Radiation Oncology Community Research Articles

ESTRO ACROP consensus guideline on CT- and MRI-based target volume delineation for primary radiation therapy of localized prostate cancer

Background and purposeDelineation of clinical target volumes (CTVs) remains a weak link in radiation therapy (RT), and large inter-observer variation is seen. Guidelines for target and organs at risk delineation for prostate cancer in the primary setting are scarce. The aim was to develop a delineation guideline obtained by consensus between a broad European group of radiation oncologists. Material and methodsAn ESTRO contouring consensus panel consisting of leading radiation oncologists and one radiologist with known subspecialty expertise in prostate cancer was asked to delineate the prostate, seminal vesicles and rectum on co-registered CT and MRI scans. After evaluation of the different contours, literature review and multiple informal discussions by electronic mail a CTV definition was defined and a guide for contouring the CTV of the prostate and the rectum was developed. ResultsThe panel achieved consensus CTV contouring definitions to be used as guideline for primary RT of localized prostate cancer. ConclusionThe ESTRO consensus on CT/MRI based CTV delineation for primary RT of localized prostate cancer, endorsed by a broad base of the radiation oncology community, is presented to improve consistency and reliability.

Optimizing immobilization, margins, and imaging for lung stereotactic body radiation therapy.

The simultaneous advancement of technologies for the delivery of precisely targeted radiation therapy and the paradigm shift to substantial hypofractionation have led to significant improvements in the treatment of early stage non-small cell lung cancer (ES-NSCLC). Stereotactic body radiation therapy (SBRT) has become a well-established option for the treatment of ES-NSCLC and is now becoming widely available within the radiation oncology community. Implementation of this technique, however, requires highly accurate target delineation, thorough evaluation of tumor motion, and improved on-board imaging at the time of treatment for patient alignment, each of which is critical for successful tumor control and mitigation of risks to normal tissues. In this article, we review updates and issues related to immobilization and image guidance for SBRT in the treatment of ES-NSCLC.

Identifying the non-addressed issues in Radiation Oncology—a preliminary opinion collection of radiation oncology community

Background: To understand the mutual professional relationship among the Radiation Oncologists (ROs) and the Medical Physicists (MPs), to identify the lacunae in the radiation planning workflow. Methods: The copies of the questionnaire were sent 1,404 MPs and 1,836 ROs through a web based survey application. Similar situations were queried from both MPs and ROs to obtain their respective opinions and the responses were compared. Results: The final analysis was done for 176 MPs and 180 ROs. When it comes to grading their peers, the ROs were happier with their counterparts and gave them relatively higher grade in their jobs. The ROs made more technical mistakes than their peers when giving final contours for planning and made changes to contours during plan evaluation as well. More than 50% of the times, MPs believed the doctors give tighter constraints than possible to achieve. About 44% of ROs and 22% of MPs complained that they are not made to understand the planning/clinical result part ever. About 10% MPs says their opinion was never sought for the choice of treatment modality. A minimum of 6% of ROs were never consulted during the planning procedure, 40% of physicians were consulted during the process of planning in 10–20% of cases. Only 25% and 30% of MPs believed they got adequate time for planning and QA respectively. Most people agreed that there was adequate number of ROs in the department. Most ROs and MPs thought that a combined planning and contouring station was necessary. The working relationship between the ROs and the MPs was good (not excellent). About 50% respondents were confident to get their kin treated (if required) in the department and another 30% people were confident about one specific counterpart. MPs were more inclined towards change of profession compared to ROs. Conclusions: This study is a preliminary attempt to identify the issues that need to be addressed in radiation oncology joint workflow. The observations of this study is limited by small sample size, qualitative nature of questions used, and the heterogeneity of radiation oncology practices worldwide that merits region-based surveys.

