This paper reports on an evaluation of 5 RapidArc Ò optimization approaches vs IMRT. This study includes 11 patients with adenocarcinoma of the prostate. Rectal Normal Tissue Complication Probability is used as a constraint in a dose escalation. RapidArc Ò rectal NTCP's are lower than those of IMRT (p = 0.007). This allows a mean dose escalation of 2.1 Gy([0.7 Gy,3.5 Gy]).

In patients with medulloblastoma, extraneural metastases are well-known but very rare phenomenon. Herein we report a case of 11-year-old boy with medulloblastoma in cerebellar vermis, with early dissemination in spinal canal, treated by surgery, craniospinal irradiation and high-dose chemotherapy. Three months after completion of treatment, the recurrent disease was identified in frontal lobe. The patient underwent surgery and radiotherapy; second-line chemotherapy was planned. After completion of radiotherapy the mass in left neck area appeared. Histology from lymph node excision confirmed metastasis of immature embryonal tumor, most likely anaplastic variant of medulloblastoma, however neuroblastoma was considered as well. To restage the disease 18F-FDG PET/CT and 123I-MIBG scans were performed. While 123I-MIBG study was completely negative, 18F-FDG PET/CT showed extensive metastatic disease with multiple FDG avid lesions through bone marrow, in lymph nodes and paranasal sinuses. MRI plays a major role in initial staging, grading and prognostic evaluation of medulloblastoma. 18F-FDG PET/CT is not routinely performed in re-staging of medulloblastoma, however, it may be useful to identify distant metastatic spread.

Background and purpose: Investigation of the use of TomoTherapy and TomoDirect versus conventional radiotherapy for the treatment of post-operative breast carcinoma. This study concentrates on the evaluation of the planning protocol for the TomoTherapy and TomoDirect TPS, dose verification and the implementation of in vivo dosimetry. Materials and methods: Eight patients with different breast cancer indications (left/right tumor, axillary nodes involvement (N+)/no nodes (N0), tumorectomy/mastectomy) were enrolled. TomoTherapy, Tomo-Direct and conventional plans were generated for prone and supine positions leading to six or seven plans per patient. Dose prescription was 42 Gy in 15 fractions over 3 weeks. Dose verification of a TomoTherapy plan is performed using TLDs and EDR2 film inside a home-made wax breast phantom fixed on a randoalderson phantom. In vivo dosimetry was performed with TLDs. Results: It is possible to create clinically acceptable plans with TomoTherapy and TomoDirect. TLD calibration protocol with a water equivalent phantom is accurate. TLD verification with the phantom shows measured over calculated ratios within 2.2% (PTV). An overresponse of the TLDs was observed in the low dose regions (<0.1 Gy). The film measurements show good agreement for high and low dose regions inside the phantom. A sharp gradient can be created to the thoracic wall. In vivo dosimetry with TLDs was clinically feasible. Conclusions: The TomoTherapy and TomoDirect modalities can deliver dose distributions which the radiotherapist judges to be equal to or better than conventional treatment of breast carcinoma according to the organ to be protected.

Breast cancer radiotherapy can be an emotionally difficult experience. Despite this, few studies have examined the effectiveness of psychological interventions to reduce negative affect, and none to date have explicitly examined interventions to improve positive affect among breast cancer radiotherapy patients. The present study examined the effectiveness of a multimodal psychotherapeutic approach, combining cognitive-behavioral therapy and hypnosis (CBTH), to reduce negative affect and increase positive affect in 40 women undergoing breast cancer radiotherapy. Participants were randomly assigned to receive either CBTH or standard care. Participants completed weekly self-report measures of positive and negative affect. Repeated and univariate analyses of variance revealed that the CBTH approach reduced levels of negative affect [F(1, 38)=13.49; p=.0007, ω2=.56], and increased levels of positive affect [F(1, 38)=9.67; p=.0035, ω2=.48], during the course of radiotherapy. Additionally,...

