Search Results (104)

Background: The use of conventional boluses in recurrent breast cancer often fails to conform to irregular surfaces, leading to air gaps and suboptimal dose distribution. We present a clinical experience involving a 3D-printed conformal bolus for a patient with gross recurrence and breast prosthesis invasion—a complex scenario where the treatment goal was surgical conversion. This report aims to generate hypotheses regarding the utility of customized boluses in facilitating the resection of initially unresectable tumors in the presence of reconstructive hardware. Case Presentation: A 58-year-old female with a history of breast cancer and prosthesis reconstruction presented with a rapid chest wall recurrence in 2018. The tumor invaded the overlying skin and the underlying prosthesis, rendering it unresectable. The patient received intensive salvage radiotherapy using Volumetric Modulated Arc Therapy (VMAT) with a dose-escalation regimen and a customized 1 cm 3D-printed bolus. While daily IGRT/CBCT and in vivo dosimetry were not available to definitively quantify the air gap reduction, the technical application of the bolus aimed to optimize surface dose coverage. Two months post-treatment, significant tumor regression was observed, allowing for the successful surgical removal of both the tumor and the prosthesis. Conclusions: To our knowledge, this case illustrates a specialized application of 3D-printed boluses in complex salvage scenarios. Following treatment, the patient experienced improved quality of life through pain reduction and reduced dressing frequency. Although the dramatic tumor response likely reflects the overall intensity of the radiotherapy regimen, our experience suggests that a 3D-printed bolus is a physically plausible tool to aid in achieving local control and facilitating surgical intervention. Further prospective studies are required to isolate the specific dosimetric advantages of this technology over conventional methods. Full article

Background/Objectives: Traditional radiotherapy treatments assume that patient anatomy remains unchanged over the course of treatment. Image guidance is used to reproduce the patient setup as closely as possible, and planning margins are used to account for setup errors. With the development of MR-guided Adaptive Radiotherapy (MRgART), daily plan adaptations are now feasible, allowing clinicians to edit the plan according to daily anatomical fluctuations. However, MRgART is currently restricted to step-and-shoot IMRT delivery, which can have reduced dose conformality compared to VMAT. In this study, we compare the accumulated dose over all fractions in prostate SBRT treatments for non-adaptive and adaptive external beam workflows. Methods: The simulation and daily images of twenty previously treated MRgART prostate SBRT patients were anonymized. On each simulation image, whole prostate VMAT and MRgART SBRT plans were generated. To simulate non-adaptive treatment dose, the daily images were rigidly registered to the planning images, and the doses were recalculated on the daily images. The MRgART plans were adapted to the daily anatomy and reoptimized. All fractional doses were accumulated, using deformable image registration, and compared to their respective planned doses. Results: All MRgART dose accumulations were within clinical tolerance. Four VMAT dose accumulations had a dose constraint that fell outside of clinical tolerance. The VMAT dose accumulations had statistically lower doses to the target compared to their planned doses. Conclusions: While high-quality plans can be delivered in a non-adaptive VMAT workflow despite interfractional motion, this study suggests that MRgART produces cumulative dose distributions that more closely resemble the initial treatment plan. Full article

