Multicentre clinical radiotherapy audit in rectal cancer: results of the IROCA project.

PURPOSE: To perform a clinical audit to assess adherence to standard clinical practice for the diagnosis, treatment, and follow-up of patients undergoing radiotherapy for rectal cancer treatment in four European countries. MATERIALS AND METHODS: Multi-institutional, retrospective cohort study of 221 patients treated for rectal cancer in 2015 at six European cancer centres. Clinical indicators applicable to general radiotherapy processes were evaluated. All data were obtained from electronic medical records. RESULTS: The audits were performed in the year 2017. We found substantial inter-centre variability in adherence to standard clinical practices: 1) presentation of cases at departmental clinical sessions (range, 0-100%) or multidisciplinary tumour board (50-95%); 2) pretreatment MRI (61.5-100%) and thoracoabdominal CT (15.0-100%). Large inter-centre differences were observed in the mean interval between biopsy and first visit to the radiotherapy department (range, 21.6-58.6 days) and between the first visit and start of treatment (15.1-38.8 days). Treatment interruptions ≥ 1 day occurred in 43.9% (2.5-90%) of cases overall. Treatment compensation was performed in 2.1% of cases. Treatment was completed in the prescribed time in 55.7% of cases. CONCLUSIONS: This multi-institutional clinical audit revealed that most centres adhered to standard clinical practices for most of the radiotherapy processes-related variables assessed. However, the audit revealed marked inter-centre variability for certain quality indicators, particularly inconsistent record keeping. Multiple targets for improvement and/or harmonisation were identified, confirming the value of routine clinical audits to detect potential deviations from standard clinical practice.

Rectal neuroendocrine carcinoma: case report of a rare entity and perspective review of promising agents.

Neuroendocrine neoplasms (NENs) comprise a heterogeneous group of tumours, which can be classified into neuroendocrine tumours (NETs), neuroendocrine carcinomas (NECs) and mixed neuroendocrine non-neuroendocrine neoplasms (MiNENs). To date, there is no consensus regarding the optimal therapy, which usually depends on the primary location and classification, according to morphological features of differentiation and proliferation rates. Nevertheless, multidisciplinary strategies combining medical treatments and locoregional strategies have yielded better efficacy results. Here, we report the case of a patient diagnosed with a nonfunctional rectal NECs with metastatic widespread to pelvic lymph nodes and bilateral lung metastases. The patient received three cycles of platinum-etoposide, concomitantly with palliative radiotherapy. Although CT scan after three cycles showed a significant partial response, there was an early fatal progression only 3 months after having stopped systemic therapy. As formerly described in the literature, this case highlights the aggressive behaviour of NECs, rare tumours that often present in advanced stages at diagnosis. Lately, new insights into the molecular biology of NECs have unveiled the possibility of using novel drugs, such as targeted agents or immunotherapy, in molecularly selected subgroups of patients. In this review, we discuss the current management of this rare entity and provide an overview of the most relevant molecular findings, whilst illustrating the potential value that prescreening panels can offer, searching for actionable targets (MSI/dMMR, PD-L1, BRAFv600E) to guide therapy with promising agents that could fill a void in this disease.

VITAL phase 2 study: Upfront 5-fluorouracil, mitomycin-C, panitumumab and radiotherapy treatment in nonmetastatic squamous cell carcinomas of the anal canal (GEMCAD 09-02).

AIM: VITAL, a phase II single-arm study, aimed to evaluate efficacy and safety of panitumumab addition to 5-fluorouracil (5-FU), mitomycin-C (MMC) and radiotherapy (RT) in patients with localized squamous cell carcinoma of the anal canal (SCCAC). METHODS: Adult, treatment-naïve SCCAC patients (Stage T2-T4, any N, M0) and ECOG-PS ≤2, received panitumumab (6 mg/kg, day 1 and Q2W; 8 weeks), 5-FU (1000 mg/m2 /d, days 1-4 and 29-32), MMC (10 mg/m2 , days 1 and 29) and RT 45 Gy (1.8 Gy/fraction) to the primary tumor and mesorectal, iliac and inguinal lymph nodes, plus 10-15 Gy boost dose to the primary tumor and affected lymph nodes. The primary objective was disease free survival rate (DFS) at 3-years (expected 3-year DFS rate: 73.7 ± 12%). RESULTS: Fifty-eight patients (31 women; median age: 59 years; ECOG-PS 0-1:98%; TNM II [29%] (T2 or T3/N0/M0)/IIIA (T1-T3/N1/M0 or T4/N0/M0) [21%]/IIIB (T4/N1/M0 or any T/N2 or N3/M0) [47%]/nonevaluable [4%]) were included. The median follow-up was 45 months. The 3-year DFS rate was 61.1% (95% CI: 47.1, 72.4). The 3-year overall survival rate was 78.4% (95% CI: 65.1, 87.1). Eighteen patients (31.0%) required a colostomy within 2 years posttreatment. Grade 3-4 toxicities were experienced by 53 (91%) patients. Most common grade 3-4 treatment-related events were radiation skin injury (40%) and neutropenia (24%). No toxic deaths occurred. Improved efficacy in colostomy-free survival and complete response rate was observed in human papilloma virus positive patients. CONCLUSIONS: Panitumumab addition to MMC-5FU regimen in SCCAC patients increases toxicity and does not improve patients' outcomes. RT plus MMC-5FU remains the standard of care for localized SCCAC patients.