Recent Time Trends and Predictors of Heart Dose From Breast Radiation Therapy in a Large Quality Consortium of Radiation Oncology Practices

Limited data exist regarding the range of heart doses received in routine practice with radiation therapy (RT) for breast cancer in the United States today and the potential effect of the continual assessment of the cardiac dose on practice patterns. From 2012 to 2015, 4688 patients with breast cancer treated with whole breast RT at 20 sites participating in a state-wide consortium were enrolled into a registry. The importance of limiting the cardiac dose has been emphasized in the consortium since 2012, and the mean heart dose (MHD) has been reported by each institution since 2014. The effects on the MHD were estimated for both conventional and accelerated fractionation using regression models, with technique (intensity modulated RT [IMRT] vs 3-dimensional conformal RT), deep inspiration breath hold use, patient position (supine vs prone), nodal RT (if delivered), and boost (yes vs no) as covariates. For left-sided breast cancer treated with conventional fractionation, the median MHD in 2012 was 2.19Gy versus 1.65Gy in 2015 (P<.001). The factors that significantly increased the MHD for conventional fractionation were increased separation relative to 22cm (1.5%/1cm), supraclavicular or infraclavicular nodal RT (17.1%), internal mammary nodal RT (40.7%), use of a boost (20.9%), treatment year before 2015 (7.7%), and use of IMRT (20.8%). For left-sided BC treated with accelerated fractionation, the median MHD in 2012 was 1.70Gy versus 1.22Gy in 2015 (P<.001). The factors that significantly increased the MHD for accelerated fractionation were separation (1.7%/1cm), use of a boost (20.0%), year before 2015 (8.5%), and use of IMRT (19.2%). The factors for both conventional fractionation and accelerated fractionation that significantly reduced the MHD were the use of deep inspiration breath hold and prone positioning. The MHD for left-sided breast cancer decreased during a recent 4-year period, coincident with an increased focus on cardiac sparing in the radiation oncology community in general and a state-wide consortium specifically. These data suggest a positive effect of systematically monitoring the heart dose delivered.

Effect of modern, high-quality prostate intensity-modulated radiation therapy on outcome: Evidence from a community radiation oncology program.

Radiation technique for prostate cancer has continuously evolved over the past several decades. The aim of the present study was to describe the effects of implementing modern prostate intensity-modulated radiation therapy (M-IMRT) on dosimetry and outcome. Between January 2010 and April 2012, 48 consecutive patients were treated with conventional prostate IMRT (C-IMRT) to a dose of 81 Gy. Between May 2012 and April 2015, 50 consecutive patients were treated with M-IMRT to the entire prostate to a dose of 75.6-79.2 Gy, while using prostate magnetic resonance imaging fusion, dose-volume constraints prioritizing normal tissue avoidance above planning target volume coverage, and boosting any dominant intraprostatic masses to 79.2-81 Gy. Rectal Dmax, V75, V60, V65 and V50, bladder Dmax, V75, V70 and V65, and acute and late toxicities were compared between the C-IMRT and M-IMRT groups. The median follow-up for the C-IMRT and M-IMRT groups was 61 vs. 26 months, respectively (P<0.001). M-IMRT resulted in a significant reduction in median rectal Dmax, rectal V75, rectal V70, rectal V65, bladder Dmax, bladder V75, bladder V70 and bladder V65 (P<0.01 for all). There was no significant difference in rectal V50. The 2-year rate of late grade ≥2 rectal bleeding was 13% with C-IMRT vs. 3% with M-IMRT (P=0.03). The 2-year rate of late grade ≥2 genitourinary toxicity was 11% for C-IMRT vs. 5% for M-IMRT (P=0.21). There were no significant differences in acute toxicity, biochemical control or overall survival. Therefore, compared with C-IMRT, M-IMRT was associated with reduced rectal toxicity without compromising disease control.

PO-0751: Uptake of a novel interactive 3D web-based contouring atlas among the radiation oncology community

PO-0751: Uptake of a novel interactive 3D web-based contouring atlas among the radiation oncology community

An evaluation of the various aspects of the progress in clinical applications of laser driven ionizing radiation

