IROCA-TES: Improving Quality in Radiation Oncology through Clinical Audits - Training and Education for Standardization.

Background: Clinical audits are an important tool to objectively assess clinical protocols, procedures, and processes and to detect deviations from good clinical practice. The main aim of this project is to determine adherence to a core set of consensus- based quality indicators and then to compare the institutions in order to identify best practices. Materials and methods: We conduct a multicentre, international clinical audit of six comprehensive cancer centres in Poland, Spain, Italy, Portugal, France, and Romania as a part of the project, known as IROCATES (Improving Quality in Radiation Oncology through Clinical Audits - Training and Education for Standardization). Results: Radiotherapy practice varies from country to country, in part due to historical, economic, linguistic, and cultural differences. The institutions developed their own processes to suit their existing clinical practice. Conclusions: We believe that this study will contribute to establishing the value of routinely performing multi-institutional clinical audits and will lead to improvement of radiotherapy practice at the participating centres.

Diagnosis and treatment of lung cancer using nuclear medicine techniques - current state of the art.

Lung cancer is the leading cause of cancer-related death worldwide. Planar radiography and computed tomography are the most common imaging modalities used in diagnosis, staging, and therapy response assessment. However, the role of nuclear methods in assessing the severity of the disease and the effectiveness of treatment has increased in recent years. Introducing these diagnostic modalities into standard practice in lung cancer may contribute to the personalization of treatment. In this review, we summarize the current knowledge of nuclear medicine techniques in the diagnosis and treatment of lung cancer.

Differences among [18F]FDG PET-derived parameters in lung cancer produced by three software packages.

Investigation of differences in derived [18F]FDG PET metabolic and volumetric parameters among three different software programs in lung cancer. A retrospective analysis was performed on a group of 98 lung cancer patients who underwent a baseline [18F]FDG PET/CT study. To assess appropriate delineation methods, the NEMA phantom study was first performed using the following software: Philips EBW (Extended Brilliance Workstation), MIM Software and Rover. Based on this study, the best cut-off methods (dependent on tumour size) were selected, extracted and applied for lung cancer delineation. Several semiquantitative [18F]FDG parameters (SUVmax, SUVmean, TLG and MTV) were assessed and compared among the three software programs. The parameters were assessed based on body weight (BW), lean body mass (LBM) and Bq/mL. Statistically significant differences were found in SUVmean (LBM) between MIM Software and Rover (4.62 ± 2.15 vs 4.84 ± 1.20; p < 0.005), in SUVmean (Bq/mL) between Rover and Philips EBW (21,852.30 ± 21,821.23 vs 19,274.81 ± 13,340.28; p < 0.005) and Rover and MIM Software (21,852.30 ± 21,821.23 vs 19,399.40 ± 10,051.30; p < 0.005), and in MTV between MIM Software and Philips EBW (19.87 ± 25.83 vs 78.82 ± 228.00; p = 0.0489). This study showed statistically significant differences in the estimation of semiquantitative parameters using three independent image analysis tools. These findings are important for performing further diagnostic and treatment procedures in lung cancer patients.

First case of acrometastases to the wrist reported from penile cancer.

Penile cancer is a rarely diagnosed cancer that affects 0.4%-0.6% of all male population. Metastases to the bones from various human cancers are common; however, acrometastases are extremely rare with the most common primary tumor from lung, kidney, and breast. We report the first case of a patient with acrometastases to the left wrist reported from penile cancer.

Results of the IROCA international clinical audit in prostate cancer radiotherapy at six comprehensive cancer centres.

