Objective. This study presents the first clinical implementation of an efficient online daily adaptive proton therapy workflow (DAPT). Approach. The DAPT workflow includes a pre-treatment phase, where a template and a fallback plan are optimized on the planning computed tomography (CT). In the online phase, the adapted plan is re-optimized on daily images from an in-room CT. Daily structures are rigidly propagated from the planning CT. Automated Quality Assurance (QA) involves geometric, sanity checks and an independent dose calculation from the machine files. Differences from the template plan are analyzed field-by-field, and clinical plan is assessed by reviewing the achieved clinical goals using a traffic light protocol. If the daily adapted plan fails any QA or clinical goals, the fallback plan is used. In the offline phase the delivered dose is recalculated from log-files onto the daily CT, and a gamma analysis is performed (3%/3 mm). The DAPT workflow has been applied to selected adult patients treated in rigid anatomy for the last serie of the treatment between October 2023 and April 2024. Main Results. DAPT treatment sessions averaged around 23 min [range: 15-30 min] and did not exceed the typical 30 minute time slot. Treatment adaptation, including QA and clinical plan assessment, averaged just under 7 min [range: 3:30-16 min] per fraction. All plans passed the online QAs steps. In the offline phase a good agreement with the log-files reconstructed dose was achieved (minimum gamma pass rate of 97.5%). The online adapted plan was delivered for > 85% of the fractions. In 92% of total fractions, adapted plans exhibited improved individual dose metrics to the targets and/or organs at risk. Significance. This study demonstrates the successful implementation of an online daily DAPT workflow. Notably, the duration of a DAPT session did not exceed the time slot typically allocated for non-DAPT treatment. As far as we are aware, this is a first clinical implementation of daily online adaptive proton therapy.

AimsSacral chordomas are locally aggressive, radio-resistant tumours. Proton therapy has the potential to deliver high radiation doses, which may improve the therapeutic ratio when compared with conventional radiotherapy. We assessed tumour control and radiation-induced toxicity in a cohort of sacral chordoma patients treated with definitive or postoperative pencil beam scanning proton therapy.Methods and materialsSixty patients with histologically proven sacral chordoma treated between November 1997 and October 2018 at the Paul Scherrer Institute with postoperative (n = 50) or definitive proton therapy (n = 10) were retrospectively analysed. Only 10 (17%) patients received combined photon radiotherapy and proton therapy. Survival rates were calculated using the Kaplan–Meier actuarial method. The Log-rank test was used to compare different functions for local control, freedom from distant recurrence and overall survival. Acute and late toxicity were assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0.ResultsThe median follow-up was 48 months (range 4–186). Local recurrence occurred in 20 (33%) patients. The 4-year local control, freedom from distant recurrence and overall survival rates were 77%, 89% and 85%, respectively. On univariate analysis, subtotal resection/biopsy (P = 0.02), tumour extension restricted to bone (P = 0.01) and gross tumour volume >130 ml (P = 0.04) were significant predictors for local recurrence. On multivariate analysis, tumour extension restricted to bone (P = 0.004) and gross total resection (P = 0.02) remained independent favourable prognostic factors for local recurrence. Twenty-four (40%), 28 (47%) and eight (11%) patients experienced acute grade 1, 2 and 3 toxicities, respectively. The 4-year late toxicity-free survival was 91%. Two patients developed secondary malignancies to the bladder 3–7 years after proton therapy.ConclusionsOur data indicate that pencil beam scanning proton therapy for sacral chordomas is both safe and effective. Gross total resection, tumour volume <130 ml and tumour restricted to the bone are favourable prognostic factors for local tumour control.

