Patients with cancer are at increased risk of hospitalisation and mortality following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, the SARS-CoV-2 phenotype evolution in patients with cancer since 2020 has not previously been described. We therefore evaluated SARS-CoV-2 on a UK populationscale from 01/11/2020-31/08/2022, assessing case-outcome rates of hospital assessment(s), intensive care admission and mortality. We observed that the SARS-CoV-2 disease phenotype has become less severe in patients with cancer and the non-cancer population. Case-hospitalisation rates for patients with cancer dropped from 30.58% in early 2021 to 7.45% in 2022 while case-mortality rates decreased from 20.53% to 3.25%. However, the risk of hospitalisation and mortality remains 2.10x and 2.54x higher in patients with cancer, respectively. Overall, the SARS-CoV-2 disease phenotype is less severe in 2022 compared to 2020 but patients with cancer remain at higher risk than the non-cancer population. Patients with cancer must therefore be empowered to live more normal lives, to see loved ones and families, while also being safeguarded with expanded measures to reduce the risk of transmission.

Purpose: People living with cancer and haematological malignancies are at an increased risk of hospitalisation and death following infection with acute respiratory syndrome coronavirus 2. Coronavirus third dose vaccine boosters are proposed to boost waning immune responses in immunocompromised individuals and increase coronavirus protection; however, their effectiveness has not yet been systematically evaluated. Methods: This study is a population-scale real-world evaluation of the United Kingdom's third dose vaccine booster programme for cancer patients from 8th December 2020 to 7th December 2021. The cancer cohort comprises individuals from Public Health England's national cancer dataset, excluding individuals less than 18 years. A test-negative case-control design was used to assess the third dose booster vaccine effectiveness. Multivariable logistic regression models were fitted to compare risk in the cancer cohort relative to the general population. Results: The cancer cohort comprised of 2,258,553 tests from 361,098 individuals. Third dose boosters were evaluated by reference to 87,039,743 polymerase chain reaction coronavirus tests. Vaccine effectiveness against breakthrough infections, symptomatic infections, coronavirus hospitalisation and death in cancer patients were 59.1%, 62.8%, 80.5% and 94.5%, respectively. Lower vaccine effectiveness was associated with a cancer diagnosis within 12 months, lymphoma, recent systemic anti-cancer therapy (SACT) or radiotherapy. Patients with lymphoma had low levels of protection from symptomatic disease. In spite of third dose boosters, following multivariable adjustment, individuals with cancer remain at an increased risk of coronavirus hospitalisation and death compared to the population control (OR 3.38, 3.01, respectively. p < 0.001 for both). Conclusions: Third dose boosters are effective for most individuals with cancer, increasing protection from coronavirus. However, their effectiveness is heterogenous and lower than the general population. Many patients with cancer will remain at the increased risk of coronavirus infections even after 3 doses. In the case of patients with lymphoma, there is a particularly strong disparity of vaccine effectiveness against breakthrough infection and severe disease. Breakthrough infections will disrupt cancer care and treatment with potentially adverse consequences on survival outcomes. The data support the role of vaccine boosters in preventing severe disease, and further pharmacological intervention to prevent transmission and aid viral clearance to limit the disruption of cancer care as the delivery of care continues to evolve during the coronavirus pandemic. (C) 2022 The Author(s). Published by Elsevier Ltd.

