Radiation Oncology Perspective Research Articles

Approach to Patients with High-Risk Localized Prostate Cancer: Radiation Oncology Perspective.

High-risk localized prostate cancer is a challenging clinical entity to treat, with heterogeneous responses to an evolving array of multidisciplinary treatment approaches. In addition, this disease state is growing in incidence due to a variety of factors, including shifting recommendations that discouraged routine prostate cancer screening. Current guidelines now incorporate an informed decision-making process for prostate cancer screening and evaluation. More work is underway to improve targeted screening for certain at-risk populations and to implement greater personalization in the use of diagnostic tools. Once diagnosed with high-risk localized disease, a multimodality treatment paradigm is warranted. Radiation-in its various forms and combinations-plays a large and continually evolving role in the management of high-risk prostate cancer, yet treatment outcomes are still suboptimal. There is a growing need to improve upon current treatment approaches, and better personalize a particular treatment recommendation based on both tumor and patient characteristics, as well as patient preference and goals of therapy. Given that treatment generally requires more than one therapy, there are notable implications on long-term quality of life, especially with respect to overlapping and cumulative side effects of local and systemic therapies, respectively. The desire for aggressive therapy to optimize cancer control outcomes must be weighed against the risk of morbidities and overtreatment and discussed with each patient so that an informed decision about treatment and care can be determined. High-level evidence to support treatment recommendations, where available, is critical for a data-driven and tailored approach to address all goals of care.

MO-0561 Defining Patient Empowerment from a radiation oncology perspective: An Expert and patient consensus

MO-0561 Defining Patient Empowerment from a radiation oncology perspective: An Expert and patient consensus

A proposed framework for the implementation of head and neck cancer treatment at a new cancer center from a radiation oncology perspective.

Establishing a new head and neck cancer (HNC) treatment center requires multidisciplinary team management and expertise. To our knowledge, there are no clear recommendations or guidelines in the literature for the commencement of HNC radiation therapy (RT) at a new cancer center. We propose a novel framework outlining the necessary components required to set-up a new radiation therapy HNC treatment. We reviewed the infrastructure and methodology in the commencement of HNC radiation therapy in our cancer care center and invited several external, experienced metropolitan head and neck radiation oncologists to develop a novel consensus guideline that may be used by new RT centers to treat HNC. Recommendations were presented to our internal and external staff specialists using a survey questionnaire with ratings utilized to determine consensus using pre-defined thresholds as per the American Society of Clinical Oncology Guidelines Methodology Manual. This consensus recommendation aims to improve RT utilization whilst advocating for optimal patient outcomes by presenting a framework for new radiation therapy centers ready to step up and manage the treatment of head and neck cancer patients. We propose these evidence-based consensus guidelines endorsed by external HNC radiation oncologists.

Breast Cancer Management During the COVID-19 Pandemic: the Radiation Oncology Perspective.

Purpose of ReviewThe coronavirus disease 19 (COVID-19) pandemic has caused disruption in healthcare throughout the world. The limitations placed on hospital resources and the need to limit potential exposure to SARS-CoV-2 for both patients and healthcare staff have affected oncologic care for patients with breast cancer (BC), including radiation therapy (RT). This review highlights published guidelines regarding the provision of radiotherapy for BC patients and their adoption by radiation oncology centers.Recent FindingsMultiple international and national consortiums plus select institutions have published formal recommendations regarding radiation therapy for BC during the COVID-19 pandemic. They embody the principles of limiting in-person visits, proper triage, and the judicious use of delay, abbreviation, or omission of RT as appropriate.SummarySince the start of the pandemic, multiple publications have provided guidance regarding RT for BC during this challenging time. The pandemic has led to increased use of telemedicine and abbreviated radiation therapy courses in the setting of BC, which are likely to persist. Future research is needed to establish the effect of these changes on oncologic outcomes.

