Pocket Guide to Radiation Oncology [2 ed.] 9780826155139, 9780826155146, 0826155138

Table of contents :
Cover
Contents
Contributors
Preface
Part I: Central Nervous System Neoplasms
1: Brain Metastasis
Workup
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
2: Glioblastoma Multiforme and High-Grade Glioma
Workup
Treatment Recommendations
Glioblastoma Adjuvant Treatment
High Grade Glioma Adjuvant Treatment
Chemotherapy/Additional Therapies
Technical Considerations Simulation
Follow Up
Selected Studies
3: Low Grade Glioma
Workup
Post-Op Treatment Recommendations by Molecular Subtype
Technical Considerations Simulation
Follow Up
Selected Studies
4: Meningioma
Workup
Meningioma Subtypes
Grading System for Surgical Resection
Treatment Recommendations by Subtype
Technical Considerations Simulation
Follow Up
Selected Studies
5: Vestibular Schwannoma
Workup
Koos Grading Scale
Treatment Recommendations for Vestibular Schwannoma
Technical Considerations Simulation
Dose Prescription
Target Delineation
Treatment Planning
Follow Up
Selected Studies
6: Pituitary Tumors
Workup
Treatment Recommendations by Tumor Type
Technical Considerations
Follow Up
Selected Studies
Part II: Head and Neck Cancers
7: Nasopharynx Cancer
Workup
Staging
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
Ongoing Trials
8: Nasal Cavity and Paranasal Sinus
Workup
Staging
Nasal Cavity and Ethmoid Sinus Treatment Recommendations by Stage
Maxillary Sinus Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
9: Oropharynx Cancer
Workup
Staging
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
Ongoing Trials
10: Oral Cavity and LIP Cancers
Workup
Staging
Treatment Recommendations for LIP and Oral Cavity Cancers by Stage
Technical Considerations
Follow Up
Selected Studies
Ongoing Trials
11: Major Salivary Gland Tumors
Workup
Staging
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
12: Larynx and Hypopharynx Cancers
Workup
Staging
Treatment Recommendations by Site and Stage
Technical Considerations
Follow Up
Selected Studies
13: Thyroid Cancer
Workup
Staging
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
14: Occult Primary Cancer of the Head and Neck
Workup
Staging
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
Part III: Thoracic Cancers
15: Non-Small Cell Lung Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
16: Small Cell Lung Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up (LS)
Selected Studies
17: Mesothelioma
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
18: Thymoma and Thymic Carcinoma
Workup
Treatment Recommendations by Modified Masaoka Stage
Technical Considerations
Follow Up
Selected Studies
Part IV: Breast Cancer
19: Breast Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies (DCIS)
Selected Studies (Early–Stage Invasive)
Selected Studies PMRT
Part V: Gastrointestinal Cancers
20: Esophageal Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
21: Gastric Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
22: Hepatobiliary Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
23: Pancreatic Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
24: Rectal Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
25: Anal Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
Part VO: Gynecologic Cancers
26: Ovarian Cancer
Workup
Adjuvant Treatment Recommendations by Stage for Epithelial Ovarian Cancer
Technical Considerations
Follow Up
Selected Studies
27: Endometrial Cancer
Workup
Treatment Recommendations by Figo Stage Following TH/BSO + Surgical Staging
Advanced Stage/Inoperable/Recurrent
Technical Considerations for Brachytherapy
Technical Considerations
Follow Up
Selected Studies
28: Cervical Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
29: Vaginal Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
30: Vulvar Cancer
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
Part VII: Genitourinary Cancers
31: Prostate Intact
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
32: Adjuvant/Salvage Prostate Cancer Treatment
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
33: Bladder Cancer
Workup
Treatment Recommendations by Stage (After Initial Turbt)
Technical Considerations
Follow Up
Selected Studies
34: Seminoma
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
Part VIII: Lymphoma
35: Hodgkin Lymphoma
Workup
Staging
Risk Stratification
Treatment Recommendations by Stage
Deauville Criteria
Technical Considerations
Follow Up
Selected Studies
36: Non-Hodgkin Lymphoma
Workup
Staging
Risk Classification
NCCN-IPI
Treatment Recommendations by Disease and Stage
Technical Considerations
Follow Up
Selected Studies
37: Multiple Myeloma and Plasmacytoma
Workup
Staging
Treatment Recommendations by Disease and Stage
Technical Considerations
Follow Up
Selected Studies
38: Cutaneous Lymphoma
Workup
Staging
Treatment Recommendations by Disease and Stage
Technical Considerations
Follow Up
Selected Studies
Part IX: Sarcoma
39: Soft Tissue Sarcoma
Workup
Treatment Recommendations of Soft Tissue Sarcoma of the Extremity/Trunk/H&N by Stage
Treatment Recommendations for Retroperitoneal Sarcomas
Treatment Recommendations for Desmoid Tumors
Technical Considerations
Follow Up
Selected Studies
Part X: Skin Cancers
40: Cutaneous Squamous Cell and Basal Cell Carcinomas
Workup
Treatment Recommendations by Clinical Presentation
Technical Considerations
Follow Up
Selected Studies
41: Malignant Melanoma
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
42: Merkel Cell Carcinoma
Workup
Treatment Recommendations by Clinical Presentation
Technical Considerations
Follow Up
Selected Studies
Part XI: Pediatric Malignancies
43: Ependymoma
Workup
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
Normal Tissue Tolerance
44: Medulloblastoma
Workup
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
Normal Tissue Tolerance
45: Neuroblastoma
Workup
Staging
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
Normal Tissue Tolerance
46: Wilms’ Tumor
Workup
Treatment Recommendations by Stage
Technical Considerations
Follow Up
Selected Studies
Normal Tissue Tolerance
47: Rhabdomyosarcoma
Workup
Clinical Staging System
Clinical Grouping System
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
Normal Tissue Tolerance
48: Ewing’s Sarcoma
Workup
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
Normal Tissue Tolerance
49: Pediatric Leukemia
Workup
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
Part XII: Metastatic Disease
50: Oligometastatic Disease
Workup
SBRT/SABR Definition
Oligometastatic Definitions
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
51: Palliative Radiation
Workup
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
Part XIII: Benign Indications
52: Benign Fibromatoses
Workup
Treatment Recomendations
Technical Considerations
Follow Up
Selected Cases
53: Keloids
Workup
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
54: Heterotopic Ossification
Workup
Treatment Recommendations
Technical Considerations
Follow Up
Selected Studies
Part XIV: Techniques
55: Proton Radiation Therapy
Overview
Treatment Recommendations
Cautionary Situations
Contraindications
Technical Considerations
Special Considerations Following Treatment Initiation
Select Ongoing National Clinical Trials Involving Proton Therapy
Proton Beam Delivery Systems
Selected Studies
References
Index