Background People with cancer are at increased risk of hospitalisation and death following infection with SARS-CoV-2. Therefore, we aimed to conduct one of the first evaluations of vaccine effectiveness against breakthrough SARS-CoV-2 infections in patients with cancer at a population level.Methods In this population-based test-negative case-control study of the UK Coronavirus Cancer Evaluation Project (UKCCEP), we extracted data from the UKCCEP registry on all SARS-CoV-2 PCR test results (from the Second Generation Surveillance System), vaccination records (from the National Immunisation Management Service), patient demographics, and cancer records from England, UK, from Dec 8, 2020, to Oct 15, 2021. Adults (aged >= 18 years) with cancer in the UKCCEP registry were identified via Public Health England's Rapid Cancer Registration Dataset between Jan 1, 2018, and April 30, 2021, and comprised the cancer cohort. We constructed a control population cohort from adults with PCR tests in the UKCCEP registry who were not contained within the Rapid Cancer Registration Dataset. The coprimary endpoints were overall vaccine effectiveness against breakthrough infections after the second dose (positive PCR COVID-19 test) and vaccine effectiveness against breakthrough infections at 3-6 months after the second dose in the cancer cohort and control population.Findings The cancer cohort comprised 377 194 individuals, of whom 42 882 had breakthrough SARS-CoV-2 infections. The control population consisted of 28 010 955 individuals, of whom 5 748 708 had SARS-CoV-2 breakthrough infections. Overall vaccine effectiveness was 69middot8% (95% CI 69middot8-69middot9) in the control population and 65middot5% (65middot1-65middot9) in the cancer cohort. Vaccine effectiveness at 3-6 months was lower in the cancer cohort (47middot0%, 46middot3-47middot6) than in the control population (61middot4%, 61middot4-61middot5).Interpretation COVID-19 vaccination is effective for individuals with cancer, conferring varying levels of protection against breakthrough infections. However, vaccine effectiveness is lower in patients with cancer than in the general population. COVID-19 vaccination for patients with cancer should be used in conjunction with non-pharmacological strategies and community-based antiviral treatment programmes to reduce the risk that COVID-19 poses to patients with cancer.Funding University of Oxford, University of Southampton, University of Birmingham, Department of Health and Social Care, and Blood Cancer UK.Copyright (c) 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Hypofractionated radiotherapy for the adjuvant treatment of breast cancer has been standard practice in the UK since 2009. Ten-year follow-up data from START-B have confirmed the efficacy of 40 Gy in 15 fractions, with reduced toxicity when compared with the previous standard of 50 Gy in 25 fractions [1]. The UK FAST-Forward trial began recruiting in 2011 to identify a five-fraction regimen that was non-inferior to the 15-fraction regimen for the prevention of ipsilateral breast cancer relapse and as safe for adverse effects.

The United Kingdom has been severely affected by the coronavirus disease 2019 (COVID-19) pandemic. As the National Health Service (NHS) has urgently prioritized management of this outbreak, the UK clinical oncology community has had to adapt rapidly to maintain cancer services and training. These unprecedented times have altered countless aspects of cancer care, education, and research, providing a legacy that will extend well beyond the pandemic that catalyzed them. This editorial focuses on 3 key themes that distinguish the United Kingdom from many other countries. Particular aspects of the organization of radiation therapy services in the United Kingdom have framed the response to COVID-19. The first is the NHS, which was established in 1948 to provide universal health care free at the point of delivery as a human right.1Tait D. Radiation therapy in the United Kingdom and the wider role of the clinical oncologist.Int J Radiat Oncol Biol Phys. 2014; 89: 1-3Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar It has grown to become the largest publicly funded health service in the world, and almost all UK radiation therapy services are delivered by the NHS. The NHS occupies a unique position in the national psyche and became integral to the government's key message during the lockdown: "Stay Home, Protect the NHS, Save Lives." The ability to plan and adapt quickly across the United Kingdom enabled rapid establishment of NHS Nightingale field hospitals for acute care and NHS Seacole centres to rehabilitate patients with COVID-19. Research and development is also embedded in the NHS through the government-funded National Institute for Health Research (NIHR), which supports clinical trials in every hospital. This structure enables rapid recruitment to national clinical trials, best