Vienna, Austria

ESTRO 2023

Session Item

May 14
10:30 - 11:30
Strauss 3
Advancements in RTT practice
Loes Bulthuis, The Netherlands;
Michelle Leech, Ireland
Proffered Papers
11:10 - 11:20
On demand peer review of Gynaecological cancer radiotherapy : Audit of a quality improvement process
Tapesh Bhattacharyya, India


On demand peer review of Gynaecological cancer radiotherapy : Audit of a quality improvement process

Santam Chakraborty1, Tapesh Bhattacharyya1, Indranil Mallick1, Rimpa Basu Achari1, Moses Arunsingh1, Sanjoy Chatterjee1

1Tata Medical Center, Radiation Oncology, Kolkata, India

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Purpose or Objective

Quality assurance of radiotherapy target volume delineation (TVD) through peer review (PR) is an important requirement for delivery of safe and effective radiotherapy. However, PR takes time and in busy oncological practices in LMICs, such protected time is often not available. We present an audit of an on-demand PR process implemented in our centre.

Material and Methods

2 senior clinical oncologists (CO) providing site-specialised radiation gynaecological oncology agreed to an on-demand PR process whose outcomes were prospectively recorded. PR was performed before final contour approval to avoid delays.The initial TVD was completed by junior COs and then PR was done by senior COs. Treatment intent, staging, elective volumes, dose prescriptions and TVD were checked.

Changes made were categorised as major change if TV was edited by more than 1 cm or to prevent geographical miss or where locoregional control could be affected. Other changes were categorised as minor changes. All patients planned for curative intent external beam radiotherapy from 15 Sept 2021 to 15 Sept 2022 were eligible for the study. A waiver of consent provided by the IRB and the protocol was prospectively registered ( The primary endpoints for the analysis were the proportion of patients where a major change was seen in GTV or CTV and the compliance with the peer review process.


231 patients with a median age of 55 years were evaluable. Majority (n = 176, 76%) had cervical cancer. 49 (21%) patients had para-aortic nodal involvement (pathological n = 15, radiological n = 34). Concurrent chemotherapy was planned for 182 (79%) patients. At least one PR session was conducted in 203 (88%) patients. More than one PR session was required in 3 patients (1.3%). Repeat PR sessions were mandated because of significant changes required in the treatment planning CT scan. Number of PR conducted per month ranged between 7 - 23.

Major changes in TVD were required in 108 (53%) of the patients, while minor changes were necessitated in 69 (34%). Most of the patients (n = 77, 38%) required changes in the nodal CTV. Additional major modifications requested after the peer review included changes in the final stage in 7 (3.4%), change in treatment intent in 1 (0.5%), inclusion of para-aortic nodes in the elective nodal volume in 24 (11.8%), and a change in image registration in 5 (2.4%) of the patients. Major changes in organ at risk contours were required in 15 (7.3%) of the patients. The median working days required from the acquisition of planning CT to the contour approval time was 4 days (IQR 2 - 5 days). 

Anatomical locations of major modifications and proportion of modifications as per the type of cancer and treatment setting are illustrated in figures.


An on-demand PR process was feasible and implementable while maintaining the treatment planning timelines. The high proportion of patients requiring major changes in TVD highlights the importance of PR as a quality assurance tool.