The purpose of this work is to analyse the collimator scatter for photon beams and the effect of scatter factor on extracorporeal irradiation.

Collimator scatter (Sc) is one of the major components in monitor unit (MU) calculations. A columnar mini-phantom was designed using wax in accordance with the European Society for Radiotherapy and Oncology (ESTRO) recommendations to measure the collimator scatter factor (Sc) for 6 MV and 15 MV photon beams from an Elekta Synergy Platform Linear Accelerator.

Measurements of collimator scatter factors were performed using brass buildup, indigenously designed columnar mini-phantom at depths of dmax and 10 cm to evaluate the influence of electron contamination on Sc. Additionally, measurements were also taken with the columnar mini-phantom at the same depths by placing a 1-mm lead sheet in the accelerator tray. The Sc measured at dmax was higher than that measured at 10 cm depth for both photon energies, indicating the presence of contaminant electrons at shallow depths. The introduction of a 1-mm lead sheet effectively reduced electron contamination during measurements at dmax.

Wedged fields produced higher Sc values compared with open fields, whereas changes in source-to-surface distance, detector type, chamber orientations and irregular field sizes showed no significant influence on Sc. Measurements obtained using the mini-phantom and a brass buildup cap showed good agreement with each other and were consistent with the AAPM TG-74 recommended data.

Accurately measured collimator scatter factors and appropriate phantom scatters are essential for reliable MU calculations and accurate dose delivery in extracorporeal irradiation, where phantom scatter is minimal.

SGRT can accurately monitor VMAT DIBH breast radiotherapy patients. Camera occlusion may provide difficulties for SGRT systems, such as VisionRT’s AlignRT, during rotational imaging (CBCT) and treatments (VMAT). Therefore, appropriate regions of interest (ROIs) need definition to ensure robust monitoring. Equally, operators must know where camera occlusion most likely occurs to optimise workflows.

A CT scan of an anthropomorphic phantom was performed to mimic a breast patient’s DIBH treatment position. A VMAT plan was produced, and six ROIs drawn on an AlignRT terminal. An ROI sensitivity test was performed, and approximate percentage surface area of occlusion was determined for all ROIs. Postural video was also utilised to determine where camera occlusion is most likely to occur.

No full camera occlusion was demonstrated using the phantom. However, postural video demonstrated camera occlusion was more probable between 10 and 60 degrees for CBCT arcs due to lateral camera occlusion. Sensitivity test results showed ROIs were more sensitive to vertical and lateral translations when both lateral cameras are blocked at CBCT50. Larger ROIs may be less sensitive and more robust when cameras were occluded. Additionally, the greatest approximate percentage of occlusion occurred at the superior lateral aspects of ROIs.

Gantry angles at higher risk of camera occlusion have been described between 10 and 60 degrees for CBCT to assist operators with troubleshooting, and a clinical workflow proposed. An ROI for VMAT DIBH breast rotational imaging and treatment has also been suggested to reduce the impact of camera occlusion.

Radiation-induced primary hypothyroidism is a common yet under-recognized toxicity after radiotherapy for undifferentiated nasopharyngeal carcinoma (UNPC). This study evaluated clinical and dosimetric predictors of hypothyroidism following intensity modulated radiotherapy (IMRT).

We retrospectively analyzed 50 non-metastatic (M0) UNPC patients treated with IMRT at the Salah Azaiez Institute (2016–2019), with regular thyroid function follow-up (12–60 months). Dosimetric parameters were reviewed for associations with thyroid dysfunction.

Hypothyroidism developed in 66% of patients (median onset: 26 months). Its risk was increased with a mean thyroid dose ≥56.67 Gy. Sparing less than 9.9 cc of thyroid tissue from 60 Gy (VS60) strongly predicted hypothyroidism (AUC 0.952, 95% CI 0.886–1; sensitivity 93.9%; specificity 100%). Affected patients had smaller thyroid glands (14.73 ± 6.14 vs. 19.17 ± 7.07cc; p = 0.026) and higher mean thyroid doses (59.8 ± 4.27 vs. 55.19 ± 3.41Gy; p < 0.001). Female sex (p = 0.035), higher T stage (p = 0.007), and nodal involvement ≥N2 (p = 0.003) were also significant predictors.

