Prostate Cancer),
as does the trial presented in the abstract “The
INTRODUCTION
role of induction chemotherapy with TPF and
radio-chemotherapy for head and neck cancer: a
meta-analysis”.
Toxicity and survival
Very interesting results on toxicity endpoints
from one of the highlighted randomised trials
will be presented: “GU and GI toxicity in ASCENDE-RT*: a multicentre randomised trial of
dose-escalated radiation for prostate cancer”.
This shows that the treatment can be more effective, with less toxicity, and that many toxicity
events are only temporary.
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PHYSICS BIENNIAL
MEETING
Interview with Robin Garcia,
Chair
Which topics attracted the largest number of abstracts?
More than 600 abstracts, from all around the
world, were submitted with the help of the
ESTRO website. The authors had to select the
domain closest to their work. The topic that attracted the largest number of abstracts concerned
all the studies and developments in planning
and dose calculation. After that, there were fairly equal numbers on: dose measurements, inter
and intra fractions, clinical and quality assurance
imaging and new technologies.
Why do you think these subjects are so
well represented?
ROBIN GARCIA
INTRODUCTION
Planning and dose calculation are often placed at
the centre of all our activities. Many issues need
to be simulated, whether for the source of variation or to display dose effects. All radiotherapy
improvements have their part in such simulations. Many imaging modalities contribute to improving the radiotherapy procedure and are included in this preparation phase. The use of light
ions, previously limited to expert departments,
can now be more accessible. The current, very sophisticated irradiation techniques, that need a lot
of investigations before being used for treatments,
are studied with the help of impressive software.
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The continuity of treatment simulation is found
in the numerous outcome evaluations that use all
the planning data. This domain should continue
to provide implementations and research activities, with the regular appearance of new options.
Are there any dominant emerging trends
that were expressed in these abstracts?
The future of radiotherapy is already contained
within current planning investigations. The domain of adaptive radiotherapy focuses on improvements coming from imaging, calculation
and automatic processes. Before reaching the
daily adaptation, many investigations are based
on these new options, which help to manage 3D
image and dose deformations. Other, more complex studies tend to apply the adaptive method
to the most important variation sources due to
breathing. These evolutions will obviously need
clinical trials to prevent any decreased quality of
outcomes. The powerful source of simulations
will help the correlations with outcome evaluations.
So the variety of the abstracts received
reflect the diversity of topics covered by
the programme?
Planning and dose calculation benefit from
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3rd ESTRO Forum
research and improvement in a large number of
clinical activities and cover multimodalities, real
time, automatic and robust processes, models,
MC simulations, functional imaging and radiobiology. This multidisciplinarity is reflected in the
meeting programme, which will satisfy all the
professionals.
Is there any other aspect of the Physics
Biennial meeting that you would like to
draw attention to?
There are an increasing number of abstracts that
relate to multi-centre studies. These concern dose
measurements, modalities evaluations and the
contributions to clinical trials. These audits may
be based on two institutions, multiple national
centres or European collaborations. The conclusions of these abstracts are often compelling and
contribute to better knowledge worldwide. The
managers of these audits should to be thanked for
their important personal investment for the benefit of the community.
INTRODUCTION
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GEC-ESTRO-ISIORT
MEETING
Interview with Jacob
Lindegaard, Chair
Which topics attracted the largest number of abstracts?
We received a lot of abstracts for gynaecology
and prostate cancers.
Why do you think these subjects are so
well represented?
First of all, these subjects are very well established indications for brachytherapy. However,
for both subjects major new improvements have
been made in the recent years with image-guided
adaptive target and treatment planning concepts
now being employed clinically. These data are
now maturing and clearly show that the therapeutic index has been significantly improved with
higher levels of tumour control and a significant
decrease in radiation-induced morbidity.
Are there any dominant emerging trends
in these abstracts?
Individualisation of radiotherapy coined to the
morphology and biology of the patients at the
time of brachytherapy. As brachytherapy delivers a very significant dose within a short overall
treatment time with a very steep dose gradient
(even steeper than for protons!) this is the ultimate in adaptive radiotherapy.
JACOB LINDEGAARD
INTRODUCTION
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Do the chosen abstracts advance new
and interesting areas within radiotherapy, and if so, in which particular areas?
In vivo dosimetry in brachytherapy is a fast
emerging subject with a significant clinical potential for improving treatment delivery so that
we can ensure that what we plan is also what
the patient is getting. This new research area is
becoming even more important as we strive to
individualise brachytherapy for each patient since
in vivo dosimetry has the capability to record in
4D (time and space) how our advanced adaptive
brachytherapy treatment plans are delivered on
line as the treatment is carried out in the patient.
Are there any randomised trials?
A major Canadian trial showing that low dose
rate brachytherapy is superior to external beam
radiotherapy in prostate cancer. This abstract has
been selected as a highlight paper.
Is there any other aspect of the GECESTRO-ISIORT meeting that you would
like to draw attention to?
It is very encouraging to see more and more departments taking up the new concepts of adaptive
brachytherapy. This is reflected in abstracts on
this subject coming from new departments
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showing that the guidelines of the GEC-ESTRO
work in the clinics around the world. Also, this
emphasises our choice to have a pre-meeting
workshop before the 3rd ESTRO Forum on adaptive brachytherapy strategies.
INTRODUCTION
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Did you receive a lot of abstracts?
RTT MEETING
Interview with Martijn
Kamphuis, Chair
First of all it’s worth mentioning that the total
number of abstracts for the RTT track increased
dramatically; 99 abstracts were submitted for the
2nd ESTRO Forum in 2013. For the 3rd ESTRO
Forum we received 197 abstracts. This seems to
show that research, as well as active participation
in conferences, is increasing among radiation
therapists. I really hope that this trend persists.
In my opinion this will not only improve the
knowledge of the individual, but also the quality
of radiotherapy on a departmental or even higher level. I’m glad to say that this opinion is also
shared by other disciplines within ESTRO.
Which topics attracted the largest number of abstracts?
Within the topic “image guided radiotherapy and
adaptive radiotherapy” we received the largest
number of abstracts (59). This was closely followed by “treatment planning” (57). The overall
quality in these topics was very high.
Why do you think these subjects are so
well represented?
MARTIJN KAMPHUIS
INTRODUCTION
have spent a lot of effort on these topics in recent
years. Nowadays, image-guided adaptive radiation therapy is very often performed by the RTTs,
which enables them to do research on this topic.
The same goes for treatment planning. In many
departments efforts are made to switch from conformal radiation therapy to intensity-modulated
radiation therapy or directly to volumetric modulated arc radiotherapy or even intensity-modulated particle therapy. This is an interesting subject
for research.
Do the chosen abstracts provide new
and interesting advances in radiotherapy, and if so, in which particular areas?
One of the highest scoring abstracts was on the
use of 3D printing for creating immobilisation
devices. I guess we will see much more of that. It’s
really nice to see that in this sub-area, in which
there has not been a lot of development over the
past few years, new techniques might improve
this important part of radiotherapy.
Both topics are still very much evolving. With regard to image guided and adaptive radiotherapy,
people working in the medical and physics areas
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PREVENT AND TARGET
MEETINGS
Interview with Brad Wouters,
Chair
Which topics attracted the largest number of abstracts?
The Forum this year has two sub-meetings. In the
PREVENT meeting the largest number of abstracts addressed genetic variation and its contribution to risk of normal tissue toxicity. In the
TARGET meeting the largest number of abstracts
were focused on novel agents used in combination with radiotherapy.
Are there any dominant emerging trends
in these abstracts?