Versión española de la Satisfaction With Decision scale: adaptación transcultural, validez y fiabilidad / Spanish version of the Satisfaction With Decision scale: cross-cultural adaptation, validity and reliability

OBJETIVO: Desarrollar la versión española de la SWDs (Escala de Satisfacción con la Decisión, ESD) y analizar sus propiedades psicométricas de validez y fiabilidad en nuestro contexto. DISEÑO: Estudio observacional, descriptivo, de validación de un instrumento de medida de satisfacción con la decisión tomada. Emplazamiento: Consultas del Servicio de Urología, Oncología radioterápica y Oncología médica del Hospital Universitari Germans Trias I Pujol, del Institut Català d'Oncologia y en la sede del Institut Oncològic del Vallès del Hospital General de Catalunya. PARTICIPANTES: Se obtuvo un total de 170 participantes diagnosticados de cáncer de próstata, que sabían leer y escribir en castellano y dieron su consentimiento informado. MEDICIONES PRINCIPALES: Se ha realizado una traducción, retrotraducción y adaptación transcultural de la SWDs. Se analizó la validez de contenido, validez de criterio, validez de constructo, la fiabilidad y la estabilidad temporal. RESULTADOS: La ESD consta de 6 ítems con respuesta Likert-5 opciones. Se obtuvo una versión española lingüística y conceptualmente equivalente a la escala original. La validez de criterio, con la correlación entre la ESD con el grado de satisfacción con la decisión tomada marcada en una escala analógica lineal, resultó significativa (r = 0,63; p < 0,01). El análisis factorial extrajo una única dimensión para explicar el 82,08% de la varianza. La ESD mostró excelentes resultados de fiabilidad: consistencia interna (alfa de Cronbach = 0,95) y estabilidad temporal test-retest (CCI = 0,711). CONCLUSIONES: La ESD es un instrumento válido y fiable para evaluar la satisfacción de la decisión tomada en salud en nuestro contexto

OBJECTIVE: The aim of this study is to develop a Spanish version of the Satisfaction With Decision scale (SWDs) and analyse the psychometric properties of validity and reliability. DESIGN: An observational, descriptive study and validation of a tool to measure satisfaction with the decision. SETTING: Urology, Radiation oncology, and Medical oncology Departments of the Hospital Universitari Germans Trias I Pujol, Institut Català d'Oncologia and the Institut Oncològic del Vallès - Hospital General de Catalunya. PARTICIPANTS: A total of 170 participants diagnosed with prostate cancer, and who could read and write in Spanish and gave their informed consent. MAIN MEASUREMENTS: A translation, back-translation and cross-cultural adaptation to Spanish was performed on the SWDs. The content validity, criterion validity, construct validity and reliability (internal consistency and stability) of the Spanish version were evaluated. RESULTS: The SWDs contains 6 items with 5-item Likert scales. A Spanish version (ESD) was obtained that was linguistically and conceptually equivalent to the original version. Criterion validity, the ESD correlated with "satisfaction with the decision" using a linear analogue scale, was significant (r = 0.63, P<.01) for all items. The factorial analysis showed a unique dimension to explain 82.08% of the variance. The ESD showed excellent results in terms of internal consistency (Cronbach alpha = 0.95) and good test-retest reliability with intraclass correlation coefficient of 0.711. CONCLUSIONS: The ESD is a validated Spanish scale to measure the satisfaction with the decisions taken in health, and demonstrates a correct validity and reliability

[Spanish version of the Satisfaction With Decision scale: cross-cultural adaptation, validity and reliability]. / Versión española de la Satisfaction With Decision scale: adaptación transcultural, validez y fiabilidad.