There has been a vast development of laser-driven particle acceleration (LDPA) using high power lasers. This has initiated by the radiation oncology community to use the dose distribution and biological advantages of proton/heavy ion therapy in cancer treatment with a much greater accessibility than currently possible with cyclotron/synchrotron acceleration. Up to now, preclinical experiments have only been performed at a few LDPA facilities; technical solutions for clinical LDPA have been theoretically developed but there is still a long way to go for the clinical introduction of LDPA. Therefore, to explore the further potential bio-medical advantages of LDPA has pronounced importance. The main characteristics of LDPA are the ultra-high beam intensity, the flexibility in beam size reduction and the potential particle and energy selection whilst conventional accelerators generate single particle, quasi mono-energetic beams. There is a growing number of studies on the potential advantages and applications of Energy Modulated X-ray Radiotherapy, Modulated Electron Radiotherapy and Very High Energy Electron (VHEE) delivery system. Furthermore, the ultra-high space and/or time resolution of super-intense beams are under intensive investigation at synchrotrons (microbeam radiation and very high dose rate (> 40 Gy/s) electron accelerator flash irradiation) with growing evidence of significant improvement of the therapeutic index. Boron Neutron Capture Therapy (BNCT) is an advanced cell targeted binary treatment modality. Because of the high linear energy transfer (LET) of the two particles (7Li and 4He) released by 10BNC reaction, all of the energy is deposited inside the tumour cells, killing them with high probability, while the neighbouring cells are not damaged. The limited availability of appropriate neutron sources, prevent the more extensive exploration of clinical benefit of BNCT. Another boron-based novel binary approach is the 11B-Proton Fusion, which result in the release of three high LET alpha particles. These promising, innovative approaches for cancer therapy present huge challenges for dose calculation, dosimetry and for investigation of the biological effects. The planned LDPA (photons, VHEE, protons, carbon ions) at ELI facilities has the unique property of ultra-high dose rate (> Gy/s−10), short pulses, and at ELI-ALPS high repetition rate, have the potential to develop and establish encouraging novel methods working towards compact hospital-based clinical applications.

SC03.01 Advances in Stereotactic Body Radiotherapy

SC03.01 Advances in Stereotactic Body Radiotherapy

Prospective Case Review in Radiation Oncology Prior to Treatment Delivery

Prospective Case Review in Radiation Oncology Prior to Treatment Delivery

Mobilising Expertise and Resources to Close the Radiotherapy Gap in Cancer Care

Closing the gap in cancer care within low- and middle-income countries and in indigenous and geographically isolated populations in high-income countries requires investment and innovation. This is particularly true for radiotherapy, for which the global disparity is one of the largest in healthcare today. New models and paradigms and non-traditional collaborations have been proposed to improve global equity in cancer control. We describe recent initiatives from within the radiation oncology community to increase access to treatment, build the low- and middle-income countries' radiation oncology workforce, mobilise more professionals from within high-income countries and raise awareness of the global need for equitable cancer care.

Promoting the Appropriate Use of Advanced Radiation Technologies in Oncology: Summary of a National Cancer Policy Forum Workshop

Leaders in the oncology community are sounding a clarion call to promote "value" in cancer care decisions. Value in cancer care considers the clinical effectiveness, along with the costs, when selecting a treatment. To discuss possible solutions to the current obstacles to achieving value in the use of advanced technologies in oncology, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine held a workshop, "Appropriate Useof Advanced Technologies for Radiation Therapy and Surgery in Oncology" in July 2015. The present report summarizes the discussions related to radiation oncology. The workshop convened stakeholders, including oncologists, researchers, payers, policymakers, and patients. Speakers presented on key themes, including the rationale for a value discussion on advanced technology use in radiation oncology, the generation of scientific evidence for value of advanced radiation technologies, the effect of both scientific evidence and "marketplace" (or economic) factors on the adoption of technologies, and newer approaches to improving value in the practice of radiation oncology. The presentations were followed by a panel discussion with dialogue among the stakeholders. Challenges to generating evidence for the value of advanced technologies include obtaining contemporary, prospective, randomized, and representative comparative effectiveness data. Proposed solutions include the use of prospective registry data; integrating radiation oncology treatment, outcomes, and quality benchmark data; and encouraging insurance coverage with evidence development. Challenges to improving value in practice include the slow adoption of higher value and the de-adoption of lower value treatments. The proposed solutions focused on engaging stakeholders in iterative, collaborative, and evidence-based efforts to define value and promote change in radiation oncology practice. Recent examples of ongoing or successful responses to the discussed challenges were provided. Discussions of "value" have increased as a priority in the radiation oncology community. Practitioners in the radiation oncology community can play a critical role in promoting a value-oriented framework to approach radiation oncology treatment.

