Fundamentals of Radiation Oncology: Physical, Biological, and Clinical Aspects

FUNDAMENTALS OF RADIATION ONCOLOGY
Dedication
Contents
Forewordd James A. Bonner
Forewordd Thomas A. Buchholz
Preface
Contributors
Reviewers
PART I BASIC SCIENCE OF RADIATION ONCOLOGY
	1. Radiation Physics, Dosimetry, and Treatment Planning
		Fundamental Physical Quantities
			Mass
			Energy
			Charge
			Force
		Atomic Structure
			Atomic Models
			Electron Binding Energy
			Atomic Shell Filling Rules
			Characteristic Radiation
			Auger Electrons
			Nuclear Binding Energy
		Nuclear Structure
		Radioactive Decay
		Modes of Radioactive Decay
			Alpha Decay
			Beta Decay
			Gamma Emission
			Isomeric Transitions
			Internal Conversion
			Mathematics of Radioactive Decay
			Activity
			Equilibrium
		Electromagnetic Radiation and Properties of Interaction
			Photon Interaction Process, Kerma, Absorbed Dose
			Modes of Photon Interaction
			Mathematics of Photon Attenuation
		Particulate Radiation Properties and Interactions
			Interactions of Electrons
			Interactions of Neutrons
			Interactions of Heavy Charged Particles
		The Physics of Dosimetry
			Inverse Square Law
			Backscatter Factor
			Peak Scatter Factor
			Depth of Maximum Dose (dmax)
			Percentage Depth Dose
			Tissue–Air Ratio
			Scatter–Air Ratio
			Tissue–Phantom Ratio, Tissue–Maximum Ratio
		Linac Calibration
			Types of Calibration
			Field Size Correction Factors
			Collimator Scatter Factor and Phantom Scatter Factor
			Beam Modifier Factors
			Patient Attenuation Factors
			Calculation of Monitor Units and Treatment Time
			Electron Beam Dosimetry
		The Physics of Radiation Treatment Planning and Delivery
			External Beam Radiation
			Internal Radiation
		Radiation Treatment Planning
		External Beam Radiation Therapy
			3-D Conformal Radiation Therapy
			Intensity-Modulated Radiation Therapy
			Volumetric Modulated Arc Therapy
			Image-Guided Radiation Therapy
		Brachytherapy
			Interstitial Brachytherapy
			Intracavitary Brachytherapy
		Other Radiation Therapy Modalities
		References
	2. Radiation Protection and Safety
		Measurement of Radiation Quantities
			Radiation Exposure
			Absorbed Dose
			Effective Dose Equivalent
			Effective Dose
		Radiation Protection Principles
		Organizations
		Regulations
		Occupational and General Public Dose Limits
		ALARA and Radiation-Induced Biological Effects
		Radiation Treatment Room Design
		Signage and Labeling Requirements
		Equipment and Area Monitoring
		Personnel Monitoring
		References
	3. Radiation Biology
		Radiobiological Quantities
			Directly and Indirectly Ionizing Radiation
			Deposition of Ionizations Along Tracks
			Direct and Indirect Effects of Radiation
			Linear Energy Transfer
			Relative Biological Effectiveness
			Therapeutic Ratio
		Radiation Effects on Chromosomes
			Chromosome-Type Aberrations
			Chromatid-Type Aberrations
			Telomeres and Telomerase
			Repair of Radiation Damage
		Cell Survival Curves
			Target Theory
			The Linear-Quadratic (L-Q) Model
			The Four “R's” of Radiobiology
		Fractionation Protocols Used in Clinical Radiotherapy
		Dose Rate Effect and Repair of Damage
			Sublethal Damage
			Potentially Lethal Damage
		The Oxygen Effect and Reoxygenation
		Radiosensitizers and Radioprotectors
		Cell and Tumor Cell Kinetics
			Molecular and Biology Techniques
			MicroRNAs
			Cell Cycle Kinetics
			Effects on Tumor Cells
		Normal Tissue Kinetics and Proliferation Status
			Effects on Normal Tissues
			Functional Subunits
			Michalowski's H Type and F Type Classification
			Radiation and Cytokines
		Early and Late Reacting Tissues: Specific Organs
			Early Reacting Tissues
			Late Reacting Tissues
		Acute Effects of Whole-Body Irradiation
			Prodromal Syndrome
			Hematopoietic Syndrome
			Gastrointestinal Syndrome
			Central Nervous Syndrome/Cerebrovascular Syndrome
		Deterministic and Stochastic Effects of Radiation
			Deterministic Effects
			Stochastic Effects
			Carcinogenesis
		Effects of Radiation on the Embryo and Fetus
		Radiation-Induced Heritable Changes
		Sources of Radiation Exposure
		References
	4. Molecular Cancer Biology
		Cell Cycle Control
			G1→S
			G2→M
		Carcinogenesis and Metastasis
			Matrix Metalloproteinases
			Integrins