Total Lymphatic Irradiation as Part of Conditioning in Pediatric Hematopoietic Stem Cell Transplantation: A Single Institution Experience From a Radiation Oncology Perspective

Purpose/Objective(s)Total lymphatic irradiation (TLI) is a procedure in which a patient's major lymph nodes and spleen are treated with low doses of radiation for recipient immunosuppression as part of multi-agent conditioning for cardiac, lung or hematopoietic stem cell transplantation, to facilitate engraftment and to decrease the risk of rejection. TLI is considered an attractive option instead of total body irradiation (TBI) to mitigate side effects of radiation exposure to normal tissues. There are no established guidelines on technique and dose fractionation. Herein, we share our experience.Materials/MethodsRetrospective review of children who received TLI for hematopoietic stem cell transplants at the hospital was done.ResultsTwenty-two patients who had TLI from 2004 to 2020, with a median age of 7.5 years (range 0.9-19.0) were included. Twelve had benign conditions and 10 had malignant conditions. Eighteen had haploidentical grafts, 2 had matched sibling and 2 had unrelated donors. Four patients had previously failed engraftment prior to TLI. Conditioning included multi-agent chemotherapy for all including rabbit-ATG for 12 patients. All patients had computer-tomographic scans simulation except for 2 patients who were treated in the earlier years when only orthogonal XR was available. Dose fractionation was single prior to 2017 (5-7Gy/1#) and in recent times more fractionated (6-7.5Gy/3#). The treatment targets were the spleen and the following nodal stations: cervical, axillary, mediastinal, hilar, paraaortic, pelvic, inguinal and femoral. Normal organs including the medial thyroid, heart, lungs, and abdominal organs were shielded with multi-leaf collimators using three-dimensional conformal technique (Figure 1, 2). Of 12 patients with benign conditions, all are alive at last follow up. Of 10 patients with malignant conditions, 3 are dead from disease. Five out of 12 patients who had haploidentical grafts, 0/2 matched sibling graft and 1/2 unrelated grafts experienced rejection. The median follow up is 14.0 months (IQR 6-41.5). None developed acute pneumonitis. One patient developed thyroid cancer 14 years after TLI.ConclusionHerein we describe our TLI experience and technique. More studies should be undertaken to evaluate the safety and efficacy of TLI compared to TBI. Going forward, a consensus on technique and dose should be developed. Total lymphatic irradiation (TLI) is a procedure in which a patient's major lymph nodes and spleen are treated with low doses of radiation for recipient immunosuppression as part of multi-agent conditioning for cardiac, lung or hematopoietic stem cell transplantation, to facilitate engraftment and to decrease the risk of rejection. TLI is considered an attractive option instead of total body irradiation (TBI) to mitigate side effects of radiation exposure to normal tissues. There are no established guidelines on technique and dose fractionation. Herein, we share our experience. Retrospective review of children who received TLI for hematopoietic stem cell transplants at the hospital was done. Twenty-two patients who had TLI from 2004 to 2020, with a median age of 7.5 years (range 0.9-19.0) were included. Twelve had benign conditions and 10 had malignant conditions. Eighteen had haploidentical grafts, 2 had matched sibling and 2 had unrelated donors. Four patients had previously failed engraftment prior to TLI. Conditioning included multi-agent chemotherapy for all including rabbit-ATG for 12 patients. All patients had computer-tomographic scans simulation except for 2 patients who were treated in the earlier years when only orthogonal XR was available. Dose fractionation was single prior to 2017 (5-7Gy/1#) and in recent times more fractionated (6-7.5Gy/3#). The treatment targets were the spleen and the following nodal stations: cervical, axillary, mediastinal, hilar, paraaortic, pelvic, inguinal and femoral. Normal organs including the medial thyroid, heart, lungs, and abdominal organs were shielded with multi-leaf collimators using three-dimensional conformal technique (Figure 1, 2). Of 12 patients with benign conditions, all are alive at last follow up. Of 10 patients with malignant conditions, 3 are dead from disease. Five out of 12 patients who had haploidentical grafts, 0/2 matched sibling graft and 1/2 unrelated grafts experienced rejection. The median follow up is 14.0 months (IQR 6-41.5). None developed acute pneumonitis. One patient developed thyroid cancer 14 years after TLI. Herein we describe our TLI experience and technique. More studies should be undertaken to evaluate the safety and efficacy of TLI compared to TBI. Going forward, a consensus on technique and dose should be developed.

