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• W3208187844 abstract "On target: ensuring geometric accuracy in radiotherapy was published in 2008 and aimed to provide guidelines for image-guided radiotherapy (IGRT) [[1]The Royal College of RadiologistsSociety and College of RadiographersInstitute of Physics and Engineering in Medicine. On target: ensuring geometric accuracy in radiotherapy. The Royal College of Radiologists, London2008Google Scholar]. At the time of publication, electronic portal imaging (EPI) was the most common imaging technology available, the implementation and use of which had increased over the previous decade. Although EPI enabled images to be acquired immediately before radiotherapy delivery, the most common correction protocols used were offline [[2]Ludbrook J.J. Greer P.B. Blood P. D’yachkova Y. Coldman A. Beckham W.A. et al.Correction of systematic setup errors in prostate radiation therapy: how many images to perform?.Med Dosim. 2005; 30: 76-84Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,[3]De Boer J.C.J. Heijmen B.J.M. A new approach to off-line setup corrections: combining safety with minimum workload.Med Phys. 2002; 29: 1998-2012Crossref PubMed Scopus (27) Google Scholar]. This was often driven by the lack of integrated couch and imaging systems; moving the couch manually increased both treatment time and the potential for error by interrupting the treatment workflow. Also, in long fractionation schedules, offline protocols are very effective. In addition, due to EPI limitations, direct visualisation of the target was often not possible and IGRT relied on matching to a surrogate structure, typically bone. The implementation of cone-beam computed tomography had a significant impact on image verification by routinely providing three-dimensional soft tissue images at the time of treatment [[4]Jaffray D.A. Siewerdsen J.H. Cone-beam computed tomography with a flat-panel imager: initial performance characterization.Med Phys. 2000; 27: 1311-1323Crossref PubMed Scopus (475) Google Scholar,[5]Korreman S. Rasch C. McNair H. Verellen D. Oelfke U. Maingon P. et al.The European Society of Therapeutic Radiology and Oncology-European Institute of Radiotherapy (ESTRO-EIR) report on 3D CT-based in-room image guidance systems: a practical and technical review and guide.Radiother Oncol. 2010; 94: 129-144Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar]. Cone-beam computed tomography enabled online and offline image verification to the target, improving the accuracy of treatment delivery. With the introduction of stereotactic body radiotherapy and hypofractionation, online delivery became more imperative. The impact of three-dimensional imaging affected the professional development of the main oncology professionals, physicists and radiographers in particular, where increased knowledge of three-dimensional anatomy, image optimisation, connectivity and networking were becoming more essential. The On target document [[1]The Royal College of RadiologistsSociety and College of RadiographersInstitute of Physics and Engineering in Medicine. On target: ensuring geometric accuracy in radiotherapy. The Royal College of Radiologists, London2008Google Scholar] had only dealt with planar imaging and therefore updated guidance was created in 2012 in an attempt to standardise the use of three-dimensional treatment imaging [[6]National Radiotherapy Implementation Group Report Image Guided Radiotherapy (IGRT). Guidance for implementation and use..August 2012https://www.sor.org/getmedia/75a96781-fb21-4f5d-bdf6-a7153788a267/National%20Radiotherapy%20Implementation%20Group%20Report%20IGRT%20Final.pdf_1Google Scholar]. However, as hypofractionation increased in many tumour sites, for example lung, prostate and breast, and with the CHHiP study (CRUK/06/016), PACE (NCT01584258) and FAST-Forward (HTA - 09/01/47) trials being implemented [7Dearnaley D. Syndikus I. Mossop H. Khoo V. Birtle A. Bloomfield D. et al.CHHiP Investigators. Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial.Lancet Oncol. 2016; 17 (Erratum: Lancet Oncol 2016;17(8):e321): 1047-1060https://doi.org/10.1016/S1470-2045(16)30102-4Abstract Full Text Full Text PDF PubMed Scopus (724) Google Scholar, 8Brand D.H. Tree A.C. Ostler P. van der Voet H. Loblaw A. Chu W. et al.PACE Trial Investigators. Intensity-modulated fractionated radiotherapy versus stereotactic body radiotherapy for prostate cancer (PACE-B): acute toxicity findings from an international, randomised, open-label, phase 3, non-inferiority trial.Lancet Oncol. 