Riesgo de osteorradionecrosis de los maxilares según el tipo de radioterapia

Introducción: El cáncer de cabeza y cuello es el séptimo más común a nivel mundial. Las opciones terapéuticas para su manejo incluyen la radioterapia, la cual debe procurar un equilibrio entre la eliminación del tumor y la preservación del tejido sano porque su aplicación implica el riesgo de desarrollar una osteorradionecrosis de los maxilares. Objetivo: Valorar si el riesgo de que se produzca osteorradionecrosis de los maxilares varía en función del tipo de radioterapia. Métodos: Diseño documental, retrospectivo basado en los principios de las revisiones sistemáticas exploratorias según lo establece la lista de chequeo PRISMA Extension for Scoping Reviews (PRISMA-ScR). Se realizaron búsquedas en inglés y español en PubMed, LILACS, ScienceDirect, Tripdatabase y Epistemonikos. Resultados: En total se incluyeron 12 estudios publicados entre 2016 y 2022 con diversos diseños de investigación; el estudio de cohorte retrospectivo fue el que tuvo mayor representación. Se analizaron distintas opciones de radioterapia y sus protocolos, entre ellos, la radioterapia de intensidad modulada, la terapia de protones de intensidad modulada, la radioterapia corporal estereotáctica y la radioterapia tridimensional. La literatura refiere que los protocolos que implican dosis totales más bajas representan un menor riesgo de osteorradionecrosis. Conclusiones: El riesgo de osteorradionecrosis de los maxilares debe atribuirse, en mayor medida, a la dosis total de radiación recibida por el paciente y a la dosis por fracción que al tipo de radioterapia.

Introduction: Head and neck cancer is the seventh most common cancer worldwide. Therapeutic options for its management include radiotherapy, which should seek a balance between tumor elimination and preservation of healthy tissue because its application implies the risk of developing osteoradionecrosis of the jaws. Objective: To assess whether the risk of developing osteoradionecrosis of the jaws varies according to the type of radiotherapy. Methods : Documentary, retrospective design based on the principles of exploratory systematic reviews as established by the PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist. PubMed, LILACS, ScienceDirect, Tripdatabase and Epistemonikos were searched in English and Spanish. Results: In total, 12 studies published between 2016 and 2022 with various research designs were included; the retrospective cohort study had the highest representation. Different radiotherapy options and their protocols were analyzed, including intensity-modulated radiotherapy, intensity-modulated proton therapy, stereotactic body radiotherapy, and three-dimensional radiotherapy. The literature refers that protocols involving lower total doses represent a lower risk of osteoradionecrosis. Conclusions: The risk of osteoradionecrosis of the jaws should be attributed, to a greater extent, to the total radiation dose received by the patient and the dose per fraction than to the type of radiotherapy.

Analysis of induced radiation and shielding materials in proton therapy room / 中国辐射卫生

Objective To analyze the dose distribution of induced radiation in fixed proton beam therapy room and the influence of shielding materials, and to provide a basis for radiation protection and shielding material selection in proton therapy. Methods FLUKA was used to simulate the dose distribution of induced radiation in fixed proton beam therapy room, the dose over time, and the influence of different concrete materials. Results The dose of induced radiation was mainly concentrated around the target, and the dose rapidly decreased to 1/5-1/10 of the value at the time of stopping irradiation after cooling for 3-5 min. The induced radiation in concrete formed a slightly higher dose area at the end of the main beam near the inner side of the shield. The content of Fe, O, and H in concrete had significant effects on induced radiation (P < 0.01), and the dose was negatively correlated with the content of Fe. Conclusion The patients after proton therapy as well as the induced radiation in air and shielding materials are the main sources of external radiation dose for workers, and waiting for a period of time is the most effective way to protect the staff. Without considering the difficulty in construction and based on the analysis of shielding materials in protection against external irradiation and their influence on induced radiation, heavy concrete with a relatively high level of Fe is the best choice of the shielding material for proton therapy room.

