Concurrent chemoradiotherapy with combined irradiation techniques of volumetric-modulated arc therapy (VMAT) and simultaneously integrated inner-escalated boost (SIEB) successfully managing a patient with cT4 nasopharyngeal carcinoma with limited toxicities: a CARE-compliant case report

Introduction

Background

Nasopharyngeal cancer (NPC) is a prevalent malignancy in South Asia, including Taiwan (1). Patients with locally advanced NPC (cT4) demonstrated superior survival compare to those with regionally advanced disease (cN3), despite both are classified as stage IVA. This disparity is primarily attributed to distinct patterns of treatment failure: cT4 disease is more prone to local recurrence, whereas cN3 disease is more prone to distant relapses (2). Consequently, some studies have suggested that cT4N0–2 disease should be classified independently from cT1–4N3 disease in the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) staging system (2).

Rationale and knowledge gap

For patients with locoregionally advanced NPC, the standard of care to improve tumor control and survival is CCRT, combined with induction or adjuvant chemotherapy (3-6). When CCRT is administered, intensity-modulated radiotherapy (IMRT) is the recommended technique (7). The recommended prescription dose for high-risk planning target volume (PTV) ranges from 70 to 70.2 Gy (1.8–2.0 Gy per fraction), a limit primarily dictated by the tolerance constraints of adjacent critical organs-at-risk (OARs) (6).

However, for patients with bulky cT4 disease, delivering the standard recommended dose often results in unsatisfied local relapse-free survival (LRFS) (8). Although the 5-year LRFS is around 80–90%, there is significant clinical necessity for further improvement. Although dose escalation, such as an additional 10-Gy boost, has been proposed for managing cT4 NPC (9), escalating the dose (e.g., up to 81 Gy) may increase the risk of late radiotherapy (RT)-induced sequelae, such as temporal lobe necrosis (10).

Objective

We report a patient with cT4 NPC successfully managed by definitive CCRT followed by adjuvant chemotherapy. RT was delivered using a combination of precise techniques, specifically volumetric-modulated arc therapy (VMAT) and simultaneously integrated inner-escalated boost (SIEB). This approach allowed for simultaneous escalation of the irradiation dose to the central part of the tumor, while attenuating the dose at the tumor periphery adjacent to critical normal tissues. The main purpose of this approach was to optimize the therapeutic gain, achieving enhanced tumor control while minimizing radiation-induced morbidity. Consequently, prolonged disease-free survival (DFS) was achieved with limited toxicities. We present this article in accordance with the CARE reporting checklist (available at https://tro.amegroups.com/article/view/10.21037/tro-24-38/rc).

Case presentation

Oncologic timeline of intervention and outcome

According to the CARE guideline and CARE-compliant case reports (11), we constructed an oncological timeline to depict the events of diagnosis, staging, intervention, and clinical outcomes chronologically (Figure 1).

Figure 1 Chronological timeline of the patient’s treatment course. 5-Fu, fluorouracil; AJCC, American Joint Committee on Cancer; C/T, chemotherapy; CCRT, concurrent chemoradiotherapy; CR, complete response; cT, clinical tumor stage; CT, computed tomography; CTCAE, Common Toxicity Criteria of Adverse Events; ECOG, Eastern Cooperative Oncology Group; Frs, fractions; M, metastasis; MRI, magnetic resonance imaging; N, node; NP, nasopharynx; NPC, nasopharyngeal carcinoma; PR, partial response; PS, performance status; PTV, planning target volume; RT, radiotherapy; SIEB, simultaneously integrated inner-escalated boost; VMAT, volumetric-modulated arc radiotherapy.

Patient information

A 64-year-old man had no chronic morbidities, presented with a 3-month history of refractory headache, epistaxis, and persistent nasal obstruction. He also reported diplopia of 1-month duration. The patient reported no history of alcohol drinking, cigarette smoking, and betel nut chewing.

Physical examination

At the time of initial evaluation, the patient demonstrated an Eastern Cooperative Oncology Group (ECOG) performance status of 1. Neurological examination for cognitive function, judgment, orientation, memory, abstraction, and calculation (JOMAC) was intact. Cranial nerve examination revealed a left-sided abducens nerve (cranial nerve VI) palsy, consistent with the reported diplopia. Neck palpation identified firm, enlarged lymph nodes, a 3-cm node over the left level II and several nodes over the right level II and V. Systemic examination, including pulmonary auscultation and abdominal palpation, was unremarkable, with no evidence of spinal or costovertebral tenderness.