Radiation-induced hypothyroidism is a frequent, dose-dependent toxicity in UNPC. Preserving ≥9.9 cc of thyroid tissue below 60 Gy may reduce risk. Prospective validation is needed to confirm reliable dose thresholds.

Rare dermatologic disorders may complicate breast radiotherapy because treatment-related skin reactions can overlap with inflammatory flare, infection, or skin fragility. Evidence guiding radiotherapy delivery in Sweet’s-syndrome and inherited epidermolysis-bullosa (EB) remains limited.

Two patients receiving adjuvant breast radiotherapy were managed prospectively using a multidisciplinary protocol. A patient with Sweet’s syndrome received chest wall and regional nodal radiotherapy (50 Gy in 25 fractions) to minimise flare risk. A second patient with inherited EB received whole-breast radiotherapy (40 Gy in 15 fractions) to balance efficacy with skin fragility concerns. Both were treated using forward-planned Intensity-modulated-radiotherapy with daily cone beam computed-tomography verification. Structured toxicity review and skin-handling precautions were employed throughout treatment. Both completed treatment without interruption. The Sweet’s syndrome patient developed mild erythema only (grade 1) with no flare. The EB patient developed limited localised blistering (grade 1) without infection or extensive skin breakdown. Acute reactions resolved within six weeks, with no recurrent dermatologic flare at 6- and 12-month follow-up.

These cases suggest that rare inflammatory or fragility-related skin disorders do not preclude curative-intent breast radiotherapy when supported by multidisciplinary care.

Individualise fractionation, minimise skin trauma, and incorporate structured toxicity monitoring and escalation pathways into routine management.

Although moderate hypofractionation is widely adopted for localized prostate cancer, predictors of late genitourinary (GU) toxicity remain largely dose-centric. This study evaluated whether baseline urinary symptom burden, assessed by the International Prostate Symptom Score (IPSS), independently identifies the risk of late GU toxicity after hypofractionated prostate radiotherapy beyond conventional bladder dosimetry.

This multi-institutional retrospective study included 156 patients with localized prostate cancer treated with definitive hypofractionated external beam radiotherapy. Acute and late GU toxicities were graded using radiation therapy oncology group (RTOG) criteria. Univariable and multivariable logistic regression models were used to assess associations between baseline IPSS, bladder dosimetric parameters and toxicity outcomes.

With a median follow-up of 42 months, late-grade ≥2 GU toxicity occurred in 3.7% of patients. In multivariable analysis adjusting for age and bladder dosimetry, baseline IPSS was the only independent predictor of late GU toxicity (adjusted odds ratio 1.11 per point increase; 95% confidence interval, 1.04–1.19; p = 0.002). This association persisted among patients who met accepted bladder dose–volume constraints.

Baseline IPSS independently identifies patients at increased risk of late GU toxicity after hypofractionated prostate radiotherapy and provides clinically meaningful prognostic information beyond conventional dosimetric parameters. Rather than serving as a contraindication, elevated baseline IPSS represents a clinically actionable marker to support individualized risk stratification, treatment planning, patient counselling and function-informed treatment delivery

Radiotherapy is a key component of cancer treatment, yet medical students often receive limited exposure to its principles and practice. This preliminary study evaluates the use of the virtual environment for radiotherapy training (VERT™), a virtual reality simulation, in enhancing medical students’ knowledge, confidence and preparedness before clinical oncology placements.

This quasi-experimental study evaluated a one-hour VERT™ session for fourth-year medical students. Using pre- and post-intervention questionnaires with Likert scale and open-ended items, the study assessed changes in knowledge, understanding and attitudes. The mixed-methods design provided a comprehensive evaluation of the intervention’s educational effectiveness.

