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Department of Pathology, Brigham and Women’sHospital, Boston, Massachusetts.Presented in part at the 39th annual meeting of theAmerican Society for Therapeutic Radiology andOncology, Orlando, Florida, October 20, 1997.Current address for Janice A. Lyons, M.D.: Depart-ment of Radiation Oncology, Cleveland ClinicFoundation, 9500 Euclid Avenue, Cleveland, OH44195.Address for reprints: Stella Hetelekidis, M.D., De-partment of Radiation Oncology, Brigham andWomen’s Hospital, 75 Francis Street, Boston, MA02115.Received June 1, 1998; revision received Septem-ber 14, 1998; accepted September 14, 1998.

(1999). Variability in the radiosensitivity of normal cells and tissues Report from a workshop organised by the European Society for Therapeutic Radiology and Oncology in Edinburgh, UK, 19 September 1998. International Journal of Radiation Biology: Vol. 75, No. 4, pp. 513-517.

SummarySelf-expanding metallic stents provide excellent palliation of inoperable malignant dysphagia with minimal morbidity; in many centres they now represent the treatment of choice. Covered stents represent the only reliable option in the management of malignant fistulae and are highly successful in this situation. Placement of stents at the oesophago-gastric junction remains problematic. Covered stents placed at this site have a high migration rate and uncovered stents have a relatively high incidence of tumour ingrowth. New developments, such as the Flamingo stent, may prove helpful in this area.

No abstract available.

In this study the authors analyze the documentation regarding the earliest known X-ray treatments with the objective of identifying the true origin of radiation therapy. The four most often quoted events, including X-ray treatments allegedly performed in 1896 are analyzed in the light of available published reports. From this it is concluded that Despeignes of Lyon, who in July of 1896 irradiated a patient with cancer of the stomach, is in all likelihood the first person to perform documented radiation therapy treatments with a scientific and logical basis.

The first annual multidisciplinary Prostate Cancer Symposium (Orlando, FL, February 17-19, 2005) was a remarkable meeting that brought together 1,035 individuals interested in the prevention and treatment of prostate cancer. This meeting, sponsored jointly by the American Society of Clinical Oncology, the American Society for Therapeutic Radiology and Oncology, the Society of Urologic Oncology, and the Prostate Cancer Foundation, was the culmination of several years of planning, and represented the first truly multidisciplinary scientific and educational meeting dedicated solely to prostate cancer.

Objective: The consultation fee for outpatient radiotherapy was newly introduced in the national health insurance system in Japan in April 2012. We conducted a survey on the use of this consultation fee and its effect on clinical practices. Methods: The health insurance committee of the Japanese Society of Therapeutic Radiology and Oncology conducted a questionnaire survey. The questionnaire form was mailed to 160 councilors of the Society, the target questionees. A total of 94 answers (58% of the target questionees) sent back were used for analyses. Results: The analyses revealed that 75% of the hospitals charged most of the patients who receive radiotherapy in an outpatient setting a consultation fee. The introduction of the consultation fee led to some changes in radiation oncology clinics, as evidenced by the response of ‘more careful observations by medical staff’ in 37% of questionees and a 12% increase in the number of full-time radiation oncology nurses. It was also shown that the vast majority (92%) of radiation oncologists expected a positive influence of the consultation fee on radiation oncology clinics in Japan. Conclusions: Our questionnaire survey revealed the present status of the use of a newly introduced consultation fee for outpatient radiotherapy, and the results suggested its possible effect on promoting a multidisciplinary medical care system in radiation oncology departments in Japan.

The radiation oncology seminar for medical students and residents was initiated by the Japanese Society for Therapeutic Radiology and Oncology (JASTRO) with the aim of increasing the numbers of radiation oncologists. We investigated the long-term results related to the career paths of the program participants. This study enrolled 531 individuals who were medical students and residents at the time of program participation, between 1995 and 2011. We surveyed participants with regard to their affiliation status with the Japan Radiological Society (JRS) and JASTRO and whether they were board-certified radiation oncologists. Forty-two percent of the participants were members of JRS and 26.4 % were members of JASTRO. The membership status with JASTRO was investigated in program participants from 2004 to 2009, and comparison by status revealed that 30.1 % of medical students and 47.2 % of residents were members, with a significant difference (p = 0.013). As high as 92.3 % of the participants in the 1995–2001 cohort who had joined JRS and JASTRO were board-certified radiation oncologists. This program has greatly contributed to increasing the numbers of radiation oncologists. Because residents had a higher rate of affiliation than medical students, it is necessary to share information with not only medical universities, but also teaching hospitals.