2019; 20: 1531-1543https://doi.org/10.1016/S1470-2045(19)30569-8Abstract Full Text Full Text PDF PubMed Scopus (226) Google Scholar, 9Murray Brunt A. Haviland J.S. Wheatley D.A. Sydenham M.A. Alhasso A. Bloomfield D.J. et al.FAST-Forward Trial Management Group. Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial.Lancet. 2020; 395: 1613-1626https://doi.org/10.1016/S0140-6736(20)30932-6Abstract Full Text Full Text PDF PubMed Scopus (344) Google Scholar], the necessity of online verification increased and updated guidance was sought. Although the guidance was 3 years in production, it is hoped to be relevant for many years in the future. With the large amount of potential image guidance solutions and workflow available, the report – published in June 2021 by the Radiotherapy Board [[10]Radiotherapy Board On Target 2: updated guidance for image-guided radiotherapy. The Royal College of Radiologists, London2021Google Scholar] – not only aims to describe these but also offers guidance in which circumstances a particular workflow may be considered. An extended chapter on margin calculation is included, with clarification of errors in the context of IGRT, focusing on uncorrected errors, such as delineation uncertainty, differential motion, rotations and guidance uncertainty. This chapter links well with the recently published British Institute of Radiology Working Party report on margins [[11]Tudor G.S.J. et al.Geometric uncertainties in daily online IGRT: refining the CTV-PTV margin for contemporary photon radiotherapy. British Institute of Radiology, London2020Google Scholar]. Also, an additional chapter on change management was added. Magnetic resonance image guidance and ultrasound are also included in the technology sections. Adaptive radiotherapy is a further additional chapter, reflecting the change of practice that treatment techniques such as using a library of plans to treat with a ‘plan of the day’ and the online adaptive workflow facilitated by novel ring-based accelerators, magnetic resonance linear accelerator systems and artificial intelligence solutions, can offer. When the site-specific sections were updated, it was interesting to note the lack of evidence for online imaging, although it is being used more widely and is recommended in guidelines, for example, the radiotherapy for lung cancer Royal College of Radiologists consensus statements [[12]The Royal College of Radiologists.Radiotherapy for lung cancerRCR consensus statements. The Royal College of Radiologists, London2020Google Scholar]. As technology becomes more commonly available, the need to prove and quantify its benefit seems less imperative and becomes almost impossible to organise. A similar situation arose during the introduction of intensity-modulated radiotherapy, which is now common practice in spite of limited evidence. By working with a large working group, we hoped to ensure that the recommendations were both optimal and relevant in the UK. IGRT remains a major technology for the future, the form of which will probably continue to change and evolve, but many principles will remain the same. We, the professionals working with IGRT, must continue to do so in multidisciplinary teams to maintain consistency with optimal imaging and decision-making. The authors acknowledge National Health Service (NHS) funding to the National Institute for Health Research (NIHR) Biomedical Research Centre at The Royal Marsden and The Institute of Cancer Research. The views expressed in this publication are those of the authors and not necessarily those of the NHS or the NIHR. H.A. McNair is funded by a NIHR and Health Education England Senior Clinical Lectureship award. M. van Herk was supported by the NIHR Manchester Biomedical Research Centre. H.A. McNair reports a relationship with Elekta AB that includes: funding grants; a relationship with the National Institute for Health Research that includes: funding grants. M. van Herk reports a relationship with Elekta AB that includes: funding grants, speaking and lecture fees, and travel reimbursement. K. Franks reports a relationship with AstraZeneca Pharmaceuticals LP that includes: consulting or advisory; a relationship with Boehringer Ingelheim International GmbH that includes: consulting or advisory; a relationship with Bristol-Meyers-Squibb that includes: board membership; a relationship with Roche and Takeda that includes: consulting or advisory; a relationship with Lilly that includes: consulting or advisory." @default.
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