illustrated by more than 10,000 patients being randomized among 6 different treatment arms in the RECOVERY trial for 8 weeks.2Wilkinson E. RECOVERY trial: The UK covid-19 study resetting expectations for clinical trials.BMJ. 2020; 369: m1626Crossref PubMed Scopus (50) Google Scholar This is currently the largest randomized trial in the world investigating treatments for COVID-19. The second aspect is the configuration of the specialty of clinical oncology (CO). The United Kingdom is one of the few countries that does not recognize radiation oncology as a separate specialty but has a combined specialty of CO delivering radiation therapy and systemic anticancer therapies.1Tait D. Radiation therapy in the United Kingdom and the wider role of the clinical oncologist.Int J Radiat Oncol Biol Phys. 2014; 89: 1-3Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Standards for UK radiation therapy are overseen by the Clinical Oncology Faculty of the Royal College of Radiologists (RCR), which also defines the curriculum for specialty training in CO.3The Faculty of Clinical Oncology, the Royal College of RadiologistsSpecialty training curriculum for clinical oncology.https://www.rcr.ac.uk/sites/default/files/2016_curriculum_-_clinical_oncology_15_november_2016.pdfDate accessed: June 5, 2020Google Scholar Entry to a 5-year CO training program requires at least 4 years of postgraduate training in internal medicine. UK clinical oncologists are responsible for delivering more systemic treatment than either medical or hemato-oncologists. These factors have conferred a number of advantages when delivering cancer care during the pandemic. Cancer policy could be decided nationally, with rapid production and adoption of guidelines such as the NICE radiation therapy guidance, which was published in late March 2020.4National Institute for Health and Care ExcellenceCOVID-19 rapid guideline: Delivery of radiotherapy. NICE guideline [NG162].https://www.nice.org.uk/guidance/NG162Date accessed: June 5, 2020Google Scholar As cancer surgery ceased almost completely in some centers, clinical oncologists quickly agreed on site-specific guidance to support nonsurgical cancer treatments, including both radiation therapy and systemic therapy in all tumor types, mitigating risks of COVID-19 but compensating for lack of surgery. Within 3 weeks of opening, the RCR repository had 26 guidelines, which have been downloaded more than 20,000 times.5Lewis PJ, Roques TW. The response of the UK clinical oncology community to the COVID-19 pandemic [e-pub ahead of print]. Clin Oncol (R Coll Radiol). https://doi.org/10.1016/j.clon.2020.05.007. Accessed June 30, 2020.Google Scholar During the pandemic, clinical oncologists also provided an additional workforce with skills in internal medicine. Many were deployed to help treat patients in COVID-19 wards and to support acute medical rotas. The UK, and by extension the NHS, response to COVID-19 has not been without significant challenges, including difficulties in the supply chain for personal protection equipment, the potential seeding of COVID-19 in care homes through inappropriate discharge decisions, and inadequate antigen testing capabilities.6Scally G. Abbasi K. The UK's public health response to covid-19.BMJ. 2020; 369: m1932Crossref PubMed Scopus (152) Google Scholar The fallout from decision-making around these issues is likely to be debated nationally for some time, especially given that the United Kingdom has one of the highest excess deaths rates in Europe.7Griffin S. Covid-19: UK deaths approach 50 000, but rate declines.BMJ. 2020; 369: m2212Crossref PubMed Scopus (1) Google Scholar The United Kingdom has more than 3 decades of experience in developing high-quality, practice-changing randomized trials (RCTs) of hypofractionated radiation therapy in tumor sites including breast, urologic, lung, and gastrointestinal cancers.8Thompson M.K. Poortmans P. Chalmers A.J. et al.Practice-changing radiation therapy trials for the treatment of cancer: Where are we 150 years after the birth of Marie Curie?.Br J Cancer. 2018; 119: 389-407Crossref PubMed Scopus (91) Google Scholar In a pandemic, giving fewer fractions reduces risk of nosocomial virus transmission and improves machine capacity when staffing levels are reduced due to sickness or redeployment. A national research framework fosters an inclusive, multidisciplinary approach with all UK radiation therapy centers encouraged to participate in centrally funded trials with support of the national Radiotherapy Trials Quality Assurance (RTTQA) group. This partnership of oncologists, physicists, radiographers, methodologists, and patient advocates has enhanced the quality of radiation research and accelerated the introduction of new radiation therapy techniques.9Venables K. Tsang Y. Ciurlionis L. et al.Does participation in clinical trials influence the implementation of new techniques? A look at changing techniques in breast radiotherapy in the UK.Clin Oncol (R Coll Radiol). 