Detailed prospective peer review in a community radiation oncology clinic

PurposeIn 2012, we instituted detailed prospective peer review of new cases. We present the outcomes of peer review on patient management and time required for peer review. Methods and materialsPeer review rounds were held 3 to 4 days weekly and required 2 physicians to review pertinent information from the electronic medical record and treatment planning system. Eight aspects were reviewed for each case: 1) workup and staging; 2) treatment intent and prescription; 3) position, immobilization, and simulation; 4) motion assessment and management; 5) target contours; 6) normal tissue contours; 7) target dosimetry; and 8) normal tissue dosimetry. Cases were marked as, “Meets standard of care,” “Variation,” or “Major deviation.” Changes in treatment plan were noted. As our process evolved, we recorded the time spent reviewing each case. ResultsFrom 2012 to 2014, we collected peer review data on 442 of 465 (95%) radiation therapy patients treated in our hospital-based clinic. Overall, 91 (20.6%) of the cases were marked as having a variation, and 3 (0.7%) as major deviation. Forty-two (9.5%) of the cases were altered after peer review. An overall peer review score of “Variation” or “Major deviation” was highly associated with a change in treatment plan (P < .01). Changes in target contours were recommended in 10% of cases. Gastrointestinal cases were significantly associated with a change in treatment plan after peer review. Indicators on position, immobilization, simulation, target contours, target dosimetry, motion management, normal tissue contours, and normal tissue dosimetry were significantly associated with a change in treatment plan. The mean time spent on each case was 7 minutes. ConclusionsProspective peer review is feasible in a community radiation oncology practice. Our process led to changes in 9.5% of cases. Peer review should focus on technical factors such as target contours and dosimetry. Peer review required 7 minutes per case.

Intensity-modulated radiotherapy for early glottic cancer: transition to a new standard of care?

For decades, the standard of care for radiation treatment of early larynx cancers has been conventional treatment using opposed lateral fields encompassing the larynx and overlying neck structures, including the adjacent carotid arteries. While intensity-modulated radiotherapy (IMRT) has replaced conventional radiotherapy for all other head/neck cancer situations, the use of IMRT to treat early glottic cancers remains controversial. The article reviews the published experience with IMRT for this clinical situation and provides a detailed review of the literature on radiation-induced carotid toxicity and how it might apply to the controversy. Finally, we discuss whether the radiation oncology community should transition to IMRT as a new standard of care for the treatment of early glottic cancers.

Will academic and community physicians engage and share knowledge in an online physician social network? Lessons from the Radiation Oncology Community

e18200Background: The exponential growth of medical knowledge has made it increasingly difficult for clinicians to make sense of new information and recognize how to incorporate new research result...

Practice Patterns of Radiation Field Design for Sentinel Lymph Node-Positive Early-Stage Breast Cancer

BackgroundRecent randomized trials have led to decreased use of completion axillary lymph node dissection (ALND) in early-stage breast cancer patients with a positive sentinel lymph node (SLN), causing controversy surrounding radiotherapy coverage of the axilla. We investigated the practice variation among radiation oncologists for regional nodal coverage for clinicopathologic scenarios and evaluated axillary field design decision-making processes. Materials and MethodsA customized, web-based questionnaire was e-mailed to 983 community (n = 617) and academic (n = 366) radiation oncologists with a breast cancer subspecialty practicing in the United States. The survey consisted of 18 multiple-choice questions evaluating general clinical preferences surrounding radiation therapy (RT) field design for patients with early-stage breast cancer and a positive SLN. Seven case scenarios were developed to investigate the field design in the setting of specific clinical and pathologic risk factors. Nodal coverage was classified as standard tangents (STs), high tangents (HTs), STs and a supraclavicular field (SCF), or STs and full axillary coverage (AX). ResultsA total of 145 evaluable responses were collected, with a response rate of 15.0%. Of the respondents, 12 (8.3%) reported using completion ALND for patients with 1 to 3 positive SLNs without extracapsular extension (ECE) and 66 (45.5%) performed ALND with 1 to 3 positive SLNs with ECE. For micrometastatic SLNs, with no lymphovascular system invasion, 115 (87.1%) used STs or HTs. The use of neoadjuvant chemotherapy (NAC) influenced RT field design for patients with a positive SLN without ECE, with 64 (48.5%) using STs and SCF or STs and AX treatment without NAC and 94 (70.7%) using SCF and AX after NAC. With macrometastatic SLN involvement, most respondents preferred SCF (45.27%) and AX (45.66%). In contrast, for micrometastatic involvement, HTs (43.61%) were frequently chosen. Forty (27.8%) reported using online predictive nomograms to predict further axillary involvement, with no difference between the academic and community radiation oncologists (P = .11). ConclusionIn SLN biopsy-positive early-stage breast cancer with omission of completion ALND, axillary RT is increasing used to cover the undissected axilla. Most respondents use SCF or AX for patients with low to intermediate pathologic features. Online prediction nomograms are used by a few practitioners to assist in clinical decision-making in this setting.

