In response to Fogarty et al. and why adjuvant whole brain radiotherapy is not recommended routinely.

The routine use of adjuvant whole brain radiotherapy (AWBRT) after surgery or stereotactic radiosurgery is now discouraged by a number of international expert panels. Three decades of randomised studies have shown that, although AWBRT improves radiological measures of intracranial disease control, the clinical benefit is unclear and it is also associated with inferior quality of life and neurocognitive function. The number of patients with melanoma in these trials was low, but data suggesting that treatment-related side effects should vary according to histology of the primary malignancy are lacking. For metastatic melanoma, the role of AWBRT to control microscopic disease in the brain is also a less relevant concern because systemic therapies with intracranial activity are now available. Whether AWBRT is useful in select patients deemed at high risk of neurologic death remains undefined.

Clinical implications of the overshoot effect for treatment plan delivery and patient-specific quality assurance for step-and-shoot IMRT.

In this work, overshoot and undershoot effects associated with step-and-shoot IMRT (SSIMRT) delivery on a Varian Clinac 21iX are investigated, and their impact on patient-specific QA point dose measurements and treatment plan delivery are evaluated. Pinnacle3 SSIMRT plans consisting of 5, 10, and 15 identical 5 × 5 cm2 MLC defined segments and MU/segment values of 5 MU, 10 MU, and 20 MU were utilized and delivered at 600/300 MU/min. Independent of the number of segments the overshoot and undershoot at 600 MU/min were approximately ± 10%, ± 5%, and ± 2.5% for 5 MU/segment, 10 MU/segment, and 20 MU/segment, respectively. At 300 MU/min, each of these values is approximately halved. Interfractional variation of these effects (10 fractions), as well as dosimetric variations for intermediate segments, are reduced at the lower dose rate. QA point-dose measurements for a sample (n = 29) of head and neck SSIMRT beams were on average 2.9% (600 MU/min) and 1.7% (300 MU/min) higher than Pinnacle3 planned doses. In comparison for prostate beams (n = 46), measured point doses were 0.8% (600 MU/min) and 0.4% (300 MU/min) higher. The reduction in planned-measured point-dose discrepancies at 300 MU/min can be attributed in part to the inclusion of the first segment (overshoot) in the admixture of segments that deliver measured dose. Pinnacle3 plans for 10/9 head and neck/prostate treatments were adjusted by ± 0.5 MU to include the effects of overshoot and undershoot at 600 MU/min. Comparing original and adjusted plans for each site indicated that the original plan was preferred in 70% and 89% of head and neck and prostate cases, respectively. The disparity between planned and delivered treatment that this suggests can potentially be mitigated by treating SSIMRT at a dose rate below 600 MU/min.