2012; 8: e100-e105Abstract Full Text Full Text PDF Scopus (14) Google Scholar An example pertinent to the pandemic is the FAST-Forward RCT in breast cancer. Engaging the research community and harnessing patient enthusiasm for the 3-week versus just 1-week breast radiation therapy trial design, this study recruited 4096 patients from 47 of the 62 radiation therapy centers across the United Kingdom in just 30 months. This was 2 years ahead of schedule and built on groundwork by the RTTQA group via the IMPORT trials.10Brunt A.M. Haviland J.S. Wheatley D.A. et al.Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects from a multicentre, non-inferiority, randomised, phase 3 trial.Lancet. 2020; 395: 1613-1626Abstract Full Text Full Text PDF PubMed Scopus (563) Google Scholar, 11Coles C.E. Griffin C.L. Kirby A.M. et al.Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial.Lancet. 2017; 390: 1048-1060Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar, 12Coles C. Griffin C. Kirby A. et al.Abstract GS4-05: Dose escalated simultaneous integrated boost radiotherapy for women treated by breast conservation surgery for early breast cancer: 3-year adverse effects in the IMPORT HIGH trial (CRUK/06/003).Cancer Res. 2019; 79Google Scholar In early March 2020, with the FAST-Forward 5-year primary outcome results imminent but unpublished, a core group of FAST-Forward trialists realized the need to offer urgent guidance for breast radiation therapy. The existing framework of the UK clinical trials community, RTTQA, and RCR provided an ideal background for collaborative working:1.An international group of breast oncologists was convened over a weekend to produce emergency international guidelines for breast radiation therapy with authors from across the world.13Coles C.E. Aristei C. Bliss J. et al.International guidelines on radiation therapy for breast cancer during the COVID-19 pandemic.Clin Oncol (R Coll Radiol). 2020; 32: 279-281Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar The time from concept to preprint publication was about 2 weeks. The article appeared online on March 31, and by the end of April there had been more than 6000 downloads.2.Concurrently, the UK group posted the breast radiation therapy guidelines on the open access RCR COVID-19 guideline repository. The FAST-Forward protocol and radiation therapy planning pack were circulated as a link within the publication and the RCR repository ahead of the primary results publication.3.Work continued on submission and fast-track review of the FAST-Forward manuscript, which was published online on April 28.10Brunt A.M. Haviland J.S. Wheatley D.A. et al.Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects from a multicentre, non-inferiority, randomised, phase 3 trial.Lancet. 2020; 395: 1613-1626Abstract Full Text Full Text PDF PubMed Scopus (563) Google Scholar It has been more than a decade since the UK START B trialists reported 5-year primary endpoint results. The change to moderate hypofractionation has been very slow for a number of reasons, including concern regarding strength of evidence to support 15 fractions in certain subgroups such as those receiving nodal radiation therapy and financial concerns, with reimbursement systems based on payment per fraction.14Bekelman J.E. Sylwestrzak G. Barron J. et al.Uptake and costs of hypofractionated vs conventional whole breast irradiation after breast conserving surgery in the United States, 2008-2013.JAMA. 2014; 312: 2542-2550Crossref PubMed Scopus (179) Google Scholar,15Prades J. Algara M. Espinàs J.A. et al.Understanding variations in the use of hypofractionated radiotherapy and its specific indications for breast cancer: A mixed-methods study.Radiother Oncol. 2017; 123: 22-28Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar In contrast, rapid adoption of the FAST-Forward protocol prompted by COVID-19 may mean we arrive at an international consensus on who should have 5-fraction breast radiation therapy within months instead of years so that our future patients have equitable access to evidence-based hypofractionation. The coronavirus pandemic had an immediate and dramatic impact on training and recruitment of clinical oncologists across the United Kingdom. As hospitals worked quickly to prepare for COVID-19, many CO trainees were redeployed into acute medical or intensive care settings. Those remaining in oncology faced new challenges as they grappled with telemedicine, COVID-specific changes in practice, and increasingly complex risk-benefit decisions. Established training courses stopped suddenly, and examinations were canceled. The unfortunate cessation of the national recruitment program midway through a 2-day interview process because of the lockdown threw a previously well-tried and trusted process into disarray. Many trainees engaged in academic work