To assess adherence to standard clinical practice for the diagnosis and treatment of patients undergoing prostate cancer (PCa) radiotherapy in four European countries using clinical audits as part of the international IROCA project. Multi-institutional, retrospective cohort study of 240 randomly-selected patients treated for PCa (n = 40/centre) in the year 2015 at six European hospitals. Clinical indicators applicable to general and PCa-specific radiotherapy processes were evaluated. All data were obtained directly from medical records. The audits were performed in the year 2017. Adherence to clinical protocols and practices was satisfactory, but with substantial inter-centre variability in numerous variables, as follows: staging MRI (range 27.5-87.5% of cases); presentation to multidisciplinary tumour board (2.5-100%); time elapsed between initial visit to the radiation oncology department and treatment initiation (42-102.5 days); number of treatment interruptions ≥ 1 day (7.5-97.5%). The most common deviation from standard clinical practice was inconsistent data registration, mainly failure to report data related to diagnosis, treatment, and/or adverse events. This clinical audit detected substantial inter-centre variability in adherence to standard clinical practice, most notably inconsistent record keeping. These findings confirm the value of performing clinical audits to detect deviations from standard clinical practices and procedures.

Multicentre clinical radiotherapy audit in rectal cancer: results of the IROCA project.

PURPOSE: To perform a clinical audit to assess adherence to standard clinical practice for the diagnosis, treatment, and follow-up of patients undergoing radiotherapy for rectal cancer treatment in four European countries. MATERIALS AND METHODS: Multi-institutional, retrospective cohort study of 221 patients treated for rectal cancer in 2015 at six European cancer centres. Clinical indicators applicable to general radiotherapy processes were evaluated. All data were obtained from electronic medical records. RESULTS: The audits were performed in the year 2017. We found substantial inter-centre variability in adherence to standard clinical practices: 1) presentation of cases at departmental clinical sessions (range, 0-100%) or multidisciplinary tumour board (50-95%); 2) pretreatment MRI (61.5-100%) and thoracoabdominal CT (15.0-100%). Large inter-centre differences were observed in the mean interval between biopsy and first visit to the radiotherapy department (range, 21.6-58.6 days) and between the first visit and start of treatment (15.1-38.8 days). Treatment interruptions ≥ 1 day occurred in 43.9% (2.5-90%) of cases overall. Treatment compensation was performed in 2.1% of cases. Treatment was completed in the prescribed time in 55.7% of cases. CONCLUSIONS: This multi-institutional clinical audit revealed that most centres adhered to standard clinical practices for most of the radiotherapy processes-related variables assessed. However, the audit revealed marked inter-centre variability for certain quality indicators, particularly inconsistent record keeping. Multiple targets for improvement and/or harmonisation were identified, confirming the value of routine clinical audits to detect potential deviations from standard clinical practice.

Improving radiation oncology through clinical audits: Introducing the IROCA project.

As radiotherapy practice and processes become more complex, the need to assure quality control becomes ever greater. At present, no international consensus exists with regards to the optimal quality control indicators for radiotherapy; moreover, few clinical audits have been conducted in the field of radiotherapy. The present article describes the aims and current status of the international IROCA "Improving Radiation Oncology Through Clinical Audits" project. The project has several important aims, including the selection of key quality indicators, the design and implementation of an international audit, and the harmonization of key aspects of radiotherapy processes among participating institutions. The primary aim is to improve the processes that directly impact clinical outcomes for patients. The experience gained from this initiative may serve as the basis for an internationally accepted clinical audit model for radiotherapy.

Dosimetric verification of dose calculation algorithm in the lung during total marrow irradiation using helical tomotherapy.

