Purpose: To investigate the value of (18)FDG PET/CT volumetric parameters in the prediction of overall survival (OS) in patients with pancreatic cancer and also, assess their independence relative to well-established clinico-pathological variables. Methods: We conducted a retrospective analysis of patients with a confirmed diagnosis of pancreatic cancer who underwent (18)FDG PET/CT. The tumour maximum standardised uptake value (SUVmax) in addition to SUVmean, metabolic tumour volume (MTV) and total lesion glycolysis (TLG) were calculated. The prognostic value of (18)FDG PET/CT and clinico-pathological parameters for OS were assessed using univariate and multivariable analyses. Results: A sum of 89 patients were analysed in this study. Median survival for patients categorised as having high TLG (>= 55) and low TLG (<55) was 18 vs 5 months (p < 0.001). Similarly, the respective high vs low SUVmean, MTV and SUVmax were 18 vs 6 months (p = 0.001), 16 vs 6 months (p = 0.002) and 18 vs 6 months (p = 0.001). Univariate analysis showed SUVmax SUVmean, MTV, TLG, tumour size, tumour differentiation and presence of distant metastasis as prognostic factors for OS. On multivariable analysis, TLG (HR 2.0, 95% CI 1.26-3.18, p = 0.004) and the presence of distant metastasis (HR 3.37, 95% CI 1.97 -5.77, p < 0.001) emerged as independent prognostic factors. Subgroup analysis identified TLG as the only significant PET metric after adjusting for the presence of distant metastasis. Conclusions: (18)FDG PET/CT is a useful tool in the preoperative evaluation of patients with pancreatic cancer. Tumour TLG offer an independent prognostic value in both potentially operable and metastatic disease settings. (C) 2020 Elsevier Ltd, BASO - The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Aims: To report outcomes for the first UK cohort treated for early stage peripheral lung cancer using stereotactic ablative radiotherapy (SABR).Materials and methods: Patients were included who received SABR between May 2009 and May 2012. Electronic medical records were reviewed for baseline characteristics, treatment details and outcomes. Patients were treated according to the UK SABR Consortium Guidelines. Univariate and multivariate Cox regression was used to determine factors that influenced overall survival and local control.Results: In total, 273 patients received SABR for 288 lesions in the time period examined. The median follow-up was 19.7 months. The median overall survival for all patients was 27.3 months, with 1, 2 and 3 year overall survival of 78.0, 54.9 and 38.6%, respectively. The 1, 2 and 3 year rates of local control were 98.2, 95.7 and 95.7%, respectively. All patients completed the planned course of treatment and rates of Common Toxicity Criteria grade 3+ toxicity were low. On multivariate analysis, patients with Medical Research Council (MRC) breathlessness scores of 3-5 had worse overall survival compared with patients with scores of 1-2 (hazard ratio: 2.10; 95% confidence interval: 1.25-3.59) and the presence of histological diagnosis conferred improved overall survival (hazard ratio: 0.54; 95% confidence interval: 0.31-0.93), probably reflecting that patients who are considered well enough to undergo biopsy are generally fitter overall. No factors were identified that significantly influenced local control.Conclusions: SABR is an effective and well-tolerated treatment option for patients with early stage peripheral lung cancer who are not suitable for surgery. No patient cohort was identified in whom SABR was considered inappropriate. This series adds to the existing positive data that support SABR for this patient group. (C) 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Lung stereotactic body radiotherapy (SBRT) is a novel and effective technique for the treatment of early stage non small cell lung cancer which is rapidly becoming the radiotherapy regime of choice for those patients unable or unwilling to undergo surgical resection.Although introduced almost 20 years ago, it was not until the wider establishment of image guided radiotherapy (IGRT) techniques that many UK departments first considered and then succeeded in implementing lung SBRT. Many have been assisted in this through membership of the national UK SBRT consortium which aims to facilitate local introduction and to provide guidelines and practical support for the wider radiotherapy community.This article will seek to place the introduction of SBRT within a broad historical context, outline basic principles for safe and effective practice and describe how such principles are currently being pursued in an era of IGRT. Additionally, the role of the UK SBRT consortium in implementation will be reported alongside the results of its first national survey on the subject.