Partial Breast Irradiation and Surgical Clip Usage for Tumor Bed Delineation After Breast-Conserving Surgery in Canada: A Radiation Oncology Perspective

PurposeOur purpose was to evaluate the usage and perceived benefit of surgical clips for breast radiation therapy planning in Canada, focusing on partial breast irradiation (PBI) after breast-conserving surgery. Methods and MaterialsA retrospective institutional review identified patients eligible for PBI based on clinicopathologic criteria, and tumor bed visualization was determined from computed tomography-planning scans. An online survey was subsequently distributed to Canadian radiation oncologists addressing the usage and added value of surgical clips for breast radiation therapy planning purposes. The survey also evaluated PBI usage and regimens. Responses were collected over a 4-week period. PBI regimen usage at our institution was also reviewed from May 1 to December 18, 2020. ResultsBased on clinicopathologic criteria, 306 patients were identified between 2013 and 2018 who were eligible for PBI. However, only 24% (72/306) of cases were noted to have surgical clips, of which over 50% did not assist in tumor bed localization due to inconsistent clip positioning. Similarly, nearly two-thirds (28/43) of survey respondents indicated that surgical clips are placed in the tumor bed in less than 50% of cases. Almost all respondents (42/43) indicated that surgical clips facilitate breast radiation therapy planning and favor the development of guidelines to increase the consistent placement of surgical clips in the tumor bed after breast-conserving surgery. Approximately two-thirds of respondents (28/43) offer PBI to eligible patients as routine treatment, with moderate hypofractionated regimens most commonly recommended. However, the 1-week daily regimen of 26 Gy in 5 fractions is now offered to the majority (77%) of patients at our institution. ConclusionsThere was strong agreement among Canadian radiation oncologists that surgical clip placement facilitates breast radiation therapy planning, and most favor the development of surgical guidelines for the consistent placement of surgical clips in this setting. With the growing use of PBI, accurate localization of the tumor bed is extremely important.

Clinical Significance of Subclassification of Stage FIGO 1B from a Radiation Oncology Perspective

Previously, 2014 FIGO staging system divided stage IB into stage IB1 and IB2 for cervical cancer patients. Currently, the revised 2018 FIGO staging system further divides stage IB into stage IB1, IB2, and IB3, aiming to specify patients with small tumors who could receive surgery only, without additional radiotherapy (RT). This study aimed to evaluate the revised FIGO staging in stage IB cervical cancer patients and to suggest the optimal treatment strategies with surgery and/or RT. Medical data of cervical cancer patients who were treated with a curative aim between September 2001 and May 2018 were reviewed. A total of 350 patients were restaged according to the revised 2018 FIGO staging system. Treatment modalities included RT or chemoradiotherapy (CRT) in 71 patients, surgery ± adjuvant chemotherapy in 182 patients, and surgery followed by adjuvant RT/CRT in 97 patients. At a median follow-up of 67.0 months (range, 4.5–215.6 months), FIGO stage IB1 (n = 149), IB2 (n = 161), and IB3 (n = 40) patients showed 5-year progression-free survival (PFS) rates of 86.6%, 80.6%, and 78.3%, respectively, although not statistically significant (p = 0.335). The PFS curve showed a tendency of stage IB2 patients towards poor rates similar with stage IB3 patients as time increased. To further investigate these results, recurrence rates were analyzed depending on the treatment modality received. Among all the stages, stage IB2 patients who received surgery only showed significantly poorer recurrence rates compared to those who received RT or surgery with adjuvant RT (p = 0.017). In addition, the major first patterns of failure were local (36%) or regional recurrences (44%) for those who received surgery only, compared to distant failure as the major first pattern of failure in those who received RT or surgery with adjuvant RT (40% and 37.5%, respectively). Thus, patients who received surgery only were further evaluated. Low risk patients determined by simplified Sedlis criteria who did not receive adjuvant RT were analyzed (n = 100). By multivariate analysis, increasing tumor size was the only significant adverse factor for local recurrence (p = 0.047) and the cutoff value determined by the receiver operating characteristic curve was 2.5 cm. For regional recurrence, the only significant unfavorable factor was adenocarcinoma (p = 0.040). Although surgery without additional RT is generally preferred for revised FIGO stage IB1 and some IB2 patients, this study showed that size and adenocarcinoma pathology were significant factors for local and regional recurrences, respectively. Thus, adjuvant vaginal brachytherapy for those who have tumors larger than 2.5 cm and adjuvant external beam RT for those diagnosed with adenocarcinoma may be considered in stage IB cervix cancer patients undergoing surgery.