The high complexity of radiation therapy for lung cancer necessitates effective planning of advanced treatments such as Volumetric Modulated Arc Therapy (VMAT) by radiation oncologists. The current VMAT treatment planning process typically involves extensive manual interaction and a time-consuming, trial-and-error, iterative approach that requires planners’ experience. This can lead to varying levels of plan quality. To improve the quality of radiotherapy treatment plans quickly and accurately, this research presents a new architecture, Enhanced UNet3D, to generate three-dimensional (3-D) dose distributions for lung cancer patients. Enhanced UNet3D utilises a symmetric encoder–decoder architecture with residual connections and a target region-attention module to achieve high accuracy in dose shaping within the PTV. A new composite objective function, Enhanced Combined Loss (ECLoss), that includes both SharpLoss, a structure-aware DVH-guided loss, and 3D gradient regularisation, has been developed to address voxel-level class imbalance and achieve realistic spatial dose falloff. This research utilised a retrospective dataset of 170 VMAT plans to train and validate the proposed model. On the test set (n = 14), the model demonstrated exceptional overall accuracy, with a Mean Absolute Error (MAE) of 0.238 ± 0.075 Gy and a structural similarity index measure (SSIM) of 0.970 ± 0.005. Moreover, the model can perform near-real-time inference at approximately 0.5 s per patient, representing a significant reduction in computational resources compared to other architectures. Therefore, these results demonstrate that the Enhanced UNet3D model with ECLoss is a clinically feasible tool for the rapid evaluation and quality assurance of radiotherapy treatment plans and may reduce the need for manual trial-and-error in VMAT workflows. Full article

Radiation therapy is a central component of the definitive and postoperative management for head and neck cancers (HNC), with intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) now standard. Within these techniques, two principal boost strategies are used: simultaneous integrated boost (SIB) and sequential boost (SEQ). Although both are guideline-supported, they differ in planning logistics, treatment delivery, potential radiobiologic effects, adaptability to anatomic change, and potential toxicity profiles. In this narrative review, we summarize the key technical, dosimetric, and radiobiologic differences between SIB and SEQ and synthesize the available comparative clinical data, with a focus on their roles in contemporary dose de-escalation strategies. SIB allows for differential dosing within a single plan and potentially shorter overall treatment time but typically delivers higher biologically effective doses (BED) to elective nodal regions. SEQ requires two plans but offers greater flexibility for adaptive replanning, facilitates a lower BED to elective nodal volumes, and may allow for partial normal tissue recovery during the boost phase. Comparative studies, including retrospective series, randomized trials, and a meta-analysis, have not demonstrated consistent differences between SIB and SEQ in survival or local control, with mixed findings regarding toxicity. In the context of de-escalation, multiple prospective studies have successfully used SEQ to reduce elective nodal dose with low rates of elective nodal failure, while recent data suggest that SIB-based elective dose reduction may also be feasible in select settings. Overall, both SIB and SEQ are effective boost strategies in HNC radiotherapy. While practice is often driven by institutional workflow and clinician preference, emerging evidence suggests potential advantages of SEQ for elective nodal dose de-escalation. Further prospective studies are needed to better define the relative impacts of SIB and SEQ on toxicity and tumor control. Full article

Background: The aim of this study was to estimate the economic burden of radiotherapy (RT) from the perspectives of payers, the healthcare system, patients, and society, and to assess associated quality-of-life (QoL) outcomes. The analysis examined direct medical and non-medical costs, as well as QoL, before, during, and up to six months after RT. Given the inclusion of multiple cancer types, the study reflects a heterogeneous real-world population. An exploratory comparison across RT techniques was also conducted to provide contextual economic insight. Methods: This analysis included data from 301 cancer patients undergoing RT using various techniques, including two-dimensional radiotherapy (2D), 3D conformal radiotherapy (3D-CRT), volumetric-modulated arc therapy (VMAT), and intensity-modulated radiotherapy (IMRT), at the University General Hospital of Heraklion, Crete, Greece. Clinical and cost data were collected retrospectively, while QoL data were collected prospectively using validated instruments at baseline, end of treatment, and six months post-treatment. Quality-adjusted life years (QALYs) were estimated. The primary analysis compared RT with a hypothetical “no RT” comparator derived from published evidence, while comparisons across RT techniques were conducted as exploratory analyses. Costs and QALYs were evaluated over a 6-month time horizon; therefore, discounting was not applied. Incremental cost-effectiveness ratios (ICERs) were calculated, and probabilistic sensitivity analysis was performed to account for parameter uncertainty. Results: The cost per QALY gained with RT compared with the hypothetical “no RT” comparator varied substantially across techniques and cancer types. In the primary analysis, 2D radiotherapy yielded the lowest ICER (€13,043.27/QALY), while VMAT demonstrated an ICER of €29,945.12/QALY. In contrast, IMRT was associated with a substantially higher ICER (€135,529.51/QALY), suggesting limited cost-effectiveness under commonly accepted willingness-to-pay thresholds, whereas 3D-CRT was found to be dominant. Subgroup analyses revealed marked heterogeneity, with ICERs ranging from €3234.45 to €30,232.50 per QALY gained across cancer types. In certain subgroups, RT was either cost-saving or dominant, particularly in breast cancer (cost-saving with similar QALYs) and in skin cancer and sarcoma (dominant strategies). Sensitivity analyses highlighted considerable uncertainty, especially for 2D radiotherapy, primarily driven by small sample sizes and variability in QALY estimates. Conclusions: This study provides short-term, real-world evidence on the cost-effectiveness and quality-of-life outcomes of radiotherapy in a Greek healthcare setting. While simpler techniques such as 2D radiotherapy may appear economically favorable, their limited effectiveness and substantial uncertainty may reduce their overall value. In contrast, advanced techniques—particularly VMAT—demonstrate a more consistent balance between cost and clinical outcomes, supporting their role within value-based, patient-centered oncology care. However, the findings should be interpreted with caution due to population heterogeneity, small subgroup sizes, the short (6-month) time horizon, and the use of a hypothetical comparator. Further research with longer follow-up and disease-specific analyses is warranted. Full article