The selected abstracts highlight the progress in
these emerging areas, and identify several new
approaches to personalised therapy.
Why do you think these subjects are so
well represented?
PREVENT
There is still intense interest in the genetic determinants of risk and the use of such information
for personalising therapy. It remains unclear how
important this contribution will be, and the approaches for answering this question are important issues in the field.
TARGET
Our increased understanding of the biological
changes in cancer continue to open new opportunities for development of targeted agents that
could increase the efficacy of radiotherapy.
BRAD WOUTERS
INTRODUCTION
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YOUNG TRACK OF THE
3RD ESTRO FORUM
Interview with the two chairs of
the Young programme:
Laura Mullaney and Kasper
Rouschop
View the programme of the young
track in the Young Corner on p116 >
Why wouldn’t you miss the young track
as a young ESTRO member?
When designing the young ESTRO track for the
3rd ESTRO Forum, the scientific advisory committee focused on what we, as young members
would like to gain most from the day. With this
in mind, we decided to focus the track on the
theme of “Career Development”.
Distinguished speakers from all disciplines will
join us on the day to discuss their experiences
of building successful careers and developing
meaningful collaborations. There will also be an
opportunity to participate in an informal “Brown
Bag” lunch seminar with experts from the different disciplines to discuss your own career.
The track will include several moving poster sessions, facilitating informal discussion of pre-selected posters with their respective authors. An
emerging theme in many aspects of research is
health economics. To support this aspect of our
research endeavours, we have a morning session
dedicated to the integration of health economics
into research. The track will close with a reception, providing an opportunity for discussion and
networking with other young ESTRO members.
LAURA MULLANEY
INTRODUCTION
The young track promises to be a beneficial day
for all those aspiring to advance their career, so
don’t miss out!
What outcomes can the participants
expect?
Through attendance at this track, you can expect to:
• Gain insights into the initiation of meaningful
collaborations
• Appreciate the importance of health economics
and its implementation in research
• Meet over lunch with experts in your discipline,
to discuss your career and potential research
opportunities
• Learn from the shared experiences of successful
individuals about how to progress your career
• Participate in topic-specific moving poster sessions
• Engage with the young ESTRO committee and
exchange ideas on future activities.
Who can attend?
The young track is open to all delegates. It may
be of particular interest to those of you interested
in progressing your careers, initiating collaborations, developing research networks or considering a health economics component to your
research.
KASPER ROUSCHOP
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557
3RD FORUM IN FIGURES
557
E-POSTERS
POSTERS
10,000 m
2
3,500
249
INVITED
SPEAKERS
DELEGATES
255
ORAL
PRESENTATIONS
INTRODUCTION
8
CONTOURING
WORKSHOPS
EXHIBITION
9
JOINT
SESSIONS
73
POSTER
DISCUSSIONS
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5
PRE-MEETING
COURSES
1,637
SUBMITTED ABSTRACTS
> Clinical & Translational : 594
> Biennial Physics: 630
> GEC-ESTRO-ISIORT: 164
> RTT: 197
> PREVENT & TARGET: 52
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FREE ESTRO FORUM APP
Maximise your time at the congress
Download the free ESTRO Forum mobile and tablet app and take advantage of the full event schedule,
as well as the personalised agenda, networking function and exhibition listings.
Sessions
You can check out the sessions you wish
to attend, view their summary and add
them to your personal agenda.
Speakers
You can view biographies, select congress
speakers, send them messages and add
them to your own personal agenda.
My event
This is your personal agenda, displaying
your selected sessions, speakers, exhibitors
and much more.
Exhibition
Thanks to the interactive floor plan, you
can easily access the information on the
booths and exhibitors you wish to visit
and save them to your personal agenda.
FREE DOWNLOAD STATION
Networking
You can create your own profile, which
gives you the opportunity to interact with
other attendees at the event via the messaging service. You can send messages
privately and arrange meetings that will
be scheduled in your personal agenda.
Social media
Stay up-to-date with the latest congress
news by using Twitter (#ESTRO3F) and
Facebook.
Abstract book
The abstract book will be directly downloadable from the app.
Download the app from www.estro.org
Come to the stand next to the registration area to download the app. However, we recommend you download it
prior to the congress.
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3rd ESTRO Forum
CONFERENCES
SOCIAL ACTIVITIES
MARK YOUR CALENDAR
Opening ceremony
Friday 24 April | 18.00 – 19.15 hrs | Main auditorium
All participants and company delegates are invited to the official opening ceremony. The opening
ceremony will be followed by the welcome reception, which will take place in the exhibition area.
Check out the latest available information
on www.estro.org
On the ESTRO website, you will be able to
access one month prior to the congress:
• the searchable programme
• the programme book
• the abstract book
And, of course, follow us on Facebook and
Twitter (#ESTRO3F) to be informed of the
latest developments.
INTRODUCTION
Opening remarks
Philip Poortmans (NL), President of ESTRO and
Chair of the 3rd Forum Scientific Programme
Committee
Krzysztof Skladowski (PL), Chair of Host Society
Committee
Krzysztof Slosarek (PL), Chair of Host Society
Committee
Jose Lopez Torrecilla (ES), Chair of Local Organising Committee
Ismael Sancho Kolster (ES), Chair of Local Organising Committee
Keynote speaker
Prof Dr Turgut Durduran (ES)
Topic: The promise of diffuse optical methods for
non-invasive diagnosis, therapy monitoring and
prediction in oncology
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Entertainment
Concert with the award-winning Catalan guitar
player, Pedro Javier González.
During his career, Pedro Javier González has collaborated with a number of different artists and
performed at major festivals with musicians such
as the “King of Blues”, B.B. King, who, according
to legend, gave him the thumbs up on numerous
occasions while watching him play. Definitely not
to be missed….
Welcome reception
Friday 24 April | 19.15 hrs | Exhibition area
All registered participants and all company delegates are invited to the welcome reception which
will take place in the exhibition area.
Poster reception & poster awards
Saturday 25 April | 18.00 hrs | Poster area
All participants and company delegates are invited to the poster reception and poster awards.
Canapés and drinks will be served while participants view more than 500 posters of the best
posters. During the reception, three ESTRO
awards of €1,000 each will be handed out to the
best scored posters.
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Social event
Monday 27 April | 22.00 hrs
The after-dinner party will take place at Teatre
Principal.
Patients Day
Monday 27 April | 17.30-20.00 hrs | Room 122/123
Cancer patients have their own session dedicated
to their needs with professionals answering their
questions. The session will be held in Spanish.
YOUNG PROGRAMME
Monday 27 April | 08.00-18.00 hrs | Room 114
& poster area
Lunch in the 'Meet the professor' area
View the full programme in the Young Corner
of this newsletter and read the interview of the
chairs of the young programme. The young scientists reception will take place from 16.45 to 17.45
hrs.
Visit to Synchrotron Alba
Tuesday 28 April | 14.00 hrs
Synchrotron Alba is a modern facility that was
inaugurated in 2010 and located at Cerdanyola
del Vallès, a town 15 kms from Barcelona city
centre. It is a great opportunity to learn about the
use of cutting-edge technology in Spain and to
see how other radiation applications are implemented.
Departure from the CCIB will be at 13.00. A
lunchbox will be provided for all participants.
Busses will return at approximately 17.00 to
CCIB. A stop at the airport will also be foreseen.
Participation fee: €35/person
Register >
INTRODUCTION
RENDEZ-VOUS WITH COLLEAGUES
GEC-ESTRO assembly
Sunday 26 April | 13.30 - 14.30 hrs |
Room 122/123
The GEC-ESTRO assembly is open to anyone
with an interest in GEC-ESTRO activities.