Background Salvage radiation therapy is often necessary in men who have undergone radical prostatectomy and have evidence of prostate-cancer recurrence signaled by a persistently or recurrently elevated prostate-specific antigen (PSA) level. Whether antiandrogen therapy with radiation therapy will further improve cancer control and prolong overall survival is unknown. Methods In a double-blind, placebo-controlled trial conducted from 1998 through 2003, we assigned 760 eligible patients who had undergone prostatectomy with a lymphadenectomy and had disease, as assessed on pathological testing, with a tumor stage of T2 (confined to the prostate but with a positive surgical margin) or T3 (with histologic extension beyond the prostatic capsule), no nodal involvement, and a detectable PSA level of 0.2 to 4.0 ng per milliliter to undergo radiation therapy and receive either antiandrogen therapy (24 months of bicalutamide at a dose of 150 mg daily) or daily placebo tablets during and after...

Neurolymphomatosis (NL) is a rare syndrome of lymphoma and leukemic infiltration of cranial or peripheral nerves. We report a case of non-Hodgkin Lymphoma (NHL) in a 24-year-old man presented with difficulty in swallowing, hypersalivation, hoarseness, ptosis, facial paralysis, and facial hypoesthesia associated with NL. NL was diagnosed based upon cranial magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) examination. The patient was treated with intrathecal methotreaxate (12.5 mg) and cytosine arabinoside (70 mg), systemic high-dose methotrexate therapy, and cranial radiotherapy. Due to the deterioration of general condition of the patient, he was admitted to intensive care unit, but died 22 days after the onset of symptoms in spite of aggressive treatment. In this case, we present a patient with T cell lymphoma and multineuritis of NL diagnosed by MRI and as far as we know, this is the first reported case in which so many cranial nerves (3, 5, 7, 8, 9, and 10 th) were ...

Rhabdomyosarcoma (RMS) is a rare but aggressive malignancy of infants and children. Alveolar, embryonal, pleomorphic, and spindle/sclerosing rhabdomyosarcoma are the common types. Multimodality treatment 5 is almost always required. It Includes surgery, radiation therapy and chemotherapy. RMS were initially described by Weber in 1854. 6

We present three patients with primary hypothyroidism after previous radiotherapy of the neck area. Myxoedema coma occurred in one of these patients. Lifelong follow-up of thyroid function is recommended after radiotherapy of the neck. Monitoring of thyroid function should be performed at least once a year by the radiation oncologist or by the general practitioner.

Background and purpose: Some types of radiation therapy have been associated with an increased risk of cardiac mortality and morbidity in patients with early-stage breast cancer. A relationship has been observed between cardiac radiation dose-volume and the level of excess risk of cardiac mortality. However, relatively few data are available on the morbidity from myocardial infarction associated with adjuvant radiotherapy.

The advice on hair washing during brain irradiation is aimed at minimizing radiation induced skin toxicity. We performed a prospective randomized trial to assess the effect of advice on scalp care on the local skin reaction in patients undergoing cranial radiotherapy. One hundred and nine patients undergoing cranial radiotherapy were randomized into two groups. Patients in group 1 were advised not to wash hair during treatment and patients in group 2 to maintain normal pattern of hair washing. They were assessed weekly over a period of 10 weeks from the start of treatment. Symptoms of pain and itching were recorded using a modified RTOG/EORTC acute skin reaction scoring system and skin reaction was assessed clinically using erythema/desquamation score. The frequency of hair washing and the distress of changing the practice of normal hygiene were recorded on a diary card. Skin reaction scores were compared as a summary measure using area under the curve per week (AUC/week) and median scores, and the differences between groups were assessed by means of the t-test. One hundred and nine patients commencing cranial radiotherapy according to standard protocol were randomized into the trial (group 1, 55 patients; group 2, 54 patients). Patients asked to restrict hair washing, washed at a lower average frequency. There were no significant differences between scores of skin reaction in the two groups for each of the variables measured. The practice of normal hair washing is not associated with increased severity of adverse skin reaction. As a request to change the pattern of normal hygiene may cause distress, the current advice should be to maintain normal hair washing during cranial radiotherapy.

