PURPOSE: To report the rapid recovery of treatment-related dysgeusia after tongue-out radiation therapy (TORT) for head and neck cancer (HNC). METHODS AND MATERIALS: We retrospectively reviewed 14 patients with HNC who c...PURPOSE: To report the rapid recovery of treatment-related dysgeusia after tongue-out radiation therapy (TORT) for head and neck cancer (HNC). METHODS AND MATERIALS: We retrospectively reviewed 14 patients with HNC who completed TORT with 70 Gy for definitive or salvage and 60 to 66 Gy for adjuvant treatment with or without concurrent chemotherapy. Patient-reported quality of taste was evaluated before, at the end of TORT therapy, and periodically 1, 3, and 6 months after TORT therapy using the University of Washington Quality of Life questionnaire version 4, question 9, including options for no-, mild-, and severe dysgeusia and ageusia. Oral cavity (OC) and oral tongue (OT) were contoured following guidelines. A portion of the anteriorly displaced OT outside the mouth was separately contoured as OT. Statistical analysis was conducted with the χ and t test. A probability level of P < .05 was considered significant. RESULTS: In 14 TORT plans, the average volume of OC and OT was 105.8 ± 25.3 and 67.6 ± 20.7 cm, respectively. OT comprised 20% (13.4 ± 9.1 cm) of the entire OT volume. Average mean dose (D) to OC, OT, and OT was 25.2 ± 6.9, 26.4 ± 6.8, and 13.3 ± 2.9 Gy, respectively. Before TORT, no-to-mild versus equal or higher than severe dysgeusia (≥ severe dysgeusia) was 86% (n = 12) versus 14% (n = 2) of patients, respectively; 14% (n = 2) versus 86% (n =12) at the end of TORT (P < .01); 57% (n = 8) versus 43% (n = 6) at 1-month post-TORT (P < .01); 79% (n = 11) versus 21% (n = 3) at 3-month post-TORT (P = .23) and 93% (n = 13) versus 7% (n = 1) at 6-month post-TORT (P = .18). CONCLUSION: TORT displaced OT anteriorly, lowered D to OT, especially to OT and facilitated rapid regaining of sense of taste at 1-month post-TORT. Patient-reported quality of taste returned to the baseline at 3-month and 6-month post-TORT. Further randomized study to verify clinical advantages with TORT for HNC is warranted.
Real-time magnetic resonance (MR) guidance during brachytherapy (MRgBT) offers superior soft tissue definition and precise target identification during catheter implantation while minimizing treatment-related complicatio...Real-time magnetic resonance (MR) guidance during brachytherapy (MRgBT) offers superior soft tissue definition and precise target identification during catheter implantation while minimizing treatment-related complications. This report reviewed the use of MRgBT in a series of complex clinical situations where brachytherapy would have been impossible without MR guidance, and alternate treatment modalities would have involved potentially significant morbidity to the patients. We highlighted the safety and efficacy of MRgBT in controlling targetable disease in a specific group of patients without precluding the ability to go for subsequent treatment options when indicated.