Physics members’ assembly
Saturday 25 April | 13.30 - 14.30 hrs |
Room 122/123
The annual Physics assembly is open to any physicist and will offer the opportunity to exchange
ideas on current issues for the radiation physics
community.
ESTRO general assembly
WRITE YOURSELF INTO THE
STORY #ESTRO3F
By connecting to ESTRO’s social media channels on Twitter and Facebook, you can:
• Find the latest updates from the Forum and
reminders on the events not to be missed
onsite
• Interact with attendees you meet face to face
• Join discussions
• Share pictures
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Monday 27 April | 18.00 hrs | Room 118/119
An agenda will be sent to full members, however
all the ESTRO members are welcomed to participate as long as they have renewed their membership by 22 April.
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EDUCATION
Five pre-meeting courses
Friday 24 April
Interdisciplinary pre-meeting course
08.30 - 17.00 hrs | Room 116
Joint ESTRO-EIBIR-EANM
Incorporating imaging in radiation oncology treatment delivery
Course directors: V. Valentini (IT) - ESTRO,
G. Krestin (NL) - EIBIR, V. Lewington (GB) EANM
Clinical pre-meeting course
08.30 - 17.00 hrs | Room 115
Data management
Course directors: G. Jones (CA) and A. Dekker (NL)
Physics pre-meeting course
08.30 - 17.00 hrs | Room 111
4D radiotherapy – from 4D-imaging to 4D dose
delivery and verification
Course directors: P. Poulsen (DK) and U. Oelfke (GB)
RTT pre-meeting course
08.30-17.00 hrs | Room 118/119
Implementation of SBRT: a review of current practice
Course directors: P. Scherer (AT) and F. Moura (PT)
INTRODUCTION
GEC-ESTRO workshop
08.30 - 17.00 hrs | Room 114
Adaptive brachytherapy strategies
Course director: J.C. Lindegaard (DK)
Eight contouring sessions
OAR - upper abdomen
Friday 24 April | 16.00 – 18.00 hrs
Repeated on Tuesday 28 April | 08.30 – 10.30 hrs
Chair: A. Morganti (IT))
Panellists: T. Brunner (UK) and A. Mendez Romero (NL)
Administrator: D. Pasini (IT)
Room 131/132
Oesophagus
Friday 24 April | 08.00 - 10.00 hrs
Repeated on Saturday 25 April | 08.00 - 10.00 hrs
Chair: O. Matzinger (CH)
Panellists: M. Hulshof (NL) and B. de Bari (IT)
Administrator: B. de Bari (IT)
Joint ESTRO – ILROG on Lymphoma
Friday 24 April | 10.30 - 12.30 hrs
Repeated on Sunday 26 April | 08.00 - 10.00 hrs
Chair: L. Specht (DK)
Panellists: S. Terezakis (US) and A.K. Berthelsen (DK)
Administrator: B. de Bari (IT)
Prostate cancer in the post-prostatectomy
setting
Friday 24 April | 13.30 - 15.30 hrs
Repeated on Monday 27 April | 08.00 – 10.00 hrs
Chairs: P. Ost (BE)
Panellists: C. Salembier (BE) and A. Henry (UK)
Administrator: D. Pasini (IT)
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Educational aims of the workshops
• Provide attendees with the opportunity for
interactive training on contouring CTV, GTV
and, when relevant, OAR and to discuss their
results with international experts in the field,
• Provide the participants with knowledge on
how contouring is performed in different institutions and on the existing recommendations
and guidelines,
• Provide the participants with consistent information to validate or modify/improve their
daily contouring practice.
Methodology for the workshops
• Clinical case presentation,
• Delineation tool presentation,
• Delineation with maximum two participants
per computer,
• Presentation of the contouring guidelines recommended by the experts for the delineation of
the CTV, GTV +/- OAR + bibliographic refer-
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3rd ESTRO Forum
ences for the therapeutic strategy chosen,
• Inter-comparison of the contours by the participants and by the experts,
• Justification and comments.
Participants are required to bring their own computer for contouring.
More information on the contouring sessions >
FALCON demos
ESTRO booth (#2000)
The eight contouring sessions will use FALCON*,
the multifunctional ESTRO platform for contouring and delineation. Free short demos of 15 minutes take place everyday at lunch time and coffee
breaks on the ESTRO booth (#2000):
• 10.10 – 10.25 hrs
• 13.30 – 13.45 hrs
• 14.15 – 14.30 hrs
• 16.25 – 16.40 hrs
*Fellowship in Anatomic delineation and CONtouring
Multidisciplinary tumour board sessions
Multidisciplinary tumour board (MTB) Upper GI
Saturday 25 April | 10.30-11.30 hrs
Case 1: Oesophageal AEG
Case 2: Mid-oesophageal squamous cell
INTRODUCTION
Chair: C. Rödel (DE)
Panellists:
1. ESTRO fellow – F. Cellini (IT)
2. Surgeon – C. Balagué (ES)
3. Medical oncologist – D. Páez (ES)
4. Imaging – R. Mast (ES)
Multidisciplinary tumour board (MTB) Prostate
Sunday 26 April | 10.30-11.30 hrs
Case 1: Locally advanced resectable RT or surgery
Case 2: Limited pN+
Chair: M. Hoyer (DK)
Panellists:
1. ESTRO fellow – M. Pinkawa (DE)
2. Urologist - M. José Ribal (ES)
3. Pathologist – F. Algaba (ES)
Multidisciplinary tumour board (MTB) - Lung
Monday 27 April | 10.30-11.30 hrs
Case 1: Early stage operable
Case 2: Early stage medically inoperable
Chair: E. Lartigau (FR)
Panellists:
1. Young ESTRO member – J.-E. Bibault (FR)
2. Surgeon - R. Rami Porta (ES)
3. Radiologist - A. Hidalgo (ES)
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AWARDS
Lifetime Achievement Award
Friday 24 April 2015 | 20.00 hrs
Harry Bartelink (NL)
Tommy Knöös (SE)
John Yarnold (GB)
ESTRO Award Lectures
Emmanuel van der Schueren Award
Saturday 25 April | 11.40 - 12.20 hrs | Main auditorium
Access to evidence-based radiotherapy in Europe
2020 – are we on the right track?
Cai Grau (DK)
Donal Hollywood Award
Monday 27 April | 11.40 - 11.50 hrs
Rescanning measurements in a 4D anthropomorphic phantom for evaluation of motion-mitigated,
PBS proton therapy
Rosalin Perrin (CH)
GEC-ESTRO Iridium 192 Award
Saturday 25 April | 12.20 - 13.00 hrs
Peter Levendag (NL)
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Klaas Breur Award
Monday 27 April | 12.20 - 13.00 hrs
Radiation oncology and technological innovation:
a fish desperately looking for a bicycle?