Volumetric modulated arc therapy-computed tomography (VMAT-CT), which is the CT reconstructed using the portal images collected during VMAT, can potentially be an effective onsite imaging tool. The goal of this study was to propose an iterative reconstruction algorithm that can further improve the image quality of VMAT-CT and reduce the number of failed reconstructions. An iterative algorithm combining total variation (TV) with block-matching and 3D filtering (BM3D) was proposed, addressing the L1-L2 regularization problem using the split Bregman method. We collected portal images from 67 VMAT cases including 50 phantom and 17 real-patient cases. Both Feldkamp–Davis–Kress (FDK) and TV-BM3D iterative algorithms were used to reconstruct VMAT-CT using the collected images. The preprocessing methods developed by our group previously were also used in this study. A total of 48 out of 50 phantom cases and 15 out of 17 real-patient cases were successfully reconstructed using the iterative algorithm together with image preprocessing. In contrast, 39 phantom cases and 8 patient cases could be reconstructed using the original FDK algorithm, and 44 phantom cases and 11 patient cases could be reconstructed using the FDK algorithm together with preprocessing. Compared with the FDK algorithm, the TV-BM3D iterative algorithm significantly improved the image quality of VMAT-CT at all treatment sites. To the best of our knowledge, this study is the first to develop an iterative VMAT-CT reconstruction algorithm. It can be used to reconstruct CT images locally, and is superior to FDK-based algorithms in terms of the success rate and reconstructed image quality. This strongly supports the use of VMAT-CT as a promising imaging tool for treatment monitoring and adaptive radiotherapy. Full article