OBJECTIVE: The aim of this study is to develop a Spanish version of the Satisfaction With Decision scale (SWDs) and analyse the psychometric properties of validity and reliability. DESIGN: An observational, descriptive study and validation of a tool to measure satisfaction with the decision. SETTING: Urology, Radiation oncology, and Medical oncology Departments of the Hospital Universitari Germans Trias i Pujol, Institut Català d'Oncologia and the Institut Oncològic del Vallès - Hospital General de Catalunya. PARTICIPANTS: A total of 170 participants diagnosed with prostate cancer, and who could read and write in Spanish and gave their informed consent. MAIN MEASUREMENTS: A translation, back-translation and cross-cultural adaptation to Spanish was performed on the SWDs. The content validity, criterion validity, construct validity and reliability (internal consistency and stability) of the Spanish version were evaluated. RESULTS: The SWDs contains 6 items with 5-item Likert scales. A Spanish version (ESD) was obtained that was linguistically and conceptually equivalent to the original version. Criterion validity, the ESD correlated with "satisfaction with the decision" using a linear analogue scale, was significant (r=0.63, P<.01) for all items. The factorial analysis showed a unique dimension to explain 82.08% of the variance. The ESD showed excellent results in terms of internal consistency (Cronbach alpha=0.95) and good test-retest reliability with intraclass correlation coefficient of 0.711. CONCLUSIONS: The ESD is a validated Spanish scale to measure the satisfaction with the decisions taken in health, and demonstrates a correct validity and reliability.

Developing a decision aid to support informed choices for newly diagnosed patients with localized prostate cancer.

BACKGROUND: Decision aids (DAs) have been developed in several health disciplines to support decision making informed by evidence, such as the benefits and risks of different treatment options. Decision aids can improve the decision-making process by reducing decisional conflict and helping patients to participate in decision making. OBJECTIVE: The aim of this study was to design and develop a DA for treatment decision making in localized prostate cancer in Spain with regard to surgery, radiotherapy, or watchful waiting. INTERVENTIONS/METHODS: We developed a DA based on the principles of the International Patient Decision Aid Standards Collaboration and according to the Ottawa Decision Support Framework. The structural development process involved DA developers, expert feedback, use of the Delphi method, and patient feedback. We conducted a pilot test on 34 men with localized prostate cancer. RESULTS: The DA is a structured booklet. According to the International Patient Decision Aid Standards checklist, the DA scored 22 of 27 points (81.48%). The development process section scored 22 of 24 points (91.6%), and the effectiveness of the decision-making process section scored 6 of 6 (100%). The clinical pilot test yielded positive feedback regarding the design, images, understandability, usability, explanations, and amount of information in the DA. CONCLUSIONS: We developed a Spanish DA with a strong quality score to help patients make an informed choice regarding their prostate cancer treatment. Future research will assess the impact of the DA and its association with improved decision making. IMPLICATIONS FOR PRACTICE: This tool provides information about the risks and benefits of different treatment options and helps patients to understand the importance of their own values for informing treatment choices.

A Decision Aid to Support Informed Choices for Patients Recently Diagnosed With Prostate Cancer: A Randomized Controlled Trial.

BACKGROUND: Decision aids provide balanced information about the benefits and risks of treatment options and improve the match between patient preferences and the treatment received. OBJECTIVE: To assess the impact of a decision aid regarding the treatment options for patients with localized prostate cancer. METHODS: A 2-arm randomized controlled trial was used to compare booklet patient decision aid (intervention group n = 61) with standard information for localized prostate cancer (control group n = 61). The study was conducted at 3 hospitals between 2011 and 2013. The main outcome measures were knowledge, decisional conflict, satisfaction with the decision-making process, and coping. RESULTS: The respective mean Decisional Conflict Scale scores before and after the intervention were 53.0 ± 16.9 and 31.2 ± 10.2 in the intervention group and 49.1 ± 13.7 and 51.7 ± 13.3 in the control group (P < .001). Mean Knowledge scores were 38.6 ± 16.5 and 75.7 ± 19.0 in the intervention group and 42.0 ± 17.6 and 49.9 ± 16.0 in the control group (P < .001). Mean Satisfaction With Decision Scale scores were 81.1 ± 8.92 and 95.7 ± 6.89 in the intervention group and 82.5 ± 12.0 and 79.3 ± 10.3 in the control group (P < .001). CONCLUSIONS: Decision aid not only improved patient knowledge about localized prostate cancer and its treatment and their satisfaction with decision making but also decreased their decisional conflict. IMPLICATIONS FOR PRACTICE: Decision aid represents a rather innovative approach for a health insurance fund to develop and offer this format of information and decision support. This opens a new field of study for nurses to empower patients in the decision-making process and develop new roles in this area.

