Brfo193 Radiotherapy Dose Fractionation Third-Edition PDF

Radiotherapy
dose fractionation
Third edition
March 2019
Contents Foreword 3 11. Prostate cancer 81
Introduction 4 12. Rectal cancer 88
Oxford Centre for 13. Renal cancer 94
Evidence-based Medicine 8
14. Sarcoma 96
1. Anal cancer 9
15. Seminoma 102
2. Bladder cancer 12
16. Skin cancer 104
3. Breast cancer 16
17. Upper gastrointestinal cancer 110
4. Central nervous system
18. Bone metastases 116
(CNS) tumours 24
19. Brain metastases 120
5. Gynaecological cancers 32
20. Oligometastases 126
6. Head and neck cancer 40
21. Metastatic spinal cord
7. Lung cancer 49
compression (MSCC) 131
8. Lymphoma 58
Acknowledgements 134
9. Paediatric cancer 65
10. Penile cancer 76
Radiotherapy dose fractionation Third edition 3
Foreword The Radiotherapy dose fractionation guidance, published in 2006, was heralded as ‘the most
important contribution that the Faculty has made to the practice of radiotherapy in the UK’. It
was certainly highly successful and remains the most widely accessed guidance document
from the Faculty of Clinical Oncology of all time. This is a tribute to the original working party,
their commitment to providing an evidence- rather than tradition-based document and
widespread involvement of Fellows with extensive open consultation prior to publication.
The second edition published in December 2016 reflected the changes in practice which
had evolved in the previous decade. It remained faithful to the vision of the original document,
focusing on clear evidence-based recommendations wherever possible. In total, 110 Fellows
and a number of stakeholder groups contributed to the final version and we are grateful to all
those who responded to the consultation.
The Professional Support and Standards Board (PSSB) review all RCR publications on a
regular basis to ensure they remain up to date. This third edition has therefore been produced
to take account of further published evidence. Many thanks to PSSB members and other
colleagues for their work in ensuring this edition is up to date. There are particular updates to
the chapters on central nervous system tumours, paediatric cancer and brain metastases with
smaller changes in many of the other sections.
I would like to express particular thanks to Professor Peter Hoskin for so ably leading the
development the second edition and this updated version and to members of his Working
Group – Dr Jeanette Dickson, Dr Raj Jena, Dr Robin Prestwich and Dr Vivek Misra – for their
extensive input and excellent contributions. Thanks are due also to the former RCR Officers
who co-ordinated the second edition, Professor Roger Taylor and Dr David Bloomfield, and
to Gillian Dollamore and Sarah Griffin at the RCR for all their tireless coordination, advice and
support.
The document is available on the RCR website to enable easy and wide access. We hope it will
meet with similar approval to its predecessors and will continue to provide a definitive guide to
dose fractionation in the UK.
Dr Tom Roques, Medical Director for Professional Practice, Clinical Oncology, The Royal
College of Radiologists
Introduction The original guidance on Radiotherapy dose fractionation was introduced against a
background of considerable variation in clinical practice across the UK.
Since that 2006 first edition there has been greater standardisation of treatment reflecting
many influences, including more widespread appreciation of evidence-based practice,
nationwide involvement in clinical trials addressing fractionation questions within the
National Cancer Research Network and National Institute for Health Research and
organisation of cancer care within networks charged with adherence to local and
national guidelines.
Despite these advances, radiotherapy in the UK remains under-resourced both in terms of
equipment and manpower, as evidenced by our standing in the recently published Health
Economics in Radiation Oncology (HERO) analyses of European radiotherapy practice.1,2,3
There is a continual challenge to upgrade linear accelerators to ensure modern therapy
using intensity-modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT) and
stereotactic body radiotherapt (SBRT) can be delivered as routine to all appropriate patients
in a system where resources for capital expenditure are severely limited.
It has been important to recognise that, despite changes to redefine fractionation during
the past decade, many clinical scenarios, particularly for palliative treatments, will still
require conventional therapy techniques and this is also reflected in these guidelines to
ensure a comprehensive cover of clinical radiotherapy.
The second edition highlighted the role of combined-modality treatment and potential for
stereotactic radiotherapy.
Brachytherapy may form part of the patient’s treatment but was not considered further as
part of this project.
The third edition includes particular updates on central nervous system tumours, brain
metastases and paediatric cancers as well as smaller updates on other sections.
This document has graded evidence according to guidelines defined by the Oxford Centre
for Evidence-Based Medicine as shown below.4
Preparation of this document