		Tumor Suppressor Genes
		DNA Repair Genes
		Proto-oncogenes and Oncogenes
			Growth Factors
			Receptor Tyrosine Kinases
			Regulatory GTPases
			Other Kinases
			Transcription Factors
		Apoptosis
			Intrinsic Apoptotic Pathway
			Extrinsic Apoptotic Pathway
			Necroptosis
		Angiogenesis
		Therapeutics
			Chemotherapeutics
			Targeted Therapies
		References
PART II TECHNIQUES AND MODALITIES OF RADIATION ONCOLOGY
	5. Brachytherapy
		Techniques of Brachytherapy
		Physics and Biology of Brachytherapy Sources
			Radioactive Sources
			Source Strength Specifications
			Source Strength Calibration
			Brachytherapy Dose Calculation: Calculation of Dose Using TG-43 Formalism
			Brachytherapy Dose Rate
			Radiobiology of High Dose Rate and Low Dose Rate
			High-Dose-Rate Remote Afterloader
			Computerized Treatment Planning Process
		Clinical Indication of Brachytherapy
			Breast Cancer
			Prostate Cancer
			Endometrial Cancer
			Cervical Cancer
			Vaginal cancer
			Soft Tissue Sarcoma
			Palliative Brachytherapy
		References
	6. Intensity-Modulated and Image-Guided Radiation Therapy
		Target Volumes, Margins and Dose–Volumes for Intensity-Modulated Radiation Therapy
		Inverse Planning Intensity-Modulated Radiation Therapy
			Volumetric-Modulated Arc Treatment
		Image-Guided Radiotherapy
		Clinical Experience of Intensity-Modulated Radiation Therapy and Volumetric-Modulated Arc Treatment
			Brain Cancer
			Head and Neck Cancer
			Breast Cancer
			Lung Cancer
			Prostate Cancer
		References
	7. Stereotactic Radiation: Cranial Lesions
		Radiobiology of Stereotactic Radiation
		Stereotactic Radiosurgery Technique
		Patient Immobilization and Setup
		Imaging
		Target Volume Delineation
			Delineation of OAR Volumes
		Treatment Plan
		Treatment Plan Assessment
		Clinical Indication of Cranial Stereotactic Radiation
			Stereotactic Radiosurgery for Single Brain Metastases
			Acoustic Neuroma
			Pituitary Adenoma
			Skull-Based Meningioma
			Arteriovenous Malformation and Cavernous Hemangioma
			Trigeminal Neuralgia
			Parkinson's Disease
		Stereotactic Radiosurgery Toxicity
		Clinical Trials of Stereotactic Radiosurgery for Metastatic Brain Cancer
		References
	8. Stereotactic Body Radiation Therapy: Lung Cancers
		Lung Cancer
		Clinical Trials for Stereotactic Body Radiation Therapy
		References
	9. Proton Radiation Therapy
		Proton Beam Depth Dose
		Proton Relative Biological Effectiveness
		Beam Production, Delivery, Treatment Planning, and Quality Assurance
		Clinical Experience of Proton Radiotherapy
			Head and Neck Cancer
			Lung Cancer
			Prostate Cancer
			Pediatric Cancer
		References
	10. Immunotherapy
		Immune System Components
			Anatomy of the Immune System
			Cells of the Immune System
			The Immune Synapse
			The Immune Tolerance Mechanisms
			Cancer Immunotherapy
				Vaccine Immunotherapy
				Antibody Immunotherapy
				Cytokine Immunotherapy
				Antivascular Endothelial Growth Factor Immunotherapy
				Adoptive T-Cell Immunotherapy
				Checkpoint Inhibitor–Targeted Immunotherapy
		Radiation and immunotherapy
		Site-Specific Cancer Immunotherapy
			Melanoma
				Ipilimumab
				Nivolumab
				Pembrolizumab
				Ipilimumab in Combination With Nivolumab
			Non–Small Cell Lung Cancer
				Pembrolizumab
				Nivolumab
				Durvalumab
				Atezolizumab
			Head and Neck Cancer
				Nivolumab
				Pembrolizumab
			Lymphoma
				Pembrolizumab
				Nivolumab
			Renal Cell Carcinoma
				Nivolumab and Ipilimumab
			Hepatocellular Carcinoma
				Nivolumab
			Gastric Cancer
				Pembrolizumab
			Colorectal Cancer
				Nivolumab
			Urothelial Carcinoma
				Pembrolizumab
				Avelumab
				Durvalumab
				Nivolumab
			Merkel Cell Carcinoma
				Avelumab
				Chimeric Antigen Receptor T-Cell Therapy
					Yescarta (Axicabtagene Ciloleucel) and Kymriah (Tisagenlecleucel)
		Immunotherapy Toxicity
		References
	11. Radiation and Combined Modality Therapy
		Radiation Therapy
		Surgery Combined with Radiation Therapy
			Side Effects of Combined Modality of Radiation and Surgery
		Chemotherapy Combined with Radiation Therapy
			Side Effects of Combined Modality Radiation and Chemotherapy
		Site-specific chemotherapeutic agents used in combination with radiotherapy: mechanisms of action and side effects. Fig. 11.2
