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Background Recurrent ovarian cancer is often treated with chemotherapy, but many patients experience multiple recurrences with progressively shorter intervals and poorer prognosis. Repeated chemotherapy reduces patients’ quality of life. Stereotactic Ablative Radiation Therapy for Recurrent Ovarian Cancer (SABR-ROC) (KGOG3064/KROG 2204) is an ongoing trial investigating the clinical efficacy of stereotactic ablative radiation therapy (SABR) for recurrent ovarian cancer. This study aimed to assess treatment planning consistency and protocol adherence in a prospective, randomized, multicenter phase III trial. Methods In this dummy run study of a prospective, randomized, multicenter phase III trial (SABR-ROC), we examined the variability in target delineation, dose prescription, and treatment planning among 10 centers participating in the SABR-ROC trial. Four representative cases, each presenting with different anatomical sites and treatment challenges, were selected for evaluation. Target volume consistency was measured using the Dice similarity coefficient, and treatment plans were reviewed to follow predefined goals and constraints in the protocol. Results Overall agreement in target delineation was low, with mean Dice similarity coefficients of 0.278 and 0.255 for gross tumor volume and planning target volume, respectively. Consistency was higher for cases involving lymph node and lung metastases but significantly lower for intraperitoneal and liver seeding metastases due to challenges in target delineation. Treatment plans generally adhered to protocol dose prescriptions, with minor deviations in planning target volume coverage, particularly in cases with multiple small metastases. Deviations from organ-at-risk constraints frequently occurred in cases involving small bowel proximity. Conclusions This study highlights the challenges in standardizing SABR for recurrent ovarian cancer, particularly in achieving a consensus on target delineation and balancing treatment efficacy with organ-at-risk safety. Clinician discretion remains essential in complex cases. The insights from this study will guide the development of standardized protocols to improve outcomes and reduce adverse effects in patients with recurrent ovarian cancer. Trial registration This trial was registered with ClinicalTrials.gov under the identifier NCT05444270 on June 29, 2022.

Background Melanoma brain metastases (MBM) often cause morbidity and mortality for stage IV melanoma patients. An ongoing randomised phase III trial (NCT01503827 – WBRT-Mel) evaluates the role of adjuvant whole brain radiotherapy (WBRT) following local treatment of MBM. Hippocampal avoidance during WBRT (HA-WBRT) has shown memory and neurocognitive function (NCF) preservation in the RTOG-0933 phase II study. This study assessed the quality assurance of HA-WBRT within the WBRT-Mel trial according to RTOG-0933 study criteria. Methods Hippocampal avoidance was allowed in approved centres with intensity-modulated radiotherapy capability. Patients treated by HA-WBRT were not randomized within the WBRT arm. The RTOG 0933 contouring Atlas was used to contour hippocampi. In the trial co-ordinating centre, patients were treated with volumetric modulated arc therapy using complementary arcs; similar techniques were used at other sites. Dosimetric data were extracted retrospectively and analysed in accordance with RTOG 0933 study constraints criteria. Results Among the 215 patients accrued to the WBRT-Mel study between April 2009 and September 2017, 107 were randomized to the WBRT arm, 22 were treated by HA-WBRT in 4 centers. Eighteen patients were treated in the same centre. The median age was 65 years. The commonest (91%) HA-WBRT schema was 30 Gy in 10 fractions. Prior to HA-WBRT, 10 patients had been treated by surgery alone, six by radiosurgery alone, four by surgery and radiosurgery and two exclusively by simultaneous integrated boost concurrent to HA-WBRT. Twenty patients were treated with intention to spare both hippocampi and two patients had MBM close to one hippocampus and were treated with intention to spare the contralateral hippocampus. According to RTOG-0933 study criteria, 18 patients (82%) were treated within constraints and four patients (18%) had unacceptable deviation in just one hippocampus. Conclusions This dosimetric quality assurance study shows good compliance (82%) according to RTOG-0933 study dosimetric constraints. Indeed, all patients respected RTOG hippocampal avoidance constraints on at least one hippocampus. In the futureanalysis of the WBRT-Mel trial, the NCF of patients on the observation arm, WBRT arm and with HA-WBRT arm will be compared.