also suspended their research and returned to full-time clinical work. Unsurprisingly, trainees reported considerable distress and frustration. Strategies to mitigate the devastating impact of these acute challenges were initiated by national education bodies and consolidated by the RCR with strong input from the Oncology Registrars' Forum, a subcommittee of CO trainee representatives from across the United Kingdom. Flexibility has also been afforded to academic trainees to resume their research, and key funders are facilitating additional research costs arising from the unavoidable delays. Longer term, the impact of COVID-19 on CO training is likely to be more positive. The emergency implementation of a self-assessment process for recruitment has made the value of face-to-face interviews clear. With local training schemes under pressure, the RCR was able to step in as the overarching source of trainee guidance and education. This drive for greater national consistency in training was galvanized by COVID-19, directed in particular by the agile initiatives of the Oncology Registrars' Forum and by sharing best practice with other specialties. Trainers and trainees are now empowered to use more modern teaching tools such as webinars and online fora. Many of these can be delivered nationally, to excellent quality-assured standards, and with best practice shared quickly. There has been real empowerment of a trainee body resolute in taking responsibility for shaping its own training in response to COVID-19, an ethos that must be built on going forward. The Final Fellowship of the Royal College of Radiologists examination is taken in the penultimate year of training and consists of both written and practical components. Examination capacity is constrained by a clinical component held in a limited number of hospitals with a need for patient volunteers and written papers taken in a large central examination hall. Before COVID-19, discussions about modernizing the Final Fellowship of the Royal College of Radiologists were just beginning. The need for change was prompted by a call to reflect the real-life model of clinical decision-making16Casswell G. Shakir R. Macnair A. et al.UK training in clinical oncology: The trainees' viewpoint.Clin Oncol. 2018; 30: 602-604Abstract Full Text Full Text PDF Scopus (12) Google Scholar and the new 2020 training curriculum. The changes enforced by the pandemic now present us with a great opportunity to transform the examination. Anticipating ongoing travel restrictions, the current intention is for examinations to be taken in a greater number of locations throughout the United Kingdom than previously. We will thereby provide an examination close to the candidate's training base, being cognizant of social distancing requirements that will be consistent across the entire country. Written examinations will be delivered in a digital format at each location. Structured oral examinations will also take place online, maintaining individual interaction between candidate and examiner independent of location. The examination will be recorded, with assessment by a second independent examiner, thus providing 2 assessments as would have been the case with the live examination. Because it will not be possible to hold face-to-face clinical examinations with volunteer patients, these practical assessments will be undertaken through additional stations in the oral examination. They will be based on curriculum-focused clinical vignettes with practical elements to demonstrate clinical skills and assess decision-making ability, such as a multidisciplinary meeting. The aim is to produce an examination format that is more versatile and responsive to increased capacity demands, evolves over time to reflect the changing needs of modern clinical practice, and is flexible to the trainee's needs. This model has potential for widespread adoption both within and beyond the United Kingdom. As in many other aspects of medicine, COVID-19 promises to be a catalyst of rapid and progressive change for the benefit of patients and health care professionals. The full impact of the COVID-19 pandemic on the UK population remains to be seen, but high death rates, enormous lifestyle changes, and massive economic pressures will reshape society for generations. Cancer will still need treatment, and the CO community is well placed to adapt to the new order and change rapidly. Centrally funded services and structures can promote fast and widespread dissemination of new techniques and therapies. Our next generation of experts can benefit from a modern approach to training and examinations. Spending on health care may not match that of other nations, but we have potential to adapt and develop in response to this unprecedented challenge, providing access to high-quality, evidence-based radiation therapy, which remains free at the point of delivery to all in the United Kingdom.