Dirk Verellen (BE)
Honorary Physicist Award
Sunday 26 April | 12.10 - 12.30 hrs | Main auditorium
Vincent Grégoire (BE)
University Award
ESTRO-Jack Fowler University of Wisconsin
Award
Sunday 26 April | 12.30-12.40 hrs | Main auditorium
Time dependent verification techniques and doserate evaluation of external beam treatments
Mark Podesta (NL)
Company Awards
ESTRO-Accuray Award
Sunday 26 April | 12.40-13.00 hrs | Main auditorium
Considerable intra-breath-hold motion and inter-breath-hold position variation of pancreatic
INTRODUCTION
tumours
Eelco Lens (NL)
ESTRO-Varian Award
Sunday 26 April | 12.40-13.00 hrs | Main auditorium
Quantification of coronary artery motion: Analysis from ECG gated radiotherapy planning scan
Shyam Bisht (IN)
ESTRO- Elekta Brachytherapy Award
Saturday 25 April | 16.45-18.00 hrs | Main auditorium
Clinical implementation of in vivo source position
verification in high dose rate prostate brachytherapy
Ryan Smith (AU)
GEC-ESTRO Best Junior Presentation - sponsored by Elekta Brachytherapy
Sunday 26 April | 10.30-11.30 hrs | Main auditorium
Brachytherapy improves survival for inoperable
stage I endometrial adenocarcinoma: a population-based analysis
Sahaja Acharya (USA)
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EXHIBITION
An exhibition featuring equipment and medical
publishers will be held in the exhibition area.
The opening of the exhibition will be on Friday
24 April 2015 at 19.15 hrs. The exhibition will
remain open from Friday 24 April to Monday 27
April between 9.30 and 17.00 hrs. Entrance is free
for all registered participants.
Visit the ESTRO booth #2000!
WIFI
Wireless internet will be available in designated
areas at the congress centre.
LUNCHEONS AND REFRESHMENTS
The registration fee for the conference includes
coffee breaks to all participants wearing their
conference badges. Lunch will be available for
purchase in the exhibition area and is not included in the registration fee.
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CONFERENCES
NATIONAL SOCIETIES HALF-DAY MEETINGS
National Day Joint Meeting ALATRO, SEOR, SPRO - 24 April
Session will be conducted in Spanish/ Portuguese.
SYMPOSIUM
Breast Cancer and Proffered Papers from Young Radiation Oncologists
13.00-13.15 hrs
Welcome Address by the President of ESTRO
Symposium Breast Cancer
Chairs: Dr Marcela de la Torre and Dr José López Torrecilla
13.30-13.55 hrs Is the "boost" necessary in breast carcinoma in situ?
Speaker: Dr Lourdes Trigo (SPRO)
13.55-14.20 hrs Partial irradiation, can we consider it like usual treatment
in some cases? What technique?
Speaker: Dr Silvia Zunino (ALATRO)
14.20- 14.45hrs Nodal irradiation after the Z0011. What we do?
Speaker: Dr Manuel Algara (SEOR)
14.45-15.15 hrs Discussion
15.15-15.45 hrs Break
Proffered Papers from Young Radiation Oncologists on breast, prostate,
lung cancer
Chairs: Dr Alfredo Ramos and Dr Jose Luis López Guerra
15.45-17.15 hrs 1. Low-kilovoltage single dose intraoperative radiation
therapy for breast cancer
Presenter: C. Flores-Balcazar (MX)
2. Early toxicity outcomes: A single 15Gy fraction HDR
INTRODUCTION
17.15-17.30 FOCUS ON NEXT CONGRESSES
brachytherapy as pre-treatment EBRT boost in prostate
cancer
Presenter: R. Chicas Sett (ES)
3. APBI single-centre experience over a decade – risk estimates and indication variations within current guidelines
Presenter: A. Aguiar (PT)
4. Role of 3T multiparametric MRI in the detection of local
recurrent prostate cancer after radical prostatectomy
Presenter: C. Felipe (ES)
5. Dosimetric impact to organs at risk when the internal
mammary node chain is included in irradiation of left
breast
Presenter: G. Gómez de Segura Melcón (ES)
6. Evaluation of image guided radiotherapy (IGRT) in lung
cancer. Is weekly cone beam CT (CBCT) enough?
Presenter: J. Luna Tirado (ES)
7. Training for RTTs in image verification in breast cancer:
from portal imaging to IGRT
Presenter: E. Rivin (FR)
8. Stereotactic body radiation therapy for localized prostate
cancer: institutional experience
Presenter: G. Heinrich (AR)
Conclusions and close session: Organisers of the National
day, Presidents of SEOR, ALATRO and SPRO
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National Day Polish Society of Radiation Oncology - 24 April
Session will be conducted in Polish.
08.30-08.45hrs Opening: Biology of high radiation doses
Speaker: Krzysztof Składowski
Session I (Physics): Stereotactic Radiation Treatment Planning
Chairs: Krzysztof Ślosarek and Marzena Janiszewska
08.45-09.00 hrs Review of delivery systems and techniques of SRT in Poland
Speaker: Krzysztof Ślosarek
09.00-09.15 hrs Linac SBRT planning of lung tumours
Speaker: Marzena Janiszewska
09.15-09.30hrs Specific aspects of Tomotherapy and CyberKnife planning
Speaker: Tomasz Piotrowski
09.30-09.45hrs GammaKnife SRT planning
Speaker: Aneta Iwanicka
09.45-09.55hrs Best physics original paper: Ga-68 DOTATATE PET/CT
imaging for robotic radiotherapy in patients with
meningiomas
Presenter: Małgorzata Fudzińska
09.55-10.10 hrs Coffee Break
10.40-10.55 hrs SBRT of liver neoplasms
Speaker: Rafał Suwiński
10.55-11.10 hrs CyberKnife for prostate cancer patients – preliminary results
of 200 patients irradiation
Speaker: Leszek Miszczyk
11.10-11.20 hrs Best clinical original paper: Can SRT preserve TCP of HNC
patient when standard therapy is not compliant?
Presenter: Łukasz Michalecki
11.20-12.20 hrs Panel discussion: Will SRT be a standard method of
malignant tumours?
Speakers and chairs
12.20-12.25 hrs Symposium Conclusions
Krzysztof Składowski
Session II (Clinical): Clinical Advances of SBRT
Chairs: Rafał Dziadziuszko and Bogusław Maciejewski
10.10-10.25 hrs Oligometastatic tumours
Speaker: Krzysztof Konopa
10.25-10.40hrs Oligo- and hypofractionated SRT of lung cancer
Speaker: Rafał Dziadziuszko
INTRODUCTION
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CONFERENCES
KEYNOTE LECTURE
The promise of diffuse optical
methods for non-invasive diagnosis, therapy monitoring and
prediction in oncology
Turgut Durduran
ICFO - The Institute of Photonic Sciences,
Spain
Diffuse optical methods using near-infrared light
are promising methods for diagnosis, therapy
monitoring and prediction in oncology. They
utilise near-infrared light in ~600-1000nm range
which allows effective penetration into tissues up
to several centimetres deep. By utilising multiple
wavelengths, they can estimate the concentration
of oxy- and deoxy-haemoglobins, blood volume,
blood oxygen saturation, water and lipid content
and tissues scattering. Furthermore, the use of
coherent light allows these methods to estimate
microvascular blood flow. Professor Turgut Durduran will describe the basis of these technologies, instrumentation and state-of-the-art results.
Professor Turgut Durduran trained at University of Pennsylvania (USA). In 2009 he moved
to ICFO - The Institute of Photonic Sciences
(SPAIN) where he leads the "Medical Optics
group". His research interests revolve around
the use of diffuse light to non-invasively probe
tissue function. The group develops new technologies and algorithms and translates them
routinely to pre-clinical and clinical applications, as well as for industries.
TURGUT DURDURAN
INTRODUCTION
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CONFERENCES
WHAT?
ESTRO JOB FAIR
Two days where participants at the 3rd ESTRO
Forum will have the opportunity to meet the industry and institutes for job interviews in a separate area within the congress centre.
pants will have free access to the Job Fair.
• Employers: exhibiting companies at the 3rd
ESTRO Forum and all the 2015 ESTRO institutional members (institutes).
HOW?
WHERE?
