LETTER TO THE EDITOR Improve the management of patients with skull bone metastases by means of helical tomotherapy C. Chargari & Y. M. Kirova & S. Zefkili & F. Campana Received: 29 October 2008 / Accepted: 1 March 2009 / Published online: 17 March 2009 # Springer-Verlag 2009 The skeleton is the first and most common site of distant metastases in breast cancer patients. Tumor bone disease is responsible for a considerable morbidity and markedly decreases the quality of life of patients [1]. Although providing rapid and lasting pain relief in symptomatic bone metastases, external beam radiotherapy may be associated with treatment-induced morbidity, particularly in patients with multiple skull metastases. For those patients, conven- tional radiotherapy may be deleterious, delivering high radiation doses to critical organs such as eyes or brain and leading to potential subsequent progressive neurocognitive decline. Helical tomotherapy (HT) combines intensity modulated fan-beam radiotherapy with megavoltage com- puted tomography imaging for patient positioning [2]. Its availability has recently opened new fields of exploration for palliative radiotherapy due to its ability to tailor very sharp dose distributions around the target volumes. Here, we report an interesting case of palliative use of HT in a breast cancer patient with multiple skull bone metastases. In October 2007, a 76-year-old patient presented with acute left peripheral facial paralysis and inflammatory bone pain occurring at the left part of her face. She had a previous history of invasive ductal carcinoma with multiple bone metastases. The CT scan and the bone scintigraphy showed multiple lytic bone metastases of the skull, predominant in the fronto-temporo-parietal area, extending to the chin, as shown in Fig. 1a and d, respectively. The patient was referred for HT, delivering 20 Gy using 6 MV photons, at 4 Gy per daily fraction, total duration 5 days, in the planning target volume (PTV), concurrently with high- dose corticoids. The patient was treated lying on her back. A customized mask was used for immobilization and patient positioning. The mean doses delivered to 20%, 40%, and 100% of the left eye were 7.5, 5, and 2.5 Gy, respectively. The mean doses delivered to 20%, 40%, and 100% of the right eye were 2.5, 2, and 1 Gy, respectively. The mean doses delivered to 20%, 40%, and 100% of the brain were 10, 6, and 2.5 Gy, respectively. No acute toxicity was observed. The patient was regularly followed up after the end of radiotherapy. The pain and facial paralysis had completely disappeared 1 month after the completion of radiotherapy. Eighteen months later, there were no new lesions. No symptoms nor delayed toxicity occurred. The patient now has a performance status of 1 and continues on capecitabine- based chemotherapy. Since the progress of systemic regimens has allowed for prolonged survival in some patients with metastatic breast cancer, it has become an ordinate challenge for radiation oncologists to make an attempt to reduce the potential radiation-induced early toxicity of palliative radiotherapy [3]. This population of patients needs rapid relief of their symptoms without any early toxicity because of the need to continue their systemic treatment. Concerning the low isodoses in normal tissues, this would normally lead to worries about an increased risk in second malignancies. However, this would not apply in this case due to the patients’ poor prognosis and because of the latency needed to develop these malignancies [4]. Support Care Cancer (2009) 17:613–615 DOI 10.1007/s00520-009-0610-x C. Chargari : Y. M. Kirova (*) : S. Zefkili : F. Campana Department of Radiation Oncology, Institut Curie, 26, rue d’Ulm, 75248 Paris-Cedex 05, France e-mail: youlia.kirova@curie.net C. Chargari Department of Medical Oncology, Radiotherapy, Hôpital du Val-de-Grâce, Paris, France