Clinical/methodical issue Oral cavity malignancies are the most common tumors in the field of ear, nose and throat medicine or otorhinolaryngology worldwide. It comprises a heterogeneous group of tumors, the knowledge of which is necessary to meet the different requirements of diagnostics and therapy. Standard radiological methods Computed tomography (CT), magnetic resonance imaging (MRI), sonography (US), nuclear medical procedures (NUK). Performance The above-mentioned diagnostics are used in a complementary manner. Achievements Early diagnosis of the tumor improves staging and thus the patient's therapy and prognosis. Practical recommendations The radiologist plays an important role in the interdisciplinary treatment of malignant tumors of the oral cavity. Despite great progress in radiotherapy, oncology and immunotherapy, surgery still plays an important role in the treatment of malignant diseases of the oral cavity.

Zusammenfassung Klinisches/methodisches Problem Mundhöhlenmalignome stellen weltweit die häufigsten Tumoren im Bereich der Hals-Nasen-Ohrenheilkunde bzw. Otorhinolaryngologie dar. Es handelt sich um eine heterogene Gruppe an Tumoren, deren Kenntnis erforderlich ist, um den unterschiedlichen Anforderungen an Diagnostik und Therapie gerecht zu werden. Radiologische Standardverfahren Computertomographie (CT), Magnetresonanztomographie (MRT), Sonographie, nuklearmedizinische Verfahren (NUK). Leistungsfähigkeit Die o. g. Diagnostika werden komplementär eingesetzt. Bewertung Eine frühzeitigere Diagnose des Tumors verbessert das Staging und somit die Therapie und Prognose des Patienten. Schlussfolgerung Dem Radiologen kommt bei der interdisziplinären Behandlung von Malignomen der Mundhöhle eine bedeutende Rolle zu. Trotz großer Fortschritte in der Radiotherapie, Onkologie und Immuntherapie spielt die Chirurgie weiterhin eine wichtige Rolle in der Behandlung maligner Erkrankungen der Mundhöhle.

AIMS:More efforts are required to minimise late radiation side-effects for paediatric patients. Pencil beam scanning proton beam therapy (PBS-PT) allows increased sparing of normal tissues while maintaining conformality, but is prone to dose degradation from interplay effects due to respiratory motion. We report our clinical experience of motion mitigation with volumetric rescanning (vRSC) and outcomes of children with neuroblastoma. MATERIALS AND METHODS:Nineteen patients with high-risk (n = 16) and intermediate-risk (n = 3) neuroblastoma received PBS-PT. The median age at PBS-PT was 3.5 years (range 1.2-8.6) and the median PBS-PT dose was 21 Gy (relative biological effectiveness). Most children (89%) were treated under general anaesthesia. Seven patients (37%) underwent four-dimensional computed tomography for motion assessment and were treated with vRSC for motion mitigation. RESULTS:The mean result of maximum organ motion was 2.7 mm (cranial-caudal), 1.2 mm (left-right), 1.0 mm (anterior-posterior). Four anaesthetised children (21%) showing <5 mm motion had four-dimensional dose calculations (4DDC) to guide the number of vRSC. The mean deterioration or improvement to the planning target volume covered by 95% of the prescribed dose compared with static three-dimensional plans were: 4DDC no vRSC, -0.6%; 2 vRSC, +0.3%; 4 vRSC, +0.3%; and 8 vRSC, +0.1%. With a median follow-up of 14.9 months (range 2.7-49.0) there were no local recurrences. The 2-year overall survival was 94% and distant progression-free survival was 76%. Acute grade 2-4 toxicity was 11%. During the limited follow-up time, no late toxicities were observed. CONCLUSIONS:The early outcomes of mainly high-risk patients with neuroblastoma treated with PBS-PT were excellent. With a subset of our cohort undergoing PBS-PT with vRSC we have shown that it is logistically feasible and safe. The clinical relevance of vRSC is debatable in anaesthetised children with small pre-PBS-PT motion of <5 mm.