Extraordinarily Prolonged Disease Recurrence in a Granulosa Cell Tumor Patient.

BACKGROUND: Granulosa cell tumors are rare sex cord stromal lesions that comprise approximately 3% of all ovarian neoplasms. The vast majority of granulosa cell tumors are considered indolent but in spite of aggressive management, delayed recurrence is of significant concern. CASE REPORT: We describe a case involving a 67-year-old woman who presented with abdominal pain, bloody stools, and mild nausea. Following a CT scan of the abdomen and pelvis, a 19-cm pelvic mass was identified. Her prior medical history included a hysterectomy for uterine fibroids 40 years ago and a bilateral salpingo-oophorectomy for a presumed granulosa cell tumor 20 years ago. Final pathology revealed granulosa cell tumor with small bowel mesentery involvement. The patient underwent surgical resection and adjuvant chemotherapy; she is currently doing well. CONCLUSION: Granulosa cell tumors are considered to be of low malignant potential but they have the capacity to recur, even several years following initial patient management. This case exemplifies the disease's capacity for prolonged recurrence and further accentuates the significance of long-term follow-up in these patients.

El análisis modal de fallos y efectos (AMFE) ayuda a aumentar la seguridad en radioterapia / No disponible

Objetivos: A raíz de una incidencia de sobredosis detectada en el servicio de radioterapia, se puso en marcha un proyecto de análisis y eliminación de riesgos para aumentar la seguridad de los pacientes.Material y método: Se aplicó el análisis modal de fallos y efectos (AMFE), un instrumento analítico aplicado en varios hospitales de Estados Unidos. Como exige la metodología, se cuantificaron los riesgos de cada modo de fallo en una escala de 1:1.000 utilizando el índice NPR (número de priorización del riesgo). En una primera fase de mejora, se definió el nivel de actuación como NPR > 100. Se detectaron varios riesgos en los protocolos actuales y se eliminaron todos ellos mediante redefinición de circuitos, controles y verificaciones adicionales, listas de comprobación y auditorias internas, entre otros. Posteriormente, se introdujo un sistema de gestión de la calidad según ISO9001, se definió una serie de indicadores y la dirección se implicó realizando revisiones mensuales de los resultados. Resultados: Se implantaron 100 acciones de mejora. El índice de riesgo calculado después de haber tomado las acciones bajó significativamente y aumentó la seguridad. Las mejoras realizadas aseguran el mantenimiento del grado de seguridad logrado. Conclusiones: La experiencia muestra que se puede identificar objetivamente los riesgos de cada paso que damos y destinar los escasos recursos de que disponemos a los procesos o actividades donde el riesgo es mayor, mediante mejoras metodológicas de nuestros protocolos de trabajo

Objectives: As a result of an adverse event detected at the Radiotherapy Treatment Unit, a safety improvement project was undertaken to analyze and eliminate risks and thus increase patient safety. Material and method: Failure Mode and Effects Analysis (FMEA), ananalytical tool used in many US hospitals, was applied. As required by FMEA, risks of potential failure modes were quantified on a scale of 1 to 1000, using the Risk Priority Number (RPN). In the first improvement phase, an RPN value greater than 100 was consideredto be the limit above which corrective actions should be taken. Several potential failure modes were detected in existing treatment protocols and all the causes of potential failure modes were eliminatedthrough corrective actions that included redefinition of treatment protocols, the creation of new records for existing controls and the addition of new controls, checklists, and internal audits, amongother measures. Subsequently, a quality management system based on ISO9001 was introduced. Process indicators were defined to measure treatment quality, and the results were analyzed on a monthly basis with top management participation.Results: A total of 100 improvement actions were taken. The RPN values calculated after the implementation of the actions were significantly lower, increasing patient safety. The actions taken ensure the maintenance of the achieved safety levels. Conclusions: The experience shows that the risks present in all steps taken can be objectively identified. Through improved procedures, the limited resources available can be allocated to those processes or activities that pose maximum risk

Stereotactic radiotherapy for ocular melanoma: initial experience using closed eyes for ocular target immobilization.