The endeavors of my predecessor, Professor Jan Lotz, a committed visionary who served the South African Journal of Radiology (SAJR) in a permanent capacity for 5 years (2008 - 2012), are gratefully acknowledged. Under his stewardship, the SAJR benefited from a consistent editorial policy. The journal grew in size to an average of 40 pages per issue, with broader editorial variety accordingly. The online manuscript management system revolutionised the submission and review process. The promised CPD programme was delivered and the journal took major steps toward international recognition, being invited to join GO RAD (Global Outreach - Radiology), a global outreach programme of the International Society of Radiology.

Purpose The goal of this study was to explore the perspectives and practice of radiation oncologists who treat breast cancer patients who have had breast reconstruction. Methods In 2010, an original electronic survey was sent to all physician members of the American Society of Radiation Oncology, National Cancer Research Institute-Breast Cancer Studies Group in the United Kingdom, Thai Society of Therapeutic Radiology and Oncology, Swiss Society of Radiation Oncology, and Turkish Radiation Oncology Society. We identified factors associated with radiation oncologists who treat breast cancer patients with reconstruction performed prior to radiation and obtained information regarding radiation management of the breast reconstruction. Results 358 radiation oncologists responded, and 60% of the physicians were from the United States. While 64% of participants agree or strongly agree that breast image affects a woman’s quality of life during radiation, 57% feel that reconstruction challenges their ability to deliver effective breast radiation. Compared with other countries, treatment within the United States was associated with a high reconstruction rate (>/= 50% of mastectomy patients) prior to radiation (p Conclusions Great variation in practice is evident from our study of radiation treatment for breast cancer patients with reconstruction. Further research on the impact and delivery of radiation to a reconstructed breast may validate some of the observed practices, highlight the variability in treatment practice, and help create a treatment consensus.

The use of adjuvant Whole Abdominal Radiation Therapy (WART) in gynecologic cancers has not achieved widespread use for a variety of reasons. Several phase III trials comparing WART with adjuvant chemotherapy (CT) in both uterine and ovarian cancers have demonstrated marginal improvement in survival favoring CT over WART. However, the dose of conventionally delivered WART has been historically limited due in large part to the low threshold of normal organ tolerance in the upper abdomen associated with significant late effects of the bowel and kidneys in particular. Yet, with the advent of Image-Guided Radiation Therapy (IGRT), the possibility of dose reduction to nearby organs at risk along with the potential to increase target volume dose is now obtainable. This paper will review the current data related to IGRT WART for several different patient populations of gynecologic cancers.

No abstract available.

This document is now in the process of being endorsed by all National Scientific Societies of Radiotherapy and Medical Physics of the European countries. It can therefore not be formally considered as the definitive version and is still susceptible to benefit from further alterations or improvements.

13 Background: Under the Choosing Wisely (CW) Campaign, the American Society of Clinical Oncology (ASCO) and the American Society of Therapeutic Radiology and Oncology (ASTRO) recommend against non-evidence-based costly medications, tests, and procedures. CW recommendation adherence in the Deep South is largely unknown, and opportunities to reduce overuse and costs may exist. Methods: Analysis of administrative claims and tumor registry data from 12 cancer centers of the University of Alabama Health System Cancer Community Network, for Medicare beneficiaries ≥65 years old with cancer. Main outcome: percent of beneficiaries adhering to 9 CW recommendations. Results: 2012-2015 (Q1) adherence varied across CW recommendations and cancer centers, and increased over time for CW 2 and 7, decreased for 3, 5, and 6, and did not change for others. Conclusions: Opportunities to improve quality and value of cancer care exist in the Deep South. Research should understand how to minimize use of non-evidence based medications, tests, and procedures. [Table: see text]

Therapeutic radiology was initially based purely on clinical experience. Radiation physics was introduced in Sweden when Rolf M. Sievert started the "Radiumhemmet Physics Laboratory" in 1920. Dosimetry standards, in vivo dosimetry, brachyradium techniques, teleradium therapy and radiation protection were areas for development. After world war II there has been a continuous expansion of the profession due to the introduction of high energy accelerators for photon and electron therapy and artificial radionuclides. Hospital physicists are responsible for the performance of advanced equipment, design and use of beaming shaping devices, and computer systems for treatment planning and verification. Swedish physicists have been engaged in the international organizations for radiation dosimetry (ICRU) and radiation protection (ICRP), in activities by IAEA, WHO, and UNSCEAR. The international cooperation in hospital physics and radiation protection has been initiated and promoted by Swedish physicists.