Background: Vestibular schwannoma (VS) stereotactic radiosurgery (SRS) requires high target conformality and rapid dose falloff to spare adjacent organs at risk (OARs), particularly the brainstem. HyperArc (HA) is an automated noncoplanar volumetric-modulated arc therapy (VMAT) approach designed to standardize and streamline cranial SRS planning and delivery. We compared CyberKnife (CK) with HA for single-fraction VS SRS and evaluated the impact of multileaf collimator (MLC) leaf width. Methods: Fifteen VS cases previously treated with single-fraction CK SRS (12.5 Gy) were retrospectively replanned using HA. HA plans used four preconfigured noncoplanar partial arcs and were created with either a standard 5.0 mm MLC (HA-SMLC) or a 2.5 mm high-definition MLC (HA-HDMLC). HA plans were normalized to match the prescription dose target coverage of the corresponding CK plan for each of the patients. Endpoints included planning target volume (PTV) dosimetric statistics (Dmean, Dmin, Dmax, D98%), Paddick conformity index (PCI), Paddick gradient index (GI), ICRU Report 83 homogeneity index (HI), brain V12Gy, and brainstem Dmax. Because plans were generated for the same patients, paired comparisons were performed using two-sided Wilcoxon signed-rank tests (p < 0.05). Results: Both HA techniques achieved a higher near-minimum target dose than CK, with significantly higher PTV D98% (CK 12.35 ± 0.52 Gy; HA-SMLC 12.54 ± 0.28 Gy; HA-HDMLC 12.57 ± 0.35 Gy; p < 0.05). HA reduced target hotspots, with lower PTV Dmax than CK (CK 15.25 ± 0.32 Gy; HA-SMLC 14.70 ± 0.39 Gy; HA-HDMLC 14.73 ± 0.32 Gy; p < 0.05), and improved homogeneity and dose falloff as reflected by HI and GI (p < 0.05). CK achieved the highest conformity by PCI (p < 0.05), while HA-HDMLC improved PCI compared with HA-SMLC (p < 0.05). Brain V12Gy and brainstem Dmax were low and did not differ significantly among techniques. Conclusions: HA provides dosimetric performance comparable to CK for single-fraction VS SRS, with improved near-minimum PTV dose, reduced hotspots, and steeper dose gradients. Although CK showed the highest PCI overall, conformity improved with HA when a high-definition MLC was used. Overall, these findings support HA, particularly HA-HDMLC, as an efficient and clinically practical option for VS SRS treatment planning. Full article

Background: An increasing number of reports showed patients with bulky tumors after lattice radiation therapy (LRT) treatment achieved good local control. However, in these reports, LRT was previously used primarily for palliation. We reported a case that LRT plays a synergistic role in the radical treatment of locally advanced bulky cervical cancer (LABCC) combined with INTERLACE study protocol. Methods: The patient was a 54-year-old female with LABCC and treated with LRT combined with the INTERLACE study protocol. She received three fractions of 3 Gy each to the gross tumor volume (GTV) and three fractions of 9 Gy each to the lattice therapy volume (LTV), on an emergent basis, using volumetric modulated arc therapy (VMAT). Subsequently, according to the INTERLACE study protocol, chemotherapy and radiotherapy were carried out and the standard follow-up examinations were conducted. Adverse events (AEs) were assessed according to the Common Terminology Criteria for AEs (CTCAE) version 5.0. Results: The patient initially received LRT, which reduced the tumor burden and controlled bleeding. After this was combined with the INTERLACE study protocol, the complete clinical response (cCR) was achieved and they maintained this status for 13 months after the completion of concurrent chemoradiotherapy (CCRT), with only manageable grade IV hematological toxicity observed after the completion of CCRT. During this period, only manageable grade IV hematological toxicity (platelet count 16 × 10⁹/L, white blood cell count 0.33 × 10⁹/L) was observed. Conclusions: In this case, LRT combined with INTERLACE study protocol appears to be a safe and effective for the treatment of LABCC which improved the patient’s quality of life without uncontrolled treatment-related toxicity. Full article