			Primary Brain Cancer
			Head and Neck Cancer
			Breast Cancer
			Lung Cancer
			Gastrointestinal Cancer
			Lymphoma
		References
	12. Statistical Considerations in Radiation Oncology
		Definition of Statistical Terms
			Mean and Mode
			Sample
			Variance
			Standard Deviation
			Confidence Intervals
			Null and Alternative Hypotheses
			p-value
			Type I (α) and Type II (β) Error
			Power
			Parametric and Nonparametric Methods
			Sensitivity, Specificity, and Predictive Value
			Clinical Trials: Phase I, II, III, IV
			Survival Analysis
			Retrospective Chart Reviews
			Metaanalyses
		Model Fitting
			Significance and Tests of Significance
			Survival Analysis and Its Pitfalls
		Logistic Regression and Its Pitfalls
		Proportional Hazards and Their Pitfalls
		Retrospective Studies and Their Pitfalls
		Metaanalysis and Its Pitfalls
		References
PART III CLINICAL RADIATION ONCOLOGY
	13. Skin Cancers
		Nonmelanoma
			Workup
				Risk Factors
				Symptoms and Signs
				Investigation
			TNM Staging (Nonmelanoma)
				Stage Grouping
			Treatment
			RT Technique
				Doses
			Outcome
			Complications
			Follow-Up
		Melanoma
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Melanoma)
				Stage Grouping
			Treatment
			RT Technique
				Volumes
				Elective Nodal Regions for Primary Tumor Location
				Doses
			Outcome
			Complications
			Follow-Up
		Merkel Cell Cancer
			Workup
				Risk factors
				Symptoms and signs
				Investigation
			TNM Staging (Merkel Cell)
				Stage Grouping
			Treatment
			RT Technique
				Doses
			Outcome
			Complications
			Follow-up
		Annotated Bibliography
		Non-Melanoma Skin Cancer
		Melanoma Skin Cancer
	14. Primary Brain Cancers
		Outline placeholder
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
		Low-Grade Glioma (WHO Grade I–II)
			Treatment
			Radiation Therapy Technique
				3D Technique
			IMRT/Proton Technique
				Volumes
				Doses
			Outcome
			Complications
			Follow-Up
		High-Grade Glioma (Anaplastic Astrocytoma Grade III/Glioblastoma Grade IV)
			Treatment
			Radiation Therapy Technique
				Volumes
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		Brainstem Glioma
			Treatment
			Radiation Therapy Technique
				Volumes
				Doses
			Outcome
			Complications
			Follow-Up
		Optic Glioma
			Treatment
			Radiation Therapy Technique
			Outcome
			Complications
			Follow-Up
		Ependymoma
			Treatment
			Radiation Therapy Technique
				Volumes
				Doses
			Outcome
			Complications
			Follow-Up
		Meningioma
			Treatment
			Radiation Therapy Technique
				Volumes
				Doses
			Outcome
			Complications
			Follow-Up
		Medulloblastoma
			Workup
				Symptoms and Signs
				Investigations
			Staging
			Treatment
			Radiation Therapy Technique
				3D Technique: Craniospinal
			IMRT/Proton Technique: Craniospinal
				Volumes
				Craniospinal Axis Volume
				Doses
			Outcome
			Complications
			Follow-Up
		Pituitary Adenoma
			Workup
				Symptoms and Signs
				Investigations
			Treatment
			Radiation Therapy Technique
				3D Three-Field Technique
				IMRT/Stereotactic Radiosurgery
				Volumes
				Doses
			Outcome
			Complications
			Follow-Up
		Craniopharyngioma
			Workup
				Symptoms and Signs
				Investigations
			Treatment
			Radiation Therapy Technique
				IMRT Technique
				Proton Therapy
				Volumes
				Doses
			Outcome
			Complications
			Follow-Up
		Annotated Bibliography
		Low-Grade Glioma
		High-Grade Glioma
			Radiation Therapy
			Chemotherapy
		Brainstem Gliomas
		Ependymoma
		Meningioma
		Medulloblastoma
		Craniopharyngioma
	15. Head and Neck Cancers
		Head and Neck Lymph Node Borders∗
		Lymph Node Risk
		Oral Cavity Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Oral Cavity)
			Stage Grouping
			Treatment
			RT Technique
				3D Technique
					Lip
					Oral Tongue/Floor of Mouth
					Buccal Mucosa
					Gingiva, Hard Palate, and Retromolar Trigone
				IMRT Technique
				Volumes
				Doses
					Standard Fraction
					Hyperfractionation RT
					Concomitant Boost
			Outcomes
			Complications
			Follow-Up
		Nasopharyngeal Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Nasopharynx)
			Stage Grouping
			Treatment
			RT Technique
				3D Technique
				IMRT Technique
				Volumes
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		Oropharyngeal and Hypopharyngeal Cancers