Interviews will be held in the Job Fair area, located in the registration hall. Each participating
company will have a specific booth designed to
welcome participants and job seekers from the
radiation oncology field. In addition, all employers with a booth in the Job Fair will have the opportunity to rent a meeting room in the congress
centre for half a day or more, in order to conduct
on-the-spot interviews in a more confidential
environment.
• Candidates: entrance to the Job Fair is free to
all the 3rd ESTRO Forum participants. No
pre-registration is needed.
• Employers will need to book a specific Job Fair
booth:
• Interested companies should contact Valérie
Cremades, [email protected]
• Interested institutes should contact Myriam
Lybeer, [email protected]
WHEN?
ESTRO
JOB FAIR
Saturday 25 April 2015 from 13.00-18.00 hrs
Sunday 26 April 2015 from 8.00-14.45 hrs
WHO?
2015
INTRODUCTION
Participating in the Job Fair are:
• Candidates: all the 3rd ESTRO Forum partici-
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CONFERENCES
ESTRO JOB FAIR
Meet with David Egan,
his recruiting team and hiring
managers from Varian Medical
Systems, USA and EMEIA
You have booked a booth at the Job Fair.
What is your motivation? Was it an initiative that you had been expecting for a
long time?
Varian sees ESTRO as an opportunity to meet the
best and brightest people in radiation oncology.
This Job Fair affords ESTRO attendees the opportunity to understand more about Varian as an
employer and the career opportunities we have to
offer.
What is the added value of the Job Fair
compared to the more traditional recruitment channels?
ny, whose mission, culture, values and business
goals align with yours.
What is for you the ideal candidate?
Experienced, innovative professionals, who have
passion for their work, serving others and saving
lives.
Is the sector of radiation oncology actively recruiting?
Yes, very much so.
Varian utilises many channels to meet potential
candidates. The ability to meet face-to-face in this
type of casual setting is an opportunity we value.
What are the profiles that will draw your
attention onsite?
Radiation therapists, medical physicists, engineers with medical device backgrounds, research
and development.
What advice would you give to a young
ESTRO member looking for a position in
the radiation oncology sector?
DAVID EGAN
INTRODUCTION
Find a career opportunity with the right compa-
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CONFERENCES
THE SUPER RUN
Patients and doctors
against cancer
Sunday 26 April, Barcelona
The Super Run is a five-kilometres run organised
by ESTRO and taking place in the scenic surroundings of the Barcelona beach. The Society is
inviting the 3,000 Forum participating scientists,
carers and doctors to join patients in the run
against cancer.
The participation fee of €10 will go directly to the
ESTRO Cancer Foundation. The ultimate goal of
the Super Run is to make people aware that it is
possible to enjoy a healthy life during and after
radiotherapy treatment; staying physically active
has become a reality for the majority of cancer
patients undergoing radiotherapy.
So join us in Barcelona on the Super Run!
How will the funds raised be used?
• The ESTRO Cancer Foundation
The not-for-profit ESTRO Cancer Foundation
(ECF) was launched in 2012 and aims to foster
research and to improve the perception of radiation oncology among target audiences such as
patients and decision-makers.
• HERO, Health Economics in Radiation Oncology
HERO is a project supported by the ECF. It was
INTRODUCTION
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launched in 2010 to assess the availability of
radiotherapy resources within Europe. Through
the collection and analysis of relevant data, the
HERO project will be used to advocate for radiotherapy to European governments and other
healthcare stakeholders, whose decisions ultimately affect the care of patients.
• Patients at the heart of the 2020 ESTRO
vision
In 2012 ESTRO’s new vision was established,
looking at the 2020 horizon. Resolutely centred
on high quality patient care, the mission statement reads:
Every cancer patient in Europe will have access
to state of the art radiation therapy as part of a
multidisciplinary approach where treatment is
individualised for the specific patient’s cancer,
taking account of the patient’s personal circumstances.
Subsequently, ESTRO determined several key
priorities and the HERO project is one of them.
Sunday 26 April - 19.00
CEM Marbella. Av. del Litoral, 86
08005 Barcelona
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CONFERENCES
LOCAL ORGANISING
COMMITTEE
Interview with Ismael Sancho,
Chair of the local organising
committee
What have been the main tasks for the
members of the local organising committee (LOC)?
The LOC has eight members from different parts
of Spain. So far we have concentrated our efforts
on organising some of the social events such as
the opening ceremony, and we have organised a
programme of grants towards registration fees
for young local people through collaboration
with Spanish companies. Work is ongoing and
will come to fruition at the congress. We are also
involved in some press activities and promotion
of the congress. For most of the LOC members,
this is the first time that we have participated in a
committee for such a big event, and we are finding it a challenging but great experience.
A visit to Synchrotron Alba is being organised for participants. Why will this be
interesting for radiation oncology professionals?
ISMAEL SANCHO
INTRODUCTION
Synchrotron Alba is a modern facility that was
inaugurated in 2010 after four years of construction. With a diameter of 140 metres and the
shape of a snail shell, it is located at Cerdanyola
del Vallés, a town 15 kms from Barcelona city
centre. Nowadays, it has seven different beamlines; each of them is used to carry out experi-
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ments, mainly in the fields of biology, nanoscience and materials. Although not directly related
to radiation oncology, it is a great opportunity to
learn about the use of this cutting-edge technology in Spain and to see how other radiation applications are implemented.
What can we expect at the opening ceremony?
Although I do not want to reveal too much about
the opening ceremony, I can say that a prestigious
researcher is going to talk about different applications of light in science and oncology in particular. This will be a novel and different point of
view to what we are used to seeing in our day-today work. After this talk, we will see a very fine
and intimate music show, with a touch of both
Spanish and more local culture. The combination
of the talk and show will be a perfect introduction to the congress and a nice way to prepare
participants for the busy programme of the following days.
Can you tell us more about the social
event on Monday 27 April?
The social event will take place at the Teatre Principal. This old theatre was built in 1600 and was
the city’s main theatre for many years. Opera,
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3rd ESTRO Forum
comedy but also circus, magic and costume balls
were, performed during this time. However, 250
years later it began to decline as most companies
moved to the more popular, stunning and recently inaugurated Teatre del Liceu, also on Las Ramblas and very close to the Teatre Principal. Moreover, several fires destroyed its interior completely
and although it was renovated, only the beautiful,
slightly curved façade still remains from the old
building. With this amazing history, it will be a
fantastic place to relax, have fun and meet other
participants.
rest of the towers and the third façade (the Glory)
are being constructed very fast and changes are
clearly visible from one month to the next. It is
better to buy tickets online in advance to avoid
long queues. But there are so many other places
to enjoy while visiting Barcelona. The best way to
discover them is walking and getting lost in the
city centre (ending, for example, with a refreshing
drink at one of the nice terraces along the beach).
Despite a busy meeting programme,
what should not to be missed by participants while visiting Barcelona?
Barcelona has a lot to offer to visitors and many
participants may have been to the city before.
However, every visit is different and a vibrant
city like Barcelona changes from year to year.
I recently visited the Sagrada Familia and was
surprised by the frenetic construction rate. As
Gaudí wanted, construction of the cathedral is
a dynamic work and each generation makes a
contribution in its own style. For example, some
months ago, the green and leafy doors of the Nativity façade were installed – a nice work by the
Japanese sculptor, Etsuro Sotoo. Moreover, the
INTRODUCTION
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ESTRO
29 April - 3 May 2016
Turin, Italy
INTRODUCTION
FOCUS ON NEXT ESTRO CONGRESSES
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INTRODUCTION
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European Cancer Congress
CONFERENCES
18th ECCO - 40th ESMO
EUROPEAN CANCER
CONGRESS
Reinforcing Multidisciplinarity
25 - 29 September 2015
Vienna, Austria
In collaboration with ESTRO
The European Cancer Congress will combine the efforts of all partner organisations to continue positioning multidisciplinarity as the way forward for improving the prevention, diagnosis, treatment and
care of cancer patients – placing the patient at the heart of all our efforts and discussions.