Statistical analysis showed significant improvements in 10 of 11 questionnaire items following the VERT™ session. Students reported large increases in perceived knowledge and understanding. Only attitudes toward virtual reality use remained unchanged, indicating limited impact on broader perceptions of VR in medical education. Thematic analysis revealed that VERT™ enhanced students’ understanding of radiotherapy concepts, planning and patient perspectives through immersive, hands-on learning. Participants valued its clarity and realism but suggested longer, more interactive sessions and clearer communication. Despite minor technical and engagement challenges, VERT™ was viewed as a valuable, confidence-building complement to traditional teaching.

Considering the confines of this preliminary study, the findings begin to suggest that VERT™-based simulation enhances medical students’ knowledge, understanding and confidence in radiotherapy. Participants felt better prepared for oncology placements, supporting VERT™’s value as an immersive learning tool. Despite limitations, results advocate its integration into medical education and further research on long-term and comparative effectiveness.

The aim of this study was to survey endometrial cancer (EC) diagnosis and treatment in Italian Radiation Oncology (RT) Centres.

In June 2024, a questionnaire was designed by the Gynecology Study Group of the Italian Association of Radiation and Clinical Oncology in collaboration with a panel of radiation oncologists and data managers. The 15-item survey gathered information about the RT centre’s profile, including geographical location and affiliations, the structure of multi-disciplinary tumour boards (MDTBs), and the number of EC cases that were discussed. It focused on the use of clinical guidelines for prescribing adjuvant treatment, as well as the use of molecular profiling and the methods employed for their analysis.

Fifteen questionnaires were returned from three centres in the north, five in the centre, and seven in the south of Italy. Most centres were national health hospitals (9/15, 60%). Thirteen centres reported cases were discussed in multi-disciplinary teams. MDTBs were held weekly (11) or fortnightly (2), with three or more specialists. All centres followed ESGO–ESTRO–ESP guidelines. Molecular profiling was conducted differently in the 15 centres. The most common method was immunohistochemical analysis. p53 and oestrogen and progesterone receptors were detected in all centres.

The present survey provided a view of Italian treatment of EC, adherence to international guidelines, and focus on molecular profiling. It revealed the strengths of the Italian healthcare system: widespread adherence to international guidelines, regular multidisciplinary team discussions, and broad access to basic molecular markers.

Radiation-associated retroperitoneal fibrosis (RPF) is a rare late complication of pelvic radiotherapy that may cause ureteric obstruction, hydronephrosis and renal impairment. Its radiological presentation may mimic tumour recurrence, making diagnosis challenging. We report a case of radiation-associated RPF following pelvic chemoradiotherapy for rectal adenocarcinoma, highlighting its diagnostic implications.

A 59-year-old man underwent total neoadjuvant treatment, pelvic chemoradiotherapy (46 Gy with a 4 Gy boost and concurrent capecitabine) and curative surgery. Eleven months after radiotherapy, surveillance computed tomography demonstrated retroperitoneal soft tissue consistent with probable radiation-associated fibrosis, associated with renal dysfunction. The patient subsequently developed severe right ureterohydronephrosis requiring percutaneous nephrostomy. Pelvic magnetic resonance imaging and positron emission tomography excluded locoregional recurrence and metastatic disease, supporting benign radiation-associated fibrosis. Follow-up imaging demonstrated stable RPF without tumour recurrence.

This case illustrates the importance of considering radiation-associated RPF in patients presenting with delayed obstructive uropathy after pelvic irradiation. Multimodal imaging was essential to distinguish benign fibro-inflammatory changes from recurrent malignancy and guide management.

Radiation-associated RPF should be considered in patients with unexplained renal dysfunction or hydronephrosis after pelvic irradiation. Early recognition, multidisciplinary assessment, urinary decompression and long-term imaging surveillance are essential to optimise patient outcomes.

