Treatment planning of radiotherapy for skull base involvement of multiple myeloma presenting with visual impairment should be optimized to alleviate symptoms immediately and sufficiently while minimizing toxicities. Two such patients were treated with fractionated stereotactic radiotherapy by using Dynamic Conformal Arcs (DCA) under image guidance based on bony anatomy alignment. DCA planning was optimized after considering the possibility for amendment of visual organ displacement resulting from early tumor shrinkage during treatment through 1) the use of a target volume with modified geometry as a surrogate for leaf adaptation in order to improve target coverage, and 2) manual adjustment of a subset of leaf positions to reduce the dose gradient immediately inside the target boundary facing the visual organs and to eliminate an undesirable dose hotspot. In both cases, anticipated geometric changes in the target volume associated with improvement of visual organ displacement toward the target centroid were observed before the completion of treatment. Favorable visual functional outcomes as well as local tumor control were achieved during 14 months and 4 months follow-up periods. Notably, inexorable visual loss in one patient was fully reversed within one month after radiotherapy. We described the modification techniques for DCA planning in detail.
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