Diagnostic assessment

The patient visited department of otorhinolaryngology where the nasopharyngolaryngoscopy revealed a granular tumor in the nasopharynx (NP); the nasal cavity, hypopharynx, and vocal cord mobility were otherwise unremarkable. Nasopharyngeal tumor biopsy confirmed undifferentiated non-keratinized carcinoma. Baseline laboratory investigations, including hemogram, coagulation profiles, liver and renal function tests, were within normal limits, with the exception of an elevated alkaline phosphatase (168 IU/L) and mild anemia (hemoglobin: 12.8 g/dL).

Contrast-enhanced computer tomography (CT) of the head and neck showed a locally invasive nasopharyngeal tumor with extension into the left cavernous sinus and significant osseous destruction of the skull base (Figure 2). There were enlarged nodal diseases over bilateral necks. Subsequent positron emission tomography (PET)/CT confirmed the nasopharyngeal malignancy with invasion of the clivus and C1 vertebra. Additionally, PET/CT imaging revealed hypermetabolic activity in the left retropharyngeal region and bilateral cervical lymph nodes (left level II; right levels II and V), highly suggestive of metastatic lymphadenopathy. Based on these findings, the disease was clinically staged as cT4N2M0, stage IVA, according to the 7^th edition AJCC staging system.

Figure 2 CT (A) and PET scan (B-E) showed a primary nasopharyngeal tumor with left carvenous sinus invasion and significant skull base bony destruction (A-C, white arrows), as well as multiple enlarged lymph nodes with hypermetabolic activity in the left retropharyngeal region (D, upper white arrow), left level II (D, lower white arrow), and right level II cervical lymph nodes (E, white arrows). CT, computed tomography; PET, positron emission tomography.

Interventions

After a discussion with the patient and families, the patient received definitive CCRT followed by adjuvant chemotherapy. CT simulation was performed under supine position, using a thermoplastic S-type mask for head through upper shoulder fixation to achieve a set up error less than 1 mm. Pre-treatment CT and PET/CT scans were co-registered to facilitate the precise contouring of the gross tumor volume (GTV) and OARs. GTV, clinical target volume (CTV), and PTV were defined as follows:

• GTV: included the primary tumor and involved lymph nodes, guided by PET hypermetabolic activity. A threshold of maximum standardized uptake value (SUV) ≥8 was utilized for the nasopharyngeal tumor and SUV ≥5 for regional nodes.
• CTV: the high-risk CTV encompassed the primary GTV and regional nodal basins with a margin of 3–5 mm, adjusted for anatomical boundaries and adjacent OARs.
• PTV: generated by adding a 3–5 mm margin to the respective CTVs, tailored to minimize overlap with critical structures.

RT was delivered by using combined VMAT technique. The SIEB plan was generated by the Varian Eclipse^TM Treatment Planning System (version 11). For gross primary and nodal tumors, SIEB dose gradience was painted: the outer PTV, covering microscopic disease at risk, receiving 60 Gy (1.5 Gy × 40 fractions); the middle PTV covering gross tumors with 1-mm margins, 72 Gy (1.8 Gy × 40 fractions); and the inner PTV prescribing escalated dose on the intra-gross-tumor zone, 80 Gy (2 Gy × 40 fractions; Figure 3). The low-risk neck nodal basin (bilateral lower necks and bilateral supraclavicular fossae) received 45 Gy (1.5 Gy × 30 fractions). Target coverage was optimal, with D95s of the target coverage were 99.0%, 99.5%, and 99.7% for the NP and gross nodal tumors, upper neck lymph basins, and lower neck lymph basins, respectively (Figure 4).

Figure 3 Color wash of the dose distribution showing an inner boost of 80 Gy to the central part of the gross tumor.

Figure 4 Dose-volume histogram of nasopharyngeal cancer showing 45 Gy/30 fractions to the low-risk neck nodal basin, 60 Gy/40 fractions to microscopic disease at risk, 72 Gy/40 fractions to gross tumors with 1-mm margins, and 80 Gy/40 fractions to inner gross tumors. L, left; PTV, planning target volume; R, right.