Oropharyngeal carcinoma is a common malignancy managed with definitive chemoradiation. While these treatments are effective, they often cause complications, such as dysphagia, mucositis, pain and infections. This case report explores the post-chemoradiation challenges in a 77-year-old male, highlighting the development of a persistent fungal infection and the subsequent process of natural healing and immune recovery.

A 77-year-old male with carcinoma of the oropharynx, treated with definitive chemoradiation and immunotherapy, presented one week after completion of treatment with dysphagia, odynophagia (Numeric Rating Scale pain score: 6) and cough while swallowing. Clinical evaluation revealed a persistent fungal infection in the oral cavity, confirmed by potassium hydroxide (KOH) mount and fungal culture. The patient received aggressive antifungal therapy and supportive care, including analgesics, nutritional support and symptom management. Despite these measures, the infection persisted, leading to reliance on natural immune recovery. Symptoms gradually improved, and the infection resolved completely by 6 months, underscoring the importance of immune recovery in disease resolution.

Chemoradiation-induced mucosal injury, xerostomia and immune suppression increase susceptibility to oral candidiasis. Non-albicans Candida species are increasingly encountered and may demonstrate reduced susceptibility to standard antifungal therapy. This case highlights the limitations of prolonged antifungal treatment alone and emphasises the importance of host immune recovery in achieving infection resolution.

Persistent fungal infections after chemoradiation require early diagnosis, microbiological confirmation, multidisciplinary management and careful monitoring. Clinicians should consider resistant non-albicans species and recognise that restoration of host immunity may play a critical role in recovery when conventional antifungal therapies are insufficient.

Non-seminomatous germ cell tumours (NSGCTs) are traditionally managed with surgery and chemotherapy, with radiotherapy rarely utilised because of perceived radioresistance. Management of oligoprogressive disease in patients unsuitable for further systemic therapy remains challenging.

We report the case of a 53-year-old man with recurrent NSGCT and oligoprogressive retrocrural lymph node metastasis, who was unsuitable for further chemotherapy because of severe neurological complications. He was treated with stereotactic ablative radiotherapy (SABR), 42 Gy in three fractions.

Treatment was well tolerated, with only Grade 1 asthenia and no significant gastrointestinal toxicity. Radiological and serological surveillance demonstrated sustained response at 15 months.

This case demonstrates that SABR may represent a safe and effective local treatment option for selected patients with oligoprogressive NSGCT who are unsuitable for systemic therapy.

Radiotherapy for head and neck cancer (HNC) requires a thermoplastic immobilisation mask, which can heighten anxiety, yet this remains poorly recognised and inconsistently measured. Virtual reality (VR)-based rehearsal has been proposed as a preparatory strategy, but patient receptivity is unknown. This study examined the prevalence of state anxiety at mask fabrication, the practicality of administering the six-item State-Trait Anxiety Inventory (STAI Y-6) in a busy pre-treatment workflow and patient interest in VR-based preparation.

In this cross-sectional study, 39 consecutively recruited adults with HNC at a tertiary cancer centre completed a 10-item questionnaire before their first CT simulation: the STAI Y-6 plus four study-specific items covering mask-specific anxiety, general treatment anxiety and interest in a guided VR rehearsal of the procedure. Associations between STAI Y-6 caseness and supplementary items were assessed using Monte Carlo-simulated chi-squared tests.

Recruitment was 93% (39/42), completion 100% and median completion time 3.6 minutes. The mean pro-rated STAI Y-6 score was 43.3 (SD 14.1, range 20–77). Seventeen participants (44%, 95% CI 29–59%) scored ≥41, the threshold for clinically meaningful state anxiety. Participants with elevated anxiety more often reported at least some mask-specific anxiety (71% vs 32%; p = 0.025) and more often expressed uncertainty about VR (p = 0.027).

Nearly half of participants reported clinically meaningful anxiety at mask fabrication, and the STAI Y-6 was quick and acceptable to administer. Larger, multi-site studies with repeated assessment are needed to confirm prevalence and test targeted preparation such as VR.