Citation preview

Second Edition

Pocket Guide to Second Edition

Daniel D. Chamberlain, MD James B. Yu, MD, MHS Roy H. Decker, MD, PhD

The pocket guide includes updates to all chapters and covers topics new to this edition, such as oligometastatic disease and benign indications, with a new chapter dedicated to proton therapy considerations. Written in outline format, Pocket Guide to Radiation Oncology takes an efficient and no-frills approach to fundamental topics in the field, making it the perfect reference for a quick review for the board exam or MOC and even serving as a handy reference during a case review at a tumor board. Chapters conclude with a list of selected summarized studies relevant to the disease n Provides essential, quick reference appendices on radiation therapy symptom management, normal tissue tolerance constraints, and radiation therapy and new systemic agents n 54 disease-based chapters make it easy to find sites without having to sift through dense, broad text n Purchase includes digital access for use on most mobile devices or computers n

Shelving Category: Oncology

Chamberlain • Yu • Decker

Key Features:

Radiation Oncology

Now in its second edition, this practical guide to clinical radiation oncology is the ideal pocket companion for the practicing physician during rounds and other clinical settings. Organized by site-specific diseases, chapters present the must-know key points, including treatment options by stage, technical considerations, and important items for follow-up. Clinical pearls and tables covering treatment options, dose constraints, side effects, target delineations, and treatment planning complete each chapter.