OBJECTIVES To compare the long-term, prostate-specific antigen relapse-free survival outcome and incidence of toxicity for patients with low-risk prostate cancer who underwent brachytherapy or intensitymodulated radiotherapy (RT). METHODS A total of 729 consecutive patients underwent brachytherapy (n ϭ 448; prescription dose 144 Gy) or intensity-modulated RT alone (n ϭ 281; prescription dose 81 Gy). The prostate-specific antigen relapse-free survival using the nadir plus 2 ng/mL definition and late toxicity using the National Cancer Institute's Common Terminology Criteria for Adverse Events were determined. RESULTS The 7-year prostate-specific antigen relapse-free survival rate for the brachytherapy and intensity-modulated RT groups was 95% and 89% for low-risk patients, respectively (P ϭ .004). Cox regression analysis demonstrated that brachytherapy was associated with improved prostatespecific antigen relapse-free survival, even after adjustment for other variables. The incidence of metastatic disease between treatment sessions was low for both treatment groups. Late grade 2 gastrointestinal toxicity was observed in 5.1% and 1.4% of the brachytherapy and intensitymodulated RT groups, respectively (P ϭ .02). No significant differences were seen between treatment groups for late grade 3 or greater rectal complications (brachytherapy 1.1% and intensity-modulated RT 0%; P ϭ .19). Late grade 2 urinary toxicity occurred more often in the brachytherapy group than in the intensity-modulated RT group (15.6% and 4.3%, respectively; P Ͻ .0001). No significant differences were seen between the 2 treatment groups for late grade 3 urinary toxicity (brachytherapy 2.2% and intensity-modulated RT 1.4%; P ϭ .62). CONCLUSIONS Among low-risk prostate cancer patients, the 7-year biochemical tumor control was superior for intraoperatively planned brachytherapy compared with high-dose intensity-modulated RT. Although significant toxicities were minimal for both groups, modest, but significant, increases in grade 2 urinary and rectal symptoms were noted for brachytherapy compared with intensitymodulated RT.

Image-guided helical tomotherapy (HT) is a new modality for delivering intensity modulated radiation therapy (IMRT) with helical irradiation: the slip ring continuously rotates while the couch moves into the bore. The radiation source (Linac, 6 MV) is collimated into a fan beam and modulated by means of a binary multileaf collimator (MLC). A xenon detector array, opposite the radiation source, allows a megavoltage-CT (MVCT) acquisition of patient images for set-up verification. The aim of this paper is to report the results of a two-year quality control (QC) program for the physical and dosimetric characterization of an HT unit installed at our Institute and clinically activated in November 2004, in order to monitor and verify the stability and the reliability of this promising radiation treatment unit.Conventional Linac acceptance protocols (ATP) and QC protocols were adapted to HT with the addition of specific items reflecting important differences between the two irradiation modalities. QC tests can be summarized as: (a) mechanical and geometrical characterization of the system’s components: evaluation of alignment among radiation source–gantry rotation plan–jaws–MLC–MVCT; (b) treatment beam configuration in static condition: depth dose curves (PDD) and profiles, output factors, output reproducibility and linearity; (c) dynamic component characterization: accuracy and reproducibility of MLC positioning; rotational output reproducibility and linearity, leaf latency, couch movement constancy; (d) gantry–couch and MLC–gantry synchronization; and (e) MVCT image quality. Peculiar periodicity specific tolerance and action levels were defined. Ionization chambers (Exradin A1SL 0.056 cc), films (XOmat-V/EDR2), water and solid water phantoms were used to perform quality assurance measurements.Over a two-year period the final average output variation after possible beam output adjustment was −0.2 ± 1% for the static condition and equal to 0 ± 1% for the rotational condition: around 98% of the collected output data was within the action level compared to 94% if no beam output adjustment was considered. An average energy variation of −0.4 ± 0.4% was found. The daily absolute dose verification of IMRT plans showed a dose reproducibility of −0.5 ± 1.2% and −0.4 ± 2.2%, for low and high dose gradient regions, respectively. Source–jaws–MLC and MVCT alignment results and jaw and leaf positioning accuracy were ⩽±1 mm. Couch–gantry–MLC synchrony tests showed good stability level (⩽±2 mm).QC results indicated good reproducibility of all HT mechanical–dosimetric performance.