Aims: To dosimetrically compare the fixed gantry intensity modulated radiosurgery (IMRS) with dynamic conformal arc radiosurgery (DCARS) for cranial lesions. This study investigates whether IMRS can be an adequate dosimetric alternative to DCARS for cranial stereotactic radiosurgery (SRS). Subjects and Methods: Forty-five SRS procedures for solitary brain metastasis (range: 0.44-29.18 cm3) performed at our institution were selected for this study. Two plans were generated per patient: One IMRS plan using a multileaf collimation (MLC) of 5 mm, and one DCARS plan designed with a 3 mm micro-MLC. Dosimetric comparison metrics include the target coverage (Cov), conformity index (CI), homogeneity index (HI), gradient index (GI), and volume of the normal brain tissue receiving ≥12 Gy (V12). In addition, maximum doses to organs at risk (OAR) (brainstem, optic apparatus and cochlea) were compared for both techniques. Results: Compared to DCARS, IMRS improved mean CI (IMRS: 0.81 vs. DCARS: 0.63, P < 0.001), with no significant difference in target Cov (IMRS: 0.99 vs. DCARS: 0.99, P > 0.05), HI (IMRS: 1.22 vs. DCARS: 1.24, P > 0.05), GI (IMRS: 5.44 vs. DACRS: 5.44, P > 0.05). A weak significant difference in V12 (IMRS: 4.6 cm3 vs. 5.2 cm3, P = 0.033) was obtained. Subgroup analysis per target volume (small: <1 cm3, intermediate: ≤1 cm3 and <5 cm3 and large: ≥5 cm3) only revealed the statistically difference for CI metric (P < 0.001). No significant differences were found for maximum dose to the OAR. Conclusions: We have shown that IMRS provides the dosimetric advantages compared with DCARS. Based on the dosimetric findings in this study, fixed gantry IMRS technique can be adopted as a standard procedure for cranial SRS when micro-MLC technology is not available on the linear accelerator.

Abstract TARGET POPULATION These recommendations apply to adult patients with new or recurrent solitary or multiple brain metastases from solid tumors as detailed in each section. QUESTION 1 Should patients with newly diagnosed metastatic brain tumors undergo stereotactic radiosurgery (SRS) compared with other treatment modalities? RECOMMENDATIONS Level 3: SRS is recommended as an alternative to surgical resection in solitary metastases when surgical resection is likely to induce new neurological deficits, and tumor volume and location are not likely to be associated with radiation-induced injury to surrounding structures. Level 3: SRS should be considered as a valid adjunctive therapy to supportive palliative care for some patients with brain metastases when it might be reasonably expected to relieve focal symptoms and improve functional quality of life in the short term if this is consistent with the overall goals of the patient. QUESTION 2 What is the role of SRS after open surgical resection of brain metastasis? RECOMMENDATION Level 3: After open surgical resection of a solitary brain metastasis, SRS should be used to decrease local recurrence rates. QUESTION 3 What is the role of SRS alone in the management of patients with 1 to 4 brain metastases? RECOMMENDATIONS Level 3: For patients with solitary brain metastasis, SRS should be given to decrease the risk of local progression. Level 3: For patients with 2 to 4 brain metastases, SRS is recommended for local tumor control, instead of whole brain radiotherapy, when their cumulative volume is < 7 mL. QUESTION 4 What is the role of SRS alone in the management of patients with more than 4 brain metastases? RECOMMENDATION Level 3: The use of stereotactic radiosurgery alone is recommended to improve median overall survival for patients with more than 4 metastases having a cumulative volume < 7 mL. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_4

Abstract Please see the full-text version of this guideline https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_2) for the target population of each recommendation listed below.  SURGERY FOR METASTATIC BRAIN TUMORS AT NEW DIAGNOSIS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo surgery, stereotactic radiosurgery (SRS), or whole brain radiotherapy (WBRT)? RECOMMENDATIONS: Level 1: Surgery + WBRT is recommended as first-line treatment in patients with single brain metastases with favorable performance status and limited extracranial disease to extend overall survival, median survival, and local control. Level 3: Surgery plus SRS is recommended to provide survival benefit in patients with metastatic brain tumors Level 3: Multimodal treatments including either surgery + WBRT + SRS boost or surgery + WBRT are recommended as alternatives to WBRT + SRS in terms of providing overall survival and local control benefits.  SURGERY AND RADIATION FOR METASTATIC BRAIN TUMORS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo surgical resection followed by WBRT, SRS, or another combination of these modalities? RECOMMENDATIONS: Level 1: Surgery + WBRT is recommended as superior treatment to WBRT alone in patients with single brain metastases. Level 3: Surgery + SRS is recommended as an alternative to treatment with SRS alone to benefit overall survival. Level 3: It is recommended that SRS alone be considered equivalent to surgery + WBRT.  SURGERY FOR RECURRENT METASTATIC BRAIN TUMORS QUESTION: Should patients with recurrent metastatic brain tumors undergo surgical resection? RECOMMENDATIONS: Level 3: Craniotomy is recommended as a treatment for intracranial recurrence after initial surgery or SRS.  SURGICAL TECHNIQUE AND RECURRENCE QUESTION A: Does the surgical technique (en bloc resection or piecemeal resection) affect recurrence? RECOMMENDATION: Level 3: En bloc tumor resection, as opposed to piecemeal resection, is recommended to decrease the risk of postoperative leptomeningeal disease when resecting single brain metastases. QUESTION B: Does the extent of surgical resection (gross total resection or subtotal resection) affect recurrence? RECOMMENDATION: Level 3: Gross total resection is recommended over subtotal resection in recursive partitioning analysis class I patients to improve overall survival and prolong time to recurrence. The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_2.