Pocket Guide to

Radiation Oncology

An Imprint of Springer Publishing

Pocket Guide to

Radiation Oncology Second Edition

Daniel D. Chamberlain James B. Yu Roy H. Decker

An Imprint of Springer Publishing

11 W. 42nd Street New York, NY 10036-8002 www.springerpub.com

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Pocket Guide to Radiation Oncology SECOND EDITION EDITORS DANIEL D. CHAMBERLAIN, MD

Division Chief Radiation Oncology West Michigan Cancer Center Kalamazoo, Michigan JAMES B. YU, MD, MHS

Professor of Therapeutic Radiology; Medical Director Smilow Radiation Oncology; Director Prostate and Genitourinary Cancer Radiotherapy Program Yale University School of Medicine New Haven, Connecticut ROY H. DECKER, MD, PhD

Professor Residency Training Program Director Department of Therapeutic Radiology Yale University School of Medicine New Haven, Connecticut

Copyright © 2021 Springer Publishing Company, LLC Demos Medical Publishing is an imprint of Springer Publishing Company. All rights reserved. First Springer Publishing edition 2017. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street, New York, NY 10036 www.springerpub.com connect.springerpub.com/ Acquisitions Editor: David D’Addona Compositor: Amnet Systems ISBN: 978-0-8261-5513-9 e-book ISBN: 978-0-8261-5514-6 DOI: 10.1891/9780826155146 Qualified instructors may request supplements by emailing [email protected] 20 21 22 23 24 / 5 4 3 2 1 Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for any errors or omissions or for any consequence from application of the information in this book and make no warranty, expressed or implied, with respect to the content of this publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Library of Congress Cataloging-in-Publication Data Names: Chamberlain, Daniel, editor. | Yu, James B., editor. | Decker, Roy H., editor. Title: Pocket guide to radiation oncology / Daniel D. Chamberlain, James B. Yu, Roy H. Decker. Description: Second edition. | New York, NY : Springer Publishing Company, [2021] | Includes bibliographical references and index. | Identifiers: LCCN 2020029074 (print) | LCCN 2020029075 (ebook) | ISBN 9780826155139 (paperback) | ISBN 9780826155146 (ebook) Subjects: MESH: Neoplasms—radiotherapy | Radiation Oncology | Handbook Classification: LCC RC271.R3 (print) | LCC RC271.R3 (ebook) | NLM QZ 39 | DDC 616.99/40642—dc23 LC record available at https://lccn.loc.gov/2020029074 LC ebook record available at https://lccn.loc.gov/2020029075 Contact us to receive discount rates on bulk purchases. We can also customize our books to meet your needs. For more information please contact: [email protected] Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or access to any included digital components. Printed in the United States of America.

To our long-suffering wives Marie, Brenna, and Elizabeth, thank you for your many years of love and patience. We love you to the moon and back.

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Contributors  xi Preface  xv PART I: CENTRAL NERVOUS SYSTEM NEOPLASMS 1: Brain Metastasis  3 Yi An 2: Glioblastoma Multiforme and High-Grade Glioma  9 Yi An 3: Low Grade Glioma  15 Wesley Talcott and Joseph N. Contessa 4: Meningioma  19 Gabrielle W. Peters and Joseph N. Contessa 5: Vestibular Schwannoma  25 Daniel D. Chamberlain 6: Pituitary Tumors  29 Yi An Central Nervous System Treatment Planning Dose Constraints  33 PART II: HEAD AND NECK CANCERS 7: Nasopharynx Cancer  37 Henry S. Park and Melissa R. Young 8: Nasal Cavity and Paranasal Sinus  41 Henry S. Park and Melissa R. Young 9: Oropharynx Cancer  45 Henry S. Park and Melissa R. Young 10: Oral Cavity and Lip Cancers  51 Melissa R. Young and Henry S. Park 11: Major Salivary Gland Tumors  57 Melissa R. Young and Henry S. Park 12: Larynx and Hypopharynx Cancers  61 Henry S. Park and Melissa R. Young 13: Thyroid Cancer  67 Henry S. Park, Patricia R. Peter, and Melissa R. Young 14: Occult Primary Cancer of the Head and Neck  71 Melissa R. Young and Henry S. Park Head and Neck Treatment Planning Dose Constraints  77