PURPOSE: The study objective is to improve breast radiation therapy clinical workflows through a quality improvement approach rooted in implementation and improvement science methodologies. This study aims to demonstrate...PURPOSE: The study objective is to improve breast radiation therapy clinical workflows through a quality improvement approach rooted in implementation and improvement science methodologies. This study aims to demonstrate the effectiveness of these data-driven, multidisciplinary processes in optimizing complex clinical processes within radiation oncology. METHODS AND MATERIALS: A multidisciplinary stakeholder team applied an improvement science methodology to identify the root cause of inefficiencies in a pretreatment breast radiation therapy workflow. The intervention involved redesigning the task sequence and implementing an automated breast treatment planning solution to replace manual planning. The study evaluated the outcome measure of the target contouring time by the radiation oncologist and the treatment planning time by the medical dosimetrist. The outcome measures for 3 cohorts were analyzed: (1) the initial cohort with manual planning prior to any process change, (2) the pilot cohort with a limited stakeholder team for rapid change cycles with the modified clinical workflow and automated planning solution, and (3) a comprehensive rollout with the entire clinical team. The balancing quality measures of dosimetric compliance to dose-volume histogram planning objectives were also assessed across the 3 cohorts. RESULTS: From 2020 to 2022, 515 patients were included in the analysis. The task times from the initial cohort to the comprehensive rollout cohort were 0.2 (± 0.07) hours and 0.2 (± 0.03) hours for radiation oncologist contouring time and 8 (± 4) hours and 4 (± 1) hours for medical dosimetrist planning time, respectively. At the conclusion of the comprehensive rollout, total professional task time was decreased, and treatment plan quality was maintained. The approach successfully scaled from the smaller stakeholder team to the entire clinical workforce, demonstrating the effectiveness of implementation and improvement science methodologies. CONCLUSIONS: This study provides a comprehensive description and evaluation of a data-driven, sustainable process change in a multidisciplinary breast radiation therapy workflow. The methodology used serves as a model for clinical workflow optimization across radiation oncology settings.
PURPOSE: Although the link between breast tissue density and cancer risk is well established, its influence on posttreatment outcomes remains unclear. Clarifying the role of breast density in these outcomes could enhance...PURPOSE: Although the link between breast tissue density and cancer risk is well established, its influence on posttreatment outcomes remains unclear. Clarifying the role of breast density in these outcomes could enhance treatment personalization and patient stratification, potentially enabling clinicians to adapt radiation therapy plans to individual breast tissue composition. This study evaluated the role of pre-radiation therapy breast densitometric state in relation to local/distant progression, overall survival, and molecular subtypes. METHODS AND MATERIALS: A mono-institutional cohort of 1127 early-stage breast cancer patients treated with 40 Gy/15 fractions (2009-2017) was analyzed. Clinical target volume segmentations from planning computed tomography were used to extract hounsfield units (HU) histograms (range, -200 HU, +50 HU), excluding clips and artifacts. Fatty and fibroglandular tissues were quantified based on selected HU ranges. Extracted parameters included volume, mean/median HU, standard deviation, percentiles, and histogram shape indices. Densitometric, clinical, and combined predictive models were developed using multivariate Cox regression, minimizing redundancy. Internal validation involved 1000 bootstrap iterations. A prognostic index was calculated for each model, and Kaplan-Meier analysis stratified patients into risk groups. Densitometric prognostic indices were also tested for potential association with molecular subtypes (luminal A/B, Her2+, triple-negative breast cancer). RESULTS: Median follow-up was 6 years (interquartile range, 4-8): local relapse/distant relapse/death rates were 2.3%/4.1%/7.0%, respectively. The combination of % fat volume (VFAT%) and HU percentiles was moderately associated with outcomes (densitometry models, C-index, 0.60-0.61): lower HU values and higher VFAT% were associated to better outcome. Clinical models showed higher predictive performance (C-index, 0.72-0.76), with key factors including tumor stage, nodal status, age, and triple-negative breast cancer subtype. Combined models (C-index, 0.71-0.79) improved the performances of the clinical model for distant progression-free survival. No significant association was found between densitometric models and molecular subtypes. CONCLUSIONS: Clinical features are the strongest predictors, though fat-related metrics offered additional biological insights, improving the ability of local and distant relapse prediction.