Objectives: To evaluate the effectiveness of different optimization parameters on radiotherapy plan quality for seventeen head and neck cancer patients. Methods: Volumetric Modulated Arc Therapy with Simultaneous Integrated Boost (VMAT-SIB) plans, involving up to three tumors, were generated. For each participant, a reference plan (Plan_Ref) was created using dual-arc with 180 control points, 20° gantry-angle increment and 1 cm minimum segment width. Modified plans were developed with dose constraints and optimization settings constant by changing to single-arc, 150 and 200 control points, 0.5 cm minimum segment width, and 30° and 40° gantry-angle increments. These plans were referred to as Plan_Arc1, Plan_CP150, Plan_CP200, Plan_SW0.5, Plan_Inc30, and Plan_Inc40, respectively. D_95% of planning target volumes (PTVs), homogeneity index (HI), monitor units (MUs), maximum dose (D_max) of spinal cord, mandible, and brainstem were recorded. Statistical and Bland–Altman analysis was performed comparing the modified plans to Plan_Ref. Results: Average D_95% values for PTV1, PTV2, and PTV3 ranged from 93.13 to 98.82%. Plan_SW0.5 provided superior target coverage and homogeneity with higher MUs than Plan_Ref. Plan_Arc1 significantly reduced PTV coverage and dose homogeneity, while increasing MUs compared with Plan_Ref (p < 0.05). The average D_max as derived from all planning approaches was up to 43.86 Gy, 65.86 Gy, and 48.85 Gy for spinal cord, mandible and brainstem, respectively. For spinal cord, Plan_Ref led to significantly lower doses compared to Plan_Arc1 and Plan_Inc30, while the brainstem recorded statistically higher D_max doses than Plan_Arc1. Significantly higher D_max was observed for the mandible using Plan_SW0.5 (p < 0.05). However, for D_max, the comparison plans showed good agreement with Plan_Ref based on Bland–Altman analysis. Conclusions: The VMAT plan quality is strongly affected by the minimum segment width whereas no differences were observed with the modification of the number of control points. Full article

Objective: This study aimed to elucidate the association between hematologic toxicity (HT) and pelvic bone marrow (PBM) dosimetric parameters in patients with cervical cancer (CC) undergoing radiotherapy (RT) combined with artificial intelligence (AI)-assisted organ at risk (OAR) delineation (Software Copyright Registration Number 2023SR0150365). Accurate delineation of bone marrow (BM) regions and analysis of radiation doses may provide a theoretical foundation for the application of AI in predicting HT. Methods: This retrospective study included 141 patients with CC who received chemotherapy (sequential or concurrent) and/or pelvic volumetric modulated arc therapy (VMAT) at the Department of Gynecology, Cancer Hospital of the Chinese Academy of Medical Sciences, between March 2019 and December 2019. PBM and its subregions (ilium, lower pelvis, lumbosacral spine, and femoral heads) were delineated using AI-based automatic segmentation of CT images. The volumes receiving 10–40 Gy (V10, V20, V30, V40) were calculated, and baseline clinical characteristics were assessed. HT endpoints included grade ≥ 2 (HT2+) and grade ≥ 3 (HT3+) leukopenia, neutropenia, anemia, or thrombocytopenia. Associations between dosimetric parameters and HT were evaluated using logistic regression models. Results: Of the 141 patients, 107 (75.8%) developed HT2+ and 33 (23.4%) developed HT3+. Univariate analysis showed that chemotherapy and age were correlated with HT2+. Multivariate analysis identified femoral head V30, femoral head V40, and chemotherapy as independent predictors of HT3+. Conclusions: This study highlights the potential of AI-based OAR delineation for assessing PBM dosimetric parameters in patients with CC. Optimizing RT to minimize BM dose and volume may mitigate HT and enhance treatment tolerance. In our cohort, receipt of combined neoadjuvant and concurrent chemotherapy (NACT+CCRT) was a stronger predictor of HT than most BM dosimetric parameters, suggesting that the systemic effect of chemotherapy may dominate the hematologic toxicity profile in this setting. Consequently, patients receiving this combined modality treatment are at particularly high risk for HT and warrant close hematologic monitoring. Full article