Prostate cancer management challenges due to COVID-19 in countries with low-to-middle-income economies: A radiation oncology perspective

Description: The COVID-19 pandemic poses an unprecedented challenge for urologic oncology and radiotherapy. Radiation oncology departments and international collaboration groups are sharing their management adaptations made in response to the pandemic. The present narrative review summarizes the current recommendations.
 Relevance:  There is a need to define which patients are candidates for safe treatment delay until the pandemic is over or controlled, to reduce exposure to the virus in the healthcare personnel and patients.  
 Conclusions:  Telemedicine is recommended for follow-up visits. Active surveillance is the preferred treatment for patients with favorable intermediate risk. In greater risk disease, hormone therapy safely postpones radiotherapy up to 7 months. Radiosurgery is suggested in centers that have the necessary technology and previous experience.  A moderately hypofractionated regimen is recommended if radiosurgery/ultra-hypofractionation is not available. Hypofractionation should be implemented if image-guided radiation therapy is already in place. Countries with low and middle-income economies face challenges in adopting the recommendations for prostate cancer management during the pandemic. Postponing treatment may result in the overwhelming of radiation oncology center capacity, after the pandemic.    

Prostate cancer management challenges due to COVID-19 in countries with low-to-middle-income economies: A radiation oncology perspective

Description: The COVID-19 pandemic poses an unprecedented challenge for urologic oncology and radiotherapy. Radiation oncology departments and international collaboration groups are sharing their management adaptations made in response to the pandemic. The present narrative review summarizes the current recommendations.
 Relevance:  There is a need to define which patients are candidates for safe treatment delay until the pandemic is over or controlled, to reduce exposure to the virus in the healthcare personnel and patients.  
 Conclusions:  Telemedicine is recommended for follow-up visits. Active surveillance is the preferred treatment for patients with favorable intermediate risk. In greater risk disease, hormone therapy safely postpones radiotherapy up to 7 months. Radiosurgery is suggested in centers that have the necessary technology and previous experience.  A moderately hypofractionated regimen is recommended if radiosurgery/ultra-hypofractionation is not available. Hypofractionation should be implemented if image-guided radiation therapy is already in place. Countries with low and middle-income economies face challenges in adopting the recommendations for prostate cancer management during the pandemic. Postponing treatment may result in the overwhelming of radiation oncology center capacity, after the pandemic.    

Disease Site-Specific Guidelines for Curative Radiation Treatment During 'Limited Surgery' and 'Hospital Avoidance': A Radiation Oncology Perspective From the Epicenter of COVID-19 Pandemic.

The COVID-19 pandemic has resulted in an unprecedented situation where the standard of care (SOC) management for cancers has been altered significantly. Patients with potentially curable cancers are at risk of not receiving timely SOC multidisciplinary treatments, such as surgery, chemotherapy, radiation therapy, or combination treatments. Hospital resources are in such high demand for COVID-19 patients that procedures, such as surgery, dentistry, interventional radiology, and other ancillary services, are not available for cancer patients. Our tertiary care center is considered the center of the epicenter in the USA. As a result, all non-emergent surgeries have been suspended in order to provide hospital beds and other resources for COVID-19 patients.Additionally, ambulatory efforts to avoid treatment-related morbidity are critical for keeping patients out of emergency departments and hospitals. In this review article, we discuss evidence-based radiation therapy approaches for curable cancer patients during the COVID-19 pandemic. We focus on three scenarios of cancer care: 1) radiation therapy as an alternative to surgery when immediate surgery is not possible, 2) radiation therapy as a ‘bridge’ to surgery, and 3) radiation options definitively or postoperatively, given the risk of hospitalization with high-dose chemotherapy.

