James A. Swinscoe, M.Sc.,* Colleen I. Dickie, M.Sc.,† and Rob H. Ireland, Ph.D.*
*Academic Unit of Clinical Oncology, University of Sheffield, UK; and †Princess Margaret Cancer Centre, University of Toronto, Canada

Abstract

Radiation therapy for limb-extremity soft tissue sarcoma (STS) requires accurate, reproducible dose delivery. However, patient positioning is challenging and there is a lack of existing guidelines to assist institutional standardization. Therefore, we conducted a multi-institutional international survey of STS immobilization, image guidance methods, and treatment protocols to investigate current practice. Seventy-three UK radiotherapy centers and 15 hospitals in 7 other countries completed a questionnaire on STS immobilization and image-guidance procedures. Specifically, the survey collated information on the current usage of immobilization equipment, including custom devices, patient setup tolerances, the use of written protocols, the modality and frequency of image guidance, the method of treatment, allocated treatment times, and the application of surgical clips. Multiple combinations of immobilization devices were reported. In the UK, 12%, 40%, 30%, 12%, and 5% use 1, 2, 3, 4, and 5 types of device for lower limb STS. Vacuum bag plus either foot or ankle support was most common (66%). Of 15 international centers, 27%, 60%, 7%, 0%, 7% use 1, 2, 3, 4, 5 devices, with vacuum bags (73%) and thermoplastic (47%) predominant, similar to UK values of 77% and 52%. For image guidance, in the UK, 37% use kV planar, 34% use MV planar, and 16% use cone-beam CT for the first 3 fractions and then weekly. Internationally, daily imaging was more prevalent with 33% using kV planar, 7% MV planar, and 40% cone-beam CT daily. Custom devices plus combinations of devices, along with 5- and 10-mm set-up tolerances, were most commonly reported. Less than half of centers have written treatment protocols.  Conventional treatment is most common in the UK, with only 42% using conformal techniques.  Treatment is allocated between 10 and 30 minutes. Twenty-six percent of UK centers and 53% of international centers use surgical clips. Across treatment centers, there is no consistent approach to STS immobilization, image-guidance methods, or treatment protocols assessed by this survey. A wide variety of immobilization devices and configurations are utilized, and the frequency and modality of imaging are similarly diverse. In the absence of guidelines, the creation of an online repository of example immobilization techniques could enable centers to compare a diversity of cases. The availability of a forum for viewing and discussing a range of cases could potentially lead to improved patient setup and reduce the time taken to devise an individual immobilization strategy.