Development of Practical Proton Therapy System Based on Clinical Needs / 中国医疗器械杂志

In recent years, proton therapy technology has developed rapidly, and the number of patients treated with proton therapy has gradually increased. However, the application of proton therapy technology was far from practical needs. Because of the shortage of resources and the high cost, proton therapy systems are not accessible and affordable for most patients. In order to change this situation, it is necessary to develop a new truly practical proton therapy system based on clinical needs. Conceptual design of a practical proton therapy system was proposed. Compared with the existing system, one feature of the newly designed system is to reduce the maximum energy of the proton beam to 175~200 MeV; another feature is the configuration of deluxe and economical treatment rooms, the deluxe room is equipped with a rotating gantry and a six-dimensional treatment bed, and the economical room is equipped with a horizontal fixed beam and a patient vertical rotating setup device. This design can not only reduce the cost of proton therapy system and equipment room construction, but also facilitate the hospital to choose the appropriate configuration, which will ultimately benefit more patients.

Verification of the range calculation accuracy of a commercial proton treatment planning system / 中华放射肿瘤学杂志

Objective:In Shanghai Advanced Proton Therapy Facility (SAPT) of Ruijin Hospital Proton Therapy Center, the calculation accuracy of the commercial proton treatment planning system RayStation (V10), especially the accuracy of the proton range calculation, was measured and verified, aiming to provide reference for the clinical application of the treatment planning system.Methods:A head phantom was used to verify the calculation accuracy of RayStation. The phantom CT was imported into treatment planning system (TPS). The phantom was followed closely by a water tank with a one-liter cubic target. A single field verification plan with the prescribed dose of 200 cGy (relative biological effectiveness) was designed and implemented. Then, the measured distribution results were compared with the calculation results.Results:When the verification plan of the phantom was designed with the default settings of RayStation, the measured longitudinal dose distribution was approximately 4 mm deeper than that of TPS, indicating that RayStation overestimated the water equivalent thickness (WET) of the tissue substitute materials in the phantom. To study the range error, the actual beam was used to measure the WET of the soft tissue substitute material. The default setting of RayStation was fine-tuned according to the measured results. It was found that the error between the measured SOBP and TPS calculations was reduced to only 2 mm.Conclusions:Using the default setting of RayStation to calculate the stopping power of the phantom may cause a large range error. A method that combines tissue segmentation with the measured WET of the tissue substitute material is proposed to improve the range calculation accuracy of the TPS. The results show that the proposed method can improve the dose and range accuracy of the commercial TPS including RayStation for tissue substitute materials.

The development and verification of an independent dose calculation toolkit for proton Therapy / 中华放射肿瘤学杂志

Objective:To develop and validate the accuracy of an independent dose calculation toolkit for the horizontal beamline of Shanghai Advanced Proton Therapy (SAPT) facility based on an open-source dose calculation engine.Methods:Machine data, such as absolute integral depth doses (IDDs) and lateral profiles in air were measured and lateral profiles in water were derived by Monte-Carlo simulations. The dose computation models for SAPT horizontal beamline pencil beams in water were achieved by combining machine data and dose calculation engine. The verification of the dose reconstruction toolkit included absolute dose verification and relative dose verification. The absolute dose verification is performed to mainly compare the reconstructed value and the measured value at different depths along the center axis of the beam direction of a cube plan. The relative dose verification is conducted to mainly compare the lateral profile or two-dimensional dose distribution between the measured value and the reconstructed value. Meanwhile, the precision of double-gaussian and single-gaussian lateral beam models was compared.Results:The deviations of the absolute dose between the calculated and measured values were basically within 2%. The deviations of 20%-80% penumbra between the measured and the calculated values were within 1 mm, and deviations of the full width at half height were within 2 mm. For 3 cube plans and 2 clinical cases, the two-dimensional gamma pass rates (3 mm/3%) between the measured and calculated dose distributions at the corresponding depths were greater than 95%. The double-gaussian lateral beam model was more accurate in the high dose gradient region and deeper depth.Conclusion:The precision of independent dose calculation toolkit is acceptable for clinical requirements, which can be employed to investigate other dose-related issues.