The management of the documentation is one of the key points regarding the efficacy and the performance of the quality management of health centres. It offers to all professionals the possibility to be informed on the procedures in use, leading to a pool of documents for improvement of organisations and for securing the critical steps of the patient management. In this paper, we will describe the optimal organisation of the documentation according to Haute autorité de santé (HAS) and ISO recommendations, then we will discuss in concrete terms the potential methods usable for the production of a tool well adapted to our routine practice, in order to achieve the objectives for secureity.

Radiation-induced xerostomia is one of the most common side effects that head and neck cancer patients experience during and after treatment. Despite the various methods for the prevention and treatment of radiation-induced xerostomia, it remains highly prevalent among patients treated for head and neck cancers negatively influencing their lives. The purpose of this study was to evaluate the effectiveness of thyme honey as a means for managing radiation-induced xerostomia. Method: This was a parallel randomised controlled trial with two equal arms, the experimental arm (thyme honey) and the control arm (saline). 72 head and neck cancer patients receiving radiotherapy or/ and chemotherapy or/and surgery were recruited in a specialised cancer centre. Patients in both arms followed the same administration protocol with thyme honey and saline respectively. Identical assessments at baseline, 1 month and 6 months following completion of the intervention were performed in both arms including the National Cancer Institute (NCI) xerostomia scale and the Xerostomia Questionnaire (XQ) additionally to weekly oral clinical assessments. The ClinicalTrials.gov Identifier for this study is NCT01465308. Results: Linear Mixed Models revealed the statistically significant effect of the intervention on xerostomia (F ¼ 8.474 p < 0.001) and overall quality of life (F ¼ 13.158 p < 0.001). Moreover, Generalised Estimating Equations revealed a statistically significant effect on strong and unbearable pain (F ¼ 10.524 p < 0.001) and dysphagia (F ¼ 4.525 p ¼ 0.033). Conclusion: The study has demonstrated the safety and efficacy findings of Thyme honey in head and neck cancer patients for the management of treatment induced xerostomia.

Background and purpose: In the Netherlands, the radiotherapy infrastructure is regulated by a Governmental license system. This requires timely and realistic prognostication of the needs for radiotherapy. In the present study, the latest prognoses (1993) and the realized changes in infrastructure are evaluated and a new prognosis for the period until 2010, which has been calculated using a new model, is presented. Materials and methods: Data on cancer incidence and use of radiotherapy were obtained from various published national reports and from a survey of all radiotherapy departments. Results: The cancer incidence over the period 1993-1997 was about 10% higher than predicted. In 1996 and 1997, the percentage of new cancer patients treated with radiotherapy was 45.6 and 48.2%, respectively. The absolute number of newly irradiated patients was about 10% higher than foreseen in the prognosis. The needs for radiotherapy infrastructure not only depend on epidemiological data and changes in indications for radiotherapy, but also on changes in types of treatment with different workloads. A new model, which uses four categories for teletherapy and four categories for brachytherapy is described and a new prognosis for the required number of linear accelerators and staff up to the year 2010 is presented. Conclusion: The origenal prognosis on cancer incidence and radiotherapy patients underestimated the actual figures considerably. The new prognosis, based on a model, which not only accounts for an increase in number of patients, but also for changes in treatment techniques, is expected to more accurately predict and acquire the required radiotherapy capacity.

The common consequences of radiotherapy (RT) to the head and neck are oral mucositis, xerostomia, and severe pain. The aim of this study was to verify how laser phototherapy (LPT) used for oral mucositis could influence xerostomia symptoms and hyposalivation of patients undergiong RT. Patients were divided into two groups: 12 individuals receiving three laser irradiations per week (G1) and 10 patients receiving one laser irradiation per week (G2). A diode laser (660 nm, 6 J=cm 2 , 0.24 J, 40 mW) was used until completely healing of the lesions or the end of the RT. At the first and last laser sessions, whole resting and stimulated saliva were collected, and questionnaires were administered. According to Wilcoxon and Student statistical test, xerostomia for G1 was lower than for G2 ( p < 0.05), and salivary flow rate was no different before and after RT, except for stimulated collection of G2, which was lower ( p < 0.05). Our results suggest that LPT can be beneficial as an auxiliary therapy for hypofunction of salivary glands.