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Oropharynx HPV+)
			Stage Grouping
			TNM Staging (Oropharynx HPV and Hypopharynx)
			Stage Grouping
			Treatment
				Oropharyngeal Cancer
			Hypopharyngeal Cancer
			RT Technique
				3D Technique
				Oropharyngeal Cancer
				Hypopharyngeal Cancer
				IMRT Technique for Oropharyngeal and Hypopharyngeal Cancer
				Volumes
				Subclinical Disease Around GTV
			Post Pharyngeal Wall: Mucosal Margin
				Doses
					Standard Fraction
					Hyperfractionation RT
					Concomitant Boost
				Constraints
			Outcome
			Complications
			Follow-Up
		Laryngeal Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Larynx)
				Supraglottis
				Glottis
				Subglottis
			Stage Grouping
			Treatment
				Supraglottic Cancer
				Glottic Cancer
				Stage CIS
				Stage T1/T2
				Stage T3
				Stage T4
			RT Technique
				3D Technique
					Supraglottic Cancer
					Glottic Cancer
					IMRT Technique for Supraglottic and Glottic Cancer
				Volumes
				Subclinical Disease Around GTV
				Ipsilateral and Contralateral at Risk LNs
				Dose
					Standard Fraction
					Hyperfractionation RT
					Concomitant Boost
			Outcome
			Complications
			Follow-Up
		Nasal Cavity and Paranasal Sinuses
			Workup
				Symptoms and Signs
				Investigations
			TNM Staging (Maxillary Sinus)
			Stage Grouping
			Treatment
				Maxillary Sinus
				Nasal Cavity and Ethmoids
			RT Technique
				3D Technique
				IMRT Technique
				Volumes
				Subclinical Disease Around Tumor Bed or GTV
				Dose
					Standard Fraction
					Hyperfractionation RT
					Concomitant Boost
			Outcome
			Complications
			Follow-Up
		Parotid Gland
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Parotid Gland)
			Stage Grouping
			Treatment
				Benign Tumors
				Malignant Tumors
			RT Technique
				3D Technique
			IMRT Technique
				Volumes
				Dose
			Outcome
			Complications
			Follow-Up
		Unknown Primary
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			Treatment
			RT Technique
				3D Technique
				IMRT Technique
				Volumes
				Dose
			Complications
			Follow-Up
		Annotated Bibliography
		Oral Cavity Site
		Nasopharynx Site
		Oropharynx Site
		Hypopharynx and Larynx Site
			Unknown Primary Site
	16. Breast Cancers
		RTOG Breast and LN Volume Guidelines1
		Risk for Axillary Nodes
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
		TNM Staging (Breast Cancer)
		Noninvasive Breast Cancer (DCIS)
			Treatment
			Outcome
		Early-Stage Breast Cancer (Stage I and II)
			Postlumpectomy Radiation Therapy
				Candidates for Breast Conservation Therapy
				Contraindications for Breast Conservation Therapy
			Treatment
			Outcome
		Postmastectomy Radiation Therapy
			Candidates for PMRT
			Indications Regional LN RT
			Treatment
			Outcome
		Locally Advanced Breast Cancer
			Treatment
			Outcome
		Recurrent Breast Cancer
			Treatment
			Outcome
			RT Technique
				3-D Technique
				Tangents Alone for Intact Breast
				Tangents Matching With Supraclavicular Area for Intact Breast/Chest Wall
				Posterior Axillary Boost
				Internal Mammary Chain
				Scar Line Boost (Postmastectomy)
			IMRT Technique
				Tangents Alone for Intact Breast
				Volumes
				Doses
					Conventional Doses
					Hypofractionation Doses
				Constraints
			Complications of Treatment
			Follow-Up
		Annotated Bibliography
		Noninvasive Breast Cancer (DCIS)
			Adjuvant Radiation Therapy
			Adjuvant Hormone Therapy for DCIS
		Early-Stage Breast Cancer
			Adjuvant Radiation Therapy
			Adjuvant Chemotherapy
			Adjuvant Hormonal Therapy
		Postmastectomy Radiation Therapy
		Locally Advanced Breast Cancer
		Locally Recurrent Breast Cancer
	17. Thoracic Cancers
		Non–Small-Cell Lung Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
				Screening
				TNM Staging (Lung)
				Stage Grouping
			Treatment
				Stages IA and 1B
				Stages IIA and IIB
				Stage III
					Resected
					Resectable
					Unresectable
				Pleural or Pericardial Effusion
				Stage IV
		Superior Sulcus Tumors
		Medically Inoperable NSCLC
			Outcome
		Small-Cell Lung Cancer
			Workup
				Symptoms and Signs
				Investigations
			Staging
			Treatment
				Limited Stage
				Extensive Stage
			Outcome
		Thymoma
			Staging
				TNM Staging
				Stage Grouping