We sought to develop a systematic spine reirradiation planning protocol prioritizing patient safety and maximizing tumor dose delivery. Patients were presented at a Multidisciplinary Spine Oncology Tumor Board to confirm...We sought to develop a systematic spine reirradiation planning protocol prioritizing patient safety and maximizing tumor dose delivery. Patients were presented at a Multidisciplinary Spine Oncology Tumor Board to confirm suspicion for recurrent or progressive malignancy and were evaluated in the clinic by the Department of Radiation Oncology and Neurosurgery. Suitable patients proceeded to computed tomography (CT)/magnetic resonance imaging scan simulation. A dedicated physics pathway was activated with the fusion of the magnetic resonance imaging scan and planned CT scan, verified independently by 2 physicists. The prior radiation data set was registered to the new imaging data set, and the prior dose was displayed on the new imaging data set. Physical dose, equivalent dose in 2 Gy fractions (EQD) α/β = 2, and EQD α/β = 3 plans were generated to evaluate prior dose to organs at risk (OARs). Target volumes were defined on the new data set. Dose, fractionation, and OAR constraints were prescribed by the treating physician in accordance with the literature, with priority given to respecting OARs. The constraints were stipulated as EQD-based objectives and converted to physical doses for the current plan. A plan-sum of the current course and all prior courses was created and displayed on the new imaging data set for evaluation. Composite, EQD α/β = 2, and EQD α/β = 3 plans were generated to evaluate current and cumulative dose to the target and OARs. Treatment was delivered on a 6°-of-freedom couch with pretreatment, midtreatment, and posttreatment cone beam CT scan imaging. Registration-based shifts > 2 mm or 1° were evaluated. When requested, physicists performed quantitative analysis of dosimetric impact using a forward calculation of the plan on the planning image with the treatment shifts applied to determine whether an offline plan adaptation is necessary. Our protocol contributed to the growing literature on spinal reirradiation with stereotactic body radiation therapy and enabled safe treatment in cases of incidental spinal cord exposure. We developed a systematic approach to planning and delivering spinal reirradiation with stereotactic body radiation therapy.
PURPOSE: After prostate radiation therapy (RT), bowel, urinary, and sexual side effects and quality of life (QOL) declines are common. Phase 3 trials of rectal spacers (RSs) using ≥20 fractions found clinical and dose be...PURPOSE: After prostate radiation therapy (RT), bowel, urinary, and sexual side effects and quality of life (QOL) declines are common. Phase 3 trials of rectal spacers (RSs) using ≥20 fractions found clinical and dose benefits and reduced QOL declines. However, the role of RS in stereotactic body radiation therapy (SBRT) is undefined. METHODS AND MATERIALS: A prospective single-institution registry of prostate SBRT from 2012 to 2023 was analyzed by RS use (n = 290) versus no-RS (n = 1815). QOL scores were collected via Expanded Prostate Cancer Index Composite-26 at baseline and up to 5 years post-RT. Treatment used computed tomography and magnetic resonance imaging fusion and 3 to 6 fiducials for real-time tracking with Robotic SBRT (CyberKnife, Accuray Inc). Clinical target volume included prostate plus proximal seminal vesicles. Planning target volume margins were 5 mm except 3 mm posteriorly (35-36.25 Gy was delivered in 5 fractions). The primary endpoint was QOL trend over time by RS versus no-RS as evaluated by linear mixed-effects models that accounted for within-subject variability by controlling for key clinical and demographic characteristics. Clinically important change analyses were conducted using established minimally important difference (MID) thresholds to compare proportion of patients in each group with meaningful QOL declines at each timepoint. RESULTS: There were no differences in age, prostate specific antigen, or prostate volume between groups. RS was associated with more recent treatment (p < .001), intermediate- and high-risk disease (96% vs 85%; p < .001), androgen deprivation therapy use (52% vs 39%; p < .001), and Caucasian patients (63% vs 55%; p < .001). Baseline EPIC scores were similar. Declines in EPIC scores post-SBRT were small, approaching baseline after 6 months and remaining stable to 5 years. There were no clinically significant differences in QOL trend over time by RS vs no-RS. For the 2-month post-RT timepoint alone, the RS group had more favorable QOL with 1×MID and/or 2×MID thresholds met for urinary irritation, bowel, and vitality domains. No durable clinically significant QOL differences occurred between RS groups even in the baseline sexual domain EPIC ≥60/no androgen deprivation therapy subgroup. CONCLUSIONS: SBRT produced only modest, largely transient QOL declines that resolved by ∼6 months. RS did not confer a durable clinically meaningful QOL improvement; an isolated 2×MID signal at 2 months favored RS in select domains, but this was transient, and nondurable.