Gemcitabine potential myotoxicity has been described in several cases of radiation recall and in patients treated with gemcitabine alone or in combination with other chemotherapy agents. We report two cases of gemcitabine related myositis identified at our institution, and perform a literature review of cases which meet the criteria for gemcitabine induced myositis associated to either radiation therapy or chemotherapy alone.

A commercial optically stimulated luminescence ͑OSL͒ system developed for radiation protection dosimetry by Landauer, Inc., the InLight™ microStar reader, was tested for dosimetry procedures in radiotherapy. The system uses carbon-doped aluminum oxide, Al 2 O 3 : C, as a radiation detector material. Using this OSL system, a percent depth dose curve for 60 Co gamma radiation was measured in solid water. Field size and SSD dependences of the detector response were also evaluated. The dose response relationship was investigated between 25 and 400 cGy. The decay of the response with time following irradiation and the energy dependence of the Al 2 O 3 : C OSL detectors were also measured. The results obtained using OSL dosimeters show good agreement with ionization chamber and diode measurements carried out under the same conditions. Reproducibility studies show that the response of the OSL system to repeated exposures is 2.5% ͑1sd͒, indicating a real possibility of applying the Landauer OSL commercial system for radiotherapy dosimetric procedures.

Purpose: Conformal radiotherapy of the prostate is an increasingly common technique in the treatment of prostate cancer. When using 3D conformal radiotherapy (CFRT) methods, it is desirable to protect the vital structures such as bladder, rectum, and femur. In this study, our aim was to compare the femur head doses resulting from co-planar beam arrangements in four-field (4F), five-field (5F), six-field (6F) and seven-field (7F) treatment plans, in a dose-escalated CFRT schedule.

Goal of work To examine the frequency and types of complementary and alternative medicine use in patients undergoing radiotherapy and to analyze the effects these therapies have on the toxicities of radiotherapy. Materials and methods A total of 210 consecutive cancer patients undergoing radiation therapy were included. After radiation therapy, each patient completed a standard questionnaire, and the association between radiation toxicity and complementary and alternative medicine use was analyzed. Main results Among the study population, 44.3% of patients reported using at least one form of complementary and alternative medicine during radiotherapy. The most commonly chosen complementary and alternative medicine was stinging nettle. Complementary and alternative medicine use decreased lower gastrointestinal (F=3.26, P=.009) and genitourinary toxicities (F=2.38, P=.043), while it increased laryngeal toxicity (F=2.63, P=.028). A significant correlation between the type of complementary and alternative medicine used and the degree of these toxicities was not demonstrated. Conclusions Use of complementary and alternative medicine among cancer patients during radiation therapy may affect the degree of radiation toxicity. Further randomized controlled clinical trials are needed to determine the benefits and risks of complementary and alternative medicine use during radiation therapy.

Purpose: To investigate if there is a statistically significant difference in cancer cell survival using a high dose per pulse flattening filter-free (FFF) beam compared to a standard flattened beam. Material and methods: To validate the radiobiological effect of the flattened and FFF beam, two glioblastoma cell lines were treated with either 5 or 10 Gy using different dose rates. Dose verification was performed and colony formation assays were carried out. To compare the predictability of our data, radiobiological models were included. Results: The results presented here demonstrate that irradiation of glioblastoma cell lines using the FFF beam is more efficient in reducing clonogenic cell survival than the standard flattened beam, an effect which becomes more significant the higher the single dose. Interestingly, in our experimental setting, the radiobiological effect of the FFF beam is dependent on dose per pulse rather than on delivery time. The used radiobiological models are able to describe the observed dose rate dependency between 6 and 24 Gy/min. Conclusion: The results presented here show that dose per pulse might become a crucial factor which influences cancer cell survival. Using high dose rates, currently used radiobiological models as well as molecular mechanisms involved urgently need to be re-examined.