Defining oligometastatic disease from a radiation oncology perspective: An ESTRO-ASTRO consensus document

BackgroundRecognizing the rapidly increasing interest and evidence in using metastasis-directed radiotherapy (MDRT) for oligometastatic disease (OMD), ESTRO and ASTRO convened a committee to establish consensus regarding definitions of OMD and define gaps in current evidence. MethodsA systematic literature review focused on curative intent MDRT was performed in Medline, Embase and Cochrane. Subsequent consensus opinion, using a Delphi process, highlighted the current state of evidence and the limitations in the available literature. ResultsAvailable evidence regarding the use of MDRT for OMD mostly derives from retrospective, single-centre series, with significant heterogeneity in patient inclusion criteria, definition of OMD, and outcomes reported. Consensus was reached that OMD is largely independent of primary tumour, metastatic location and the presence or length of a disease-free interval, supporting both synchronous and metachronous OMD. In the absence of clinical data supporting a maximum number of metastases and organs to define OMD, and of validated molecular biomarkers, consensus supported the ability to deliver safe and clinically meaningful radiotherapy with curative intent to all metastatic sites as a minimum requirement for defining OMD in the context of radiotherapy. Systemic therapy induced OMD was identified as a distinct state of OMD. High-resolution imaging to assess and confirm OMD is crucial, including brain imaging when indicated. Minimum common endpoints such as progression-free and overall survival, local control, toxicity and quality-of-life should be reported; uncommon endpoints as deferral of systemic therapy and cost were endorsed. ConclusionWhile significant heterogeneity exists in the current OMD definitions in the literature, consensus was reached on multiple key questions. Based on available data, OMD can to date be defined as 1–5 metastatic lesions, a controlled primary tumor being optional, but where all metastatic sites must be safely treatable. Consistent definitions and reporting are warranted and encouraged in ongoing trials and reports generating further evidence to optimize patient benefits.

An evaluation of hepatocellular carcinoma practice guidelines from a radiation oncology perspective

IntroductionExternal beam radiotherapy (EBRT) is actively used for hepatocellular carcinoma (HCC) treatment in clinical practice but has not got attention in several guidelines owing to the lack of high-level evidences. We evaluated HCC treatment guidelines from the radiation oncology perspective using the Appraisal of Guidelines for Research and Evaluation (AGREE II) model, to provide information to choose suitable guidelines and for future guidelines developments. MethodsGuidelines and consensuses for HCC management involving EBRT that have been published until May 2019 were included. Seven appraisers from 6 countries participated; all were radiation oncologists specialized in HCC. Guidelines were assessed using the AGREE II (December 2017 update), and we added an additional domain, “Radiotherapy Content,” to evaluate the fidelity of evidence and participation of relevant specialists. Inconsistency among appraisers was evaluated, and standard deviations (SD) among the average scores of each domain were calculated. ResultsEighteen guidelines or consensuses were included; 4 of them (NCCN, EASL, AASLD, and KLCSG)* were considered applicable without modification. Overall scores were evenly and significantly affected by all domain scores, with “Rigour of Development” showing the most significant correlation. The median scores were the highest for “Scope and Purpose” (63.9%) and “Clarity of Presentation” (65.7%) and the lowest for “Applicability” (36.1%). Inconsistency among appraisers was higher in “Editorial Independence” (median SD: 1.96) than in other domains. ConclusionAlthough the median overall score was moderate (64.3%), further efforts are necessary as all domains had scores <50% except “Scope and Purpose” and “Clarity of Presentation”. Future guidelines need to consider more on “Applicability” because modern HCC treatment requires multidisciplinary approaches involving up-to-date techniques and systemic agents. The independency of development and role of funders should be comprehensively described in future guidelines.*National Cancer Comprehensive Network, European Association for the Study of the Liver, American Association for the Study of the Liver Disease, Korean Liver Cancer Study Group.