			Treatment
			Outcome
		Malignant Mesothelioma
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			Staging
				TNM Staging
				Group Staging
			Treatment
			Outcomes
			RT Technique
				3D Technique
				IMRT/SBRT Technique
				Volumes
				Stage I SBRT
				Locally Advanced
				Postoperative for R0, pN2
				Doses
				NSCLC
				SCLC
				Constraints
			Complications
			Follow-up
		Annotated Bibliography
		Non–Small-Cell Lung Cancer
			Outline placeholder
				Stages IA/IB and IIA/IIB
				Stage III—Resected
				Stage III—Resectable
				Stage III—Unresectable
				Stage IV
		Superior Sulcus Tumors
		Medically Inoperable Tumors
		Limited-Stage Small-Cell Lung Cancer
		Extensive-Stage Small-Cell Lung Cancer
	18. Gastrointestinal Cancers
		Esophageal Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Esophageal Cancer)
				Stage Grouping
				Stage Grouping
				Histologic Grade (G)
			Treatment
			RT Technique
				3D Technique
				IMRT Technique
				Volumes
				Elective Nodal Regions for Primary Tumor Location
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		Gastric Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Gastric Cancer)
				Histologic Grade (G)
					Pathological (pTNM) Staging
			Treatment
			RT Technique
				3D Technique
				IMRT Technique
				Volumes
				Elective Nodal Regions for Primary Tumor Location
				Dose
				Constraints
			Outcome
			Complications
			Follow-Up
		Pancreatic Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Pancreatic Cancer)
				Stage Grouping
			Treatment
			RT Technique
				3D Technique
				IMRT Technique
				Volumes
				Elective Nodal Regions for Primary Tumor Locations
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		Colon and Rectal Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Colon Cancer)
				Stage Grouping
			Treatment
				Colon Cancer
				Rectal Cancer
			RT Technique
				3D Technique
				IMRT Technique
				Volumes
				Elective Nodal Regions for Primary Tumor Locations
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		Anal Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Anal Cancer)
			Stage Grouping
			Treatment
			RT Technique
				3D Technique
				IMRT Technique
			IMRT Dose Painting Plan per RTOG 0529
				Volumes
				Doses for Dose Painting plan per RTOG
			IMRT Sequential Plan
				Volumes
				Doses for Sequential Plan
				Constraints
			Outcome
			Complications
			Follow-Up
		Annotated Bibliography
		Esophageal Cancer
		Gastric Cancer
		Pancreatic Cancer
			 
				Resectable Pancreatic Cancer
				Unresectable Pancreatic Cancer
		Colon Cancer
		Rectal Cancer
			 
				Pre-op RT
		Anal Cancer
	19. Genitourinary Cancers
		RENAL CELL CANCER
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
		TNM STAGING (RENAL CANCER)
			Stage Grouping
			Treatment
			Radiation Therapy Technique
				3D Technique
				IMRT Technique
				Volumes
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		BLADDER CANCER
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
		TNM STAGING (BLADDER CANCER)
			Stage Grouping
			Treatment
				Superficial Disease (Ta, Tis, T1)
				Invasive Disease, N0
				Invasive Disease, N+, and Metastatic
			Radiation Therapy Technique
				3D Technique
				IMRT Technique
				Volumes
				Elective Lymph Nodes/Radical Cystectomy Structures
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		PROSTATE CANCER
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			International Society of Urological Pathology Grade Groupsa
			TNM Staging (Prostate Cancer)
			Stage Grouping
			Treatment
				Very Low-Risk
				Low-Risk
				Favorable Intermediate-Risk
				Unfavorable Intermediate-Risk
				High-risk
				Very high-risk
				Regional (N+)
				Postprostatectomy Radiation Therapy
				Post–Radiation Rising PSA
				Metastatic Disease
				Hormonal Refractory Prostate Cancer
			Radiation Therapy Technique
				3D Technique
				IMRT Technique
				Volumes
				Pelvic Elective LNs:
				Brachytherapy Technique
				Low-Dose Rate Brachytherapy
				High-Dose Rate Brachytherapy
				Doses for External Beam Radiation Therapy and Brachytherapy
				Constraints
				Standard Fractionation (180–200 cGy/fx)
				Moderate Hypofractionation (270 cGy/fx)
				Combination EBRT + Brachytherapy (HDR) Boost
				Brachytherapy
			Outcome