A preliminary study on modeling and commissioning method of the treatment planning system used in the first domestic proton therapy device / 中华放射医学与防护杂志

Objective:To introduce the method and result of the modeling and preliminary dose verification of the treatment planning system used in the first domestic proton therapy device of China (Raystation 10B, a system of scientific research version with no available registration certificate) and to verify the modeling accuracy using dose verification result.Methods:The modeling method for a treatment planning system (TPS) mainly included the data acquisition and modeling of integrated depth dose (IDD) curves, the data acquisition and modeling of beam spot profiles in air, and the calibration and modeling of absolute dose by scanning a 10 cm ×10 cm square field with a spot spacing of 2.5 mm. By measuring the dose distributions in three cases with different complexity levels and comparing them with the dose distributions calculated using the TPS, this study verified and analyzed the modeling accuracy and proposed the requirements for beam parameters and the commissioning suggestions of the proton device.Results:The peak values of the IDD curves of low-energy regions fitted using the TPS model were less than the measured values, while those of medium- and high-energy regions fitted using the TPS model approximated the measured values. The range in all energy regions fitted accurately. For the three cases with different complexity levels, the deviation between the average dose calculated by the TPS and that measured was within ±5% (national standard for type tests of medical devices). Moreover, the DTA of high-dose-gradient areas was less than 3 mm.Conclusions:The modeling accuracy of the TPS generally meets the verification requirements. However, due to the low resolution of IDDs obtained by Monte Carlo simulation in the TPS model and the sharp Bragg peaks of low-energy regions, the IDD modeling accuracy of low-energy regions is insufficient.

Discussion on shielding calculation method for proton therapy room / 中国辐射卫生

@#<b>Objective</b> To discuss the shielding calculation method for proton therapy room, and to provide a scientific basis for shielding design of proton therapy room and improvement of existing national standards. <b>Methods</b> Using the calculation formula and key characteristic parameters from national standards and Chinese and foreign literature, combining with the FLUKA Monte Carlo method, empirical formula calculation and Monte Carlo simulation were conducted for the neutron ambient dose equivalent rates of the focuses outside the shielding of proton therapy room. The estimation results of the two methods were analyzed. <b>Results</b> Relative to the calculation results of the single exponential formula in the two directions of 0° and 50° in the beam loss point of divergence slit (0.13 and 12.4), the calculation results of the double exponential formula (0.40 and 17.9) were more consistent with the Monte Carlo simulation results (0.32 ± 0.19 and 18.2 ± 4.98). The Monte Carlo simulation results of copper target and nickel target were similar, suggesting that the key characteristic parameters of concrete shielding for copper target could be well applied to the calculation of nickel target, but the neutron ambient dose equivalent rates were underestimated when applied to tantalum target, with a difference of 5.7 times and 1.3 times in the two directions of 0° and 40°, respectively. <b>Conclusion</b> The dose rate estimates based on the calculation formula and key characteristic parameters from Chinese and foreign literature are consistent with FLUKA simulation results, and this method can be used in the shielding design of proton therapy room as a supplement and improvement to the existing national standards.

Current status and progress of proton and heavy ion radiotherapy for glioma in adults / 中华放射肿瘤学杂志

Glioma is the most common primary malignant brain tumor. Surgery combined with postoperative radiotherapy is the standard treatment, but the outcome is unsatisfactory. Currently, proton and carbon ion, the most advanced radiotherapy technology, offer substantial clinical advantages over the conventional photon therapy in multiple tumors. However, the effect of proton and carbon ion radiotherapy in glioma has not been clarified clearly. This article will elaborate on the basic research and clinical outcomes of proton and carbon ion radiotherapy for glioma.

Study of dose distortion and Bragg peak location correction in MRI-guided proton therapy / 中华放射肿瘤学杂志

Objective:To analyze the influence of magnetic field on the proton beam delivery and dose distribution, and develop a correction method for the Bragg peak (BP) shift under the vertical magnetic field, providing reference for the dose calculation and beam delivery of MRI-guided proton therapy.Methods:Monte Carlo (MC) simulation was used to study the dose distribution of the proton beam in the water phantom under the magnetic field. The BP location was corrected by the method of" angle correction+ energy correction" , and the correction parameters were calculated by the analytical formula based on the simulation data.Results:The magnetic field caused the dose distortion and shift of BP location. The shift degree was increased with the increase of field strength and initial energy. Compared with MC simulation, the result of calculating proton deflection in the air by the analytical method yielded a deviation within 0.2%. Based on the simulation data and calculation formulas, the correction parameters under different conditions could be calculated within 1 s by using the MATLAB programming. The calculation results showed that the air layer with magnetic field, isocenter depth, irradiation direction exerted different influence on the correction parameters. After correction, the BP location was basically consistent with the expected (offset ≤0.2 mm).Conclusions:The BP shift under the vertical magnetic field can be effectively corrected by " the angle correction+ energy correction" method. The correction parameters under different conditions can be quickly and accurately calculated by the calculation formulas based on simulation data.