INTRODUCTION: Treatment of proliferative diseases of the hematopoietic system involves, in most cases, chemotherapy combined with radiation therapy, which is intended to provide adequate immunosuppressant. Conventionally, total body irradiation (TBI) was used; however, total marrow irradiation (TMI) performed with helical tomotherapy (HT) has been proposed as an alternative, with the aim of delivering the highest dose in the target area (skeleton bone). PURPOSE: The purpose of this study is to evaluate the accuracy of the dose calculation algorithm for the lung in TMI delivered with HT. METHODS: Thermoluminescent detectors (TLD-100 Harshaw) were used to measure delivered doses. Doses were calculated for 95 selected points in the central lung (53 TLDs) and near the rib bones (42 TLDs) in the anthropomorphic phantom. A total of 12 Gy were delivered (6 fractions of 2 Gy/fraction). RESULTS: HT-TMI technique reduces the dose delivered to the lungs in a phantom model to levels that are much lower than those reported for TBI delivered by a conventional linear accelerator. The mean calculated lung dose was 5.6 Gy versus a mean measured dose of 5.7 ± 2.4 Gy. The maximum and minimum measured doses were, respectively, 11.3 Gy (chest wall) and 2.8 Gy (central lung). At most of the 95 points, the measured dose was lower than the calculated dose, with the largest differences observed in the region located between the target volume and the adjacent lung tissue. The mean measured dose was lower than the calculated dose in both primary locations: -3.7% in the 42 rib-adjacent detectors and -3.0% in the 53 central lung TLDs. CONCLUSION: Our study has shown that the measured doses may be lower than those calculated by the HT-TMI calculation algorithm. Although these differences between calculated and measured doses are not clinically relevant, this finding merits further investigation.

Preoperative radiotherapy for rectal cancer: a comparative study of quality control adherence at two cancer hospitals in Spain and Poland.

BACKGROUND: We performed a clinical audit of preoperative rectal cancer treatment at two European radiotherapy centres (Poland and Spain). The aim was to independently verify adherence to a selection of indicators of treatment quality and to identify any notable inter-institutional differences. METHODS: A total of 162 patients, in Catalan Institute of Oncology (ICO) 68 and in Greater Poland Cancer Centre (GPCC) 94, diagnosed with locally advanced rectal cancer and treated with preoperative radiotherapy or radio-chemotherapy were included in retrospective study. A total of 7 quality control measures were evaluated: waiting time, multidisciplinary treatment approach, portal verification, in vivo dosimetry, informed consent, guidelines for diagnostics and therapy, and patient monitoring during treatment. RESULTS: Several differences were observed. Waiting time from pathomorphological diagnosis to initial consultation was 31 (ICO) vs. 8 (GPCC) days. Waiting time from the first visit to the beginning of the treatment was twice as long at the ICO. At the ICO, 82% of patient experienced treatment interruptions. The protocol for portal verification was the same at both institutions. In vivo dosimetry is not used for this treatment localization at the ICO. The ICO utilizes locally-developed guidelines for diagnostics and therapy, while the GPCC is currently developing its own guidelines. CONCLUSIONS: An independent external clinical audit is an excellent approach to identifying and resolving deficiencies in quality control procedures. We identified several procedures amenable to improvement. Both institutions have since implemented changes to improve quality standards. We believe that all radiotherapy centres should perform a comprehensive clinical audit to identify and rectify deficiencies.

Basic tests in mammography as a tool in quality improvement.

BACKGROUND: Mammography is a radiological diagnostic method which relies on an X-ray examination of breasts and is a process involving the use of low-dose amplitude-X-rays (usually around 0.7 mSv). Combining the use of small doses and high quality images requires extensive quality protocols, part of them being included in regulations adopted by the Minister of Health. AIM: The aim of this study was to check the usefulness and efficacy of selected quality tests associated with mammography. MATERIAL/METHODS: The study was performed in the mammography service of the Greater Poland Cancer Centre in Poznan. Following equipment was used: densitometer, sensitometer, mammographic scales, electronic scales, thermometer, hygrometer, PMMA plates, Europhantom, screen film contact phantom, viewing boxes and magnifying glasses. The methods were based on basic mammography tests. Quality control in mammography demands: clean darkroom, marked and clean cassettes, clean viewing boxes with homogenous light. RESULTS: The results of the "Development Process" test show that each sensitometer has to be used with an appropriate densitometer. Phantoms with abnormal structures cannot be used to "AEC System - Solidity exposure" test. "Compression - The force of compression" test may only be carried out with suitable scales and compressible material. Analysis of rejected films shows that the main reasons for rejection were wrong collimation and underexposure. CONCLUSION: Every quality control in mammography provides essential information about the functioning of a laboratory. Apart from recommended standard sterility, it should be remembered that equipment should always be adjusted and repaired.