CONTENTS

CONTENTS

viii

CONTENTS

PART III: THORACIC CANCERS 15: Non-Small Cell Lung Cancer  81 Daniel D. Chamberlain 16: Small Cell Lung Cancer  87 Brandon R. Mancini and Roy H. Decker 17: Mesothelioma  93 Brandon R. Mancini and Roy H. Decker 18: Thymoma and Thymic Carcinoma  97 Brandon R. Mancini and Roy H. Decker Thoracic Treatment Planning Dose Constraints  101 PART IV: BREAST CANCER 19: Breast Cancer  105 Christin A. Knowlton and Meena S. Moran Breast Treatment Planning Dose Constraints  116 PART V: GASTROINTESTINAL CANCERS 20: Esophageal Cancer  119 Gabrielle W. Peters, Charles E. Rutter, and Kimberly L. Johung 21: Gastric Cancer  127 Gabrielle W. Peters, Charles E. Rutter, and Kimberly L. Johung 22: Hepatobiliary Cancer  133 Gabrielle W. Peters, Charles E. Rutter, and Kimberly L. Johung 23: Pancreatic Cancer  141 Gabrielle W. Peters, Charles E. Rutter, and Kimberly L. Johung 24: Rectal Cancer  149 Gabrielle W. Peters, Charles E. Rutter, and Kimberly L. Johung 25: Anal Cancer  159 Gabrielle W. Peters, Charles E. Rutter, and Kimberly L. Johung Gastrointestinal Treatment Planning Dose Constraints  165 PART VI: GYNECOLOGIC CANCERS 26: Ovarian Cancer  171 James Laird, Joan R. Tymon-Rosario, and Shari Damast 27: Endometrial Cancer  177 James Laird, Yi An, and Shari Damast 28: Cervical Cancer  183 James Laird, Melissa R. Young, and Shari Damast 29: Vaginal Cancer  189 James Laird and Shari Damast

30: Vulvar Cancer  195 James Laird, Melissa R. Young, and Shari Damast Gynecologic Treatment Planning Dose Constraints  201 PART VII: GENITOURINARY CANCERS 31: Prostate Intact  205 David G. Wallington and Brandon R. Mancini 32: Adjuvant/Salvage Prostate Cancer Treatment  213 David G. Wallington and Brandon R. Mancini 33: Bladder Cancer  217 David G. Wallington and Brandon R. Mancini 34: Seminoma  221 David G. Wallington and Brandon R. Mancini Genitourinary Treatment Planning Dose Constraints  225 PART VIII: LYMPHOMA 35: Hodgkin Lymphoma  229 Shang-Jui Wang and Rahul R. Parikh 36: Non-Hodgkin Lymphoma  235 Shang-Jui Wang and Rahul R. Parikh 37: Multiple Myeloma and Plasmacytoma  243 Shang-Jui Wang and Rahul R. Parikh 38: Cutaneous Lymphoma  249 Shang-Jui Wang and Rahul R. Parikh Lymphoma Treatment Planning Dose Constraints  255 PART IX: SARCOMA 39: Soft Tissue Sarcoma  259 Andrew J. Bishop and B. Ashleigh Guadagnolo Sarcoma Treatment Planning Dose Constraints  265 PART X: SKIN CANCERS 40: Cutaneous Squamous Cell and Basal Cell Carcinomas  269 Anna Likhacheva 41: Malignant Melanoma  273 Anna Likhacheva 42: Merkel Cell Carcinoma  277 Anna Likhacheva

