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Congenital diaphragmatic hernia (CDH) can be associated with genetic or structural anomalies that render the prognosis overall poor. In isolated cases, survival is dependent on the degree of lung hypoplasia and potentially also liver position. Isolated CDH remains today, fatal in around 30% of prenatally diagnosed cases. Cases should be referred in utero to tertiary care centers familiar with this condition for comprehensive assessment, prediction of individual outcome as well as timed delivery. Individual prognosis can be estimated based on lung size measurement as well as documentation of the degree of liver herniation into the thorax. The use of imaging to document pulmonary vascularization is promising, but is at present still under investigation. Based on the predicted survival rate, parents can be counseled about their options. In those with a poor prognosis, termination of pregnancy can be considered. Antenatal intervention, aiming to stimulate lung growth, has become an alternative for these cases. Lung growth is triggered by temporary fetal endoscopic tracheal occlusion (FETO). Growing experience has demonstrated the feasibility and safety of the technique, and survival has increased from around 15% to over 50% in this group. In Europe a trial has now started, documenting the place of FETO in moderate cases (predicted survival rate 50%), and soon also in severe cases. It is hypothesized that prenatal intervention might decrease oxygen dependency in survivors (moderate), or increase survival (severe).

In head and neck cancer, intensity modulated radiotherapy (IMRT) allows to generate concave dose distributions to match the shape of the planning target volume (PTV). In our department, IMRT is delivered by multiple static convergent beams, that consist of superposition of unmodulated segments. The segment shapes were obtained from the beam’s eye view (BEV) projection of PTV(s) and organs at risk (OARs). By making the shape of segments also a function of the patient’s outlines (skin surface), a substantial refinement was obtained.

The case in favour of IMRT is made as IMRT allows to shape the dose distribution in such a way that at least three challenges in clinical radiotherapy can be addressed. These are i) conforming dose to concave PTV shapes (i.e. head and neck (HN ii) reducing the volume of surrounding tissues irradiated to intermediate dose levels by using beam combinations with restricted hinge angles (lung, mediastinal tumours) and iii) generating controlled 3D-inhomogeneous dose distributions (i.e. prostate, paranasal sinus tumours). The two largest groups of patients that we treat with IMRT are H&N and prostate cancer patients.