To assess the reliability and target positioning reproducibility with eyes closed in uveal melanoma patients treated with a micromultileaf-based linear accelerator dedicated for stereotactic radiotherapy. Five consecutive patients treated with curative radiotherapy for uveal melanoma were monitored for positioning reproducibility with resimulation CT scans performed every two days while on treatment (23 resimulation CTs available). All patients underwent MRIs of the orbits before simulation to help to define the target and organs at risk (e.g., lenses, optic nerves, ciliary bodies, and lacrimal glands) in the simulation CT (MRI-to-CT bone registration). Patients were simulated, resimulated, and treated with eyes closed. Patient #1 was treated with 5 daily fractions while patients #2 to #5, were treated with 10 daily fractions. We chose the lens of the tumor-bearing eye as the structure to be controlled, assuming that correct repositioning of the lens should be a valid surrogate for correctness of target repositioning. Displacements (mean and standard deviations, SD) of the lens in the three axes were measured for each patient. Systematic and standard errors were calculated. Planning target volume (PTV) margins were estimated according to McKenzie et al. [Phys Med Biol 45, 3331-3342 (2000)]. For both AP-PA and left-right shifts calculated SD were always below 1 mm, except for patient #4, who was treated with a non-customized bolus that pushed the globe backwards in a random fashion. In ideal set-up conditions PTV margins around the target were estimated to be 3 mm. Asking patients to close their eyes is a simple and reliable immobilization procedure when treating ocular tumors with stereotactic radiotherapy. Margins of 3 mm around the target may be necessary to safely treat these tumors under ideal set-up conditions.

Impact of nutrition on quality of life during cancer.

PURPOSE OF REVIEW: This review addresses the relationship between nutritional intervention and quality of life in oncology patients. RECENT FINDINGS: Nutrition related symptoms, such as anorexia and weight loss, reflect impaired nutritional status, which is often associated with reduced quality of life. Malnutrition can be related to reduced response or tolerance to cancer treatment. Early nutritional intervention may positively impact on quality of life and enhance clinical response in oncology patients. SUMMARY: Nutritional intervention should be considered as a supportive measure within the global oncology strategy. In curative oncology care, it contributes to reduced postoperative infection rate, better control of cancer-related symptoms, shortened length of hospital stay and improved tolerance to treatment. In palliative care, the nutritional intervention focuses on controlling symptoms, thus improving quality of life. The evaluation of nutritional status should include an assessment of quality of life in order to optimize nutritional treatment for patients' individual requirements. Because of the potentially clinically relevant impact of nutritional intervention on quality of life, nutritional care should be included in any antineoplastic strategy.

Nutritional intervention and quality of life in adult oncology patients.

The evaluation of quality of life (QoL) assesses patients' well-being by taking into account physical, psychological and social conditions. Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of QoL. These metabolic changes lead to decreased food intake and promote wasting. Cancer-related malnutrition can evolve to cancer cachexia due to complex interactions between pro-inflammatory cytokines and host metabolism. Beside and beyond the physical and the metabolic effects of cancer, patients often suffer as well from psychological distress, including depression. Depending on the type of cancer treatment (either curative or palliative) and on patients' clinical conditions and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counselling, oral supplementation, enteral or total parenteral nutrition). Such an approach, which should be started as early as possible, can reduce or even reverse their poor nutritional status, improve their performance status and consequently their QoL. Nutritional intervention accompanying curative treatment has an additional and specific role, which is to increase the tolerance and response to the oncology treatment, decrease the rate of complications and possibly reduce morbidity by optimizing the balance between energy expenditure and food intake. In palliative care, nutritional support aims at improving patient's QoL by controlling symptoms such as nausea, vomiting and pain related to food intake and postponing loss of autonomy. The literature review supports that nutritional care should be integrated into the global oncology care because of its significant contribution to QoL. Furthermore, the assessment of QoL should be part of the evaluation of any nutritional support to optimize its adequacy to the patient's needs and expectations.

Gene expression profiling of adult acute myeloid leukemia identifies novel biologic clusters for risk classification and outcome prediction.