CONTENTS

ix

x

CONTENTS

PART XI: PEDIATRIC MALIGNANCIES 43: Ependymoma  283 Amit Roy, Sahaja Acharya, and Stephanie M. Perkins 44: Medulloblastoma  287 Amit Roy, Sahaja Acharya, and Stephanie M. Perkins 45: Neuroblastoma  291 Amit Roy, Sahaja Acharya, and Stephanie M. Perkins 46: Wilms’ Tumor  297 Amit Roy, Sahaja Acharya, and Stephanie M. Perkins 47: Rhabdomyosarcoma  301 Amit Roy, Sahaja Acharya, and Stephanie M. Perkins 48: Ewing’s Sarcoma  307 Amit Roy, Sahaja Acharya, and Stephanie M. Perkins 49: Pediatric Leukemia  311 Amit Roy, Sahaja Acharya, and Stephanie M. Perkins PART XII: METASTATIC DISEASE 50: Oligometastatic Disease  319 Daniel D. Chamberlain 51: Palliative Radiation  325 Yi An PART XIII: BENIGN INDICATIONS 52: Benign Fibromatoses  333 Wesley Talcott and James Yu 53: Keloids  337 Wesley Talcott and James Yu 54: Heterotopic Ossification  341 Wesley Talcott and James Yu PART XIV: TECHNIQUES 55: Proton Radiation Therapy  347 Cristina M. DeCesaris, Jenna Jatczak, Sina Mossahebi, and Mark V. Mishra Appendix 1: Common Medications in Radiation Oncology  357 Appendix 2: Normal Tissue Tolerances 361 Appendix 3: Radiation and Targeted or Immunotherapeutic Agents 367 Index 371

xi

Sahaja Acharya, MD Assistant Member Department of Radiation Oncology St. Jude Children’s Research Hospital Memphis, Tennessee Yi An, MD Assistant Professor Department of Radiation Oncology Yale School of Medicine New Haven, Connecticut Andrew J. Bishop, MD Assistant Professor Department of Radiation Oncology The University of Texas MD Anderson Cancer Center Houston, Texas Daniel D. Chamberlain, MD Division Chief Radiation Oncology West Michigan Cancer Center Kalamazoo, Michigan Joseph N. Contessa, MD, PhD Professor and Vice Chair Department of Therapeutic Radiology Yale University School of Medicine New Haven, Connecticut Shari Damast, MD Associate Professor Department of Therapeutic Radiology Yale University School of Medicine New Haven, Connecticut Cristina M. DeCesaris, MD Resident Physician Department of Radiation Oncology University of Maryland Medical Center Baltimore, Maryland Roy H. Decker, MD, PhD Professor Residency Training Program Director Department of Therapeutic Radiology Yale University School of Medicine New Haven, Connecticut

CONTRIBUTORS

CONTRIBUTORS

CONTRIBUTORS

xii

B. Ashleigh Guadagnolo, MD, MPH Professor Department of Radiation Oncology The University of Texas MD Anderson Cancer Center Houston, Texas Jenna Jatczak, MS, CMD Dosimetrist Maryland Proton Treatment Center Baltimore, Maryland Kimberly L. Johung, MD, PhD Associate Professor Department of Therapeutic Radiology Yale School of Medicine New Haven, Connecticut Christin A. Knowlton, MD Assistant Professor of Clinical Therapeutic Radiology Department of Therapeutic Radiology Yale School of Medicine New Haven, Connecticut James Laird, MD Resident Department of Therapeutic Radiology Yale University School of Medicine New Haven, Connecticut Anna Likhacheva, MD, MPH Radiation Oncologist Department of Radiation Oncology Sutter Medical Center Sacramento, California Brandon R. Mancini, MD, MBA Radiation Oncologist Department of Radiation Oncology West Michigan Cancer Center Kalamazoo, Michigan Mark V. Mishra, MD Associate Professor Director, Clinical Research Department of Radiation Oncology University of Maryland School of Medicine Baltimore, Maryland