Intensity-modulated radiotherapy (IMRT) is the delivery of radiation to the patient via fields that have non-uniform radiation fluence. IMRT allows concave dose distributions and dose gradients with narrower margins than those possible using conventional methods [1,2]. IMRT is ideal for irradiating complex treatment volumes and avoiding close proximity organs at risk that may be dose limiting [2]. This can provide increased tumour control through allowing safer dose escalation and/or can reduce normal tissue complications through organ at risk sparing. The technique has been driven by sophisticated, computer-based inverse planning programs and computed tomography-based planning capabilities [3]. IMRT began in the Karolinska Institute in Stockholm in 1982 [4]. The first clinical IMRT in theworld by any techniquewas performed at Baylor College of Medicine, Houston, Texas, USA in March 1994 [5]. Since 2000, IMRT use has exploded, particularly for the treatment of localised prostate cancer and head and neck cancer. Goldin and colleagues [6] presented a Surveillance, Epidemiology and End-Results analysis of the use of IMRT for prostate cancer at the American Society of Therapeutic Radiology and Oncology Annual Scientific Meeting in 2011. They reported that, of patients treated with external radiation, IMRT use rose from 0.2% in 2000 to 97% in 2008 for the primary treatment of prostate cancer (and 0 to 82% in the postoperative setting). In this special issue, a compendium of systematic reviews of the literature on the benefits of IMRT is presented, as well as a practice guideline based on each review. Carried out by a renowned guideline group, Cancer Care Ontario, the authors have painstakingly combed the modern literature (up to 2009). What little they found was surprising, given how avidly IMRT has been adopted in North America. For all

Summary This paper explores historical and current roles of pharmaceutical industry sponsorship of clinical trials testing radiation therapy combinations with molecularly targeted agents and attempts to identify potential solutions to expediting further combination studies. An analysis of clinical trials involving a combination of radiation therapy and novel cancer therapies was performed. Ongoing and completed trials were identified by searching the clinicaltrials.gov Web site, in the first instance, with published trials of drugs of interest identified through American Society of Clinical Oncology, European CanCer Organisation/European Society for Medical Oncology, American Society for Radiation Oncology/European Society for Therapeutic Radiology and Oncology, and PubMed databases and then cross-correlated with clinicaltrials.gov protocols. We examined combination trials involving radiation therapy with novel agents and determined their distribution by tumor type, predominant molecular mechanisms examined in combination to date, timing of initiation of trials relative to a novel agent’s primary development, and source of sponsorship of such trials. A total of 564 studies of targeted agents in combination with radiation therapy were identified with or without concomitant chemotherapy. Most studies were in phase I/II development, with only 36 trials in phase III. The tumor site most frequently studied was head and neck (26%), followed by non-small cell lung cancer. Pharmaceutical companies were the sponsors of 33% of studies overall and provided support for only 16% of phase III studies. In terms of pharmaceutical sponsorship, Genentech was the most active sponsor of radiation therapy combinations (22%), followed by AstraZeneca (14%). Most radiation therapy combination trials do not appear to be initiated until after drug approval. In phase III studies, the most common (58%) primary endpoint was overall survival. Collectively, this analysis suggests that such trials are not given priority by pharmaceutical companies. The potential reasons for this and some challenges and possible solutions are discussed. 2012 Elsevier Inc.

Purpose:Although there is increasing interest in radiosurgery, little quantitative data regarding current patterns of radiosurgery practice are available. We developed a radiosurgery questionnaire to obtain information on radiosurgery practice. Methods and Materials: We distributed the questionnaire to the entire membership of the American Society of Therapeutic Radiology and Oncology in early 1993. Responses were obtained from 74 facilities that practice radiosurgery, corresponding to over 6000 treatments carried out since 1983 by 135 radiation oncologists and 130 physicists. Results: Most respondents were found to work within a multidisciplinary team, consisting of the following specialists (Average hours devoted per patient on day of treatment in parentheses): radiation oncologist (3.8), neurosurgeon (3.2), physicist (6.1), radiologist (0.7), nurse (2.7), other (3.0). On average, neurosurgeons and nurses who perform Gamma Knife radiosurgery devote significantly more time-per-patient on the day of treatment than their peers who perform linac radiosurgery. On average, less experienced radiation oncologists and physicists (≤ 24 months experience, or ≤ 50 patients treated) devote significantly more time-per-patient on the day of treatment than their more experienced peers. Although there are many more linac radiosurgery facilities than Gamma Knife facilities, on average the number of patients treated per month per facility is significantly larger at the latter. On average, follow-up responsibilities are nearly equally shared by radiation oncologists and neurosurgeons, except at Gamma Knife facilities, where neurosurgeons assume a larger percentage of follow-up responsibility. The percentages of patients treated at linac facilities for metastases or primary CNS malignancy are larger than the corresponding percentages at Gamma Knife facilities; the opposite is true for arteriovenous malformation, acoustic neuroma, and meningioma. Conclusion: Current radiosurgery practice usually involves a team approach, with participation of specialists from radiation oncology, neurosurgery, physics, radiology, and nursing. The average number of M.D. and Ph.D. hours required per treatment on the day of radiosurgery is high.