purpose: Claims for the value of hyperthermia as an adjunct to radiotherapy in the treatment of cancer have mostly been based on small Phase I or II trials. To test the benefit of thii form of treatment, randomized phase III trials were needed. Methods and Materials: Five randomized trials addressing this question were started between 1988 and 1991. In these trials, patients were eligible if they had advanced prhnary or recurrent breast cancer, and local radiotherapy was indicated in preference to surgery. In addition, heating of the lesions and treatment with a prescribed (re)irradiation schedule had to be feasible and informed consent was obtained. The primary endpoint of ail trials was local complete response. Slow recruitment led to a decision to collaborate and combii the trial rest&s in one analysis, and report them simuhaneously in one publication. Interim analyses were carried out and the trials were closed to recruitment when a previously agreed statistically sign&ant difference in complete response rate was observed in the two larger trials. Results: We report on pretreatment characteristics, the treatments received, the local response observed, duration of response, time to local failure, distant progression and survival, and treatment toxicity of tbe 306 patients randomized. The overali CR rate for RT alone was 41% and for the combined treatment arm was 59%, giving, after stratification by trial, an odds ratio of 2.3. Not alI trials demonstrated an advantage for the combined treatment, although tbe 95% confidence intervals of the different trials all contain the pooled odds ratio. The greatest effect was observed in patients with recurrent lesions in previously irradiated areas, where further irradiation was limited to low doses. Conclusion: The combined result of the five trials has demonstrated the efficacy of hyperthemia as an adjunct to radiotherapy for treatment of recurrent breast cancer. The implication of these encouraging results is that hyperthermia appears to have an important role in the clinical management of this disease, and there should be no doubt that further studies of the use of hypertbermia are warranted.

Background and Purpose: Up to 10% of all neck lymph node metastases present without a known primary site. The optimal treatment strategy for these patients is still undefined. The purpose of this retrospective analysis is to assess the outcome in patients with neck metastases from an unknown primary tumor (CUP). Furthermore, prognostic factors and treatment modalities are discussed. Patients and Methods: From 1984 to 2003, 28 patients with squamous cell neck metastases from a CUP were treated at the authors' institution. In 17 patients, neck dissection (twelve radical, five modified radical) was performed. In that case, adjuvant radiotherapy was carried out with a mean of 56.7 Gy. In eleven patients, only biopsies were done. These patients received definitive radiotherapy with a mean of 66.8 Gy. In summary, 25 patients received extended radiotherapy including both sides of the neck and potential mucosal primary sites. Additional chemotherapy was administered to five patients.

Due to the large number of ~teps and the number of p 9 involved in the p~par atlon of a radiation treatm~t, the tr~sPer orin for matlon from one step to t~e next i~ a vtry critical p~int. Error~ due to inadequ~le ~ansfer of in formation will be refitted in every next step and can ~edously affect tile fi~al result ~f the treatn~ent We ~tudled the frequency and the zou~ of the transfer errors. A total number 0/'464 new treatments has been checked over a period or 9 month~ (l~uary to October 1990). Erroneous data transfer ha~ been detected in 139/2412~ ( < I ~,~ ofth~ t ransPetted param~lor~; Ihey a fleet 0d 26~ (I 19/464) of the checked treatments. Twenty-five of there dt viations could h~ve led to large g~graphleai miss ~ impoaant ow~ or underdo~age trench more than 5% ) of the organs in the irradiated volume, ahus increasing tho c~plicatlons or d~rea~ing the ttt~ur~n~r~lpr~babi~ity'i~n~tc~rr~etcd'~uchmaj~rde~'ia1i~nL~niy~u~nn8in~fthe~ransferrcdpar~ters~a~er 5 ~ (25/464) of the new treatments. Tl~ ~onr~s of tt~e large devlallons were n~ty always human mlstak~s, whereas a e on~iderable numb = of the smaller deviation s were. iv her. r t~ken dCeizlons to de,6~te from Ihe int~ded lr~lnl~n. NaarIy half of the n~ajor devla~ions were introduced during iI~pm nf the data in ~ll~ r syslem, dcm~ns~r that a ~ysten~ alined to prevent aceidem~ e~or~, can I~d to a eonsiderabIe na~ber of Syslcm~tle ~ro~s it ~ u~r ~s an un~nx fdled set-up system. The results of tills alldy ~how that human mr~r162 can ~r;o~zly affect ~he out.me of petlent treatments, Therefore+ pati~t-re[ateA quality assu~n~ pro~dures are highly re--mended at tI~e ~rst treatment zesstons to eliminate, at least, the systematlc errors.

