March 2013 - Institute of Physics and Engineering in Medicine

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NEWS BY USMAN I. LULA AND RICHARD AMOSRadiotherapy physics research in the UK:challenges and proposed solutionsTABLE 1StrengthsInfrastructure• Modern equipment• CR-UK cancer centre statusStaff• Motivated and highly skilled staffFunding• Good grant funding track record• Industrial linksCulture• Track record in research• Track record in translational research• Trial involvementLinks• Academic links• Links to academic oncologistsWeaknessesInfrastructure• Therapy equipment access andlaboratory spaceStaff• Lack of protected time for physicsresearch• Lack of critical mass• Staffing establishment less than IPEMstandardsFunding• Lack of grant income or core fundingClinical academics• Limited number of research-activeclinicians or no academic leadCulture• Large clinical service hamperingresearch• Progress in advanced radiotherapyAcademic links• No academic linksOpportunitiesInfrastructure• New technology opportunitiesLinks• Academic links• Increased links withmanufacturers• Increased number of academiconcologistsThreatsFunding• NHS funding cuts and costimprovement programmes• Current economic climate• Lack of (national) funding streamsfor radiotherapy-related researchClinical radiotherapy service• NHS service pressureTable 1: Summary of pre-meeting strengths, weaknesses,opportunities and threats (SWOT) analyses from 23 radiotherapyphysics departments. Key factors (nominated by >5 centres) in bold,common factors (nominated by >2 centres) in plain text. Table kindlysupplied by Dr Ranald Mackay, Christie Medical Physics andEngineering, The Christie NHS Foundation Trust, Manchester M204BX. © BIR, ‘Commentary – radiotherapy physics research in the UK:challenges and proposed solutions’, RI Mackay, NG Burnet, S Green,TM Illidge, JN Staffurth, Brit J Radiol 2012; 85: 1354–62RADIOTHERAPY PHYSICSRadiotherapy is a potent, costeffective,technology-ledtreatment modality. Scientificadvances such as IMRT, IGRT andSABR provide real improvementin patients’ outcomes. Innovationand implementation requiresignificant additional expertise, aswell as high levels of researchexpertise within leading centres.The Clinical and TranslationRadiotherapy Research WorkingGroup (CTRad) is an NCRI workinggroup formally launched in 2009to focus on clinical andtranslational issues relating toradiotherapy and radiobiology. In2011, CTRad organised a meetinginvolving 23 departments (withCR-UK status) to address theissues affecting radiotherapyphysics research in the UK.Departments were asked tocomplete a pre-meetingevaluation of their researchinfrastructure and the strengths,weaknesses, opportunities andthreats (SWOT) within their owncentre (table 1). There wereseveral meeting discussionthemes including: R&D processfor radiotherapy physics; barriersto research; research time andstaffing models; academic careerstructure; funding dilemmas, andthe impact of expansion ofradiotherapy services.The meeting discussions andevaluation forms highlightedseveral issues: lack of dedicatedaccess to a linac for research;research conducted ’out of hours’or fitted around a clinical servicerunning at full capacity and theneed for dedicated time toconduct research. In terms ofpriorities for research, the topthree areas were image guidance,verification of complex treatmentsand radiobiological modelling.The expansion of radiotherapy hasstretched physics services anddepartments have been underpressure to expand IGRT/IMRT. Asa result, R&D in radiotherapy hassuffered due to staff not keepingpace with the expansion in clinicalwork. This has further hamperedprogression towards the‘Roadmap to modern 4D-adaptiveRT’ for a world-class radiotherapyservice as envisioned byNRIG/NCAT. There is arequirement to reinforce guidancefrom professional bodies toincrease technologist numbersand thus liberate time forscientists to dedicate todevelopment and research.A symbiotic relationship isrequired between the medicalphysicist and the clinician foreffective multidisciplinaryworking. Several models werediscussed when maximising onthe effective use of staff forclinical research and also whenrolling out a well-developedtechnique into all centres.It is clear that there arechallenges in both funding andstaffing of radiotherapy physics.Recommendations forimprovements included:n funding opportunities (e.g. fromEPSRC, the STF and CR-UK);n identification of academictraining routes withinModernising Scientific Careers;n introduction of formal job plansto allow protected research time;n improved access to researchfacilities;n benchmarking of researchinfrastructure against othersuccessful centres;n developing strategies withpartner HEI’s and local initiativesand collaboration betweenradiotherapy physicsdepartments.To realise the full potential ofradiotherapy in improvingoutcomes for cancer patients, theNHS, HEIs and funders need toprovide a more secure physicsR&D environment.‘ MORE INFORMATIONThis work was published in Brit JRadiol 2012; 85: 1354–62.http://dx.doi.org/10.1259/bjr/6153068608 | MARCH 2013 | SCOPE