National Residency Matching Program (NRMP) Results for Radiation Oncology: 2011 Update Sanjay Aneja, B.S.,* Lynn D. Wilson, M.D., M.P.H.,* Bruce G. Haffty, M.D.,y and James B. Yu, M.D.*,z *Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut; yDepartment of Radiation Oncology, University of Medicine and Dentistry of New JerseyeRobert Wood Johnson Medical School, New Brunswick, New Jersey; and zCancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut

The current issue of Clinical and Translational Oncology includes an article that summarises and contextualises the recently published Libro Blanco de la Oncologia Radioterapica, a book written by members of the Spanish Society of Radiation Oncology (SEOR). The White Book of Radiation Oncology is the fi rst of its kind in Spain and its importance cannot be overstated. The White Book consists of 13 chapters on a wide range of topics that cover all aspects of radiation oncology and its role in cancer care in Spain. The aim of the book is to give a comprehensive overview of the current state of radiation oncology in Spain and to serve as a reference for physicians, health care administrators and hospital managers. Although it may be hard to remember a time when radiation oncology did not exist as a distinct speciality, it was only just over three decades ago (in 1978, to be precise) that the Association of Radiotherapy and Oncology (AERO) was created. In 2006, the name of the association was changed to SEOR to refl ect the fact that specialists in our fi eld are oncologists fi rst and radiotherapy experts second. The SEOR has grown signifi cantly since its founding and now has more than 750 members. In addition, the SEOR is also active internationally and has signed numerous agreements for cooperation with other medical societies, including the European Society for Therapeutic Radiology and Oncology (ESTRO). The rapid technological progress that has been made in the last decade allows us to deliver radiation with increasing precision and effectiveness, thus increasing the number of tumour localisations amenable to treatment with radiation therapy. As a result, approximately half of all cancer patients are now treated with radiotherapy. While these technological advances are clearly welcome, they also present new challenges, as specialists must constantly strive to keep up to date with the latest techniques and equipment. Technologies that seemed cutting edge only a few years ago, for example intensity-modulated radiotherapy (IMRT), are now considered standard treatment for certain tumours. Still, many of the newer technologies–4D radiotherapy, image-guided RT (IGRT), breathing-synchronised RT, SBRT, radiosurgery and intraoperative RT (IORT)–have yet to be installed in smaller clinics, even as they become increasingly common in larger RT centres. In Spain, radiotherapy centres tend to purchase and incorporate “new” machinery slowly (for a myriad of reasons, not least of which is cost) and it seems clear that we need to fi nd ways to accelerate the purchase of newer, more effective technologies for the benefi t of our patients. Even as we recognise the importance of state of the art technologies, it is important to remember that we are physicians fi rst and our main priority is to provide the patient with the best care possible. Quality care in our fi eld depends not only on fi rst-rate technology, but also on the skill and training of the specialists responsible for treating patients. Radiation oncologists must be experts in both the technical and clinical aspects of radiotherapy. Cancer treatment in general has become more interdisciplinary, thus requiring the cooperation of a larger number of specialists. The growth of tumour boards, where complex cases are discussed, is a prime example. It is during these meetings that each specialist can share his/her specialised knowledge so that a well founded treatment decision can be made. Important changes have also occurred in training new specialists (residency) and continuing education for current staff. Spain, along with all other member countries of the European Union, has had to reorganise its university curriculum to bring it in line with the new European standards as established by the Bologna Agreement. As a result, students must now complete 360 European credits (9000 hours) to obtain a degree in medicine. Although the current transition period has been challenging, it also offers new opportunities for our fi eld, and several universities have proposed new courses that combine aspects of both medical and radiation oncology. These courses are intended for the fi fth or sixth year of the degree programme. F. Guedea ( ) Department of Radiation Oncology Catalan Institute of Oncology Gran via, s/n km 2,7 ES-08907 L’Hospitalet de Llobregat, Barcelona, Spain e-mail: guedea@iconcologia.net

The European Society for Medical Oncology (ESMO) Congress is organized by the ESMO every second year, alternating with the European Cancer Organisation-ESMO-European Society for Therapeutic Radiology and Oncology multidisciplinary cancer conference. The ESMO Congress provides current information on the latest research results in medical oncology and offers state-of-the-art educational programs to support medical oncologists in their training and practice. A record number of attendees (16,000 people) made the 35th ESMO Congress a great success, including over 13,000 oncologists and other cancer healthcare professionals, 360 media representatives and 400 cancer patients who participated in a dedicated seminar. To contextualize the magnitude of the data reported, it should be noted that over 63,000 patients have been treated in the randomized studies that were presented.