Contingency Plans in a Radiation Oncology Department Amid the 2019-nCoV Outbreak in Switzerland

The ongoing novel coronavirus (2019-nCoV) pandemic is expected to develop into an unprecedented stress test for health care systems worldwide. This brief report, written from a radiation oncology perspective during the developing outbreak of 2019-nCoV in Switzerland, highlights the challenges identified and measures taken in our department to mitigate risks and ensure continued operations during the outbreak.

Where Do We See Alpha Emitters in Clinical Practice? A Radiation Oncology Perspective

Alpha emitters have always promised to deliver potential benefit in cancer therapy. Using the example of radium-223 (Xofigo) and the paradigm of ionising radiation, this review looks at targeted alpha therapy from the perspective of a radiation oncologist.

The Role of Standard and Advanced Imaging for the Management of Brain Malignancies From a Radiation Oncology Standpoint.

Radiation therapy (RT) plays a critical role in the overall management of many central nervous system (CNS) tumors. Advances in RT treatment planning, with techniques such as intensity modulated radiation therapy, volumetric modulated arc therapy, and stereotactic radiosurgery, now allow the delivery of highly conformal dose with great precision. These techniques rely on high-resolution 3-dimensional anatomical imaging modalities such as computed tomography or magnetic resonance imaging (MRI) scans to accurately and reliably define CNS targets and normal tissue avoidance structures. The integration of cross-sectional imaging into radiation oncology has directly translated into improvements in the therapeutic window of RT, and the union between radiation oncology and imaging is only expected to grow stronger. In addition, advanced imaging modalities including diffusion, perfusion, and spectroscopic MRIs as well as positron emission tomography (PET) scans with novel tracers are being utilized to provide additional insight into tumor biology and behavior beyond anatomy. Together, these standard and advanced imaging modalities hold significant potential to improve future RT delivery and response assessment. In this review, we will discuss the current utilization of standard/advanced imaging for CNS tumors from a radiation oncology perspective as well as the implications of novel MRI and PET modalities currently under investigation.

Diagnosis and management of brain metastases: an updated review from a radiation oncology perspective

Journal of Cancer Metastasis and Treatment is an open access journal, focusing on basic and clinical studies related to cancer cell, cell biology, oncology, radiation therapy and radiology, obstetrics and gynecology, pediatrics, surgery, hematology, neuro-oncology, etc.

Utility of Molecular Imaging with 2-Deoxy-2-[Fluorine-18] Fluoro-DGlucose Positron Emission Tomography (18F-FDG PET) for Small Cell Lung Cancer (SCLC): A Radiation Oncology Perspective.

Although accounting for a relatively small proportion of all lung cancers, small cell lung cancer (SCLC) remains to be a global health concern with grim prognosis. Radiotherapy (RT) plays a central role in SCLC management either as a curative or palliative therapeutic strategy. There has been considerable progress in RT of SCLC, thanks to improved imaging techniques leading to accurate target localization for precise delivery of RT. Positron emission tomography (PET) is increasingly used in oncology practice as a non-invasive molecular imaging modality. Herein, we review the utility of molecular imaging with 2-deoxy-2-[fluorine-18] fluoro-Dglucose PET (18F-FDG PET) for SCLC from a radiation oncology perspective. There has been extensive research on the utility of PET for SCLC in terms of improved staging, restaging, treatment designation, patient selection for curative/palliative intent, target localization, response assessment, detection of residual/recurrent disease, and prediction of treatment outcomes. PET provides useful functional information as a non-invasive molecular imaging modality and may be exploited to improve the management of patients with SCLC. Incorporation of PET/CT in staging of patients with SCLC may aid in optimal treatment allocation for an improved therapeutic ratio. From a radiation oncology perspective, combination of functional and anatomical data provided by integrated PET/CT improves discrimination between atelectasis and tumor, and assists in the designation of RT portals with its high accuracy to detect intrathoracic tumor and nodal disease. Utility of molecular imaging for SCLC should be further investigated in prospective randomized trials to acquire a higher level of evidence for future potential applications of PET.