			Complications
				EBRT
				Brachytherapy
				Hormone Therapy Toxicity
			Follow-Up
		TESTICULAR CANCER
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Testicular Cancer)
			Stage Grouping
			Treatment
				Seminoma
				Nonseminoma
			Radiation Therapy Technique
				3D Technique
				Volumes
				Elective LNs
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		ANNOTATED BIBLIOGRAPHY
		RENAL CELL CANCER
		BLADDER CANCER
			Neoadjuvant/Adjuvant Chemotherapy
			ChemoRT Bladder Conservation
		PROSTATE CANCER
			Conservative Treatment
			Brachytherapy
			Lymph Node Treatment
			Dose Escalation With Higher Radiation Dose Treatment
			Hypofractionated Radiation Treatment
			Neoadjuvant and Adjuvant Hormonal Treatment
			Hormonal Treatment and Chemotherapy
			Postoperative Radiation Treatment
				Postoperative Radiation Treatment and Hormone Therapy
		TESTICULAR CANCER
	20. Gynecological Cancers
		Endometrial Cancer
			Pelvic/Paraaortic Node Risk
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Endometrial Cancer)
			TNM FIGO
			Stage Grouping
			Treatment
				Stage IA (Gr 1, 2)
				Stage IA (Gr 3)
				Stage IB (Gr 1, 2)
				Stage IB (Gr 3), II, III
				Stage IV
				Medically Inoperable
				Papillary Serous or Clear Cell Carcinoma
				Uterine Sarcoma
			Radiation Therapy Technique
				3D Technique
				IMRT Technique
				Volume
				Vaginal Target and Lymph Nodes
				Dose for External Beam Radiation Therapy and Brachytherapy
				Constraints
			Outcome
			Complications
			Follow-Up
		Cervical Cancer
			Lymph Node Risk
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Cervical Cancer)
			TNM FIGO
			Stage Grouping
			Treatment
				Cervical Intraepithelial Neoplasia
				Carcinoma in situ
				Stage IA1, IA2
				Stage IB1, IIA1
				Stage IB2–IVA
				Stage IVB
				Medically Inoperable
			Radiation Therapy Technique
				3D Technique
				IMRT Technique
				Volumes
				Gyn Targets and Lymph Nodes
				Brachytherapy Technique
				External Beam Radiation Therapy and Brachytherapy Doses
				Stage IIB–IVA
				GEC ESTRO Planning Target Goals
				Constraints
			Outcome
			Complications of Radiation Therapy
			Follow-Up
		Ovarian Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Ovarian Cancer)
			TNM FIGO
			Stage Grouping
			Treatment
				Stage IA, IB (G1, 2)
				All Other Stages
			Radiation Therapy Technique
				3D Technique
			Outcome
			Complications
			Follow-Up
		Vaginal Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Vaginal Cancer)
			TNM FIGO
			Stage Grouping
			Treatment
				Vaginal Intraepithelial Neoplasia
				Carcinoma in situ
				Stage I
				Stage II
				Stage II (Paravaginal/Parametrial Invasion), III and IV
			External Beam Radiation Therapy Technique
				Volumes
			Intracavitary Technique
			Interstitial Technique
				Doses
			Outcome
			Complications
			Follow-Up
		Vulvar Cancer
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
			TNM Staging (Vulvar Cancer)
			TNM FIGO
			Stage Grouping
			Treatment
			Radiation Therapy Technique
				Volumes
				Gross Disease and Elective Lymph Nodes
				Doses
				Constraints
			Outcome
			Complications
			Follow-Up
		Annotated Bibliography
		Endometrial Cancer
		Cervical Cancer
		Ovarian Cancer
		Vulvar Cancer
	21. Lymphoma and Hematologic Cancers
		Hodgkin Lymphoma
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
				Classifications
		Staging
			Ann Arbor Staging System Updated by Lugano Classification (2012) (see Fig. 21.1)
				Limited Stage
				Advanced Stage
			Patients with Hodgkin Lymphoma are Classified into Groups
			PETCT Response Assessment
			Treatment
				Early Stage Favorable (Stage I, II No Risk Factors)∗
				Early Stage Unfavorable (Stage I, II with Risk Factors)∗
				Stage II B Bulky∗
				Advanced Stage (Stage III, IV)∗
			Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL)∗∗
				Early-Stage disease

					Stage 1A, IIA (nonbulky)
					Stage IB, IIB (nonbulky)
					Stage I, II (bulky)
				Advanced-Stage Disease
			Outcome
				International Prognostic Score for Advanced Disease: 1 Point Per Factor
		Non-Hodgkin Lymphoma
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
		Staging/Grading
			Follicular Lymphoma International Prognostic Index
			Revised International Prognostic Index for Non-Hodgkin Lymphoma