During RT, the patient initially received concurrent chemotherapy consisting of the PF regimen: cisplatin (75 mg/m²) on day 1 plus 5-fluorouracil (FU) (750 mg/m²/day) on days 1–5. The patient suffered from Grade 4 neutropenia complicated by febrile neutropenia and Grade 3 mucositis after the first cycle which was resolved after antibiotic therapy, growth-colony stimulating factor (G-CSF) injection, and well supportive care. To improve tolerability while maintaining treatment intensity, the concurrent PF was changed to weekly cisplatin (30 mg/m²). Four cycles were completed without further interruption or treatment delays between May and July 2014 (Figure 1). Subsequently, four cycles of adjuvant PF chemotherapy were administered every four weeks from July to October 2014, in accordance with established protocols (4).

Follow-up and outcomes

The patient tolerated the definitive CCRT and adjuvant chemotherapy well, with no adverse events greater than Grade 2. According to the Common Toxicity Criteria of Adverse Events (CTCAE) version 4.0 (12), the maximum RT-induced toxicity was Grade 2 oral mucositis. For managing and alleviating oral mucositis, a proactive supportive care regimen was implemented. Systemic analgesia included a combination of Ultracet^® (tramadol/acetaminophen, 37.5 mg/325 mg) and oral morphine 10 mg at bedtime.

Additionally, a specialized topical gargling solution, the Little-Lin gargling solution was prescribed, containing cyproheptadine, neomycin, nystatin oral suspension (Mycostatin^®), and morphine dissolved in dextrose 5% water. The patient was instructed to gargle 20–30 mL of this solution for 3–4 sessions daily (Appendix 1).

Treatment response was defined according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). One month after RT, tumor volume reduction was compatible with partial response (PR) (Figure 5). Subsequent series contrast-enhanced CT scan and magnetic resonance imaging (MRI) studies showed gradual replacement of the tumor with reparative soft tissue in the clivus, notably with complete tumor remission.

Figure 5 Neck contrast-enhanced MRI (A,B) at 1 month after RT showing tumor volume reduction and soft tissue replacement of the clivus bone (white arrow). CT scan at 5 months after RT showing tumor regression and clivus bone regeneration (C, white arrow). CT, computer tomography; MRI, magnetic resonance imaging; RT, radiotherapy.

A significant finding in this case was the slow but persistent osseous regeneration of the skull base following the eradication of the invasive tumor (Figures 5,6). By 11 years post-treatment, the prior cancer-induced destruction had stabilized with evidence of bony remodeling. The most recent nasopharyngoscopy, performed on August 30, 2024, showed no evidence of local recurrence or osteoradionecrosis.

Figure 6 CT scan at 3 years after radiotherapy demonstrating bony regeneration (white arrow) following eradication of cancer cells. CT, computer tomography.

The patient has maintained an excellent quality of life with no significant late radiation sequelae for over 136 months (July 2014 to November 2025) (Figure 1). Good quality of life was reported during all subsequent outpatient department visits, consistently recorded the absence of xerostomia, fatigue, neck stiffness, chronic headache, or cranial neuropathy. Furthermore, the patient maintained a full range of motion in the bilateral upper extremities. As of the last follow-up in November 2025, the patient remains alive and disease-free.

Ethical considerations

All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committees and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The main finding of the present report: precise RT with combined VMAT and SIEB techniques may be useful in managing this cT4 NPC patient, in terms of a durable DFS with a high quality of life

The management of intracranial invasive cT4 NPC presents a therapeutic challenge: the necessity for dose escalation to overcome local resistance versus the mandatory sparing of adjacent neurological structures. Standard CCRT plus adjuvant chemotherapy yield suboptimal 5-year LRFS, around 80–90% for cT4 disease (6,8). This report demonstrates that VMAT-based SIEB effectively resolves this dilemma by providing precise dose-sculping, delivering an ablative 80 Gy to the hypoxic geometric center while maintaining a protective gradient (60 Gy) at the periphery. This “inner-escalation” strategy translated physical dosimetric advantages into superior clinical outcomes, achieving durable DFS exceeding eleven years.

Dose escalation for cT4 NPC

While NPC is generally radiosensitive, cT4 tumors require intensified dosing to improve outcomes. In the literature, irradiation dose is escalated for improving tumor control. Prior study reported mean total and fractionated doses delivered to GTV of the NP as 74.55 and 2.49 Gy [estimating an equivalent dose in 2Gy fractions (EQD2) of 77.59 Gy₁₀ and a biologically effective dose (BED) of 93.11 Gy₁₀]. A 5-year locoregional recurrence-free survival for the entire cohort was 93.0% (13).