Background/Objectives: Radiotherapy can severely impair skin and soft tissue healing, particularly when high doses or subsequent surgical interventions are involved. Robust experimental platforms that replicate clinically relevant radiation-impaired wound healing remain limited. This study aims to establish a reproducible experimental model for radiation-induced cutaneous injury using contemporary clinical radiotherapy techniques. Methods: A Wistar rat model was developed using single-dose external beam irradiation delivered by clinical-grade volumetric modulated arc therapy (VMAT; 6 MV FFF), at doses of 20 Gy or 30 Gy. Animals were distributed in five distinct groups: G1—control, G2—20 Gy irradiation only, G3—20 Gy irradiation followed by excision, G4—excision only, G5—30 Gy irradiation only. Standardized full-thickness skin excision (1.5 × 1.5 cm) was performed one-week post-irradiation to simulate surgical intervention in pre-irradiated tissue. Animals were monitored for up to 42 days, through skin damage macroscopic scoring, body weight, hematological and biochemical parameters, and a qualitative histological exam. Results: Single-dose irradiation with 20 Gy induced moderate, self-limiting radiation dermatitis with complete healing. When combined with delayed excision, 20 Gy irradiation resulted in more severe and prolonged wound healing impairment, and transient systemic alterations. Excision alone produced controlled wounds with predictable healing. Exploratory observations following 30 Gy irradiation revealed severe cutaneous injury and marked systemic involvement, with a high mortality rate. Conclusions: This study establishes a foundational model for radiation-impaired wound healing using clinical-grade VMAT delivery and standardized delayed excision. The 20 Gy-based protocols provide an ethically sustainable and experimentally tractable platform for future mechanistic and therapeutic studies. Full article

Background: Stereotactic body radiotherapy (SBRT) for prostate cancer delivers high doses in few fractions but poses challenges in sparing adjacent organs at risk (OARs), particularly the intra-prostate urethra, bladder, rectum and penile bulb. Magnetic resonance-guided radiotherapy (MRgRT) using MR-Linac offers superior soft-tissue visualization and daily adaptive planning, potentially reducing OAR dose while maintaining target coverage. This study aimed to compare dose–volume parameters among MR-Linac (ML), volumetric modulated arc therapy (VMAT), and Tomotherapy (HT) plans for prostate SBRT. Methods: Thirty patients with localized prostate cancer were retrospectively analyzed. For each patient, three plans were generated: ML, VMAT and HT, using identical prescription and planning objectives. Dose–volume histogram (DVH) metrics were evaluated for clinical target volume (CTV), planning target volume (PTV), and OARs. Statistical comparisons were performed using non-parametric Friedman’s Test with post hoc Bonferroni test, with significance set at a p < 0.05. Results: CTV coverage was comparable across all modalities. ML achieved significantly higher PTV Dmin and near-maximum doses compared to VMAT and HT. Notably, ML provided substantial urethral sparing, reducing Dmax and Dmean by approximately 3.3 Gy compared to both VMAT and HT (p < 0.001). Rectal dose metrics were also lower with ML, while bladder and penile bulb doses showed minor increases (<3.5 Gy), considered clinically negligible. Femoral head doses were reduced in ML plans. Conclusions: MR-Linac planning for prostate SBRT offers meaningful dosimetric advantages, particularly in intra-prostate urethra urethral dose reduction, without compromising target coverage. These findings support incorporating MR-guided adaptive workflows into SBRT protocols to enhance OAR protection and potentially reduce treatment-related toxicity. Full article

Background: One method for the radiation therapy of rectal cancer is to set patients supine and treat them with volumetric modulated arc therapy (VMAT). The posterior skin dose is of concern due to undesirable bolusing from mounting surfaces the patient lays upon, namely the carbon fiber couch (CFC). The posterior skin dose may be mitigated by positioning the patient on top of a low-density material that separates the patient from the CFC. Purpose: Our objective was to determine the reduction in the posterior surface dose when a mattress or foam board is used to prop the patient away from the CFC. Materials and Methods: Three clinical rectal cancer patient VMAT plans were selected. A solid water phantom with optically stimulated luminescence dosimeters (OSLDs) placed at the posterior surface was mounted using three setups: directly on the CFC, with a mattress on the CFC, and with a 10 cm thick foam board on the CFC. The three VMAT plans were delivered to this phantom, with OSLDs measuring the posterior surface dose with each setup. In the treatment planning system (TPS), the CFC only, mattress, and foam board setups were simulated on the patient’s anatomy with posterior surface doses reported. Results: The OSLD measurements in the phantom showed that the mattress reduced the posterior surface dose on average by 1.3%, and the foam board reduced the dose by 8.3%. The TPS estimates demonstrated that, on average, the mattress reduced the surface dose by 15.8%, and the foam board reduced the dose by 33.0%. It is likely that the TPS had limitations accurately modeling the surface dose, so OSLD measurements were closer to clinical reality. Conclusions: The mattress does not reduce the posterior skin dose enough to warrant its use as a skin sparing device. The CFC produces a bolusing effect that can be reduced by separating the patient from the CFC with a 10 cm thick foam board. Full article