			Treatment
				Indolent, Stage I/II
					Nonbulky
					Noncontiguous, Bulky
				Indolent, Stage III/IV
				Follicular Grade 3B
				Aggressive, Stage I/II
					Nonbulky, IPI 0-1
					Bulky, IPI ﹥1
				Aggressive, Stage III/IV
				Highly Aggressive
				Gastric MALT Lymphoma
				Extranodal Marginal Zone B Cell Lymphoma (Nongastric MALT Lymphoma)
				Mantle Cell Lymphoma
				Primary CNS Lymphoma
				Primary Testicular Lymphoma
				Primary Mediastinal B-Cell Lymphoma
				NK-T Cell Lymphoma
			Outcome
			RT Technique
				3D Technique
					Preauricular Field
					Waldeyer Field
					Mantle Field
					PA Field
					Pelvic Field/Inverted Field
					Involved Site and Involved Node Field
					Involved Field
					Extended Field
				IMRT Technique
				Volumes
				Volumes for site-specific extranodal lymphoma
					Gastric MALT lymphoma
					Conjunctival and eyelid MALT lymphoma
					Retrobulbar, lacrimal gland, and deep conjuctival lymphomas MALT lymphoma
					Nasal NK T-Cell lymphoma
					Waldeyer's ring NK T-cell lymphoma
				Doses
					Hodgkin Lymphoma
					Non-Hodgkin Lymphoma
				Constraints
			Complications
			Follow-Up
		Annotated Bibliography
		Early-Stage Hodgkin Disease
		Advanced-Stage Hodgkin Disease
		Non-Hodgkin Lymphoma
			Indolent Non-Hodgkin Lymphoma
			Aggressive Non-Hodgkin Lymphoma
	22. Sarcomas
		Soft-Tissue Sarcomas
			Workup
				Risk Factors
				Symptoms and Signs
				Investigations
		TNM Staging (Soft-Tissue Sarcomas) Trunk and Extremities
		FNCLCC Histologic Grade
			Stage Grouping
			Treatment
				Stage 1a/b, Extremity, Superficial Trunk, and H&N Lesions
				Stage II, III, Extremity, Superficial Trunk, and H&N Lesions
				Unresectable, Node-Positive, Distant Metastasis
				Retroperitoneal/Intraabdominal Sarcomas
				GIST
				Kaposi sarcoma
			RT Technique
				Volumes
				Preoperative
				Postoperative
				Doses
				Constraints
			Complications
			Outcome
			Follow-up
		Annotated Bibliography
		Preoperative RT
		Postoperative RT
		Neoadjuvant and Adjuvant Chemotherapy
	23. Pediatric Cancers
		Hodgkin's Lymphoma
			Workup
				Symptoms and Signs
				Investigations
			Staging
			Children's Oncology Group Risk Classification and Response Definitions
			Treatment
				Low-Risk Hodgkin's Lymphoma (Favorable Stages I and IIA)
				Intermediate-Risk Hodgkin's Lymphoma (Unfavorable Stage I, II, and IIIA)
				High-Risk Hodgkin's Lymphoma (Stages IIIB/IVB, ± Unfavorable IIB)
			Radiotherapy Technique
				Photon
				Proton
			Outcome
			Complications
		Neuroblastoma
			Workup
				Symptoms and Signs
				Investigations
			Staging
				International Neuroblastoma Staging System (INSS)
				International Neuroblastoma Risk Group (INRGSS)
			Treatment
				Low Risk (Stage 1, 2A/B N-MYC Nonamplified)
				Intermediate Risk (Stage 3, 4N-MYC Nonamplified)
				High Risk (Stage 3N-MYC Nonamplified Unfavorable Histology, Stage 2A/B, 3, 4N-MYC Amplified)
				Stage 4S
			Treatment Technique
				Volumes
				Dose
				Constraints
			Outcome
			Complications
		Wilms′ Tumor (Nephroblastoma)
			Workup
				Symptoms and Signs
				Investigations1
			Histology
				Favorable
				Unfavorable
			Staging
				Children's Oncology Group Staging System
			Treatment
				Stage I Favorable Histology
				Stage I Unfavorable Histology, Stage II Favorable Histology
				Stage II Unfavorable Histology, Stage III, IV Favorable Histology/Unfavorable Histology
				Stage IV Lung Metastases
				Stage V
				Unresectable
				Clear Cell Sarcoma
				Rhabdoid
			Radiotherapy Technique
				Tumor Bed Field (Flank)
				Whole Abdomen Field
				Whole Lung Field
			Outcome
			Complications
		Rhabdomyosarcoma
			Workup
				Symptoms and Signs
				Investigations
			Histology
				Favorable
				Unfavorable
			Staging
			TNM Pretreatment Staging System
				Clinical Group Staging
				Risk Grouping
			Treatment
				Local Control
				Chemotherapy
				Radiation in Stage IV
			Radiotherapy Technique
				Radiotherapy Volume
			Outcome
			Complications
		Ewing's Sarcoma
			Workup
				Symptoms and Signs
				Investigations
			Treatment
				Chemotherapy
				Surgery
				Radiotherapy
					Primary site
					Lymph nodes
					Askin tumor
					Metastatic disease
			Radiotherapy Technique
				Volumes
					Pre-op Volumes
					Post-op Volumes