Unlike conventional SIB, which applies uniform doses to gross volumes, firstly, our SIEB approach utilized PET/CT-guided tumor targeting to identify the high-risk zones, defined as the “middle PTV”, which was covered by 72 Gy. Second, we adopted the geometric-central boost for intra-tumor dose escalation (the inner PTV). Third, for PTV that was only at risk for harboring microscopic disease (the outer PTV), we simultaneously delivered 60 Gy in 40 fractions to minimize the potential risk of toxicities and late sequelae, such as temporal lobe necrosis (14).

Modern RT techniques for managing NPC: IMRT, VMAT, SIEB, and proton beam therapy (PBT)

While IMRT (15) and VMAT (16) are standards for NPC, delivering curative doses to cT4 tumors is often limited by adjacent neurological OARs (6,17,18). In the complicated cases, PBT is favored for its superior dose fall-off via the Bragg peak (19,20). However, when PBT is unavailable, several alternatives exist. Adaptive RT has emerged as a strategy for invasive NPC, adjusting plans in response to real-time anatomical changes to improve targeting and OAR sparing (21). Alternatively, as demonstrated in this case, SIEB offers a potent approach. By utilizing a heterogeneous dose-painting strategy, delivering 2.0 Gy per fraction to the “inner” geometric center and reduced 1.5 Gy per fraction to the “outer” periphery, we mimicked the dosimetric advantages of PBT. This approach maximized dose intensity within the GTV while maintaining a steep gradient to protect neural structures, resulting in durable local control with no Grade ≥3 toxicities (22,23).

Gradual bony regeneration occurred after durable tumor control of irradiated NPC

A unique feature of this case was the long-term observation of skull base remodeling. Dose escalation in cT4 NPC increases the risk of high-dose radiation being delivered to or scattered to adjacent involved bone, potentially leading to osteoradionecrosis. However, if the dose is precisely modulated, the elimination of invasive tumor cells may allow for physiological recovery. This case confirms the phenomenon of post-treatment bony regeneration within the skull base. This process similar to the hepatic regeneration observed following the management of liver tumors (11,21,24). This suggests that the steep dose fall-off of our SIEB technique effectively preserved the osteogenic potential of the surrounding microenvironment, even in cases of significant prior bony destruction.

Study strengths and limitations

The primary strength of this study is the documentation of significant structural skull base bone remodeling following application of VAMT-SIEB. Second, this patient demonstrated exceptional long-term survival of 136 months without Grade ≥3 late sequelae. This far exceeds the median DFS typically observed for cT4 disease in our institution during the same period. Third, compared to IMRT (25), the VMAT (26,27) technique achieved a similar target coverage (28) but a superior dosimetric profile (29). By combining intra-tumoral dose escalation with extra-tumoral dose attenuation, we achieved excellent local control while facilitating the functional recovery of the skull base, a finding that correlates strongly with long-term local control and improved prognosis. This case demonstrates that VMAT-SIEB is a viable strategy for tumors in close proximity to critical OARs, providing a foundation for future comparative studies (Table 1).

While this report adheres strictly to the CARE guidelines, its primary limitation is its nature as a single-case study. The clinical outcomes observed here cannot be generalized to the entire cT4 NPC population without further validation.

Generated a testable hypothesis

Based on the clinical success of this approach, we propose the following testable hypothesis for further research: in patient with cT4 NPC (Table 1), the integration of VMAT and SIEB provides a superior therapeutic ratio, yielding higher tumor control and bone remodeling potential while maintaining a lower (or equivalent) radiation-associated toxicities, compared to VMAT or IMRT alone.

Conclusions

For patients with intracranial-invaded cT4 NPC, the integration of VMAT and SIEB techniques during CCRT facilitates durable DFS while mitigating severe toxicities. A hallmark of this approach is the preservation of bone regenerative capacity. Our findings demonstrate that even extensive skull base destruction can undergo slow, persistent physiological remodeling following the precise eradication of malignant cells.

While modern adjuvant strategies are shifting toward highly tolerable regimens, such as gemcitabine or oral fluoropyrimidines (capecitabine or S-1), this case underscores that individualized toxicity management can achieve treatment completion even with conventional PF regimens, which was reported to be poorly tolerated (4,30). The precision dose-sculpting afforded by SIEB-VMAT resolves the traditional therapeutic dilemma of balancing dose escalation with OARs preservation. Further prospective trials are warranted to validate this strategy as a standard-of-care intensification option for aggressive cT4 disease.