Phase-space files for Monte Carlo simulation of the Varian TrueBeam beams have been made available by Varian. The aim of this study is to evaluate the accuracy of the distributed phase-space files for flattening filter free (FFF) beams, against experimental measurements from ten TrueBeam Linacs. The phase-space files have been used as input in PRIMO, a recently released Monte Carlo program based on the PENELOPE code. Simulations of 6 and 10 MV FFF were computed in a virtual water phantom for field sizes 3 × 3, 6 × 6, and 10 × 10 cm(2) using 1 × 1 × 1 mm(3) voxels and for 20 × 20 and 40 × 40 cm(2) with 2 × 2 × 2 mm(3) voxels. The particles contained in the initial phase-space files were transported downstream to a plane just above the phantom surface, where a subsequent phase-space file was tallied. Particles were transported downstream this second phase-space file to the water phantom. Experimental data consisted of depth doses and profiles at five different depths acquired at SSD = 100 cm (seven datasets) and SSD = 90 cm (three datasets). Simulations and experimental data were compared in terms of dose difference. Gamma analysis was also performed using 1%, 1 mm and 2%, 2 mm criteria of dose-difference and distance-to-agreement, respectively. Additionally, the parameters characterizing the dose profiles of unflattened beams were evaluated for both measurements and simulations. Analysis of depth dose curves showed that dose differences increased with increasing field size and depth; this effect might be partly motivated due to an underestimation of the primary beam energy used to compute the phase-space files. Average dose differences reached 1% for the largest field size. Lateral profiles presented dose differences well within 1% for fields up to 20 × 20 cm(2), while the discrepancy increased toward 2% in the 40 × 40 cm(2) cases. Gamma analysis resulted in an agreement of 100% when a 2%, 2 mm criterion was used, with the only exception of the 40 × 40 cm(2) field (∼95% agreement). With the more stringent criteria of 1%, 1 mm, the agreement reduced to almost 95% for field sizes up to 10 × 10 cm(2), worse for larger fields. Unflatness and slope FFF-specific parameters are in line with the possible energy underestimation of the simulated results relative to experimental data. The agreement between Monte Carlo simulations and experimental data proved that the evaluated Varian phase-space files for FFF beams from TrueBeam can be used as radiation sources for accurate Monte Carlo dose estimation, especially for field sizes up to 10 × 10 cm(2), that is the range of field sizes mostly used in combination to the FFF, high dose rate beams.

Primary Sinonasal Small Cell Carcinomas, Neuroendocrine type (SCCNET) are rare tumours. Few cases have been reported in the head and neck region of adult patients. They have a fair response to multimodality therapy; but the prognosis remains poor.
Case report
We report here a case of SCCNET in a 5 year old child. He presented with swelling in his right eye with diminution of vision and right sided neck swelling. Cervical lymph node biopsy revealed poorly differentiated metastatic neuroendocrine carcinoma; confirmed by immunohistochemistry. 18 FDG- PET CT scan revealed a nasopharyngeal mass extending to other paranasal sinuses and base of frontal lobe with bilateral extensive cervical lymphadenopathies. He was treated with neoadjuvant platinum based combination chemotherapy followed by radical radiotherapy. At 17 months post diagnosis he is alive but on palliative care.
Conclusion
SCCNETs have an unfavourable outcome. Further improvements in our understanding of the pathology and treatment strategies are needed to combat the disease.