Proton FLASH radiotherapy / 中华放射肿瘤学杂志

FLASH radiotherapy (FLASH-RT) is a treatment modality that delivers ultra-high dose rate and ultra-fast radiation for cancer treatment. Compared to conventional dose rate radiotherapy, FLASH-RT can yield similar efficacy for tumors and achieve normal tissue protection, translating to an increased therapeutic window. Due to this unique feature, FLASH-RT is attracting increasing attention from the radiotherapy community, both academia and industry. Due to its unique Bragg peak as well as intrinsic high dose rate, application of FLASH has more value and profound significance in proton therapy while achieving highly conformal dose deposition simultaneously. This article reviews research progress on FLASH-RT, relevant cell and animal studies, experimental conditions and results. Moreover, this article also investigates the potential biological mechanisms, technical challenges for implementation and potential clinical applications of FLASH-RT.

Improving the accuracy of pencil beam dose calculation of intensity-modulated proton therapy for lung cancer patients using deep learning / 中华放射肿瘤学杂志

Objective:Proton pencil beam (PB) dose calculation can achieve rapid dose calculation, whereas it is inaccurate due to the approximation in dealing with inhomogeneities. Monte Carlo (MC) dose calculation is recognized as the most accurate method, but it is extremely time consuming. The aim of this study was to apply deep-learning methods to improve the accuracy of PB dose calculation by learning the difference between the MC and PB dose distribution.Methods:A model which could convert the PB dose into the MC dose in lung cancer patients treated with intensity-modulated proton therapy (IMPT) was established based on the Hierarchically Densely Connected U-Net (HD U-Net) network. PB dose and CT images were used as model input to predict the MC dose for IMPT. The beam dose and CT images of 27 non-small cell lung cancer patients were preprocessed to the same angle and normalized, and then used as model input. The accuracy of the model was evaluated by comparing the mean square error and γ passing rate (1 mm/1%) results between the predicted dose and MC dose.Results:The predicted dose showed good agreement with MC dose. Using the 1 mm/1% criteria, the average γ passing rate (voxels receiving more than 10% of maximum MC dose) between the predicted and MC doses reached (92.8±3.4)% for the test patients. The average dose prediction time for test patients was (6.72±2.26) s.Conclusion:A deep-learning model that can accurately predict the MC dose based on the PB dose and CT images is successfully developed, which can be used as an efficient and practical tool to improve the accuracy of PB dose calculation for IMPT in lung cancer patients.

Implementation of meta-analysis approach, comparing conventional radiotherapy, and proton beam therapy treating head and neck cancer

Introduction: Radiation therapy is commonly used in the treatment of head and neck cancer in both the definitive and postoperative settings. Proton therapy, due to its intrinsic physical properties, has the ability to reduce the integral dose delivered to the patients while maintaining highly conformal target coverage Materials and Methods:.A literature search was performed on scientific databases, and Preferred Reporting Items for Meta-Analyses guidelines were followed to compute results. Only original studies were selected. Selected studies were used to extract some proposed data for comparison, dosimetry, site, complications, and survival. Results: Proton beam therapy technology can be used against the conventional radiotherapy and shows satisfactory results. Yet conventional therapy is not less advantageous considering the amount of work available for any cross interpretations. Conclusion: Comparative preplanning could be beneficial considering multiple therapies for ruling out the best treatment outcomes that could be expected

Proton Therapy: Malaysian Perspective

@#Proton therapy is an advanced type of radiotherapy and the use of charged particle proton instead of high energy X-rays to treat cancer has been increasing in recent years, as it offers superior dose distribution and more effectively spares healthy tissues compared to conventional radiotherapy. Proton therapy has potential clinical advantages for some types of tumours that are difficult to treat by conventional radiotherapy, it also has the added benefits of no exit dose beyond tumour. Many countries that established cancer treatment facilities in the last decade chose proton therapy because of its lower capital cost and higher cost-effectiveness compared to carbon ions therapy. This review first describes the physical characteristics of proton beam for radiotherapy, followed by potential clinical benefits of proton beam therapy in Malaysia. The paper also discusses the challenges of implementing the first proton centre in Malaysia.