Stereotactic radiotherapy with its forms of intracranial stereotactic radiosurgery (SRS), intracranial fractionated stereotactic radiotherapy (FSRT) and stereotactic body radiotherapy (SBRT) is today a guideline-recommended treatment for malignant or benign tumors as well as neurological or vascular functional disorders. The working groups for radiosurgery and stereotactic radiotherapy of the German Society for Radiation Oncology (DEGRO) and for physics and technology in stereotactic radiotherapy of the German Society for Medical Physics (DGMP) have established a consensus statement about the definition and minimal quality requirements for stereotactic radiotherapy to achieve best clinical outcome and treatment quality in the implementation into routine clinical practice.

This study evaluates a novel three-dimensional (3D) quality assurance (QA) device, the Mobile Phosphor Probe (MPP), for pretreatment dose verification in Gamma Knife (GK) stereotactic radiosurgery. The MPP system consists of a cylindrical phantom with a phosphor screen, an imaging unit with a charge-coupled device (CCD) camera, and a motorized driving unit. Dose distributions are reconstructed from images using a lookup table, which correlates CCD pixel optical density with dose values, calibrated against EBT3 film readings. Results show that the full width at half maximum of normalized dose distributions between film and CCD were consistent within a 0.2 mm margin. A 3D dose distribution was constructed by stacking two-dimensional images obtained at 0.3 mm intervals over a ± 30 mm range in the superior-inferior direction. Validation was achieved by comparing the reconstructed 3D doses with planned distributions across multiple planes using gamma evaluation. All cases within the 20–80% isodose line (IDL) range achieved a 95% gamma passing rate under 2.0%/2.0 mm criteria, and the 1.0%/1.0 mm criteria were met at the 50% IDL in all dimensions. The MPP system demonstrates potential as an efficient patient-specific QA tool for GK radiosurgery, offering a streamlined alternative to traditional film dosimetry.

This work is aimed at investigating treatment planning strategies to optimally combine stereotactic body radiation therapy (SBRT) with intracavitary brachytherapy (ICBT) for the treatment of locally advanced cervical cancer. Forty patients (stage IIB – IIIB) previously treated with combined SBRT and ICBT were randomly selected for this retrospective study. All patients were CT‐ and MR‐scanned with a ring applicator in situ. HR‐CTV and OARs were contoured according to fused CT and MR images. Several ICBT plans were generated for each patient based on different dose prescription points, and then a matching SBRT plan was generated for each ICBT plan. The dose distribution of each composite plan was analyzed with a focus on the doses received by 90% and 100% of the target volume (D90 and D100), the target volume receiving 100% of the prescription dose (V100%), and the doses received by 2 cc and 40% of the OARs (D2cc and D40). As the distance, d, between the prescription point and the tandem varied within 1.0 and 1.9 cm, the D90, D100 and V100% for the target, as well as D2cc and D40 for the bladder and rectum approached their optimal values for d value between 1.0 and 1.4 cm. When designing a combined ICBT+SBRT plan, one should measure the size of the cervix and set the prescription isodose line 1.0 to 1.4 cm away from the tandem for the ICBT plan first and then optimize the SBRT plan based on the ICBT dose distribution to achieve the best target coverage and critical structures sparing. PACS number: 87.53.jw; 87.55.D‐