Aims: The outcome of chordoma patients with local or distant failure after proton therapy is not well established. We assessed the disease-specific (DSS) and overall survival of patients recurring after proton therapy and evaluated the prognostic factors affecting DSS. Materials and methods: A retrospective analysis was carried out of 71 recurring skull base (n = 36) and extracranial (n = 35) chordoma patients who received adjuvant proton therapy at initial presentation (n = 42; 59%) or after post-surgical recurrence (n = 29; 41%). The median proton therapy dose delivered was 74 GyRBE (range 62-76). The mean age was 55 +/- 14.2 years and the male/female ratio was about one. Results: The median time to first failure after proton therapy was 30.8 months (range 3-152). Most patients (n = 59; 83%) presented with locoregional failure only. There were only 12 (17%) distant failures, either with (n = 5) or without (n = 7) synchronous local failure. Eight patients (11%) received no salvage therapy for their treatment failure after proton therapy. Salvage treatments after proton therapy failure included surgery, systemic therapy and additional radiotherapy in 45 (63%), 20 (28%) and eight (11%) patients, respectively. Fifty-three patients (75%) died, most often from disease progression (47 of 53 patients; 89%). The median DSS and overall survival after failure was 3.9 (95% confidence interval 3.1-5.1) and 3.4 (95% confidence interval 2.5-4.4) years, respectively. On multivariate analysis, extracranial location and late failure (>= 31 months after proton therapy) were independent favourable prognostic factors for DSS. Conclusion: The survival of chordoma patients after a treatment failure following proton therapy is poor, particularly for patients who relapse early or recur in the skull base. Although salvage treatment is administered to most patients with uncontrolled disease, they will ultimately die as a result of disease progression in most cases. (C) 2020 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Clinical OtolaryngologyVolume 43, Issue 2 p. 742-745 CORRESPONDENCE: OUR EXPERIENCE The effect of adjuvant radiotherapy on radial forearm free flap volume after soft palate reconstruction in 13 patients G. Haymerle, G. Haymerle orcid.org/0000-0002-2464-6856 Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorE. Enzenhofer, E. Enzenhofer orcid.org/0000-0002-0502-4250 Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorW. Lechner, W. Lechner Department of Radiation Oncology, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorM. Stock, M. Stock Department of Radiation Oncology, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorA. Schratter-Sehn, A. Schratter-Sehn Institute for Radiooncology, Kaiser-Franz-Josef-Hospital, Vienna, AustriaSearch for more papers by this authorE. Vyskocil, E. Vyskocil orcid.org/0000-0003-1458-9824 Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorB. Bachtiary, B. Bachtiary Rinecker Proton Therapy Center, Munich, GermanySearch for more papers by this authorE. Selzer, E. Selzer Department of Radiation Oncology, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorB.M. Erovic, Corresponding Author B.M. Erovic boban.erovic@meduniwien.ac.at Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, Austria Correspondence B.M. Erovic, Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, Austria. Email: boban.erovic@meduniwien.ac.atSearch for more papers by this author G. Haymerle, G. Haymerle orcid.org/0000-0002-2464-6856 Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorE. Enzenhofer, E. Enzenhofer orcid.org/0000-0002-0502-4250 Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorW. Lechner, W. Lechner Department of Radiation Oncology, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorM. Stock, M. Stock Department of Radiation Oncology, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorA. Schratter-Sehn, A. Schratter-Sehn Institute for Radiooncology, Kaiser-Franz-Josef-Hospital, Vienna, AustriaSearch for more papers by this authorE. Vyskocil, E. Vyskocil orcid.org/0000-0003-1458-9824 Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorB. Bachtiary, B. Bachtiary Rinecker Proton Therapy Center, Munich, GermanySearch for more papers by this authorE. Selzer, E. Selzer Department of Radiation Oncology, Medical University of Vienna, Vienna, AustriaSearch for more papers by this authorB.M. Erovic, Corresponding Author B.M. Erovic boban.erovic@meduniwien.ac.at Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, Austria Correspondence B.M. Erovic, Department of Otolaryngology Head and Neck Surgery, Medical University of Vienna, Vienna, Austria. Email: boban.erovic@meduniwien.ac.atSearch for more papers by this author First published: 01 December 2017 https://doi.org/10.1111/coa.13042Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume43, Issue2April 2018Pages 742-745 RelatedInformation