Radiology literally erupted onto the medical and scientific community following publication of the paper by Wilhelm Conrad Roentgen on December 28, 1895, describing the discovery of new rays. The immediacy of the impact on the world was strikingly evident by the speed with which physics laboratories, hospitals, and clinics began assembling equipment. Within a year there was a substantial and positive experience using radiographs for diagnosis and a beginning of testing of their very low kVp beams as treatment for superficial lesions. Reflecting the literally fantastic excitement in medicine and physics generated by Roentgen’s paper were the >1000 scientific papers and ~50 books during 1896 on the new rays [6].

The Department of Radiation Oncology was established effective June 1, 1970, with separation of radiology into imaging radiology and therapeutic radiology. Accordingly, the Chief of Radiation Oncology would report directly to the General Director of the hospital, John Knowles, and serve as a member of the General Executive Committee. An interesting point is that then and for many years, the Chief of Radiation Oncology was the only oncologist on the General Executive Committee.

These were held as a tribute to the first radiologist at the MGH to limit his practice almost exclusively to therapeutic radiology. Many interest facets of the life and career of Milford were illuminated in this series. These were held on a yearly and then on a bi-annual basis and the event was designated the department Science Festivity Day.

To evaluate the actual work environment of radiation oncologists (ROs) in Japan in terms of working pattern, patient load, and quality of cancer care based on the relative time spent on patient care.In 2008, the Japanese Society of Therapeutic Radiology and Oncology produced a questionnaire for a national structure survey of radiation oncology in 2007. Data for full-time ROs were crosschecked with data for part-time ROs by using their identification data. Data of 954 ROs were analyzed. The relative practice index for patients was calculated as the relative value of care time per patient on the basis of Japanese Blue Book guidelines (200 patients per RO).The working patterns of RO varied widely among facility categories. ROs working mainly at university hospitals treated 189.2 patients per year on average, with those working in university hospitals and their affiliated facilities treating 249.1 and those working in university hospitals only treating 144.0 patients per year on average. The corresponding data were 256.6 for cancer centers and 176.6 for other facilities. Geographically, the mean annual number of patients per RO per quarter was significantly associated with population size, varying from 143.1 to 203.4 (p0.0001). There were also significant differences in the average practice index for patients by ROs working mainly in university hospitals between those in main and affiliated facilities (1.07 vs 0.71: p0.0001).ROs working in university hospitals and their affiliated facilities treated more patients than the other ROs. In terms of patient care time only, the quality of cancer care in affiliated facilities might be worse than that in university hospitals. Under the current national medical system, working patterns of ROs of academic facilities in Japan appear to be problematic for fostering true specialization of radiation oncologists.

In our institution, there has been a long tradition of brachytherapy, especially in gynecological tumours. From the beginning, there was an attempt to adapt the brachytherapy dose to the volume and the shape of the tumour and to take the anatomy of the vagina into account. The first step to achieve this goal was the use of the vaginal mould, performed for each patient. It was initially used with low dose-rate brachytherapy. When MRI images became available, we had the opportunity to use these MRI data with the mould in, as this applicator was perfectly MRI-compatible. The first step was to collect all the MRI images and to retrospectively look at the tumour coverage, without modifying our dosimetric policy. In any case, the potential dosimetric modification would have been limited as low dose-rate brachytherapy was performed using cesium sources. Almost 120 patients had MRI images without dosimetric modifications. In 2004, after the introduction of pulse dose-rate brachytherapy in our department, it became possible to adapt brachytherapy doses to MRI findings, using the European Gynecological Brachytherapy Group/European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) recommendations.

The South African Journal of Radiology reports below a South African 'first' : the award of the Frank Doyle Medal to Dr Pieter Janse van Rensburg by the Royal College of Radiologists for being the highest-scoring candidate in the autumn 2009 part A final examination.

The past decade has provided many technological advances in radiotherapy. The European Institute of Radiotherapy (EIR) was established by the European Society of Therapeutic Radiology and Oncology (ESTRO) to provide current consensus statement with evidence-based and pragmatic guidelines on topics of practical relevance for radiation oncology. This report focuses primarily on 3D CT-based in-room image guidance (3DCT-IGRT) systems. It will provide an overview and current standing of 3DCT-IGRT systems addressing the rationale, objectives, principles, applications, and process pathways, both clinical and technical for treatment delivery and quality assurance. These are reviewed for four categories of solutions; kV CT and kV CBCT (cone-beam CT) as well as MV CT and MV CBCT. It will also provide a framework and checklist to consider the capability and functionality of these systems as well as the resources needed for implementation. Two different but typical clinical cases (tonsillar and prostate cancer) using 3DCT-IGRT are illustrated with workflow processes via feedback questionnaires from several large clinical centres currently utilizing these systems. The feedback from these clinical centres demonstrates a wide variability based on local practices. This report whilst comprehensive is not exhaustive as this area of development remains a very active field for research and development. However, it should serve as a practical guide and framework for all professional groups within the field, focussed on clinicians, physicists and radiation therapy technologists interested in IGRT. (C) 2010 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 94 (2010) 129-144

