Background: Postoperative recurrence of sacrococcygeal chordomas presents significant clinical challenges due to unusual recurrence patterns. This study aimed to characterize these patterns of recurrence to inform improved adjuvant radiotherapy planning. Methods: We retrospectively analyzed 31 patients with recurrent sacrococcygeal chordoma following surgery, assessing recurrence locations considering initial tumor extent, resection levels, and postoperative anatomical changes on MRI. In 18 patients, pre- and postoperative imaging enabled the spatial mapping of early recurrence origins relative to the initial tumor volume using isotropic expansions. The median initial gross tumor volume was 113 mL. Results: Recurrences were mostly multifocal and predominantly involved soft tissues (e.g., mesorectal/perirectal space (80.6%), piriformis and gluteal muscles (80.6% and 67.7%, respectively) and osseous structures, particularly the sacrum (87.1%)). The median time to recurrence was 15 months. The initial surgery was R0 in 17 patients (55%). The highest infiltrated sacral vertebra was S1 in 3%, S2 in 10%, S3 in 35%, S4 in 23%, S5 in 10%, and coccygeal in 19%. Anatomical changes post-resection, including rectal herniation into gluteal and subcutaneous tissues, significantly affected radiotherapy planning. Expansion of the initial tumor volume by 2 cm failed to encompass all recurrence origins in 72% of cases. A 5 cm expansion was required to achieve full coverage in 56% of patients, though 22% of recurrences still lay beyond this margin and the remaining were covered only partially. Conclusions: Recurrent sacrococcygeal chordomas exhibit complex, soft-tissue-dominant patterns and are influenced by significant anatomical displacement post-surgery. Standard target volume expansions are often insufficient to cover the predominantly multifocal recurrences.

Background/Objectives: The implementation of tattoo-free radiotherapy (RT) for breast cancer reflects an effort to mitigate the psychological distress of permanent marks through surface-guided techniques, while simultaneously evaluating its utility in meeting setup precision requirements. Methods: In this prospective trial, patients were positioned for breast cancer RT including regional nodal irradiation exclusively using surface-guided RT (SGRT). Cone-beam computed tomography (CBCT) was acquired at each fraction as the ground truth to analyze translational setup deviations. Results: A total of 457 paired SGRT–CBCT data points in 30 patients were acquired. A residual translational setup deviation of ≤6 mm was achieved in 97.6% of all fractions with a median deviation of 2 mm (range: 0–12). Neither age, comorbidities, body mass index, extent of target volumes, choice of breathing technique, nor patient-reported symptoms (pain, dermatitis, anxiety) correlated significantly with setup deviations. The median in-room positioning time was 92 s (range: 20 s–6 min and 37 s) and significantly prolonged in patients with an elevated BMI and higher grades of pain and skin dermatitis, and for chest wall irradiation. Manual assessment of the accuracy of regional nodal CTVs in each CBCT relative to the planning CT showed good-to-minor deviations in 99.7% (Level 1/2), 95.0% (Supra-/infraclavicular), and 90.8% (Internal mammary), respectively, with major deviations in only 0.3% (Level 1/2), 5.0% (Supra-/infraclavicular) and 9.2% (Internal mammary). A forward dose calculation on CBCT geometries (n = 86) revealed high median CTV dose coverage of 100.0% (range: 57.1–107.7%) of the original target dose for all lymph node levels combined. Conclusions: The tattoo-free positioning setup for regional nodal irradiation in breast cancer patients exhibited pronounced robustness, maintaining its accuracy and reliability irrespective of patient-, tumor-, or treatment-specific variables with high clinical efficiency. However, larger cohorts are required to confirm whether these parameters genuinely operate independently of setup accuracy.

Background/Objectives: Proton therapy is widely used in paediatric neuro-oncology because of its favourable dose distribution and reduced exposure to radiation of healthy tissue. Nevertheless, current knowledge regarding radiation-induced contrast enhancements (RICE) is largely derived from adult proton therapy cohorts, while evidence in paediatric patients remains limited and the underlying biological mechanisms are still incompletely understood. This study investigated the incidence of RICE in paediatric patients with low-grade glioma (LGG) and ependymoma and evaluated potential associations with linear energy transfer (LET) and variable relative biological effectiveness (RBE)-weighted dose distributions. Methods: In this retrospective single-centre study, paediatric patients with LGG or ependymoma were identified from a prospectively maintained institutional registry patients treated with proton therapy at the Heidelberg Ion-Beam Therapy Centre (HIT) between 2010 and 2024. Follow-up magnetic resonance imaging examinations were systematically reviewed for RICE. Lesions were contoured in RayStation and assessed dosimetrically using a fixed RBE of 1.1 and three variable RBE models. LET-weighted dose metrics and Dose_(RBE) × LET products were compared between RICE regions and planning target volumes (PTVs). Overall survival and progression-free survival were estimated using Kaplan–Meier method. Results: Seventy-six patients met the inclusion criteria, including 33 patients with LGG and 43 with ependymoma. A total of 724 follow-up magnetic resonance imaging examinations were reviewed. RICE occurred in six patients (7.9%), exclusively in the ependymoma subgroup (14.0%). Higher prescribed radiation dose was significantly associated with RICE occurrence (p = 0.031). Across all variable RBE models, biologically weighted dose estimates and Dose_(RBE) × LET products were consistently elevated within RICE regions compared with corresponding PTV regions, particularly at low- and intermediate-dose levels. Five-year overall survival rates were 91.7% for LGG and 86.6% for ependymoma, while corresponding progression-free survival rates were 84.4% and 69.3%, respectively. Conclusions: Variable RBE models identified biologically relevant dose heterogeneities within RICE regions that were not adequately captured by the conventional fixed RBE approach. These findings suggest that LET-associated biological dose escalation may contribute to radiation-related brain tissue changes after proton therapy and support further investigation and prospective validation of LET- and RBE-informed normal-tissue risk assessment in paediatric neuro-oncology.