Study on the conversion between CT hounsfield units and relative stopping power in proton therapy and the improvement in adipose tissue / 中华放射医学与防护杂志

Objective To introduce a method for calibrating the conversion from CT Hounsfield units (HU) to relative stopping power ( RSP) for proton therapy, and improve the precision of the conversion in the region for adipose tissues. Methods The HU and RSP values of human tissues were calculated by a stoichiometric calibration method. Animal tissue was used to simulate subcutaneous adipose tissue of patients, and the HU and RSP of the animal tissue were measured. The effect of subcutaneous adipose tissue on conversion between HU and RSP were analyzed by piecewise fitting. Results The precision of conversion curve was improved significantly with the measured HU and RSP of adipose tissue in the fitting. The effect caused by different choice in different ionization energy was less than 0. 6％, and the effect of proton energy differential was less than 0. 8％. Conclusions The precision of conversion curve for the transformation of HU into RSP in adipose tissues could be improved by taking subcutaneous adipose tissue into account, which would reduce the range error of proton beams when such tissues are present in the target volumes or in the beam path.

Robust optimization of intensity-modulated proton therapy for range uncertainty / 中华放射肿瘤学杂志

Objective Because of high precision and mild side effects,intensity-modulated proton therapy (IMPT) has become a hot spot in the radiotherapy field.Nevertheless,the precision of IMPT is extremely sensitive to the range uncertainties.In this paper,a novel robust optimization method was proposed to reduce the effect of range uncertainty upon IMPT.Methods Firstly,the robust optimization model was established which contained three types of range including the increased range,the normal range and the shortened range.The objective function was expressed in quadratic function.The organ dose contribution matrix of each range was calculated by proton pencil beam algorithm.The range deviation was discretized and the probability of each range was obtained based on the Gauss distribution function.Finally,the conjugate gradient method was adopted to find the optimal solution to make the actual dose coverage of the target area and the organs at risk distributed within the expected dose as possible.Results The 3 sets of simulation tests provided by the AAPM TG-119 Report were utilized to evaluate the effectiveness of this method:nasopharyngeal carcinoma,prostate and "C"-type cases.Compared with conventional IMPT optimization approach,this novel method was less sensitive to the range uncertainty.When the range deviation occurred,the dose coverage of the target area and organs at risk of the nasopharyngeal carcinoma and prostate cases almost reached the expected dose,and the high dose coverage of the target area and organs at risk protection were improved in the"C"-type cases.Conclusions To compensate for the range uncertainty,this novel method can enhance the dose coverage of the target area and reduce the dose coverage of the organs at risk.

Study on the conversion between CT hounsfield units and relative stopping power in proton therapy and the improvement in adipose tissue / 中华放射医学与防护杂志

Objective@#To introduce a method for calibrating the conversion from CT Hounsfield units (HU) to relative stopping power (RSP) for proton therapy, and improve the precision of the conversion in the region for adipose tissues.@*Methods@#The HU and RSP values of human tissues were calculated by a stoichiometric calibration method. Animal tissue was used to simulate subcutaneous adipose tissue of patients, and the HU and RSP of the animal tissue were measured. The effect of subcutaneous adipose tissue on conversion between HU and RSP were analyzed by piecewise fitting.@*Results@#The precision of conversion curve was improved significantly with the measured HU and RSP of adipose tissue in the fitting. The effect caused by different choice in different ionization energy was less than 0.6%, and the effect of proton energy differential was less than 0.8%.@*Conclusions@#The precision of conversion curve for the transformation of HU into RSP in adipose tissues could be improved by taking subcutaneous adipose tissue into account, which would reduce the range error of proton beams when such tissues are present in the target volumes or in the beam path.

Current status of proton therapy techniques for lung cancer

Proton beams have been used for cancer treatment for more than 28 years, and several technological advancements have been made to achieve improved clinical outcomes by delivering more accurate and conformal doses to the target cancer cells while minimizing the dose to normal tissues. The state-of-the-art intensity modulated proton therapy is now prevailing as a major treatment technique in proton facilities worldwide, but still faces many challenges in being applied to the lung. Thus, in this article, the current status of proton therapy technique is reviewed and issues regarding the relevant uncertainty in proton therapy in the lung are summarized.