Yang NX, Rosamilia GL, Arifin AJ
… +13 more, Salem AF, Yoder AK, Keatts SA, Jerez O, Lin R, Bishop AJ, Farooqi AS, Weiser R, Ross MI, Mericli AF, Guadagnolo BA, Goepfert RP, Mitra D
PURPOSE: Adjuvant radiation therapy (RT) to a cutaneous target has been associated with elevated risk of surgical complications such as graft, flap, or skin substitute reconstruction failure. We sought to better quantify...PURPOSE: Adjuvant radiation therapy (RT) to a cutaneous target has been associated with elevated risk of surgical complications such as graft, flap, or skin substitute reconstruction failure. We sought to better quantify the risk of surgical site complications after hypofractionated adjuvant RT delivered in the modern era to patients undergoing surgical reconstruction for their primary site cutaneous melanoma. METHODS AND MATERIALS: We reviewed clinical data on all patients treated for cutaneous melanoma at our center between 2008 and 2021 with primary tumor resection and reconstruction (graft, flap, or skin substitute), followed by 5 × 6 Gy RT. Details on post-treatment complications were assessed. RESULTS: A total of 193 patients with melanoma undergoing surgical reconstruction followed by hypofractionated RT were identified. Most patients carried at least 1 risk factor for wound healing complications (70% with cardiovascular disease, 64% overweight, and 23% with diabetes). Most tumors were located in the head and neck (89%). Patients initiated RT a median of 7 weeks (IQR, 5-9 weeks) from surgical reconstruction. Skin grafts were used in 62% of reconstructions, and flaps used in 44%. Electron-based RT was used for the majority of patients (n = 166, 86%). Ten patients (5%) required surgical revision after reconstruction, with half occurring after RT. The primary reconstruction for all 5 patients requiring surgical revision after RT was graft reconstruction of the scalp, with a wide range of times from reconstruction to RT (5-11 weeks) and a wide range of times from RT to surgical revision (2-28 months). CONCLUSIONS: The risk of surgical revision after adjuvant hypofractionated RT to a surgical reconstruction involving a graft, flap, or skin substitute is low. Half of graft failures occurred before adjuvant RT and half after, which suggests that adjuvant RT only marginally increases the risk of postreconstruction complications if adequate time for healing is given.
PURPOSE: Stereotactic body radiation therapy (SBRT) is increasingly used for spinal metastases. Contouring for SBRT typically follows the International Spine Radiosurgery Consortium (ISRC) guidelines, leading to large pl...PURPOSE: Stereotactic body radiation therapy (SBRT) is increasingly used for spinal metastases. Contouring for SBRT typically follows the International Spine Radiosurgery Consortium (ISRC) guidelines, leading to large planning target volumes (PTV). We compared minimal-volume contouring, which yields a more focused PTV, with conventional contouring and developed predictive models for adverse outcomes. METHODS AND MATERIALS: We analyzed all patients treated for spinal metastases at our center over the past decade. After exploratory and correlation analyses, we compared the contouring methods for adverse outcomes and PTV and spinal cord dose distributions. Logit and support vector machine (SVM) models were used for outcome prediction. RESULTS: Among 121 patients (235 lesions), 147 lesions received minimal-volume contouring, 67 followed ISRC recommendations, and 21 were unassigned. The median prescription dose was 20 Gy (15-22 Gy) for single-session, and 24 Gy (19.5-30 Gy) for hypofractionated treatments. The median PTV was 11.1 cm (0.2-173.7 cm). Complications correlated significantly with pre-SBRT Karnofsky status (Cramer V = 0.277). Local control rates were comparable (80.5% vs 78.4%), but complication rates were lower with minimal contouring (15.1% vs 27.8%). Minimal contouring resulted in significantly higher median PTV biologically effective dose (BED) (75.9 Gy vs 57.5 Gy) and lower maximum spinal cord BED (72.7 Gy vs 81.9 Gy, both P < .001). Logit models identified mean PTV (P = .001) and vertebral dose (P < .001) as significant predictors of vertebral fractures but showed limited accuracy (49.3% for local recurrence, 73.3% for fractures). SVM classifiers outperformed logit models, achieving higher accuracy (89.9% for recurrence, 92.0% for fractures) and improved positive predictive values (83.7% and 86.7%, respectively). CONCLUSIONS: Minimal-volume target delineation based on thin-layer magnetic resonance imaging and prostate-specific membrane antigen/fluorodeoxyglucose-positron emission tomography-computed tomography/magnetic resonance imaging may be as effective as contouring according to the ISRC guidelines, if those imaging modalities are available. Further studies are warranted to assess minimal and expanded volumes. SVM models show promising potential for predicting patient outcomes, warranting further exploration.