Purpose To provide a historical and personal narrative of the development of radiation oncology at Memorial Sloan-Kettering Cancer Center (MSKCC), from its founding more than 100 years ago to the present day. Methods and Materials Historical sources include the Archives of MSKCC, publications by members of MSKCC, the author's personal records and recollections, and her communications with former colleagues, particularly Dr. Basil Hilaris, Dr. Zvi Fuks, and Dr. Beryl McCormick. Conclusions The author, who spent 38 years at MSKCC, presents the challenges and triumphs of MSKCC's Radiation Oncology Department and details MSKCC's breakthroughs in radiation oncology. She also describes MSKCC's involvement in the founding of the American Society for Therapeutic Radiology and Oncology.

These guidelines are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the developers of this guideline cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the

*Department of Radiation Medicine, Long Island Jewish Medical Center, New Hyde Park, New York; yDepartment of Radiation Oncology, University of Colorado, Denver, Colorado; zDepartment of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania; xSection of Radiation Oncology, Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; {CyberKnife Center of Miami, Miami, Florida **Department of Radiation Oncology, MD Anderson Cancer CenterOrlando, Orlando, Florida; yyDepartment of Radiation Oncology, Northwest Community Hospital, Arlington Heights, Illinois; zzDepartment of Radiation Oncology, Mt. Sinai Medical Center, Miami, Florida; xxDepartment of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas; {{Department of Radiation Oncology, Scripps Clinic, La Jolla, California; ***Department of Radiation Oncology, Wayne State University, Detroit, Michigan; yyyDepartment of Radiation Oncology, Stanford University, Stanford, California; and zzzRadiation Oncology Center, Radiological Associates of Sacramento, Sacramento, California

*Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT; yDepartment of Radiation Therapy, The William W. Backus Hospital, Norwich, CT; zThe Cancer Institute of New Jersey, University of Medicine & Dentistry of New Jersey– Robert Wood Johnson Medical School, New Brunswick, NJ; xBellingham Breast Center, University of Washington, Bellingham, WA; and kThe American College of Surgeons, Chicago, IL

11 (RSROC) in Taiwan [6]. With the assistance of Paul C. Hodges of the University of Chicago and the many radiologists who returned to Taiwan from the United States in the aftermath of World War II, radiology as a specialty gradually matured in the country [7]. In 1987, the Society of Nuclear Medicine in Taiwan was established, followed in 1993 by the formation of the Taiwan Society for Therapeutic Radiology and Oncology. Since its inception, the RSROC has evolved into a society focusing on diagnostic and interventional radiology. To avoid confusion with the existing Chinese Society of Radiology [8] in the People’s Republic of China (PROC), the council of the RSROC is considering renaming the society the Taiwan Society of Radiology. The official journal of the RSROC is the Chinese Journal of Radiology, which commenced publication in March 1976 as a quarterly journal. The English-language journal’s mandate is the publication of original research, workshop proceedings, technical notes, and case reports of the society’s members. The Chinese Journal of Radiology is currently cited by EMBASE/Excerpta Medica. The current Taiwan medical education system is a modification of the American system [9]. After senior high school, students undertake a 7-year medical university training period that includes a 1-year rotating internship. Students who choose radiology as their career then undertake a 4-year radiology resident training program that includes a 6-month period of general medicine training. After passing the radiology board examination administered by the Department of Health, they are qualified as radiologists. Currently, most subspecialties work as subcommittees under the RSROC umbrella. Every year in March, the 733 radiologists (as of December 31, 2007), more than 130 trainees, and about 200 technical exhibitors attend the society’s annual meeting, which Radiology in Taiwan

Approximately 40% of all cancer patients will develop metastatic spinal disease [1]. Some patients may be satisfactorily treated with conventional radiotherapy for palliation of pain and neurologic symptoms arising from spinal metastases. For other patients, a conventional dose of 30 to 45 Gy may be inadequate to achieve durable control. Furthermore, reirradiation of the spine with conventional means is rarely an option. The American Society for Therapeutic Radiology and Oncology (ASTRO) has described a new field of stereotactic body radiation therapy (SBRT) in conjunction with the American College of Radiology (ACR). SBRT is a “newly emerging radiotherapy treatment method to deliver a high dose of radiation to the target, utilizing either a single dose or small number of fractions with a high degree of precision within the body. The ability to deliver a single or a few fractions of high dose ionizing radiation with high targeting accuracy and rapid dose falloff gradients encompassing tumors within a patient provides the basis for the development of SBRT [2].” This perspective explores the respective merits of single-dose and hypofractionated SBRT to the spine.