Meena S. Moran, MD Professor of Therapeutic Radiology Director, Yale Breast Radiotherapy Program Yale School of Medicine New Haven, Connecticut Sina Mossahebi, PhD Assistant Professor Division of Physics Department of Radiation Oncology University of Maryland School of Medicine Baltimore, Maryland Rahul R. Parikh, MD Associate Professor Department of Radiation Oncology Rutgers Cancer Institute of New Jersey New Brunswick, New Jersey Henry S. Park, MD, MPH Assistant Professor Department of Therapeutic Radiology Yale School of Medicine New Haven, Connecticut Stephanie M. Perkins, MD Associate Professor Department of Radiation Oncology Washington University Saint Louis, Missouri Patricia R. Peter, MD Assistant Professor Section of Endocrinology Department of Medicine Yale School of Medicine New Haven, Connecticut Gabrielle W. Peters, MD Medical Resident Department of Therapeutic Radiology Yale School of Medicine New Haven, Connecticut Amit Roy, MD Resident Department of Radiation Oncology Washington University Saint Louis, Missouri

CONTRIBUTORS

xiii

CONTRIBUTORS

xiv

Charles E. Rutter, MD Attending Radiation Oncologist Department of Radiation Oncology Hartford Hospital Hartford, Connecticut Wesley Talcott, MD, MBA Medical Resident Department of Therapeutic Radiology Yale School of Medicine New Haven, Connecticut Joan R. Tymon-Rosario, MD Gynecologic Oncology Fellow Section of Gynecologic Oncology Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine New Haven, Connecticut David G. Wallington, MD, MS Resident Western Michigan University School of Medicine Kalamazoo, Michigan Shang-Jui Wang, MD, PhD Assistant Professor Department of Radiation Oncology The Ohio State University Comprehensive Cancer Center—James Cancer Hospital and Solove Research Institute Columbus, Ohio Melissa R. Young, MD, PhD Assistant Professor Department of Therapeutic Radiology Yale University School of Medicine New Haven, Connecticut James B. Yu, MD, MHS Professor of Therapeutic Radiology; Medical Director Smilow Radiation Oncology; Director Prostate and Genitourinary Cancer Radiotherapy Program Yale University School of Medicine New Haven, Connecticut

xv

We are delighted to present the second edition of Pocket Guide to Radiation Oncology. Since the first edition came out four years ago, we have been gratified by its reception in radiation oncology practices worldwide. We ourselves have used the handbook in our own lives as practicing radiation oncologists and we refer to the book regularly, flipping through the text when asked a question by an astute medical student or when covering a colleague’s unfamiliar tumor board to find the right answer to a clinical question. Like the first edition, this quick pocket-sized reference can be carried for a rapid review during clinic or in between family and home activities as opposed to dense textbooks, which are often filled with esoteric topics and lengthy minutiae. The second edition of Pocket Guide to Radiation Oncology provides an updated review of the existing standard of care and the most relevant literature. We have added new chapters on the growing areas of oligometastatic disease, benign indications, and particle therapy. As the field changes, so has Pocket Guide to Radiation Oncology. We hope that this second edition of Pocket Guide to Radiation Oncology will continue to reside in the pockets of our colleagues, trainees, and staff. We are once again indebted to the authors who have contributed their expertise to this text to bring our readers the most up-to-date and clinically relevant information. Daniel D. Chamberlain, MD James B. Yu, MD, MHS Roy H. Decker, MD, PhD

Preface

PREFACE

PART I CENTRAL NERVOUS SYSTEM NEOPLASMS

3

Yi An, MD WORKUP All Cases ■ ■

H&P (age, performance status, neurological deficits, cancer history) MRI brain +/- gadolinium contrast

Considerations ■ ■ ■

■ ■ ■

Consider biopsy/surgery if solitary lesion (may be found to actually be primary CNS tumor at biopsy). Consider biopsy/surgery if no known malignancy or no prior metastatic disease If both upfront SRS vs. WBRT are options, one must assess the morbidity of neurocognitive decline and likelihood of adhering to posttreatment follow up. Consider histology—for instance: may favor SRS over WBRT for melanoma. May favor WBRT over SRS for small cell lung cancer. Consider systemic therapy options, and potential for CNS penetration of systemic therapy Disease-Specific Graded Prognostic Assessment (ds-GPA) to assess prognosis (Sperduto et al., J Clin Oncol. 2012;30(4):419–425. doi:10.1200/JCO.2011.38.0527)