Abstract P3-12-06: Active breathing control in the management of left-sided breast cancer with irradiation: A dosimetric analysis of cardiac and lung dose

Abstract Purpose: Deep inspiratory breath hold (DIBH) is a technique that has been increasingly utilized over the past several years for the purpose of reducing the radiation dose received by the heart and ipsilateral lung during radiotherapy (RT) for breast cancer. The purpose of this study was to provide a comparative analysis of cardiac and lung dose in patients treated with and without moderate DIBH with an active breathing control (ABC) device during RT for left-sided breast cancer at a community radiation oncology center. Methods: From June 2013 to December 2014, 83 patients with stages 0-III left-sided breast cancer were treated with RT. Of these, 45 patients underwent CT simulation with an ABC device and the remaining 38 patients underwent standard free-breathing CT simulation for RT planning. Twenty-eight patients in the ABC cohort were treated with standard tangent fields and 18 were treated with locoregional RT. The non-ABC cohort included 26 patients treated with standard tangents and 12 treated with locoregional RT. A 4- or 5-field technique was utilized in all locally advanced patients to allow for coverage of the supraclavicular fossa and internal mammary lymph nodes with inclusion of low axillary coverage based on individual risk factors. All patients were treated with 3D-conformal techniques utilizing multi-leaf collimators to block the heart. Comparisons were made between mean heart dose, heart V5, mean lung dose, and lung V5 with and without the use of ABC. Kruskal-Wallis tests were used to determine significance between groups with α for significance set at p ≤0.05. Results: On combined analysis, the use of DIBH with ABC resulted in a reduction in heart V5 (1.5 versus 5.4%; p=0.018). Mean heart dose, mean lung dose, and lung V5 were not significantly improved with the use of ABC. On subgroup analysis, patients treated with locoregional RT had reduced mean heart dose (161 cGy versus 309 cGy; p=0.014) and heart V5 (2.3% versus 14.8%; p&amp;lt;0.001) compared to patients treated with a standard free-breathing technique. Conclusions: The use of ABC provided a significant reduction in heart V5 in all patients with left-sided breast cancer and in mean heart dose and heart V5 in patients treated with locoregional RT. This retrospective, single-institution analysis demonstrates the feasibility of implementing moderate DIBH with ABC technology in the treatment of left-sided breast cancer in a community radiation oncology center. Citation Format: Gogineni ES, Kehrer JD, Jones GC, Premo C, Stinson S. Active breathing control in the management of left-sided breast cancer with irradiation: A dosimetric analysis of cardiac and lung dose. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-06.

Proton therapy for paediatric medulloblastoma

Radiation oncology has changed greatly in recent decades, driven mainly by technical advances in treatment planning and delivery. Proton radiation therapy is a further advance; however, it is more expensive than traditional photon therapy and its critics argue that its costs are not justifi ed. Proton therapy is distinct from traditional photon or x-ray-based therapy since the physical properties of charged particles such as protons enable radiation oncologists to control more precisely the radiation dose, and thus spare healthy tissues outside the target volume. A visual comparison of photon treatment and proton treatment plans will nearly always show that the spread of low-dose radiation is less with proton therapy. This is pertinent for medulloblastoma, the most common malignant paediatric brain tumour, for which the entire brain and spine must be irradiated to minimise the risk of recurrence, and for which late adverse eff ects can severely aff ect quality of life. Although visual comparisons of proton and photon radiotherapy are compelling, debate within the radiation oncology community continues as to the clinical benefi ts of this low-dose, tissue-sparing technique. Proton therapy has been in clinical use for decades; however, until recently, few centres have had access to it. This lack of availability is largely responsible for the paucity of clinical data supporting the routine use of protons for cancer treatment. In The Lancet Oncology, investigators from the Massachusetts General Hospital, one of the institutions that pioneered proton therapy, present outcomes from a prospective study of proton therapy for childhood medulloblastoma. 1 Given the rarity