Purpose To evaluate the structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and improve any deficiencies. Methods and Materials A questionnaire-based national structure survey was conducted between March 2006 and February 2007 by the Japanese Society of Therapeutic Radiology and Oncology. These data were analyzed in terms of the institutional stratification of the Patterns of Care Study. Results The total numbers of new cancer patients and total cancer patients (new and repeat) treated with radiotherapy in 2005 were estimated at approximately 162,000 and 198,000, respectively. In actual use were 765 linear accelerators, 11 telecobalt machines, 48 GammaKnife machines, 64 60 Co remote-controlled after-loading systems, and 119 192 Ir remote-controlled after-loading systems. The linear accelerator systems used dual-energy function in 498 systems (65%), three-dimensional conformal radiotherapy in 462 (60%), and intensity-modulated radiotherapy in 170 (22%). There were 426 Japanese Society of Therapeutic Radiology and Oncology-certified radiation oncologists, 774 full-time equivalent radiation oncologists, 117 medical physicists, and 1,635 radiation therapists. Geographically, a significant variation was found in the use of radiotherapy, from 0.9 to 2.1 patients/1,000 population. The annual patient load/FTE radiation oncologist was 247, exceeding the Blue Book guidelines level. Patterns of Care Study stratification can clearly discriminate the maturity of structures according to their academic nature and caseload. Conclusions The Japanese structure has clearly improved during the past 15 years in terms of equipment and its use, although the shortage of manpower and variations in maturity disclosed by this Patterns of Care Study stratification remain problematic. These constitute the targets for nationwide improvement in quality assurance and quality control.

In the past decade, brachytherapy has shifted from the traditional surgical paradigm to more modern three-dimensional image-based planning and delivery approaches. The role of intraoperative and multimodality image-based planning is growing. Published American Association of Physicists in Medicine, American College of Radiology, European Society for Therapeutic Radiology and Oncology, and International Atomic Energy Agency quality assurance (QA) guidelines largely emphasize the QA of planning and delivery devices rather than processes. These protocols have been designed to verify compliance with major performance specifications and are not risk based. With some exceptions, complete and clinically practical guidance exists for sources, QA instrumentation, non–image-based planning systems, applicators, remote afterloading systems, dosimetry, and calibration. Updated guidance is needed for intraoperative imaging systems and image-based planning systems. For non–image-based brachytherapy, the American Association of Physicists in Medicine Task Group reports 56 and 59 provide reasonable guidance on procedure-specific process flow and QA. However, improved guidance is needed even for established procedures such as ultrasound-guided prostate implants. Adaptive replanning in brachytherapy faces unsolved problems similar to that of image-guided adaptive external beam radiotherapy.

Medicine was revolutionized at the end of the 19th centurythanks to a number of discoveries in the field of physics. In1895, Roentgen discovered X-rays, which made it possible tovisualize internal structures in the human body. The followingyear Becquerel discovered radioactivity, and in 1898 the Curies(husband and wife) announced the discovery of two radioactiveelements: polonium and radium. The latter was immediatelyput to use to obliterate skin cancers and deep-seated tumors orreduce their size (1). However, these new technologies were notwithout dangers: the first report of adverse effects of X-rays onhuman health, after overexposure in a patient who underwentradiography in Chicago, Illinois, United States of America, waspublished in 1896 (2). Since their inception, image-based diag-nostic techniques, radiotherapy (also known as radiation ther-apy), and radiation protection have evolved in parallel.Regrettably, advances in physics in the field of radiationduring World War II also led to the invention of nuclear weapons,which in turn gave rise to an era of competition between worldpowers to develop and produce arms of this type. During the1950s, the United States—aware of the potential applications ofthese new technologies to agriculture, industry, and medicine,and in an effort to further the use of nuclear energy for peacefulends—promoted the Atoms for Peace initiative, which fomentedthe development of nuclear and radiological techniques through-out the world. This initiative also involved developing countries,many of them in Latin America and the Caribbean.It was also during the 1950s when a new discipline,known as medical physics, made its appearance in certainEuropean countries such as Sweden and the United Kingdom.Medical physicists are science professionals who, just asRoentgen, Becquerel, and the Curies did in their day, apply theirknowledge of physics to medicine, particularly in the area ofdiagnostic and therapeutic radiology. As of 2006, medical physi-cists number more than 16 000 throughout the world (3), andthis number continues to rise with continuing technologicaladvances.In the 1970s, the invention of the first computed tomogra-phy scanner changed the world of radiological physics once again(1). Currently, most of the equipment used in this field is com-puterized, and imaging techniques are now being applied at thecellular level, with the result that molecules that play a criticalrole in the development of certain diseases can be identified longbefore the clinical symptoms appear.The beneficial effects of these technological advances forpublic health are substantial. Thanks to these innovations we areable to diagnose a number of diseases, such as cardiovascular