PURPOSE: Recurrence in glioblastoma (GBM) is common, and the success of salvage strategies, including re-resection and reirradiation, is limited. Brachytherapy with Cs-131 collagen tiles enables intraoperative focal dose...PURPOSE: Recurrence in glioblastoma (GBM) is common, and the success of salvage strategies, including re-resection and reirradiation, is limited. Brachytherapy with Cs-131 collagen tiles enables intraoperative focal dose intensification with rapid dose fall-off and limited normal brain radiation exposure. We report the outcomes of Cs-131 collagen tile implantation at the time of resection for recurrent GBM. METHODS AND MATERIALS: We reviewed 15 adults with previously irradiated, recurrent isocitrate dehydrogenase (IDH) wild-type GBM who underwent maximal safe resection followed by intraoperative Cs-131 collagen tile implantation at a single institution. Candidates had surgically accessible, primarily enhancing recurrences ≥6 months after prior external beam radiation therapy, and were anticipated to have a gross total resection. The prescription dose was 60 Gy at a depth of 5 mm. We assessed overall survival, progression-free survival, toxicity, and patterns of failure (local ≤0.5 cm from the cavity, marginal 0.5-1 cm, and distant >1 cm) after implantation. RESULTS: Patients (median age, 63 years; range, 39-76) had good performance status (median Karnofsky Performance Status score, 90; range, 70-100) and prior chemoradiation (most to 60 Gy/30 fractions). Tiles (median, 6.5/patient; range, 3-13) were implanted at first recurrence in 12 of 15 patients (80%) and at second recurrence in 3 (20%), at a median of 15 months after external beam radiation therapy (range, 8.9-47). At 13 months median follow-up (range, 1.4-21), the median overall survival after Cs-131 implantation was not reached (NR) (95% CI, 6.7-NR months); the median time to progression after Cs-131 implantation was 9 months (95% CI, 6.0-NR); and the cumulative incidence of first progression (local or distant) after Cs-131 implantation was 53.3% over the follow-up period. The first failures were local (n = 2), marginal (n = 2), distant (n = 3), and combined local and distant (n = 1). One patient developed symptomatic grade 3 radionecrosis, which improved with bevacizumab. No patients required reoperation for Cs-131 toxicity. CONCLUSIONS: Intraoperative Cs-131 tile brachytherapy for recurrent GBM is feasible and well tolerated. Distant failures remain common. Integrating effective systemic therapy and careful patient selection may optimize outcomes.