To determine whether gene expression profiling could improve risk classification and outcome prediction in older acute myeloid leukemia (AML) patients, expression profiles were obtained in pretreatment leukemic samples from 170 patients whose median age was 65 years. Unsupervised clustering methods were used to classify patients into 6 cluster groups (designated A to F) that varied significantly in rates of resistant disease (RD; P < .001), complete response (CR; P = .023), and disease-free survival (DFS; P = .023). Cluster A (n = 24), dominated by NPM1 mutations (78%), normal karyotypes (75%), and genes associated with signaling and apoptosis, had the best DFS (27%) and overall survival (OS; 25% at 5 years). Patients in clusters B (n = 22) and C (n = 31) had the worst OS (5% and 6%, respectively); cluster B was distinguished by the highest rate of RD (77%) and multidrug resistant gene expression (ABCG2, MDR1). Cluster D was characterized by a "proliferative" gene signature with the highest proportion of detectable cytogenetic abnormalities (76%; including 83% of all favorable and 34% of unfavorable karyotypes). Cluster F (n = 33) was dominated by monocytic leukemias (97% of cases), also showing increased NPM1 mutations (61%). These gene expression signatures provide insights into novel groups of AML not predicted by traditional studies that impact prognosis and potential therapy.

Proton beam radiotherapy versus fractionated stereotactic radiotherapy for uveal melanomas: A comparative study.

PURPOSE: A comparative treatment planning study was undertaken between proton and photon therapy in uveal melanoma to assess the potential benefits and limitations of these treatment modalities. A fixed proton horizontal beam (OPTIS) and intensity-modulated spot-scanning proton therapy (IMPT), with multiple noncoplanar beam arrangements, was compared with linear accelerator-based stereotactic radiotherapy (SRT), using a static and a dynamic micromultileaf collimator and intensity-modulated RT (IMRS). METHOD AND MATERIALS: A planning CT scan was performed on a brain metastasis patient, with a 3-mm acquisition slice spacing and the patient looking at a luminous spot with the eyes in three different positions (neutral and 25 degrees right and left). Four different gross tumor volumes were defined for each treatment technique. These target scenarios represented different locations (involving vs. not involving the macula and temporal vs. nasal) and volumes (10 x 6 mm vs. 16 x 10 mm) to challenge the proton and photon treatment techniques. The planning target volume was defined as the gross tumor volume plus 2 mm laterally and 3 mm craniocaudally for both modalities. A dose homogeneity of 95-99% of the planning target volume was used as the "goal" for all techniques. The dose constraint (maximum) for the organs at risk (OARs) for both the proton and the SRT photon plans was 27.5, 22.5, 20, and 9 CGE-Gy for the optic apparatus, retina, lacrimal gland, and lens, respectively. The dose to the planning target volume was 50 CGE-Gy in 10 CGE-Gy daily fractions. The plans for proton and photon therapy were computed using the Paul Scherrer Institute and BrainSCAN, version 5.2 (BrainLAB, Heimstetten, Germany) treatment planning systems, respectively. Tumor and OARs dose-volume histograms were calculated. The results were analyzed using the dose-volume histogram parameters, conformity index (CI(95%)), and inhomogeneity coefficient. RESULTS: Target coverage of all simulated uveal melanomas was equally conformal with the photon and proton modalities. The median CI(95%) value was 1.74, 1.86, and 1.83 for the static, dynamic, and IMSRT plans, respectively. With proton planning, the median CI(95%) was 1.88 for OPTIS and substantially improved with IMPT in some tumor cases (median CI(95%), 1.29). The tumor dose homogeneity in the proton plans was, however, always better than with SRT photon planning (median inhomogeneity coefficient 0.1 and 0.15 vs. 0.46, 0.41, and 0.23 for the OPTIS and IMPT vs. the static, dynamic, and IMSRT plans, respectively). Compared with the photon plans, the use of protons did not lead to a substantial reduction in the homolateral OAR total integral dose in the low- to high-dose level, except for the lacrimal gland. The median maximal dose and dose at the 10% volume with the static, dynamic, and IMSRT plans was 33-30.8, 31.8-28, and 35.8-49 Gy, respectively, for the lacrimal gland, a critical organ. For protons, only the OPTIS plans were better, with a median maximal dose and dose at the 10% volume using OPTIS and IMPT of 19.2 and 8.8 and 25.6 and 23.6 CGE, respectively. The contralateral OARs were completely spared with the proton plans, but the median dose delivered to these structures was 1.2 Gy (range, 0-6.3 Gy) with the SRT photon plans. CONCLUSION: These results suggest that the use of SRT photon techniques, compared with protons, can result in similar levels of dose conformation. IMPT did not increase the degree of conformality for this small tumor. Tumor dose inhomogeneity was, however, always increased with photon planning. Except for the lacrimal gland, the use of protons, with or without intensity modulation, did not increase homolateral OAR dose sparing. The dose to all the contralateral OARs was, however, completely eliminated with proton planning.