133 Background: In 2013, the American Society of Therapeutic Radiology released its list of Choosing Wisely Initiatives. One of these initiatives was to use fraction schemes which may allow less than 10 fractions for the palliation of bony metastatic disease. Such schemes may use one or five fractions to treat an uncomplicated case of bone metastases. This project looks at a rural radiation practice, both before and after a decision was made to employ the Choosing Wisely guidelines when appropriate. Methods: This is a non-randomized, retrospective analysis of 12 months of bone metastases treatments in a single provider practice comparing the 6 months before Choosing Wisely adoption to the 6 months after. A total of 37 consecutive patients, 63 treatment sites were examined. Comparing to a standard 10 fractions of 300 cGy, fifteen treatment fractions were eliminated before adoption, 84 treatment fractions were saved after the guidelines were published. Results: Because of the bias of the practitioner, 14% of the patients received shorter fraction schedules before the Choosing Wisely adoption, 68% of patients after. As far as radiation treatment charges, $12,000 in treatments were saved before adoption, $69,000 in treatments were saved after. Besides the cost savings for the treatments, there were benefits to the patient and to the caregivers. The average patient receiving a shortened fraction schedule saved 145 miles of commuting during the course of their treatment, and saved 5 hours of commuting and treatment time. Assuming that caregivers were employed, a caregiver bringing a patient in for their treatment saved $170.00 in lost wages during the commuting and treatment time. One patient was hospitalized for her treatment and her hospital stay was reduced by the altered fractionation. No patient in the study required retreatment, the minimum follow up period was 6 months. Conclusions: Shorter fraction schemes when used as clinically appropriate do offer savings, not only to health care payers, but also to patients and to patients’ families. Consideration of Choosing Wisely Initiatives has saved patients time and expense as opposed to a similar time period before the initiative. With patients with pain from metastases, these savings are significant.

Introducing a Quality Assurance methodology appears particularly useful in Radiation Oncology due to the complexity of the procedures involved and the heterogeneity of the standards adopted, if any, in the great majority of the Centers. There are two possible ways of evaluating quality in the Health Environment: a formal, Institutional certification, or a voluntary one obtained through a mechanism of peer review. The European Society for Therapeutic Radiology and Oncology (ESTRO) started in 1994 with the publication of a methodological Report intended to be adopted by the individual national Societies, and this paper is an invitation to do it.

Maintenance of Certification is a physician-based response to public concerns about the quality of medical care and physician competency in a rapidly evolving, technically demanding specialty. The American Board of Radiology (ABR) has previously described the first three components of the Maintenance of Certification. The ABR is currently developing a program in practice performance, completing Part IV of the competencies. The Practice Quality Improvement (PQI) program is meant to critically evaluate meaningful aspects of a physician's practice in a simple manner, using identifiable metrics and self-assessment to include an action plan for quality improvement. Each diplomate will be expected to complete three PQI projects during a full 10-year Maintenance of Certification cycle. Current diplomates with time-limited certificates will find prorated requirements determined by their year of certification on the ABR Website. Diplomates will have the option of completing zero to two Type I PQI projects (assessing factors relevant to clinical practice by peer review and self-reporting) and one to three Type II projects (i.e., at least one Type II projects of the three required, assessing parameters of practice by comparison with evidence-based guidelines, consensus statements, or peer comparisons; Type II projects are initiated and managed by professional societies). Several examples of Type I projects that might be offered by societies or directly through the ABR are provided, as well as highlights of the two Type II projects that have sought ABR qualification: the American Society for Therapeutic Radiology and Oncology's Performance Assessment for the Advancement of Radiation Oncology Treatment program and American College of Radiology's RO-PEER program. An additional objective of the PQI is to develop national databases for future reference using aggregate data from the PQI projects.

Portal Hypertension can be successfully managed using a variety of interventional radiology techniques. The presinusoidal, sinusdoidal and post sinusoidal categories have different options available, as does segmental portal hypertension. The major role of TIPS has been tempered by early occlusions and high rates of hepatic encephalopathy .

Vascular laboratories play an increasing part in treating patients via intravascular procedures. The diagnostic purpose of vascular laboratories is being somewhat diminished by excellent diagnostic imaging machines like the 64-slice CT scanner and three Tesla MRI scanners. Thus, the emphasis falls on treating patients using intravascular procedures rather than performing diagnostic procedures. When planning a vascular laboratory it should be kept in mind that the main purpose of such a laboratory is to treat patients using various interventional skills. Planning a vascular laboratory depends on various factors like the geographic environment of the radiology practice, the need for interventional procedures, types of angiography procedures, the number of patients, building size, and lastly the budget available for equipment and running costs. Usually the suppliers of the angio-equipment will play an integral part in planning and developing a catheterisation laboratory. Some of the practical planning aspects are discussed in this article. South African Journal of Radiology Vol. 10 (2) 2006: pp. 13-14