Questionnaire survey to assess the pattern and characteristics of cell-phone usage among Indian oncologists

Obtain baseline data of cell-phone usage in the medical (MO), surgical (SO) and radiation (RO) oncology community practicing in India. Indigenously prepared cell-phone usage related questionnaire was used in the present study after approval by the Institutional Ethics/Scientific Committees. The questionnaire had 41 items and was made to assess the cell-phone usage parameters, utility in clinical practice, awareness, and to compare parameters between oncology specialties. Between November 2009 and January 2010, the questionnaire was sent as an E-mail attachment to 200 oncologists in India. In all, 123 responses were received (61% responders); 84 (68.3%) were RO. The median age of responders was 35 years. Overall, 80% felt handicapped without cell-phone. The Mean cell-phone score, an index to assess overall usefulness over a score of 1-10, was 6.46 (median 7, standard deviation 1.709). There was no significant difference between RO, MO and SO in duration of usage (P = 0.235), number of cell-phones (P = 0.496), call duration per day (P = 0.490) and dependence on cell-phone (P = 0.574). Age of starting cell-phone usage was earlier in RO (P = 0.086). Professional usage was significantly more by MO and SO compared to RO (P < 0.001); however, the former were less aware of any potential cell-phone hazards compared to RO (P < 0.007). The results of the first such questionnaire based study have been presented. Most oncologists consider cell-phones a useful tool in patient care. More RO are aware of potential cell-phone hazards compared to non-RO's.

Need of collaborative radiology-radiation oncology workshops in decision making for head and neck cancer (HNC) management in India: Perspectives of the radiation oncologists.

In India, head and neck cancer (HNC) has always been a challenge to treatment due to its various disease., treatment., and patient.related factors. Recent developments in the field of both radiology and radiation oncology brings us to a stage where combined collaborative efforts are required for proper management of HNC. The article identifies the potential areas of such need through online survey. This anonymous online survey with specific questions and their responses from radiation oncology community identifies potential areas of radiology expertise as perceived by a radiation oncologist. The questions were simple Likert-type and the best possible response was sought for. There were 57 email responses and majority (37) agreed upon the extreme importance of such collaborative efforts. The major areas where a radiation oncologist would seek help are target volume delineation and response evaluation posttreatment in HNC, though other areas are also important albeit to a lesser degree. There is urgent need of radiology.radiation oncology workshops in managing HNC in the modern era of image.based and image-guided treatment. Future larger hospital.based survey would determine need on a large scale basis at resolving these issues.

Data management, documentation and analysis systems in radiation oncology: a multi-institutional survey.

IntroductionRecently, information availability has become more elaborate and widespread, and treatment decisions are based on a multitude of factors. Gathering relevant data, also referred to as Big Data, is therefore critical for reaching the best patient care, and enhancing interdisciplinary and clinical research. Combining patient data from all involved systems is essential to prepare unstructured data for analyses. This demands special coordination in data management. Our study aims to characterize current developments in German-speaking hospital departments and practices. We successfully conducted the survey with the members of the Deutsche Gesellschaft für Radioonkologie (DEGRO).MethodsA questionnaire was developed consisting of 17 questions related to data management, documentation and clinical trial analyses, reflecting the clinical topics such as basic patient information, imaging, follow-up information as well as connection of documentation tools with radiooncological treatment planning machines.ResultsA total of 44 institutions completed the online survey (University hospitals n = 17, hospitals n = 13, practices/institutes n = 14). University hospitals, community hospitals and private practices are equally equipped concerning IT infrastructure for clinical use. However, private practices have a low interest in research work. All respondents stated the biggest obstacles about introducing a documentation system into their unit lie in funding and support of the central IT departments. Only 27 % (12/44) of responsible persons are specialists for documentation and data management.ConclusionOur study gives an understanding of the challenges and solutions we need to be looking at for medical data storage. In the future, inter-departmental cross-links will enable the radiation oncology community to generate large-scale analyses.Electronic supplementary materialThe online version of this article (doi:10.1186/s13014-015-0543-0) contains supplementary material, which is available to authorized users.