Acknowledgments

This study utilizes research data from the Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tro.amegroups.com/article/view/10.21037/tro-24-38/rc

Peer Review File: Available at https://tro.amegroups.com/article/view/10.21037/tro-24-38/prf

Funding: This study was supported by Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation [grant Nos. TCMF-CP 111-11, TCMF-CP 113-02 (KPI), TCMMP105-09-02, TCMMP106-02-02, and DTCRD1062-E-18].

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tro.amegroups.com/article/view/10.21037/tro-24-38/coif). D.W.L. and S.K.H. serve as unpaid editorial board members of Therapeutic Radiology and Oncology from October 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committees and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Huang SF, Hsiao JH, Young CK, et al. Familial aggregation of nasopharyngeal carcinoma in Taiwan. Oral Oncol 2017;73:10-5. [Crossref] [PubMed]
2. Huang CL, Guo R, Li JY, et al. Nasopharyngeal carcinoma treated with intensity-modulated radiotherapy: clinical outcomes and patterns of failure among subsets of 8th AJCC stage IVa. Eur Radiol 2020;30:816-22. [Crossref] [PubMed]
3. Petit C, Lee A, Ma J, et al. Role of chemotherapy in patients with nasopharynx carcinoma treated with radiotherapy (MAC-NPC): an updated individual patient data network meta-analysis. Lancet Oncol 2023;24:611-23. [Crossref] [PubMed]
4. Liu LT, Liu H, Huang Y, et al. Concurrent chemoradiotherapy followed by adjuvant cisplatin-gemcitabine versus cisplatin-fluorouracil chemotherapy for N2-3 nasopharyngeal carcinoma: a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet Oncol 2023;24:798-810. [Crossref] [PubMed]
5. Dai J, Zhang B, Su Y, et al. Induction Chemotherapy Followed by Radiotherapy vs Chemoradiotherapy in Nasopharyngeal Carcinoma: A Randomized Clinical Trial. JAMA Oncol 2024;10:456-63. [Crossref] [PubMed]
6. NCCN. Head and Neck Cancers (Version 1. 2026). Available online: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf
7. Chen JL, Huang YS, Kuo SH, et al. Intensity-modulated radiation therapy achieves better local control compared to three-dimensional conformal radiation therapy for T4-stage nasopharyngeal carcinoma. Oncotarget 2017;8:14068-77. [Crossref] [PubMed]
8. Zhang LL, Li YY, Hu J, et al. Proposal of a Pretreatment Nomogram for Predicting Local Recurrence after Intensity-Modulated Radiation Therapy in T4 Nasopharyngeal Carcinoma: A Retrospective Review of 415 Chinese Patients. Cancer Res Treat 2018;50:1084-95. [Crossref] [PubMed]
9. Jen YM, Lin YS, Su WF, et al. Dose escalation using twice-daily radiotherapy for nasopharyngeal carcinoma: does heavier dosing result in a happier ending? Int J Radiat Oncol Biol Phys 2002;54:14-22. [Crossref] [PubMed]
10. Yeh SA, Huang YJ. Dose escalation for patients with locally advanced nasopharyngeal carcinoma treated with radiotherapy alone. Am J Clin Oncol 2007;30:401-5. [Crossref] [PubMed]
11. Lin YH, Hung SK, Chiou WY, et al. Significant symptoms alleviation and tumor volume reduction after combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy in a patient with unresectable bulky hepatocellular carcinoma: A care-compliant case report. Medicine (Baltimore) 2016;95:e4717. [Crossref] [PubMed]
12. Liu YJ, Zhu GP, Guan XY. Comparison of the NCI-CTCAE version 4.0 and version 3.0 in assessing chemoradiation-induced oral mucositis for locally advanced nasopharyngeal carcinoma. Oral Oncol 2012;48:554-9. [Crossref] [PubMed]
13. Miao J, Wang L, Zhu M, et al. Reprint of Long-term survival and late toxicities of elderly nasopharyngeal carcinoma (NPC) patients treated by high-total- and fractionated-dose simultaneous modulated accelerated radiotherapy with or without chemotherapy. Oral Oncol 2019;90:126-33. [Crossref] [PubMed]