To investigate the use of EPI and CBCT verification methods for implementation into the standard breast radiation therapy treatment pathway. Sixteen breast patients receiving whole breast radiation therapy (tangential beam arrangement with matched supraclavicular fossa SCF if required) were imaged on treatment fractions 0, 1 and 8 and 12 (fraction 0 being a pretreatment verification appointment). Patients were supine and immobilized on a Posiboard with ipsilateral arm raised only. CBCT was acquired and assessed online, consisting of an automatic bone match in comparison to the planning CT. EPIs were taken of both tangential fields. One patient had SCF irradiation and EPIs were acquired of this region. Offline CBCT assessment consisted a manual tumor bed match compared to the planning CT. The EPI image registration method consisted of a bony match compared with digitally reconstructed radiographs (DRR). The bony registrations of the CBCT and EPI methods were evaluated. All data was transformed into the U/V co-ordinate system as carried out by Topolnjak et al. U refers to the lateral field placement error and V refers to the longitudinal position. Further comparisons were made between the bony CBCT match and the manual tumor bed match. The U/V shifts inferred by CBCT and those measured on EPID were recorded for each patient at each imaging fraction, giving a sample of 70 paired measurements. The differences between them were calculated. The mean difference between CBCT U/V and EPI U/V was found to be less than 1mm. The spread was evaluated by calculating the standard deviation of the differences and constructing ∼95% confidence intervals. This indicated results for CBCT and EPI agree to +/- 8mm in the U direction and +/- 6mm in the V direction. Also for each measured fraction the CBCT X, Y, and Z set up errors for manual tumor bed match and bony landmark match were compared. The mean differences between the results in each axis were calculated and found to be less than 1mm in the X and Y directions and 1.2mm in the Z direction. The accuracy of the mean was evaluated by calculating the standard error of the mean (SEM) and constructing ∼95% confidence intervals. However, on the Z axis, the results exhibit an average difference of 1.2mm. EPI verification is suitable for patients receiving whole breast irradiation due to planning margins. For conformal treatments with smaller planning margins CBCT verification is essential.

Introduction: At St James's Institute of Oncology, stereotactic body radiotherapy (SBRT) is standard treatment for early stage inoperable NSCLC. High fractional doses make verification of patient position before and during treatment critical. Elekta Synergy cone beam CT (CBCT) remains our benchmark for assessment of correct isocentre position relative to the target. AlignRT (Vision RT, UK) is an in-room system that maps patient surfaces using optical technology. This could complement CBCT during SBRT delivery and has the potential to predict when additional CBCT scans may be required. This could improve SBRT delivery safety while offering potentially reduced treatment times, important for a technique requiring patient compliance for up to 1 h.

Abstract Lung stereotactic body radiotherapy (SBRT) is a novel and effective technique for the treatment of early stage non small cell lung cancer which is rapidly becoming the radiotherapy regime of choice for those patients unable or unwilling to undergo surgical resection. Although introduced almost 20 years ago, it was not until the wider establishment of image guided radiotherapy (IGRT) techniques that many UK departments first considered and then succeeded in implementing lung SBRT. Many have been assisted in this through membership of the national UK SBRT consortium which aims to facilitate local introduction and to provide guidelines and practical support for the wider radiotherapy community. This article will seek to place the introduction of SBRT within a broad historical context, outline basic principles for safe and effective practice and describe how such principles are currently being pursued in an era of IGRT. Additionally, the role of the UK SBRT consortium in implementation will be reported alongside the results of its first national survey on the subject.

Introduction: Approximately 30% of patients diagnosed with pancreatic cancer will present with locally advanced unresectable disease (LAPC). Improved planning techniques provide the opportunity for dose escalation.

Introduction: Lung SBRT is an established technique at SJIO for treatment of early stage inoperable NSCLC. Daily verification, essential for hypofractionated regimes is performed using cone beam CT (CBCT) with online correction of all translational errors >2 mm. During verification, volumetric registration occurs between a reference scan selected from a 4DCT dataset and a CBCT scan acquired over a 2 min period. Although matching visible tumour to the ITV is usually straightforward, in situations where tumours are located close to the diaphragm or demonstrate excessive movement, this registration process can be problematical. In around 5% of cases, uncertainty about optimal registration requires multidisciplinary presence during all treatment sessions.

Introduction: Approximately 30% of patients diagnosed with pancreatic cancer will present with locally advanced unresectable disease (LAPC). Improved planning techniques provide the opportunity for dose escalation. Methods: From February 2010 to September 2010, patients with LAPC suitable for CRT were planned using contrast enhanced 4D CT scanning. We compared 4D CT treatment planned according to local protocol using 50.4 Gy (4D50.4) and 55.8 Gy (4D55.8) compared with the NCRN/SCALOP protocol (50.4 Gy SCALOP50.4). Our local protocol defines gross tumour volume (GTV) outlined on all respiratory phases of image sets generated by 4D CT with a radiologist (using the SCALOP study protocol). An internal target volume (ITV) was generated as a composite of all GTVs. This ITV was grown with 1 cm circumferential margin and 1.2 cm superior–inferiorly to define a PTV. Dose constraints and PTV coverage were defined by the SCALOP protocol. Results: We identified nine patients who had 4D CT scans from April to October 2010. We found that the mean reduction in small bowel doses for V15small bowel was 17% and the mean V45small bowel was reduced by 28% when 4D50.4 was compared with SCALOP50.4. With dose escalation to 55.8 Gy, 4D55.8 remained compliant with the organs at risk constraints and these values, including the mean small bowel doses (V15small bowel and V45small bowel) remained comparable to the SCALOP50.4. Patients set-up errors were reviewed during treatment and found to be acceptable for our PTV margins. No acute grade 3 or 4 toxicity was observed of the eight patients treated with 4D50.4 plans. Conclusion: In this study, 4D CT planning using our protocol would allow dose escalation without a significant increase in the small bowel dose.

Purpose: At St James's Institute of Oncology (SJIO) we introduced stereotactic body radiotherapy (SBRT) into routine clinical practice for early lung cancer and present our initial results to determine feasibility and early outcomes.