Anker CJ, Arshad J, Cellini F
… +18 more, Dehal A, Dolan J, Gillett SR, Haddock MG, Haustermans K, Hong TS, Howell KJ, Jabbour SK, Kitano M, Lin C, Lloyd S, Peterson J, Roeder F, Smith GL, Stewart J, Tchelebi LT, Bradfield L, Willett CG
Pract Radiat Oncol
· 2026 · PMID 41317985
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Full text
PURPOSE: This guideline provides evidence-based recommendations addressing the indications for radiation therapy (RT) for gastric cancer in a variety of clinical settings, ranging from patients with resectable locoregion...PURPOSE: This guideline provides evidence-based recommendations addressing the indications for radiation therapy (RT) for gastric cancer in a variety of clinical settings, ranging from patients with resectable locoregional disease to metastatic and symptomatic disease. METHODS: The American Society for Radiation Oncology convened a task force to address 3 key questions: (1) indications for and timing of RT for patients with resectable and nonmetastatic gastric cancer; (2) indications for and timing of RT in patients with unresectable locoregional disease, oligometastases, and/or requiring palliation; and (3) appropriate RT dose-fractionation regimens, target volumes, and techniques in these clinical settings. Recommendations are based on a systematic literature review and were created using a predefined consensus-based methodology with a system for grading evidence quality and recommendation strength. RESULTS: Multidisciplinary evaluation and decision-making are recommended for all patients. For patients with cT2-4 and/or N+ resectable gastric cancer, perioperative chemotherapy is recommended, preferably FLOT (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel). Recently, perioperative durvalumab and FLOT has shown a significant improvement in event-free survival versus FLOT only for patients with resectable disease and is now being adopted as a standard of care. Preoperative chemoradiation is recommended for patients who are not candidates for perioperative chemotherapy and conditionally recommended if there is concern for a margin-positive (R1) or incomplete (R2) resection. Postoperative chemoradiation is conditionally recommended for patients who are not candidates for perioperative or postoperative chemotherapy or if a suboptimal resection was done (eg, <D2 or R1-R2) for those who proceeded directly to surgery. Definitive chemoradiation may provide durable control for nonmetastatic patients who are inoperable either at initial diagnosis or at the time of locoregional recurrence. For patients with oligometastatic gastric cancer, metastasis-directed therapy along with systemic therapy is conditionally recommended. Palliative RT is efficacious for patients with bleeding, pain, and obstruction. Target coverage goals and dose guidance for normal tissues are provided. CONCLUSIONS: These evidence-based recommendations guide clinical practice on the use of RT for gastric cancer. Future studies will further refine the indications and role of RT in the management of these patients.
PURPOSE: The digitally reconstructed radiograph (DRR) has traditionally been used for geometric radiation therapy (RT) treatment verification, with no reported dosimetric applications to date. This study aimed to introdu...PURPOSE: The digitally reconstructed radiograph (DRR) has traditionally been used for geometric radiation therapy (RT) treatment verification, with no reported dosimetric applications to date. This study aimed to introduce a methodology for the first time, allowing us to derive a dose distribution within an RT treatment plan using the DRR image. METHODS AND MATERIALS: Initially, the correlation between the pixel values of the DRR image and the depth of the water phantom was established. Subsequently, the relationship between depth and absorbed dose was derived. By combining these 2 equations, the connection between the pixel values of the DRR and the absorbed dose was established. This approach was then used to calculate the dose distribution for homogeneous and RANDO phantoms. To verify the accuracy of this technique, the results were compared with the dose distribution from the treatment planning system. RESULTS: The comparison of point doses at the isocenter of the RANDO phantom indicated differences of 1% and 2.4% for energies of 6 and 15 MV, respectively. A region-based dose distribution comparison using gamma analysis (3%-3 mm criteria) resulted in agreements of 98% and 95% for energies of 6 and 15 MV, respectively. CONCLUSIONS: DRR dosimetry is an innovative method that employs DRR images to calculate dose distribution in RT planning, enhancing their traditional geometric use. It operates independently of a treatment planning system, making it a cost-effective solution that can run on personal computers. This approach acts as a supplementary tool, ensuring dosimetric verification and quality control in RT treatments.