To the Editor: We read with great interest the article titled “Unilateral Radiotherapy for the Treatment of Tonsil Cancer” by Chronowski et al ( 1 Chronowski G.M. Garden A.S. Morrison W.H. et al. Unilateral radiotherapy for the treatment of tonsil cancer. Int J Radiat Oncol Biol Phys. 2012; 83: 204-209 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar ). We noticed that in this paper, none of the 22 patients with N2b disease experienced recurrence in the contralateral neck. Three other studies of ipsilateral radiation therapy for tonsil cancer had also reported similar outcomes ( 2 O'Sullivan B. Warde P. Grice B. et al. The benefits and pitfalls of ipsilateral radiotherapy in carcinoma of the tonsillar region. Int J Radiat Oncol Biol Phys. 2001; 51: 332-343 Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar , 3 Jackson S.M. Hay J.H. Flores A.D. et al. Cancer of the tonsil: the results of ipsilateral radiation treatment. Radiother Oncol. 1999; 51: 123-128 Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar , 4 Rusthoven K.E. Raben D. Schneider C. et al. Freedom from local and regional failure of contralateral neck with ipsilateral neck radiotherapy for node-positive tonsil cancer: results of a prospective management approach. Int J Radiat Oncol Biol Phys. 2009; 74: 1365-1370 Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar ). However, the number of patients with N2b disease in each study was small. We are concerned that the inference that ipsilateral radiation therapy is adequate in tonsil cancer with N2b disease may be falsely reassuring. Unilateral Radiotherapy for the Treatment of Tonsil CancerInternational Journal of Radiation Oncology, Biology, PhysicsVol. 83Issue 1PreviewTo assess, through a retrospective review, clinical outcomes of patients with squamous cell carcinoma of the tonsil treated at the M. D. Anderson Cancer Center with unilateral radiotherapy techniques that irradiate the involved tonsil region and ipsilateral neck only. Full-Text PDF In Reply to Geropantas et alInternational Journal of Radiation Oncology, Biology, PhysicsVol. 85Issue 1PreviewTo the Editor: We appreciate the commentary by Geropontas et al regarding our experience treating early T-stage tonsil cancer with unilateral radiation therapy (1, 2). We thank Dr Geropontas and his group for sharing their unpublished data, which suggest increased contralateral failure rates in patients with N2b neck disease. Full-Text PDF

To the Editor: Warthin’s tumour (WT) is also known as adenolymphoma or papillary cystadenoma lymphomatosum. It is the most common ‘monomorphic’ adenoma of the major salivary glands and accounts for 12% of all parotid tumours [1, 2]. It is benign and is predominantly found within the parotid gland. The majority of extra-parotid WT occur in the peri-parotid and cervical lymph nodes. They are usually incidental findings and arise as a result of inclusion of salivary gland tissue within the adjacent lymph nodes during embryogenesis [3]. We describe a patient with an extra-parotid WT mimicking nodal relapse of a previously treated invasive follicular thyroid cancer on ultrasound, computerised tomography (CT) and post-treatment iodine-131 (131I) whole body scan. An 81 years old asymptomatic woman was noted to have a rising serum thyroglobulin (Tg) level. Ten years previously, she had an invasive follicular thyroid cancer treated with total thyroidectomy followed by an ablative dose of 131I, achieving complete remission with an undetectable serum Tg in the absence of interfering antibodies and negative post-treatment 131I whole body scan. Her serum levels of thyroid-stimulating hormone remain adequately suppressed throughout. Non-contrast CT of the neck, thorax and abdomen performed to evaluate rising Tg revealed an enlarged right low level 2, cervical lymph node measuring 17mm in short axis dimension (Fig. 1A). This was confirmed on neck ultrasound. Bone scan was unremarkable. Fine needle aspiration cytology of this neck node was non-diagnostic. She was treated with 5.6GBq of 131I for probable nodal recurrence. Post-treatment whole body 131I scan performed 10 days following treatment showed uptake in the superior aspect of her right neck (Fig. 1B). This corresponded to the position of the lymph node noted on her diagnostic CT. Despite 131I treatment, her unstimulated serum Tg continued to rise to 27.7ng/mL. A repeat CT showed no change in the size of the cervical node with no evidence of recurrent disease elsewhere. A right-sided neck dissection revealed no malignancy but a Warthin’s tumour within a level 2 cervical lymph node. No cause for the rising serum Tg was found on further investigations including fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG-PET/CT). In view of her continued lack of symptoms, she was managed with close observation and imaging surveillance. A continuously rising serum Tg from undetectable levels at follow-up suggested thyroid cancer recurrence. Imaging was required to look for sites of recurrent or metastatic disease. Fine