KEY DATES
• 7 April 2015: Early rate registration deadline
• 28 April 2015: Abstract submission deadline
• 29 April 2015: Fellowship grant application deadline
• 22 July 2015: Late breaking abstract submission opens
• 4 August 2015: Regular rate registration deadline
• 5 August 2015: Late breaking abstract submission deadline
• 18 September 2015: Late rate registration deadline
ECC2015 ADVANCED PROGRAMME NOW AVAILABLE
The ECC2015 Advanced Programme provides a clear pathway and a definitive supplement for all attendees to discover all the information concerning
the Congress. It is a detailed programme showing all the special, integrated
and teaching sessions as well as Oxford-styles debates and much more.
More information:
www.europeancancercongress.org >
Registration:
www.europeancancercongress.org/
Registration >
INTRODUCTION
Read/download to discover at a glance all the tracks, chairs and experts that
will be part of the event as well as useful practicalities:
www.ecco-org.eu/sitecore/RedirectUrlPage.aspx?ec_camp=7D9BC2EDC0084CC2A0DB50B05663823B&ec_as=C4910921A3F74869A72F38A9BD93CA17&ec_url=%2f~%2fmedia%2fDocuments%2fVienna+2015%2fECC2015+Advance+Programme.pdf >
ESTRO members will benefit from a discount on the registration fee.
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European Cancer Congress
ESTRO AWARDS
ESTRO - VARIAN AWARD
A prize of €2,500 will be given to a radiation oncology professional for research in the field of radiobiology, radiation physics, clinical radiotherapy or
radiation technology.
Criteria for Eligibility
1. Candidates should be ESTRO members, having completed the submitted
work in the previous year.
2. Submissions should be brought forward by the candidates or their department heads and may be work done as an individual piece of research or as
a thesis complete in the field of biological, physical and clinical research.
3. Candidates should be younger than 36. Exceptions will be made for female
applicants who had to interrupt their research for pregnancy/maternity
reasons; for them the maximum age is fixed at 40.
4. Candidates should submit:
• A curriculum vitae and a list of publications
• A copy of the abstract on the project which should have been submitted
for the European Cancer Congress (indicate abstract title and submitting
author with your application)
• An English summary of their work (max two pages).
Applications for the above listed awards are to be addressed to:
Eralda Azizaj, ESTRO Programme Manager
Rue Martin V 40, 1200 Brussels, Belgium
INTRODUCTION
ESTRO - ACCURAY AWARD
A prize of €2,500 will be given to a radiation oncology professional for research in the field of “High Precision Radiotherapy”. Awardees may be qualified in the field of clinical radiotherapy, radiation physics, radiation technology or radiobiology.
Criteria for Eligibility
1. Candidates should be ESTRO Members, having completed the submitted
work in the previous or current year.
2. Submissions should be brought forward by the candidates and may be
work done as an individual piece of research or as a thesis completed in the
field of biological, physical or clinical research.
3. Candidates should be younger than 36. Exceptions will be made for female
applicants who had to interrupt their research for pregnancy/maternity
reasons; for them the maximum age is fixed at 40.
4. Candidates should submit:
• A curriculum vitae and a list of publications,
• A copy of the abstract on the project which should have been submitted
for the European Cancer Congress (indicate abstract title and submitting
author with your application)
• An English summary of their work (max two pages).
Tel: +32 2 775 93 40
E-mail: [email protected]
Deadline for submission: 1 April 2015
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European Cancer Congress
CONFERENCES
WORLD CONGRESS
ON LARYNX
CANCER
26-30 July 2015
Cairns, Queensland, Australia
In collaboration with ESTRO
Hosted by the Australian and New Zealand Head
& Neck Cancer Society, the World Congress on
Larynx Cancer 2015 will include over 100 local
and international faculties involved in the care of
patients with larynx cancer, not only at presentation, but also in the years afterwards.
The congress will be held from Sunday 26 to
Thursday 30 July 2015 at the Cairns Convention
Centre. An impressive four-day multidisciplinary
programme has been developed. In excess of 500
local and international delegates, including surgeons, radiation oncologists, medical oncologists,
speech pathologists, nurses, dieticians and other
health professionals, are expected to attend.
Early registration fees apply until Sunday 14 June
2015.
Register online at www.wclc2015.org
For any enquiries, please contact the congress
organisers, telephone +61 3 9249 1260 or email:
[email protected]
Associate Professor Robert Smee
FRANZCR
Convener, World Congress on Larynx Cancer 2015
The Cairns Convention Centre was recently
awarded the World’s Best Congress Centre 2014
/ AIPC Apex Award. Several domestic and international airlines fly direct to Cairns, making the
venue very accessible for delegates.
More information and registration:
www.wclc2015.org >
INTRODUCTION
The provisional programme can be viewed on the
congress website: www.wclc2015.org. Free paper
sessions have also been incorporated into the
programme. Health professionals are encouraged
to submit an abstract for the free paper sessions,
which can be completed via the congress website.
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CONFERENCES
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HADRONS IN THERAPY AND SPACE
III Course of the International School of Heavy
Ions, Ettore Majorana Foundation
1 - 4 October 2014
Erice, Italy
INTRODUCTION
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Hadrons in therapy and space
CONFERENCES
HADRONS IN THERAPY
AND SPACE
III Course of the International School of
Heavy Ions, Ettore Majorana Foundation
1 - 4 October 2014
Erice, Italy
School directors: Roberto Battiston (Italian Space Agency,
Italy) and Marco Durante (GSI Helmholtzzentrum für Schwerionenforschung, Director of the Biophysics Department,
Darmstadt, Germany)
MARCO DURANTE
INTRODUCTION
Introduction
The human mission to Mars is a major enterprise
for mankind in the 21st century. Space agencies
consider Mars the ultimate goal of exploration,
and the recent Inspiration Mars project propose a
flyby in 2018. The Mars Science Laboratory (MSL)
[1-2], carrying the Curiosity Rover (Fig. 1), and
the Alpha Magnetic Spectrometer (AMS) [3] are
now in space and provide careful measurements
of the radiation field on the route to Mars and
on the planet, supporting previous simulations
pointing to radiation as a major showstopper
for the mission. However, health risks related
to exposure to energetic protons are affected
by large uncertainties, due to the unique radia-
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tion field experienced in space compared to the
background radiation on earth [3]. Nevertheless,
medicine has experience on the effects of charged
particles in humans, gathered by treating over
100,000 patients worldwide with high-energy
protons and heavy ions [4]. The success of this
therapy has been made possible by the past, present and future contribution of physicists: accelerators, detectors, beam delivery, treatment-planning software are typical examples.
The course was a unique attempt to bring together the top world experts in particle therapy and
space travel to discuss the problems related to the
exposure of humans to high-energy protons
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Hadrons in therapy and space
co-sponsored by GSI (Germany), INFN (Italy),
IARR, ENLIGHT, ESA, ASI (Italy), Verein zur
Förderung der Tumortherapie mit schweren
Ionen e.V. (Darmstadt), and the Universities of
Darmstadt (Germany) and Trento (Italy). All
lectures were held in the ancient San Domenico
Monastery (Fig.2), now the Patrick M.S. Blackett
Institute with the "Paul A.M. Dirac" Lecture Hall.