MTE07.01 From Radiation Oncology Perspective

Radiation therapy (RT) plays an important role in the multimodality management of thymic malignancies and is an effective local treatment modality with the goal of reducing the risk of local recurrence. It can be employed in the neoadjuvant, adjuvant, definitive or palliative setting. It is important to evaluate the role of RT for pleural recurrence in the context of surgery and systemic treatment options as part of a multimodality approach and carefully coordinate the three modalities for optimal outcomes. Studies on the specific role of RT in pleural recurrences are sparse. However, there are several recent large database and population-based studies that indicate which patient subsets may benefit the most from RT. The indication and clinical setting for RT (perioperative versus definitive RT) depends on surgical resectability and operability of the patient. The adjuvant setting is the most extensively studied setting for RT in thymic malignancies. The greatest benefit of adjuvant RT appears to be in patients with newly diagnosed locally advanced stage III and IV thymomas, including patients with pleural dissemination.1-4 For thymic carcinomas the impact of adjuvant RT appears more significant.5-7 For incompletely resected thymic tumors there is a stronger rationale for adjuvant RT based on emerging data and general oncologic principles. The principles of adjuvant RT may be applied to surgically resected pleural recurrences as well. A range of modern radiation therapy techniques is available to aid the radiation oncologist in optimally targeting the tumor bed, while maximally reducing the radiation dose to surrounding organs at risk.8,9 The radiation technique should be uniquely tailored to the needs of each individual patient’s presentation. Techniques include 3D conformal radiation therapy, intensity-modulated radiation therapy, proton therapy and intraoperative radiation therapy using high dose rate brachytherapy or low dose rate seed implantation. The extent of the radiation treatment field will depend on the intraoperative findings, pathologic results, proximity to and dosimetric assessment of critical organs at risk. This may vary from treatment of a small tumor bed of a single pleural metastasis to hemithoracic pleural RT following an extrapleural pneumonectomy or lung-sparing pleurectomy/decortication in select cases. For inoperable or unresectable patients definitive RT is an excellent treatment option. A subset of patients is technically or medically inoperable, due to invasion of critical structures such as the heart, great vessels, spine, esophagus etc. or comorbidities. In general, thymic malignancies are radiosensitive, allowing for long-term local control rates, even when treated with definitive RT in the absence of surgery. Stereotactic ablative RT may be used for oligometastatic disease as an alternative to surgical resection and has been shown to be a highly effective treatment modality with >90% long-term local control rates and minimal morbidity in multiple histologies of intrathoracic metastases, including thymic tumors.10 Lastly, palliative RT should be considered whenever surgical management or definitive radiation treatment options are not feasible. Conventional palliative RT is an important modality to improve quality of life by alleviating pain, treating SVC syndrome, airway compression and other symptoms. 1. Fernandes AT, Shinohara ET, Guo M, et al. The role of radiation therapy in malignant thymoma: A surveillance, epidemiology, and end results database analysis. Journal of Thoracic Oncology. 2010;5(9):1454-1460. 2. Rimner A, Gomez DR, Wu AJ, et al. Failure patterns relative to radiation treatment fields for stage II-IV thymoma. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2014;9(3):403-409. 3. Rimner A, Yao X, Huang J, et al. Postoperative Radiation Therapy Is Associated with Longer Overall Survival in Completely Resected Stage II and III Thymoma-An Analysis of the International Thymic Malignancies Interest Group Retrospective Database. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2016;11(10):1785-1792. 4. Modh A, Rimner A, Allen PK, et al. Treatment Modalities and Outcomes in Patients With Advanced Invasive Thymoma or Thymic Carcinoma: A Retrospective Multicenter Study. American journal of clinical oncology. 2016;39(2):120-125. 5. Ahmad U, Yao X, Detterbeck F, et al. Thymic carcinoma outcomes and prognosis: results of an international analysis. J Thorac Cardiovasc Surg. 2015;149(1):95-100, 101.e101-102. 6. Omasa M, Date H, Sozu T, et al. Postoperative radiotherapy is effective for thymic carcinoma but not for thymoma in stage II and III thymic epithelial tumors: the Japanese Association for Research on the Thymus Database Study. Cancer. 2015;121(7):1008-1016. 7. Ruffini E, Detterbeck F, Van Raemdonck D, et al. Thymic carcinoma: a cohort study of patients from the European society of thoracic surgeons database. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2014;9(4):541-548. 8. Gomez D, Komaki R. Technical advances of radiation therapy for thymic malignancies. Journal of Thoracic Oncology. 2010;5(10 SUPPL. 4):S336-S343. 9. Gomez D, Komaki R, Yu J, Ikushima H, Bezjak A. Radiation therapy definitions and reporting guidelines for thymic malignancies. Journal of Thoracic Oncology. 2011;6(7 SUPPL. 3):S1743-S1748. 10. Baschnagel AM, Mangona VS, Robertson JM, Welsh RJ, Kestin LL, Grills IS. Lung metastases treated with image-guided stereotactic body radiation therapy. Clinical oncology (Royal College of Radiologists (Great Britain)). 2013;25(4):236-241. Thymoma, radiation, pleural recurrence