PURPOSE: The integration of artificial intelligence auto-contouring (AAC) in radiation oncology has streamlined the delineation of organs at risk (OARs). Assessing OAR contours is a vital skill in radiation oncology. Thi...PURPOSE: The integration of artificial intelligence auto-contouring (AAC) in radiation oncology has streamlined the delineation of organs at risk (OARs). Assessing OAR contours is a vital skill in radiation oncology. This study assessed the impact of AAC on residents' contouring education and skill acquisition and its consequences for educational programming. METHODS AND MATERIALS: We conducted a cross-sectional survey of residents and resident-facing faculty at 2 tertiary centers that implemented AAC within the prior year. Respondents completed anonymous Likert (1-5) and free-text items; group differences were analyzed using 2-sample t tests (p ≤ .05). Free-text comments underwent thematic analysis. RESULTS: Responses were received from 24 of 30 residents (80%) and 20 of 35 faculty (57%). Compared with faculty, residents more often reported that AAC improved their anatomic understanding (residents: 3.9 vs faculty: 2.1, p < .001) and overall education (4.2 vs 2.3, p < .001). Both groups agreed that AAC reduced time spent contouring (4.6 vs 4.4, p = .39) and improved the workflow from simulation to plan approval (4.5 vs 4.0, p = .08). Perceived AAC contour quality was neutral (3.33 vs 2.85, p = .11). AAC was viewed as improving familiarity with standardized OAR nomenclature (4.3 vs 3.3, p = .001) and as contributing positively to clinic (4.7 vs 3.7, p < .001) and resident well-being (4.6 vs 3.6, p < .001). Faculty comments highlighted inaccurate or incomplete contours and uncertainty about residents' systematic review or correction of AAC output, raising concerns about reduced practice with de novo delineation and computed tomography anatomy. Residents acknowledged AAC's imperfections but emphasized time savings and the ability to redirect effort toward other educational activities. CONCLUSIONS: Residents and faculty diverge on AAC's educational value, particularly its effect on anatomic learning. However, both recognize benefits for workflow and well-being. Improving the integration and understanding of AAC-derived OARs during contouring will be crucial to improving resident training and ensuring high-quality care delivery in the era of artificial intelligence.
PURPOSE: Total skin irradiation (TSI) techniques vary widely in dosimetric performance, yet no standardized metric exists to evaluate their overall quality. Current guidelines address parameters such as dose homogeneity,...PURPOSE: Total skin irradiation (TSI) techniques vary widely in dosimetric performance, yet no standardized metric exists to evaluate their overall quality. Current guidelines address parameters such as dose homogeneity, depth-dose fall-off, and x-ray contamination, but lack a comprehensive quantitative tool. This study introduces and validates the Total Skin Irradiation Quality Index (TSI-QI), a novel composite metric for assessing TSI techniques based on these 3 critical parameters. METHODS AND MATERIALS: Radiographic films were placed in transverse sections of an anthropomorphic phantom and irradiated using full-treatment TSI to generate entrance-to-exit dose profiles (EEDP). From these profiles, 3 key metrics were derived: dose uniformity within the target, dose fall-off beyond the target, and internal x-ray contamination. Each factor was normalized against established clinical thresholds and combined to calculate the TSI-QI using the formula TSI-QI = H + D + X, where H represents homogeneity, D denotes dose fall-off, and X indicates x-ray contamination. The index's efficacy was evaluated on 2 widely adopted techniques: Stanford total skin electron irradiation (TSEI) and total skin helical irradiation (TSHI). RESULTS: TSEI yielded a TSI-QI score of 0.554, within the acceptable quality range, whereas TSHI scored 1.893, exceeding the threshold. Thresholds were defined according to AAPM Report No. 23 and European Organization for Research and Treatment of Cancer recommendations (EORTC). Detailed analysis showed that TSEI provided superior homogeneity, sharper fall-off, and lower x-ray contamination compared with TSHI. CONCLUSIONS: These dosimetric parameters are directly related to clinical safety and toxicity, because dose fall-off and photon contamination reflect healthy tissue protection, whereas homogeneity ensures effective skin tumor coverage. The TSI-QI, thus, offers a reliable tool for evaluating and comparing TSI techniques, supporting institutional quality assurance and cross-center standardization while helping identify protocols unsuitable for safe clinical implementation.