Monte Carlo simulation and verification of a scanning proton beam nozzle / 中华放射医学与防护杂志

Objective To establish an accurate simulation model for proton scanning beam using Monte Carlo (MC) code.Methods The MC model of proton scanning beam treatment nozzle was established by using MC code FLUKA combined with the geometric structure of the treatment nozzle in Shanghai Proton and Heavy Ion Center (SPHIC).The MC beam model was established through the simulation of the integrated depth dose distribution (IDD) in water and the lateral profile in air at the isocenter points.The model was used to simulate the depth and lateral dose profile of Spread Out Bragg Peak (SOBP) of proton beam.The calucated result were compared with TPS calculation values.Results For the distal R90,the deviations of simulation and measurement at all energies were less than 0.5 mm.For distal fall off (R80-20),the deviations between simulation and measurement at each energy were within 0.1 mm.The biggest difference between measurement and simulation of the proton beam spot size was within 0.45 mm.The result of simulation and TPS calculation of proton SOBP matched well,with the γ index pass rate being higher than 90％ (Criteria:2 mm,2％).Conclusions The MC code FLUKA can be used to model the nozzle of scanning proton beam,which can meet the clinical requirements and accurately simulate the proton beam transport in material.After construction and verification on the basis of measurement,this model can be used as a dose verification tool to evaluate clinical proton treatment plans,in order to reduce the beam time for dose verification and thus increase the number of patient treatment in proton therapy.

Clinical Outcomes of Proton Beam Therapy for Choroidal Melanoma at a Single Institute in Korea / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study retrospectively evaluated the clinical outcomes and complications of proton beam therapy (PBT) in a single institution in Korea and quantitatively analyzed the change in tumor volume after PBT using magnetic resonance imaging (MRI). MATERIALS AND METHODS: Twenty-four treatment-naïve patients who underwent PBT for choroidal melanoma between 2009 and 2015 were reviewed. Dose fractionation was 60-70 cobalt gray equivalents over 5 fractions. Orbital MRIs were taken at baseline and 3, 6, and 12 months after PBT and annually thereafter. The tumor volume was reconstructed and evaluated by stacking the tumor boundary in each thin-sliced axial T1-weighted image using MIM software. RESULTS: The median follow-up duration was 36.5 months (range, 9 to 82 months). One patient had suspicious local progression and two patients had distant metastasis. The 3-year local progression-free survival, distant metastasis-free survival, and overall survival rates were 95.8%, 95.8%, and 100%,respectively. Five Common Terminology Criteria for Adverse Event ver. 4.03 grade 3-4 toxicities were observed in four patients (16.7%), including one with neovascular glaucoma. The mean tumor volume at the baseline MRI was 0.565±0.084 mL (range, 0.074 to 1.610 mL), and the ratios of the mean volume at 3, 6, and 12 months to that at baseline were 81.8%, 67.3%, and 60.4%, respectively. CONCLUSION: The local controlrate and complication profile after PBT in patientswith choroidal melanoma in Korea were comparable with those reported in a previous PBT series. The change in tumor volume after PBT exhibited a gradual regression pattern on MRI.

Clinical outcome of proton therapy for patients with chordomas

PURPOSE: To investigate the clinical outcome of proton therapy (PT) in patients with chordoma. MATERIALS AND METHODS: Fifty-eight patients with chordoma treated with PT between June 2007 and December 2015 at the National Cancer Center, Korea, were retrospectively analyzed. The median total dose was 69.6 cobalt gray equivalent (CGE; range, 64.8 to 79.2 CGE). Local progression-free survival (LPFS), distant metastasis-free survival (DMFS), overall survival (OS), and diseasespecific survival (DSS) rates were calculated by the Kaplan–Meier method. RESULTS: With the median follow-up of 42.8 months (range, 4 to 174 months), the 5-year LPFS, DMFS, OS, and DSS rates were 87.9%, 86.7%, 88.3%, and 92.9%, respectively. The tumor location was associated with the patterns of failure: the LPFS rates were lower for cervical tumors (57.1%) than for non-cervical tumors (93.1%) (p = 0.02), and the DMFS rates were lower for sacral tumors (53.5%) than for non-sacral tumors (100%) (p = 0.001). The total dose was associated with both the LPFS rate and DMFS rate. The initial tumor size was associated with the DMFS rate, but was not associated with the LPFS rate. Three patients had grade 3 late toxicity with none ≥grade 4. CONCLUSION: PT is an effective and safe treatment in patients with chordomas. The tumor location was associated with the patterns of failure: local failure was common in cervical tumors, and distant failure was common in sacral tumors. Further refinement of PT, such as the utilization of intensity modulated PT for cervical tumors, is warranted to improve the outcome.