More information on the school is available at:
events.unitn.it/en/ishi2014
Particle therapy session
Figure 1. This image was acquired on November 2, 2014, by the Mast Camera (Mastcam) on NASA's Curiosity Mars
rover, at a target called "Whale Rock" in the basal geological unit of Mount Sharp on Mars. Cross-bedding seen in the
layers of this Martian rock is evidence of movement of water recorded by waves or ripples of loose sediment the water
passed over. Curiosity landed on Mars on 6 August 2012, following a 253-day, 560-million-kilometre space trip. The
Curiosity rover, with the Radiation Assessment Detector (RAD) mounted to its top deck, was inside the MSL spacecraft.
RAD measured the space radiation doses during the cruise in deep space [1] and on the Mars surface [2]. Image Credit:
NASA/JPL-Caltech/MSSS.
and heavy ions. The current status of particle
therapy for cancer worldwide was described with
emphasis on side-effects, including second cancers. Recent data from space missions were presented, along with simulations of the radiation
INTRODUCTION
risk for the Mars mission and possible countermeasures for risk mitigation.
The school was attended by 40 students and
18 speakers. It was endorsed by ESTRO and
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The meeting was opened by Marco Durante (GSI,
Germany), who discussed the many common research issues relevant for both particle therapy in
oncology and radiation protection in space. Late
risk of cancers, biomarkers of sensitivity, normal
tissue damage, radiogenomics, mixed radiation
fields, shielding, radioprotectors are only some of
the topics shared by the two communities. The
main issues of this school are dose limits for the
Mars mission, gathering on the experience on late
morbidity and second cancers in particle therapy
(Fig. 3).
The session on therapy was chaired by Karin
Haustermans, as ESTRO representative, and it
had both medical and physics lectures. Hak
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Hadrons in therapy and space
Choy (UT Southwestern, USA) (Fig. 4), Jürgen
Debus (HIT, Germany) and Jay Loeffler (MGH,
USA) gave an overview of the clinical results in
cancer therapy using protons and heavier ions.
Medical physics and facilities were discussed by
Marco Schwarz (APSS, Italy), Reinhard Schulte
(LLUMC, USA), Piero Giubilato (INFN-LNL,
Italy), and Manjit Dosanjh (CERN, Switzerland).
Nancy Tarbell (MGH, USA) presented the risk of
second cancers in paediatric patients treated with
protons versus X-rays based on the experience at
MassGeneral Hospital in Boston, MA, USA (Fig.
5). The epidemiological studies [5-6] show that
the risk is lower for protons compared to photons,
as expected [7] due to the lower integral dose in
proton therapy, and give no evidence of a high
RBE for carcinogenesis induced by protons.
Figure 3. Opening session with the main questions for
this workshop presented by Marco Durante.
Space radiation protection session
Figure 2. San Domenico Monastery in Erice, now the
Patrick M.S. Blackett Institute with the "Paul A.M. Dirac"
Lecture Hall.
INTRODUCTION
The information on secondary tumours in paediatric patients is very relevant for space radiation
protection, where cancer is the main late risk
related to exposure to protons and heavier ions.
Günther Reitz (DLR, Germany) presented (Fig.
6) the first measurements of the radiation dose
during the cruise to Mars [1] and on the surface
of the planet [2] by the RAD instrument on MSL
(Fig. 1). The dose during the cruise is
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Figure 4. Karin Haustermans and Hak Choy.
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Hadrons in therapy and space
Figure 5. Nancy Tarbell presented the risk of second
cancers in paediatric patients treated with protons versus
X-rays based on the experience at MassGeneral Hospital
in Boston, MA, USA.
1.8 mSv/day, and 0.4 mSv/day on Mars. This
should be compared with 1-3 mSv/year on Earth.
A long-term mission to Mars will expose the
astronauts to an excess cancer risk higher than
three percent, and Frank Cucinotta (NASA, USA)
presented the current model for risk estimation.
The flight surgeon, Ulrich Straube (ESA, Germany), discussed the eradiation risk in the more
general framework of space medicine. The problems related to radiation hardness of the electronic components were discussed by Eamonn Daly
(ESA, The Netherlands), while Chiara La Tessa
(BNL, USA) and Lembit Sihver (Chalmers University, Sweden) presented nuclear physics measurements and codes with applications to both
therapy and space. Space radiation protections
by passive and active shielding were summarised
by Martina Giraudo (TAS, Italy), William Burger
(TIFPA-INFN, Italy), and Piero Spillantini (University of Florence, Italy).
Conclusions
Figure 6. Günther Reitz’s first slide on MSL.
INTRODUCTION
In the last session, chaired by the ASI President
Roberto Battiston, the lecturers and students
had a lively discussion on the topic. In general, it
was re-affirmed that dose limits for interplanetary missions are required, but that they should
be based on risk rather than on dose, or perhaps
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on life loss in months. This effort would require
more research on the biological effects of charged
particles, research that can be at least in part
performed at the clinical centres where charged
particles are used for cancer treatment. Given the
importance of the topic and the success of the
school it was decided to open a research topic in
“Frontiers in oncology” on “charged particles in
oncology”. In this research topic we will aim to
gather the experiences and opinions of scientists
dealing with high-energy charged particles either
for cancer treatment or for space radiation protection. Clinical results with protons and heavy
ions, as well as ongoing and planned clinical trials will be described. In addition, ground-based
and spaceflight studies on the effects of space radiation will be reported. Particularly relevant for
space studies are the clinical results on normal
tissue complications and second cancers.
Physics, biology, and medical contributions
in this field are welcome. Physics manuscripts
should focus on contributions of nuclear and
medical physics to particle therapy, and measurements or calculations of the dose to normal
tissues. They should also include mitigation strategies for spaceflight, such as passive and active
shielding. Biology contributions should focus on
charged particle carcinogenesis or cancer
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Hadrons in therapy and space
radiobiology with heavy ions. Medical studies
should describe clinical outcomes in patients or
impact on astronauts’ health. Authors can submit
manuscripts on journal.frontiersin.org/ResearchTopic/3520
Marco Durante
GSI Helmholtzzentrum für Schwerionenforschung, Director of the Biophysics Department,
Darmstadt, Germany
REFERENCES
1. Zeitlin C et al. Measurements of energetic particle
radiation in transit to Mars on the Mars Science Laboratory. Science. 2013;340:1080-1084.
2. Hassler DM et al. Mars' surface radiation environment
measured with the Mars Science Laboratory's Curiosity
rover. Science. 2014;343:1244797.
3. Durante M, Cucinotta FA. Heavy ion carcinogenesis and human space exploration. Nat Rev Cancer.
2008;8:465-472.
4. Loeffler JS, Durante M. Charged particle therapy--optimization, challenges and future directions. Nat Rev
Clin Oncol. 2013;10:411-424.
5. Chung CS et al. Incidence of second malignancies
among patients treated with proton versus photon radiation. Int J Radiat Oncol Biol Phys. 2013;87:46-452.
6. Sethi RV et al. Second nonocular tumors among survivors of retinoblastoma treated with contemporary photon and proton radiotherapy. Cancer. 2014;120:126-133.
7. Newhauser WD, Durante M. Assessing the risk of
second malignancies after modern radiotherapy. Nat Rev
Cancer. 2011;11:438-448.
A LITTLE BIT OF IMAGINATION…
Bart Van Daele, one of the participants, was
very inspired by the course and came up with
a fictional story with a typical Sicilian flavour…
Michael Corleone was invited as a guest of
honour and sponsor to the congress on proton
therapy and cosmic radiation that took place in
the Sicilian city, Erice.