NEWS BY USMAN I. LULA AND RICHARD AMOSModel for IMRT of glioblastoman AN IMAGING OXIMETERDynamic imaging techniquessuch as contrast-enhancedoptical imaging can be used tocharacterise physiologicalprocesses. To quantifyprocesses such as blood flow,the time-dependantconcentration of dye in arterialblood – the arterial inputfunction (AIF) – must bedetermined. The AIF can bemeasured using a pulse dyedensitometer (PDD), which isan expensive and specialiseddevice. However, researchers inLondon, ON, and Hanover, NH,have shown that it is possible tomeasure the AIF with a simplepulse oximeter, a device foundin virtually every intensive careunit in the world (Phys Med Biol2012; 57: 8285).n SECOND TEXAS CENTREIBA (Ion Beam Applications) hasannounced that it has signed aformal contract with the TexasProton Therapy Center. The newproton therapy centre is acollaborative effort betweenDallas-based Texas Oncologyand Baylor Health Enterprises,an affiliate of Baylor HealthCare System. This will be thesecond Texas-based protonfacility, the other being at theUniversity of Texas MDAnderson Cancer Center inHouston.n ENHANCING THERAPYUsing a combination of singleBragg peak proton beams andpreferential tumour uptake ofmetallic nanoparticles (gold oriron) to generate short-rangesecondary radiation,researchers at the CatholicUniversity of Daegu, the KoreaAtomic Energy ResearchInstitute and Seoul NationalUniversity in Korea haveobserved remarkabletherapeutic enhancement,percentage tumour regressionand 1-year survival (Phys MedBiol 2012; 57: 8309).ADAPTIVE RADIOTHERAPYFigure 1: Simulated T2 MRI radii vs time for the radio-resistant patient.Image from CH Holdsworth et al. Phys Med Biol 2012; 57: 8271Figure 2: Simulated T2 MRI radii vs time for the radio-sensitive patient.Image from CH Holdsworth et al. Phys Med Biol 2012; 57: 8271Glioblastoma multiforme (GBM)is a common brain tumour,characterised by extensiveinfiltration of normalparenchyma. Radiotherapy ofGBM typically involves delivery ofa uniform dose with largemargins, which does not accountfor patient-specific factors suchas diffuse disease or tumourheterogeneity. Researchers at theUniversity of Washington MedicalCenter in Seattle are addressingthis with an intensity-modulatedradiotherapy (IMRT) optimisationalgorithm that incorporatespatient-specific parameters.The researchers used a multiobjectiveevolutionary algorithm(MOEA) to perform IMRT planoptimisation. They combined thisalgorithm with a GBM modeldescribing spatial and temporalchanges in tumour cell density.The GBM model quantifies ratesof proliferation and invasion usingdata derived from MR images.The resulting algorithm enabledweekly re-optimisations based onpredicted changes in the tumourarising from radiation-inducedcell kill, tumour diffusion andproliferation.The team simulated 7 weeks ofIMRT for a patient with radioresistantGBM and a patient withradio-sensitive disease. Theystudied five differentoptimisations. Three of the plansminimised tumour cell survivalafter 1 week of treatment, whilerestricting dose per fraction toany voxel to 3 Gy, 8 Gy or no limit.The other two plans wereoptimised for maximum tumourcell kill 11 weeks after 1 week oftreatment, both using an 8 Gyrestriction.The researchers assessed thepredicted tumour radii (as visibleon T2 MRI) over time, andcompared to a standard clinicalplan delivering 61.2 Gy at 1.8 Gyper fraction. They also recordedthe ‘treatment gain’, defined asthe added number of days for thetumor radius to reach 4 cm postradiotherapy,compared with anuntreated control.For both patients, plans with a3 Gy dose limitation showed worseperformance compared to thestandard plan. Tumour controlwas improved by increasing themaximum dose restriction. Forthe radio-resistant patient, theother four plans improvedtreatment gain from 27 days forthe standard plan to between 77and 90 days.For the radio-sensitive patient,tumour response depended uponboth the maximum dose and thedecision criteria used. With nodose limit, treatment gainimproved from 68 days for thestandard plan to 157 days.However, optimisation based ontumour survival 11 weeks after 1week of treatment gave a similartreatment gain of 153 days, but ata lower dose, suggesting this asthe best target objective for use inthe MOEA.The team concluded thatMOEA-optimised plansdemonstrated potential forimproved tumour control overcurrent clinical practice.‘ MORE INFORMATIONThis paper was published in PhysMed Biol 2012; 57: 8271.doi:10.1088/0031-9155/57/24/8271SCOPE | MARCH 2013 | 09
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