Abstract TARGET POPULATION Adult patients (older than 18 yr of age) with newly diagnosed brain metastases. QUESTION If whole brain radiation therapy (WBRT) is used, is there an optimal dose/fractionation schedule? RECOMMENDATIONS Level 1:  A standard WBRT dose/fractionation schedule (ie, 30 Gy in 10 fractions or a biological equivalent dose [BED] of 39 Gy10) is recommended as altered dose/fractionation schedules do not result in significant differences in median survival or local control. Level 3: Due to concerns regarding neurocognitive effects, higher dose per fraction schedules (such as 20 Gy in 5 fractions) are recommended only for patients with poor performance status or short predicted survival. Level 3: WBRT can be recommended to improve progression-free survival for patients with more than 4 brain metastases. QUESTION What impact does tumor histopathology or molecular status have on the decision to use WBRT, the dose fractionation scheme to be utilized, and its outcomes? RECOMMENDATIONS There is insufficient evidence to support the choice of any particular dose/fractionation regimen based on histopathology. Molecular status may have an impact on the decision to delay WBRT in subgroups of patients, but there is not sufficient data to make a more definitive recommendation. QUESTION Separate from survival outcomes, what are the neurocognitive consequences of WBRT, and what steps can be taken to minimize them? RECOMMENDATIONS Level 2: Due to neurocognitive toxicity, local therapy (surgery or SRS) without WBRT is recommended for patients with ≤4 brain metastases amenable to local therapy in terms of size and location. Level 2:  Given the association of neurocognitive toxicity with increasing total dose and dose per fraction of WBRT, WBRT doses exceeding 30 Gy given in 10 fractions, or similar biologically equivalent doses, are not recommended, except in patients with poor performance status or short predicted survival. Level 2: If prophylactic cranial irradiation (PCI) is given to prevent brain metastases for small cell lung cancer, the recommended WBRT dose/fractionation regimen is 25 Gy in 10 fractions, and because this can be associated with neurocognitive decline, patients should be told of this risk at the same time they are counseled about the possible survival benefits. Level 3: Patients having WBRT (given for either existing brain metastases or as PCI) should be offered 6 mo of memantine to potentially delay, lessen, or prevent the associated neurocognitive toxicity. QUESTION Does the addition of WBRT after surgical resection or radiosurgery improve progression-free or overall survival outcomes when compared to surgical resection or radiosurgery alone? RECOMMENDATIONS Level 2: WBRT is not recommended in WHO performance status 0 to 2 patients with up to 4 brain metastases because, compared to surgical resection or radiosurgery alone, the addition of WBRT improves intracranial progression-free survival but not overall survival. Level 2: In WHO performance status 0 to 2 patients with up to 4 brain metastases where the goal is minimizing neurocognitive toxicity, as opposed to maximizing progression-free survival and overall survival, local therapy (surgery or radiosurgery) without WBRT is recommended. Level 3: Compared to surgical resection or radiosurgery alone, the addition of WBRT is not recommended for patients with more than 4 brain metastases unless the metastases’ volume exceeds 7 cc, or there are more than 15 metastases, or the size or location of the metastases are not amenable to surgical resection or radiosurgery. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_3.

The purpose of this European Society for Radiotherapy and Oncology (ESTRO) project, endorsed by the European Association of Urology, is to explore expert opinion on the management of patients with oligometastatic and oligoprogressive renal cell carcinoma by means of stereotactic ablative radiotherapy (SABR) on extracranial metastases, with the aim of developing consensus recommendations for patient selection, treatment doses, and concurrent systemic therapy. A questionnaire on SABR in oligometastatic renal cell carcinoma was prepared by a core group and reviewed by a panel of ten prominent experts in the field. The Delphi consensus methodology was applied, sending three rounds of questionnaires to clinicians identified as key opinion leaders in the field. At the end of the third round, participants were able to find consensus on eight of the 37 questions. Specifically, panellists agreed to apply no restrictions regarding age (25 [100%) of 25) and primary renal cell carcinoma histology (23 [92%] of 25) for SABR candidates, on the upper threshold of three lesions to offer ablative treatment in patients with oligoprogression, and on the concomitant administration of immune checkpoint inhibitor. SABR was indicated as the treatment modality of choice for renal cell carcinoma bone oligometatasis (20 [80%] of 25) and for adrenal oligometastases 22 (88%). No consensus or major agreement was reached regarding the appropriate schedule, but the majority of the poll (54%–58%) retained the every-other-day schedule as the optimal choice for all the investigated sites. The current ESTRO Delphi consensus might provide useful direction for the application of SABR in oligometastatic renal cell carcinoma and highlight the key areas of ongoing debate, perhaps directing future research efforts to close knowledge gaps.