needle aspiration cytology of cervical nodes may not always be diagnostic though its sensitivity may be improved by measuring Tg level in the needle washout fluid [4]. Empirical 131I treatment can be considered which may be both therapeutic and diagnostic [5]. Data from the published literature showed that 63% of these patients will achieve a reduction in serum Tg while 62% will demonstrate uptake on whole-body scanning post-treatment [6]. However, a reduction in serum Tg alone does not equate therapeutic benefit and there is no evidence that such an approach improves survival. Moreover, normalisation of serum Tg may occur spontaneously in a substantial proportion of patients without treatment [7]. The cause of our patient’s rising serum Tg remains unknown. Preparation before 131I whole body scanning was adequate and there was absence of circulating interfering Tg antibodies. A recent review identified presence of low volume metastatic thyroid cancer too small to be visualised on 131I scan and dedifferentiated tumour that lost its ability to concentrate iodine as other possible causes of an elevated serum Tg and false-negative 131I whole body scan [8]. In conclusion, our case highlights two important learning points. Firstly, extra-parotid WT can mimic lymph node metastasis on ultrasound and CT in patients with a history of thyroid malignancy. It should therefore form part of the differential diagnosis in such patients with cervical nodal enlargement. Secondly, WT can lead to false-positive result on 131I whole body scan. This should always be considered, especially if the serum Tg continues to rise despite uptake on the post-treatment scan.

Variability in gross tumour volume (GTV) definition is a major source of systematic error in conformal radiotherapy. This prospective study assesses the role of multidisciplinary collaboration between oncologists and radiologists in defining lung cancer volumes. Twenty patients with non-small cell lung cancer due to receive three-dimensional conformal radiotherapy formed the study population. GTVs were defined by a radiologist (GTVrad) and an oncologist (GTVonc) using available clinical information and imaging. A collaborative meeting was then held to agree on a final, common GTV (GTVfin) to be used for treatment planning, and differences analysed. The collaboration changed the GTV in 19/20 patients with a total of 50 regions being edited. Changes made were categorized as (a) differentiation of tumour from atelectasis or ground glass shadowing, (b) separation of tumour from vasculature, and (c) defining mediastinal extent of tumour. Oncologists were more confident in the GTVfin than the GTVonc. The radiologist took longer to define the GTV than the oncologist. Real-time collaborative GTV definition by a radiologist and oncologist is practical and feasible. This approach allows specific areas of uncertainty to be categorized and focussed on, reducing systematic error in GTV definition. The physician's approach to risk and decision making for each patient may also play a role.

The purpose of this study was to explore how radiologist and oncologists may work together efficiently and effectively to define target volume for radiotherapy treatment. Ten patients were chosen at random from those needing radiotherapy between December 2004 and June 2005. Sites of primary cancer included head and neck, pelvis, lung and brain. Diagnostic scans were available on the hospital PACS system and radiotherapy planning image data sets were available on the Eclipse radiotherapy planning system. A radiologist and two oncologists (one consultant, one senior registrar) outlined separately and without initial consultation the gross tumour volume (GTV). Analysis of target volume concordance rates was undertaken to assess and explore the reasons for any differences noted. Three of ten volumes defined (all head and neck tumours) were judged to be similar based on quantitative and qualitative data. There were varying degrees of difference in volume definition for the remaining seven patients. In three of these there were differences in GTV but when the treatment volume was drawn the differences were not clinically significant, as any areas of disagreement were included anyway in the fields in both plans. The remaining four cases had showed significant differences between the volume delineated by the oncologist and the radiologist. In all cases where the GTV was easily identifiable on the diagnostic and planning scans, there was concordance. In cases where the final treatment field used was much bigger than the GTV (e.g. a four-field box for pelvic fields) then small differences were negligible, although with conformal therapy these differences could become important. There were specific radiological anatomy learning points for the oncologists and the radiologist needed to be familiar with the process of treatment planning. A larger prospective study will continue to explore the potential gains from and the practicalities of collaborative working.