TREATMENT RECOMMENDATIONS Single metastasis, resectable, limited size (3–4 cm)

Surgery ➔ single vs. multi fraction SRS to resection cavity ± WBRT OR Surgery ➔ WBRT (prefer if mass effect)

Limited #/volume of brain metastases, unresectable

Single vs. multi fraction SRS alone (preferred) OR WBRT OR WBRT + SRS

High #/volume brain metastases, no mass effect

WBRT ➔ SRS OR WBRT alone OR SRS alone (if can be done safely) (continued )

1: BRAIN METASTASIS

1: BRAIN METASTASIS

4

PART I: CENTRAL NERVOUS SYSTEM NEOPLASMS

(continued ) Multiple metastases, significant metastases causing mass effect, prognosis >3–6 months

Surgery of metastases causing mass effect ➔ WBRT OR surgery of metastases causing mass effect ➔ SRS ± WBRT OR WBRT ± SRS

Poor prognosis or poor performance status

WBRT alone OR best supportive/palliative care alone

Consider hippocampal sparing WBRT and/or giving patients memantine while receiving WBRT. TECHNICAL CONSIDERATIONS Simulation for Linac-Based RT

Simulate neutral head position and treat with Aquaplast mask if whole brain. More robust immobilization and/or image guidance for enhanced precision if SRS treatment. Fuse with thin-slice MRI (≤1–2 mm) for SRS planning. Consider steroids and anti-epileptics with SRS treatment. Dose Prescription ■ ■

Whole brain: 30 Gy in 10 fx; 35–37.5 Gy in 14–15 fx; 20 Gy in 5 fx (very poor prognosis) SRS: Consider from RTOG 9005 20 to 24 Gy for tumor size ≤2 cm 18 Gy for tumor 2.1–3 cm 15 Gy for tumor 3.1–4 cm

For Gamma Knife, Rx prescription is typically to the 50% isodose line (IDL), and 80% for Linac-SRS ■

May need to dose reduce or fractionate if exceeding OAR dose (including optic structures, brainstem).

Target Delineation ■

■

Whole brain: typically flash 1.5–2 cm anteriorly, superiorly, and posteriorly. Inferior border: C1 or C2. Include lens blocks and minimize pharyngeal dose if possible. SRS: 0–2 mm margin around lesion or resection cavity.

Treatment Planning

Whole brain: opposed laterals For hippocampal-sparing WBRT use IMRT* *see Gondi et al., IJROBP 2010;78:1244–52 (doi:10.1016/j.ijrobp​ .2010​ .11.001).

■ ■

5

MRI brain every 2–3 months for 1 year, then every 4–6 months indefinitely SELECTED STUDIES Single Brain Met Patchell II (Patchell, JAMA 1998; doi:10.1001/jama.280.17.1485)

95 patients with MRI-confirmed gross resection randomized to adjuvant WBRT or observation. WBRT dose 50.4 Gy over 5.5 weeks. Post-op WBRT reduced local recurrence (10% vs. 46%), distance recurrence (18% vs. 70%), and neurological death (14% vs. 44%). No change in overall survival (OS) or time patient remained functionally independent. Limited Brain Metastases (1–3) WBRT versus WBRT + SRS RTOG 9508 (Andrews, Lancet 2004; doi:10.1016/ S0140-6736(04)16250-8)

331 patients with lesions 40 with any surgery. Randomized to RT alone versus RT followed by PCV chemo. OS and PFS curves were similar for the first 2 years. However, after 2 years, OS and PFS curves separate. For 2-year survivors the probability of OS for an additional 5 years was 59% with RT versus 74% with RT + PCV (p = .02). RTOG 9402 (Cairncross, J Clin Oncol 2013; doi:10.1200/ JCO.2012.43.2674)

