This study presents data for verification of the iPlan RT Monte Carlo (MC) dose algorithm (BrainLAB, Feldkirchen, Germany). MC calculations were compared with pencil beam (PB) calculations and verification measurements in phantoms with lung-equivalent material, air cavities or bone-equivalent material to mimic head and neck and thorax and in an Alderson anthropomorphic phantom. Dosimetric accuracy of MC for the micro-multileaf collimator (MLC) simulation was tested in a homogeneous phantom. All measurements were performed using an ionization chamber and Kodak EDR2 films with Novalis 6 MV photon beams. Dose distributions measured with film and calculated with MC in the homogeneous phantom are in excellent agreement for oval, C and squiggle-shaped fields and for a clinical IMRT plan. For a field with completely closed MLC, MC is much closer to the experimental result than the PB calculations. For fields larger than the dimensions of the inhomogeneities the MC calculations show excellent agreement (within 3%/1 mm) with the experimental data. MC calculations in the anthropomorphic phantom show good agreement with measurements for conformal beam plans and reasonable agreement for dynamic conformal arc and IMRT plans. For 6 head and neck and 15 lung patients a comparison of the MC plan with the PB plan was performed. Our results demonstrate that MC is able to accurately predict the dose in the presence of inhomogeneities typical for head and neck and thorax regions with reasonable calculation times (5-20 min). Lateral electron transport was well reproduced in MC calculations. We are planning to implement MC calculations for head and neck and lung cancer patients.

The aim of this work is to evaluate dosimetric accuracy of a new treatment modality, HybridArc, in iPlan RT Dose 4.5 (BrainLAB, Feldkirchen, Germany) using a four-dimensional diode array (ArcCHECK, Sun Nuclear Corporation, Melbourne, USA). HybridArc is able to enhance dynamic conformal arcs with inversely planned elements. HybridArc plans for various sites (intracranial and extracranial) were constructed and after that these plans were recalculated for the ArcCHECK diode array with Monte Carlo (MC) and Pencil Beam (PB) dose algorithms in iPlan RT Dose. All measurements of these HybridArc plans were performed with 6 MV photon beams of a Novalis accelerator (BrainLAB, Feldkirchen, Germany) using the ArcCHECK device without and with an insert containing an ionization chamber. Comparison of the absolute dose distributions measured and calculated in iPlan RT Dose with the MC algorithm at the cylinder of the ArcCHECK diode array for HybridArc plans gives good agreement, even for the 2% dose difference and 2 mm distance-to-agreement criteria. The PB calculations significantly differ from the ArcCHECK measurements so that the MC algorithm is found to be superior to the PB algorithm in the calculation of the HybridArc plans. One of the drawbacks of the PB calculations in iPlan RT Dose is the too large arc step size of 10°. Use of a finer angular resolution may improve the PB results significantly.

Objective Vestibular schwannomas are benign tumors that are often managed by radiotherapy. Minimizing long-term toxicity is paramount for a population that remains at normal life expectancy and at risk for loss of quality of life for years if not decades. Whereas current radiotherapy standard utilizes photon radiation, proton radiotherapy characteristics may enable a reduction of toxicity by reducing the volume of collateral irradiated healthy tissue. A systematic review was conducted to assess tumor control and short-and long-term sequelae after proton irradiation. Methods Studies that reported on treatment outcomes of proton radiotherapy in vestibular schwannoma patients were included. Results Five peer-reviewed retrospective series met the inclusion criteria. Quality of the studies varied from low to good. There were 276 unique patients described. Tumor control rates ranged from 85 to 100% (radiological median follow-up of 2.2-7.4 years). Hearing loss rates, defined as losing Gardner Robertson class I/II hearing, showed an weighted crude average 52% (depending on follow-up duration). The weighted averages for post-irradiation facial and trigeminal neuropathy were 5% and 4%, respectively. The risk of neuropathy seems to decrease with lower radiation dosages. Conclusion Proton irradiation for vestibular schwannomas achieves high tumor control rates, equivalent to photon irradiation. Reported cranial nerve preservation rates vary, partly due to an apparent selection bias with a high percentage of patients with clinical symptoms prior to treatment. Results of cranial nerve function preservation, quality of life, and cognitive functioning are currently insufficiently reported. In addition, advances in proton radiotherapy technology warrant re-evaluation of current techniques and protocols for the management of vestibular schwannomas.

This study reports two cases of fatal necrosis of the lesser pelvis in patients with advanced cervical carcinoma, who had received combined radiotherapy and hyperthermia. The necrosis reached far from the high dose area, in one of the cases even outside the radiation portals. Both patients initially had treatment-related morbidity which responded well to surgical treatment. After a disease-free interval, a rapidly progressive necrosis developed. Necrosis to this extent after combined modality treatment has, to the authors' knowledge, not been described.

The purpose was to compare linac-based stereotactic radiosurgery and hypofractionated radiotherapy plan quality of automated planning, intensity modulated radiotherapy (IMRT) and manual dynamic conformal arc (DCA) plans as well as single- and multiple-isocenter techniques for multiple brain metastases (BM). For twelve patients with four to ten BM, seven non-coplanar linac-based plans were created: a manually planned DCA plan with a separate isocenter for each metastasis, a single-isocenter dynamic IMRT plan, an automatically generated single-isocenter volumetric modulated arc radiotherapy (VMAT) plan, four automatically generated single-isocenter DCA plans with three or five couch angles, with high or low sparing of normal tissue. Paddick conformity index, gradient index (GI), mean dose, total V12Gy and V5Gy of uninvolved brain, number of monitor units (MUs), irradiation time and pass rate were compared. The GI was significantly higher for VMAT than for separate-isocenter, IMRT, and all automatically generated plans. The number of MUs was lowest for VMAT, followed by automatically generated DCA and IMRT plans and highest for manual DCA plans. Irradiation time was the shortest for automatically planned DCA plans. Automatically generated linac-based single-isocenter plans for multiple BM reduce the number of MUs and irradiation time with at least comparable GI and V5Gy relative to the reference separate-isocenter DCA plans.