14. Huang J, Kong FF, Oei RW, et al. Dosimetric predictors of temporal lobe injury after intensity-modulated radiotherapy for T4 nasopharyngeal carcinoma: a competing risk study. Radiat Oncol 2019;14:31. [Crossref] [PubMed]
15. Gou X, Duan B, Shi H, et al. The relations of dosimetric parameters with long-term outcomes and late toxicities in advanced T-stage nasopharyngeal carcinoma with IMRT. Head Neck 2020;42:85-92. [Crossref] [PubMed]
16. Wang J, Chen Z, Li W, et al. A new strategy for volumetric-modulated arc therapy planning using AutoPlanning based multicriteria optimization for nasopharyngeal carcinoma. Radiat Oncol 2018;13:94. [Crossref] [PubMed]
17. Tian YM, Liu MZ, Zeng L, et al. Long-term outcome and pattern of failure for patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy. Head Neck 2019;41:1246-52. [Crossref] [PubMed]
18. Chen BB, Huang SM, Xiao WW, et al. Prospective matched study on comparison of volumetric-modulated arc therapy and intensity-modulated radiotherapy for nasopharyngeal carcinoma: dosimetry, delivery efficiency and outcomes. J Cancer 2018;9:978-86. [Crossref] [PubMed]
19. Dionisi F, Croci S, Giacomelli I, et al. Clinical results of proton therapy reirradiation for recurrent nasopharyngeal carcinoma. Acta Oncol 2019;58:1238-45. [Crossref] [PubMed]
20. Liu C, Patel SH, Shan J, et al. Robust Optimization for Intensity Modulated Proton Therapy to Redistribute High Linear Energy Transfer from Nearby Critical Organs to Tumors in Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2020;107:181-93. [Crossref] [PubMed]
21. Zhou X, Wang W, Zhou C, et al. Long-term outcomes of replanning during intensity-modulated radiation therapy in patients with nasopharyngeal carcinoma: An updated and expanded retrospective analysis. Radiother Oncol 2022;170:136-42. [Crossref] [PubMed]
22. Xie D, Cheng W, Lv S, et al. Target delineation and dose prescription of adaptive replanning intensity-modulated radiotherapy for nasopharyngeal carcinoma. Cancer Commun (Lond) 2019;39:18. [Crossref] [PubMed]
23. Crane CH, Koay EJ. Solutions that enable ablative radiotherapy for large liver tumors: Fractionated dose painting, simultaneous integrated protection, motion management, and computed tomography image guidance. Cancer 2016;122:1974-86. [Crossref] [PubMed]
24. Farach A, Quesada J, Teh BS. Liver regeneration following repeat SBRT. J Gastrointest Oncol 2015;6:E2-6. [Crossref] [PubMed]
25. Tomasoa NB, Meulendijks D, Nijkamp J, et al. Clinical outcome in patients treated with simultaneous integrated boost - intensity modulated radiation therapy (SIB-IMRT) with and without concurrent chemotherapy for squamous cell carcinoma of the anal canal. Acta Oncol 2016;55:760-6. [Crossref] [PubMed]
26. Arnesen MR, Rekstad BL, Stokke C, et al. Short-course PET based simultaneous integrated boost for locally advanced cervical cancer. Radiat Oncol 2016;11:39. [Crossref] [PubMed]
27. Avanzo M, Chiovati P, Boz G, et al. Image-guided volumetric arc radiotherapy of pancreatic cancer with simultaneous integrated boost: Optimization strategies and dosimetric results. Phys Med 2016;32:169-75. [Crossref] [PubMed]
28. Liu J, Ng D, Lee J, et al. Chest wall desmoid tumours treated with definitive radiotherapy: a plan comparison of 3D conformal radiotherapy, intensity-modulated radiotherapy and volumetric-modulated arc radiotherapy. Radiat Oncol 2016;11:34. [Crossref] [PubMed]
29. Popescu CC, Olivotto IA, Beckham WA, et al. Volumetric modulated arc therapy improves dosimetry and reduces treatment time compared to conventional intensity-modulated radiotherapy for locoregional radiotherapy of left-sided breast cancer and internal mammary nodes. Int J Radiat Oncol Biol Phys 2010;76:287-95. [Crossref] [PubMed]
30. Miao J, Wang L, Tan SH, et al. Adjuvant Capecitabine Following Concurrent Chemoradiotherapy in Locoregionally Advanced Nasopharyngeal Carcinoma: A Randomized Clinical Trial. JAMA Oncol 2022;8:1776-85. [Crossref] [PubMed]