Background/Objectives: Posterior fossa brain metastases (PFBMs) pose particular risks owing to their proximity to the brainstem and fourth ventricle. We evaluated the safety (treatment-related complications), local effectiveness, and procedural efficiency of volumetric modulated arc therapy (VMAT)-based stereotactic radiosurgery (VMAT-SRS) for PFBMs. Methods: This single-centre, retrospective study derived a PFBM subgroup from an overall institutional cohort of 123 patients treated with VMAT-RapidArc SRS/fSRS. The doses were 12–20 Gy (single fraction) or 5 × 6 Gy (selected cases). Local response (mRECIST) and predefined safety endpoints (symptomatic oedema with brainstem/IV-ventricle compromise, obstructive hydrocephalus, haemorrhagic transformation, CSF diversion, and urgent neurosurgery) were assessed. Overall survival and procedural time were analysed. Results: Thirty-one patients (39 lesions) were included; 76.9% of them received single-fraction SRS. In addition, 74.2% of patients had supratentorial metastases with posterior fossa involvement. Kaplan–Meier overall survival at 6, 12, 24, and 48 months was 74%, 58%, 26%, and 9.7%, respectively; the median survival time was 12.6 months. Among evaluable lesions, local control was 84.5% (per-lesion response: 15.5% PD, 28.1% SD, 34.4% PR, and 22.0% CR). No clinically significant posterior fossa local complications were observed. Three patients developed radiation-induced leukoencephalopathy after whole-brain radiotherapy (WBRT) and radiosurgery for synchronous supratentorial metastases. The median procedural time was 25.0 min (IQR 9.0) with one isocentre versus 52.5 min (IQR 9.75) with two. Conclusions: VMAT-SRS/fSRS for PFBMs achieved high local control, very low posterior fossa toxicity, and favourable procedural efficiency, supporting its use as a safe, rapid, frameless alternative to WBRT and other radiosurgical platforms such as Gamma Knife in appropriately selected patients. Full article

Small cell lung cancer (SCLC) is an aggressive malignancy with a high incidence of brain metastases. Prophylactic cranial irradiation (PCI) was developed to reduce central nervous system (CNS) relapses and has been shown to improve survival, particularly in limited-stage disease. The pivotal Auperin meta-analysis and subsequent studies confirmed its role in patients achieving a complete response to initial therapy. In extensive-stage SCLC, earlier trials demonstrated reduced brain metastases and modest survival gains, but more recent studies incorporating routine magnetic resonance imaging (MRI) surveillance failed to show overall survival benefits, supporting MRI monitoring with salvage therapy as an alternative. Neurocognitive toxicity remains the major limitation of PCI, especially in older adults. Common effects include memory impairment, cognitive changes, and a reduced quality of life. Advances such as hippocampal avoidance PCI and neuroprotective strategies like memantine have shown the ability to mitigate long-term decline. Modern radiotherapy techniques, including intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT), enable the precise sparing of critical structures while maintaining intracranial control. The integration of immunotherapy has shifted treatment paradigms in SCLC. While checkpoint inhibitors have improved systemic outcomes, their impact on brain relapses and interactions with PCI remain uncertain. This review provides an overview of the evolution of PCI in SCLC, while emphasizing current challenges and future directions. Full article