Randomized 298 pts with anaplastic oligodendroglioma or anaplastic oligoastrocytoma to PCV chemo followed by RT, versus RT alone. RT in both arms was 59.4 Gy in 33 fx. For the entire cohort there was no difference in median survival (4.6 years vs. 4.7 years). Unplanned analysis of patients with pts with 1p/19q co-deleted tumors showed improved median survival in both treatment arms favoring 1p/19q co-deletion (PCV + RT: 14.7 years vs. 2.6 years), (RT alone: 7.3 years vs. 2.7 years). Pts with 1p/19q co-deleted tumors treated with PCV + RT had twice the median survival compared to pts with 1p/19q co-deleted tumors receiving RT alone (14.7 years vs. 7.3 years; p = .03). EORTC 26951 (van den Bent, J Clin Oncol 2013; doi:10.1200/JCO.2012.43.2229)

368 pts with anaplastic oligodendroglial tumors randomized to RT followed by six cycles PCV versus RT alone. RT dose was 59.4 Gy in both arms. Median follow up was 140 months. OS was improved in the RT+ PCV arm (42.3 months vs. 30.6 months). 1p/19q-co-deleted tumors had improved median OS (not reached at 140 months vs. 112 months) with a trend toward more benefit from adjuvant PCV. IDH mutational status was also prognostic. Interim Results From the CATNON Trial (EORTC Study 26053-22054) (van den Bent, Lancet 2017; doi:10.1016/ S0140-6736(17)31442-3)

745 pts with non-co-deleted anaplastic glioma randomized trial with 2 × 2 factorial design. Treatment arms were RT alone versus RT + adjuvant TMZ versus RT + concurrent TMZ versus RT + concurrent TMZ + adjuvant TMZ. 5-year OS 55.9% with adjuvant TMZ versus 44.1% without adjuvant TMZ.

3: Low GRade GLIOMA

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PART I: CENTRAL NERVOUS SYSTEM NEOPLASMS

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CODEL RT Versus RT+TMZ Versus TMZ for 1p/19q-Co-Deleted Anaplastic Oligodenrogliomas (Jaeckle, Neurology 2016; https://n.neurology.org/content/86/16_Supplement/PL02.005)

(Abstract only) Randomized trial of 36 patients with 1p/19q co-deleted grade III gliomas treated with RT (5,940 cGy) alone versus RT+TMZ versus TMZ alone. Grade 3+ toxicity 25% versus 42% versus 33%, respectively. Median followup of 3.5 years. 12.5% of pts in RT treatment groups progressed versus 58% of TMZ-alone pts progressed. Median PFS was 2.5 years in TMZ-alone pts versus not reached for pts in the groups receiving RT. OS shorter in TMZalone pts. TMZ-alone arm was closed and trial reopened as RT + adjuvant PCV versus RT + concomitant and adjuvant TMZ. NOA-4 (Wick, Neuro Oncol 2016; doi:10.1093/ neuonc/now133)

318 pts randomized to sequential RT then chemo at failure versus sequential chemo then RT at failure. Chemo was randomized to TMZ versus PCV. 9.5 years follow up. No statistically significant difference between pts who started with RT versus pts who started with chemo. molecular studies (CpG island methylator phenotype [CIMP] and 1p/19q co-deletion status) more prognostic than histology (oligodendroglial vs. astrocytic). Patients with CIMPcodel tumors had better PFS with PCV versus TMZ. (Suzuki, Nat Genet 2015; doi:10.1038/ng.3273)

Mutational landscape and clonal architecture in grade II and III gliomas. 

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Gabrielle W. Peters, MD Joseph N. Contessa, MD, PhD WORKUP ■ ■

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Many cases are asymptomatic and discovered incidentally on imaging. H&P (headaches, seizures, visual changes, hearing loss, mental status changes, extremity weakness) including a thorough neurological exam. Note prior history of radiation or multiple meningiomas. MRI with contrast for diagnosis and treatment planning. Neurosurgical consultation Consider visual field testing for tumors affecting or adjacent to the optic structures.

MENINGIOMA SUBTYPES WHO Grade I (benign)

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