				Doses, No Chemo
				Doses, Post-op
			Outcome
			Complications
			Follow-Up
		Retinoblastome
			Workup
				Symptoms and Signs
				Investigations
			Staging
				Reese–Ellsworth Classification
				International Classification for Intraocular Retinoblastoma
			Treatment
				Limited Disease <4 Disc Diameters
				Advanced Unilateral Disease
				Bilateral Disease
				External Beam Technique
			Outcome
			Complications
		Annotated Bibliography
		Low-Risk Hodgkin’s Lymphoma
		Intermediate-Risk Hodgkin's Lymphoma
		High-Risk Hodgkin's Lymphoma
		Neuroblastoma
		Wilms′ Tumor
		Rhabdomyosarcoma
		Ewing’s Sarcoma
		Retinoblastoma
	24. Benign Diseases
		Skin and Connective Tissue Disorders
			Keloid
			Desmoid Tumor/Aggressive Fibromatosis
			Peyronie Disease
			Dupuytren's Contracture
			Gynecomastia
		Benign Neoplasms of the Brain, Head, and Neck
			Meningioma
			Pituitary Adenoma
				Volumes
				Dose
			Craniopharyngioma
				Volumes
			Acoustic Neuroma
				Dose
			Chordoma
				Dose
		Paraganglioma/Pheochromocytoma (Glomus Tumor)
		Eye/Orbit Diseases
			Pterygium
			Graves Opthalmopathy
		Vascular Disorders
			Arteriovenous Malformation/Cavernous Hemangioma
				Volume
		Functional Disorders
			Trigeminal Neuralgia
			Parkinson Disease
		Diseases of the Bone
			Heterotopic Ossification
		References
PART IV PALLIATIVE CARE AND RADIATION TREATMENT TOXICITY
	25. Metastatic Cancers
		Metastatic Brain Cancer
			Workup
				Symptoms and Signs
				Investigations
			Treatment
			RT Technique
				Volume/Borders
				Doses
					WBRT
					SRS
				Constraints
			Outcome
			Complications
			Follow-Up
		Spinal Cord Compression
			Workup
				Symptoms and Signs
				Investigations
			Treatment
			RT Technique
				Volume/Borders
				Dose
				3D technique
				SBRT
			Outcome
			Complications
			Follow-Up
		Superior Vena Cava Syndrome
			Workup
				Symptoms and Signs
				Investigations
			Treatment
			Outcome
			Complications
			Follow-Up
		Metastatic Bone Cancers
			Workup
				Symptoms and Signs
				Investigations
			Treatment
			Outcome
			Complications
			Follow-Up
		Annotated Bibliography
		Metastatic Brain Cancers
		Spinal Cord Compression
		Metastatic Bone Cancers
	26. Radiation Treatment, Toxicity, and Their Management∗
		Normal Tissue Tolerance to Therapeutic Irradiation
		Skin
			Early Radiation Dermatitis and Focal Pruritus
			Dry and Moist Desquamation
			Ulceration—Slow Healing
			Antibiotics/Wound Infection Treatment
			Antifungals/Antivirals
			Generalized Pruritus
		Head and Neck
			Eye
			Dry Eye
			Ear
			Mucositis
			Oral Infection and Candidiasis
			Sialdenitis
			Sinuses
			Teeth and Osteoradionecrosis
			Xerostomia
		Thorax
			Air Hunger
			Obstructive Airways Disease (Asthma, COPD)
			Cough
			Infectious Processes
			Radiation Pneumonitis and Pulmonary Fibrosis
			NSAID
			Smoking Cessation
		Breast
			Abscess/Infection
			Costochondritis
			Lymphedema
			Hot Flashes
		Gastrointestinal Tract
			Antacids/Hypersecretion Medications
			Diarrhea
			Antiflatulents
			Anorexia/Appetite Stimulant
			Chronic Radiation Enteritis, Proctitis, or Rectal Bleeding
			Esophagitis
			General Guidelines for Calculating Basic Nutritional Needs
			Oral Intake/Supplements
			General Guidelines for Tube Feedings
			Feedings May Be
			Potential Problems
			Hiccups
			Motility Agents
			Nausea/Vomiting
			Constipation
			Acute Proctitis/Tenesmus
		Genitourinary
			Analgesics/Antispasmodics/Incontinence
			Antibiotics
			Erectile Dysfunction Therapy
			Hematuria and Chronic Radiation Cystitis
			Urinary Obstruction Modifiers
		Gynecological
			Perineal Reaction
			Acute Vaginitis
			Vaginal Late Toxicity
		Nervous System
			Edema Management
			Vertigo
			Seizure
		Pain Management
			Nonopioid Analgesics
			Opioid Analgesics for Severe Pain (Class II Narcotics)
			Coanalgesics
			Narcotic Antagonist
		Psychotropic Medications
			Somnolence and Fatigue
			Antianxiety
			Antidepressants
			Antipsychotics
			Hypnotics/Sleep Aids
			Sedatives
		Radiation Fibrosis and Muscle Relaxants
		Common Toxicity (Side Effect) Criteria
		References
Acronyms and Abbreviations
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	K
	L
	M
	N
	O
	P
	R
	S
	T
	U
	V
	W
	X
	Z
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