How Long Does Contouring Really Take? Results of the Royal College of Radiologists Contouring Surveys

AIMS

The success and safety of modern radiotherapy relies on accurate contouring. Understanding the time taken to complete radiotherapy contours is critical to informing workforce planning and, in the context of a workforce shortfall, advocating for investment in technology and multi-professional skills mix. We aimed to quantify the time taken to delineate target volumes for radical radiotherapy.

MATERIALS AND METHODS

The Royal College of Radiologists circulated two electronic surveys via email to all clinical oncology consultants in the UK. The individual case survey requested anonymous data regarding the next five patients contoured for radical radiotherapy. The second survey collected data on respondents' usual practice in radiotherapy contouring.

RESULTS

The median time to contour one radiotherapy case was 85 minutes (IQR = 50-131 minutes). Marked variability between and within tumour sites was evident: paediatric cancers took the most time (median = 210 minutes, IQR = 87.5 minutes), followed by head and neck and gynaecological cancers (median = 120 minutes, IQR = 71 and 72.5 minutes respectively). Breast cancer contouring required the least time (median = 43 minutes, IQR = 60 minutes). Radiotherapy technique, inclusion of nodes and 4D CT planning were associated with longer contouring times. A non-medical professional was involved in contouring in 65% of cases, but clinical oncology consultants were involved in target volume delineation in 90% of cases, and OARs in 74%. Peer review took place in 46% of cases with 56% of consultants reporting no time for peer review in their job plan.

CONCLUSION

Contouring for radical radiotherapy is complex and time-consuming, and despite increasing involvement of non-medical professionals, clinical oncology consultants remain the primary practitioners. Peer review practice is variable and time is often a limiting factor. Many factors influence the time required for contouring, and departments should take these factors and the need for peer-review into account when developing job plans.

Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study

AIMS

The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment.

MATERIALS AND METHODS

Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively.

RESULTS

Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains.

CONCLUSION

In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.

Interobserver variation in clinical target volume and organs at risk segmentation in post-parotidectomy radiotherapy: can segmentation protocols help?

OBJECTIVE

A study of interobserver variation in the segmentation of the post-operative clinical target volume (CTV) and organs at risk (OARs) for parotid tumours was undertaken. The segmentation exercise was performed as a baseline, and repeated after 3 months using a segmentation protocol to assess whether CTV conformity improved.

METHODS

Four head and neck oncologists independently segmented CTVs and OARs (contralateral parotid, spinal cord and brain stem) on CT data sets of five patients post parotidectomy. For each CTV or OAR delineation, total volume was calculated. The conformity level (CL) between different clinicians' outlines was measured using a validated outline analysis tool. The data for CTVs were re-analysed after using the cochlear sparing therapy and conventional radiation segmentation protocol.

RESULTS

Significant differences in CTV morphology were observed at baseline, yielding a mean CL of 30% (range 25-39%). The CL improved after using the segmentation protocol with a mean CL of 54% (range 50-65%). For OARs, the mean CL was 60% (range 53-68%) for the contralateral parotid gland, 23% (range 13-27%) for the brain stem and 25% (range 22-31%) for the spinal cord.

CONCLUSIONS

There was low conformity for CTVs and OARs between different clinicians. The CL for CTVs improved with use of a segmentation protocol, but the CLs remained lower than expected. This study supports the need for clear guidelines for segmentation of target and OARs to compare and interpret the results of head and neck cancer radiation studies.

High remission rate in T-cell prolymphocytic leukemia with CAMPATH-1H

T-cell prolymphocytic leukemia (T-PLL) is a chemotherapy-resistant malignancy with a median survival of 7.5 months. Preliminary results indicated a high remission induction rate with the human CD52 antibody, CAMPATH-1H. This study reports results in 39 patients with T-PLL treated with CAMPATH-1H between March 1993 and May 2000. All but 2 patients had received prior therapy with a variety of agents, including 30 with pentostatin; none achieved complete remission (CR). CAMPATH-1H (30 mg) was administered intravenously 3 times weekly until maximal response. The overall response rate was 76% with 60% CR and 16% partial remission (PR). These responses were durable with a median disease-free interval of 7 months (range, 4-45 months). Survival was significantly prolonged in patients achieving CR compared to PR or no response (NR), including one patient who survived 54 months. Nine patients remain alive up to 29 months after completing therapy. Seven patients received high-dose therapy with autologous stem cell support, 3 of whom remain alive in CR 5, 7, and 15 months after autograft. Stem cell harvests in these patients were uncontaminated with T-PLL cells as demonstrated by dual-color flow cytometry and polymerase chain reaction. Four patients had allogeneic stem cell transplants, 3 from siblings and 1 from a matched unrelated donor. Two had nonmyeloablative conditioning. Three are alive in CR up to 24 months after allograft. The conclusion is that CAMPATH-1H is an effective therapy in T-PLL, producing remissions in more than two thirds of patients. The use of stem cell transplantation to consolidate responses merits further study.

The use of recombinant factor VIIa in a patient with acquired haemophilia A undergoing surgery

An elderly woman with acquired haemophilia A secondary to a monoclonal gammopathy, required elective surgery for a parotid tumour but was unable to tolerate conventional treatment. Recombinant activated factor VII (rVIIa) was used successfully to cover a biopsy and then subsequent resection of the tumour. The use of rVIIa in the management of acquired inhibitors is discussed.

The prevalence and morbidity of snake bite and treatment-seeking behaviour among a rural Kenyan population

Snake-bite mortality among a rural population in Kenya was estimated to be 6.7/100,000 people each year, representing 0.7% of all deaths. A community-based retrospective survey of 4712 households provided estimates of the incidence of snake bite in this population. Although 151/100,000 people are bitten each year, only 19% of these are bitten by potentially venomous snakes. When those who had been bitten were shown photographs of a range of locally prevalent snakes, most indicated that both venomous and non-venomous snakes were capable of causing death. Most (68%) of bite cases sought treatment from a traditional healer who invariably used local herbal preparations applied to the bite site and/or in a ring around the bitten limb. Local skin incisions were also commonly practised. The use of traditional medicine for snake bite is a feature of most areas of the developing world where venomous snakes are prevalent. Improvements in early referral and appropriate care will only occur when traditional healers are integrated into primary health care and hospital-based health systems.