Adherence to the American Society of Radiation Oncology Choosing Wisely Campaign Recommendations for Treatment of Bone Metastasis: Analysis of Medicare Data at 12 Centers in the Southeast US (SA527C)

•Understand adherence to Choosing Wisely guidelines from a radiation oncology perspective.•Appreciate the impact of patient, practitioner, and system on choice of duration of treatment. The American Society of Therapeutic Radiation Oncology (ASTRO) Choosing Wisely (CW) campaign recommends avoidance of extended fractionation (>10 treatments) for palliation of bone metastasis with radiation therapy (RT). The purpose of this study is to analyze palliative fractionation schemes in a cohort of Medicare patients. Data were for Medicare patients > 65 with bone metastasis diagnosis from 12 cancer community networks affiliated with an academic center in Alabama, Mississippi, Georgia, Tennessee, and Florida. Stage IV cancer patients treated with radiation for bone metastasis from Quarter 1, 2012 to Quarter 1, 2015 were eligible and identified using ICD-9(198.5) and CPT/HCPCS codes. Adherence was measured by treatment duration ≤ 14 vs >14 calendar days. 2194 patients with bone metastasis were identified, 427 (19.5%) of which were treated with RT: 16.6% (2012), 37.5% (2013), 27.4% (2014), 18.5% (2015). Median age at diagnosis was 69.2 (IQR 9.0), and 1928 (87.8%) patients were Caucasian. In the 427 patients treated with RT, 25.8%, 37.0%, and 33.0% were treated in 2012, 2013, and 2014. The top 4 primary sites were: genitourinary (22.7%), breast (20.4%), gastrointestinal (15.7%), and lung (10.8%). Overall guideline adherence was 65.1%: 1 fraction in 33.3%, <14 calendar days in 31.9%, and > 14 calendar days in 34.9%. Average adherence by upper, middle, and lower tertile of sites was 52.0%, 64.5%, 71.5%. Adherence by primary cancer type was similar: breast (58.6%), lung (65.2%), gastrointestinal (67.2), and genitourinary (72.5%). In patients treated < 14 days, 4% were treated with either 1 or 2-5 fractions of stereotactic body radiotherapy. While compliance was high overall with ASTRO CW recommendations, there remained a significant portion (36%) of patients who received a prolonged course of palliative radiation.

Recent advances in the management of renal cell carcinoma-a radiation oncology perspective.

Renal cell carcinoma (RCC) is a rare cancer in developing countries like Nigeria. However, with an increasing understanding of its epidemiology, the increasing availability of trained personnel, improvement in diagnostic facilities, and greater awareness in the populace, an increase in its incidence as was witnessed in developed nations in the last few decades could be safely predicted. This narrative review highlights the international best practices in the multidisciplinary approach to the management of RCC, its diagnosis and treatment, with emphasis on recent advances and radiation treatment. The National Comprehensive Cancer Network (NCCN) guideline (version 3.2015) served as a guide to select relevant articles through a PubMed and Google scholar query.