After the murder of his daughter, the former
godfather, overwhelmed by feelings of regret
and guilt, had sunk into a continuous depressive state.
His short visit to Western Sicily confronted
him with the cultural roots of his family and
the mafia, and brought back memories of his
exile and marriage to a Sicilian woman when
he was in his twenties.
At a moment when he had become prey to
despair, the conference offered him an opportunity to escape…
Read the full story:
turimm.blogspot.com/2015/02/with-mafia-tomars.html >
INTRODUCTION
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CALENDAR
OF EVENTS
MARCH 2015
6 - 7 MARCH 2015 | TURIN, ITALY
ESTRO
ENDORSED
EVENT
Perspectives in Lung cancer
medex.com/lung-cancer-congress-europe/ >
12 - 14 MARCH 2015 | ST. GALLEN, SWITZERLAND
Advanced prostate cancer consensus conference 2015
www.prostatecancerconsensus.org/ >
22 - 26 MARCH 2015 | PORT SUNLIGHT, WIRRAL, UK
Radiobiology & radiobiological modelling in radiotherapy course
www.estro.org/binaries/content/assets/estro/school/supported-courses/ccc_rblgy_flyer_2015.pdf >
ESTRO
RECOMMENDED
EVENT
ESTRO
SUPPORTED
COURSE
27 - 28 MARCH 2015 | ISTANBUL, TURKEY
Trends in Central Nervous System Malignancies
EORTC-EANO-ESMO Conference
ESTRO
ENDORSED
EVENT
www.ecco-org.eu/EEE2015 >
APRIL 2015
14 - 15 APRIL 2015 | GENEVA, SWITZERLAND
ELCC - 5th European Lung Cancer Conference
IN COLLABORATION
WITH ESTRO
www.esmo.org/Conferences/ELCC-2015-Lung-Cancer >
20 - 22 APRIL 2015 | MAASTRICHT, THE NETHERLANDS
10th International Conference on Carbonic Anhydrases
www.carbonicanhydrasemaastricht.info/ >
22 - 23 APRIL 2015 | BARCELONA, SPAIN
Towards biologically relevant dosimetry workshop
www.ptb.de/emrp/bioquart_2015.html >
ESTRO
RECOMMENDED
EVENT
ESTRO
RECOMMENDED
EVENT
24 - 28 APRIL 2015 | BARCELONA, SPAIN
3rd ESTRO Forum
www.estro.org/congresses-meetings/items/3rd-estro-forum >
29 APRIL - 1 MAY 2015 | ATHENS, GREECE
EMSOS - 28th Annual meeting of the European Musculo-Skeletal Oncology Society
www.emsos.org/ >
ESTRO
INTERDISCIPLINARY
CONGRESS
ESTRO
ENDORSED
EVENT
MAY 2015
8 - 9 MAY 2015 | NEW YORK, USA
Modern Radiation For Lymphoma
www.mskcc.org/events/cme/modern-radiation-lymphoma-updated-role-and-new-rules/form >
18 - 22 MAY 2015 | ROME, ITALY
25th Advanced Multichannel Teaching Course
www.gemelli-art.it/course2015 >
ESTRO
ENDORSED
EVENT
ESTRO
ENDORSED
EVENT
25 - 29 MAY 2015 | KYOTO, JAPAN
ICRR 2015 - 15th International Congress of Radiation Research
www.congre.co.jp/icrr2015/ >
IN COLLABORATION
WITH ESTRO
JUNE 2015
16 - 17 JUNE 2015 | LUND, SWEDEN
3rd International Symposium on Magnetic Resonance in Radiation Therapy
mrinrt.com/ >
17 - 20 JUNE 2015 | LUGANO, SWITZERLAND
13th International Conference on Malignant Lymphoma
www.lymphcon.ch/imcl/index.php >
ESTRO
RECOMMENDED
EVENT
ESTRO
ENDORSED
EVENT
20 - 22 JUNE 2015 | WOLFSBERG, SWITZERLAND
Wolfsberg Meeting
IN COLLABORATION
WITH ESTRO
www.wolfsberg-meeting.com/ >
24 - 27 JUNE 2015 | LJUBLJANA, SLOVENIA
PROS Congress - Congress of the Paediatric Radiation Oncology Society
www.intpros.org/pros-congress/congress.php >
ESTRO
RECOMMENDED
EVENT
JULY 2015
26 - 30 JULY 2015 | CAIRNS, AUSTRALIA
ESTRO
ENDORSED
EVENT
World Congress on Larynx Cancer
www.wclc2015.org/home/ >
SEPTEMBER 2015
25 - 29 SEPTEMBER 2015 | VIENNA, AUSTRIA
ECC2015 - European Cancer Congress 2015
www.ecco-org.eu/Events/ECC2015.aspx >
18
18th ECCO - 40th ESMO
European Cancer Congress
Reinforcing multidisciplinarity
VIENNA, AUSTRIA, 25 - 29 SEPTEMBER 2015
OCTOBER 2015
18 OCTOBER 2015 | SAN ANTONIO, TEXAS, USA
Joint ESTRO-ASTRO session at the 57th ASTRO’s annual meeting
35
SIOP
SIOP Europe
www.astro.org/Meetings-and-Events/2015-Annual-Meeting/Index.aspx >
the European Society for Paediatric Oncology
www.ecco-org.eu
24 - 27 OCTOBER 2015 | NICE, FRANCE
Joint ESTRO-ESGO session at the European Gynaecological Oncology Congress
esgo2015.esgo.org/ >
ESTRO
JOINT EVENT
NOVEMBER 2015
5 - 7 NOVEMBER 2015 | STOCKHOLM, SWEDEN
ESDE Congress - Congress of the European Society for Diseases of the Esophagus
esde2015.axacoevent.com/sv/ >
12 - 15 NOVEMBER 2015 | BARCELONA, SPAIN
EMUC - 7th European Multidisciplinary Meeting on Urological Cancers
ESTRO
ENDORSED
EVENT
JOINT EAU, ESTRO AND
ESMO CONFERENCE
emuc15.uroweb.org/ >
APRIL 2016
29 APRIL - 4 MAY 2016 | TURIN, ITALY
ESTRO 35
ESTRO CONGRESS
CREDITS
ESTRO
Bimonthly newsletter
N° 99 | March - April 2015
European Society for
Radiotherapy & Oncology
OFFICERS
President: Philip Poortmans
President-elect: Yolande Lievens
Past-president: Vincenzo Valentini
EDITOR
Cécile Hardon-Villard
EDITORIAL ADVISERS
Joanna Kazmierska and Ludvig Muren
(ESTRO Board Members)
Emma Mason and Mary Rice
GRAPHIC DESIGN
Daneel Bogaerts
Published every two months and distributed
by the European Society for Radiotherapy
& Oncology.
DEADLINES FOR SUBMISSION
OF ARTICLES IN 2015
July/August 2015 Issue > 4 May 2015
Sept./Oct. 2015 Issue > 1 July 2015
Nov./Dec. 2015 Issue > 1 September 2015
For permission to reprint articles please
contact the editor.
If you want to submit articles for
publication, please contact the editor:
[email protected]
For advertising, please contact:
[email protected]
ARCHIVE
Latest issues of the newsletter can be found on
the ESTRO website under www.estro.org/about
and older issues are accessible on DOVE, from
the home page of www.estro.org.
Opinions expressed in the ESTRO newsletter do
not necessary reflect those of the Society or of its
officers.