The third edition has been reviewed by members of the RCR’s Clinical Oncology
Professional Support and Standards Board and the working party of the second edition to
ensure that the guideline continues to reflect current practice at a time of rapid change in
radiotherapy technologies.
Most of the guidance remains unchanged from the second edition which was subject
to extensive peer review. The process for the review of this second edition, on which the
content of this third edition is based, is summarised below:
First stage consultation

Reviewers, based on those who contributed to the 2006 document, two members of the
RCR’s Clinical Oncology Professional Support and Standards Board (PSSB) and additional
site-specific experts, were invited to review the sections of the 2006 document relevant to
their site specialty and to advise on current fractionation schedules and the new evidence
base for these.
Second stage consultation

Each chapter was revised by the working at the first stage of consultation and were
group, taking account of comments received also posted on the Clinical Oncology Online
from reviewers. These revised chapters Fora on the RCR website.
were sent to all those who had commented
All Clinical Oncology Fellows and members were notified by email of the review of the
original document and invited to contribute their views on the revised chapters. A notice
about the review was included in two editions of the RCR monthly news ebulletin.
Third stage consultation

Following further editing in light of comments received, revised chapters were sent to
stakeholder groups:
• British Association of Head and Neck • Children’s Cancer and Leukaemia Group
Oncologists
• National Cancer Research Institute (NCRI)
• British Thoracic Society Clinical and Translational Radiotherapy
Research Working Group (CTRad)
• British Uro-oncology Group
• Radiotherapy Clinical Reference Group
They were also sent to clinical oncology members of the following NCRI clinical
studies groups:
• Bladder and renal cancer • Lymphoma
• Breast cancer • Prostate cancer
• Brain tumour • Sarcoma
• Colorectal cancer • Skin cancer
• Gynaecological cancers • Testis cancer
• Head and neck cancer • Upper gastrointestinal
• Lung cancer
Comments received from the above were again reviewed by the working group, leading to a
final draft of the second edition which was published in 2016.
Update of guidance – third edition

For this third edition, chapters were initially reviewed by the RCR’s Clinical Oncology
Professional Support and Standards Board, in consultation with other site-specialty experts
as necessary. The review was not intended as a full peer review, but rather as a sense check
of the document to ensure it continued to contain accurate and up-to-date information.
Suggested changes to the document were considered by Professor Peter Hoskin, lead
author of the second edition, and the rest of the working party, and a final draft of this third
edition was agreed.
Comparison with the Malthus model5

The Malthus model is an evidence-based radiotherapy demand simulation tool, originally
commissioned by the National Health Service in England (NHS England) in 2011. The
model incorporates clinical decision trees which encode best practice for 22 different
adult tumour types. The radiotherapy indications were established by a review of published
literature and surveys of key opinion leaders. The most recent refresh of the clinical decision
trees was undertaken in March 2014.
The Malthus team has undertaken a sense check of fractionation regimens referenced
in this document. While a wider range of alternative fractionation regimens for specific
indications are cited in this document, there is a high level of concordance in the cited
fractionation regimens from both sources.
The salient differences are as follows:
• Hypofractionation
At release, the Malthus model defaulted to 2 Gray (Gy) per fraction regimens for curative
indications with the exception of adjuvant breast radiotherapy, where robust evidence
for hypofractionation from the the UK Standardisation of Breast Radiotherapy (START)
trial and other studies was present.5,6 The Malthus team acknowledged that stronger
evidence now exists for hypofractionation in curative treatment of head and neck, and
prostate cancer, as discussed in the relevant sections of this document.
• Palliative treatment of head and neck cancer
The use of 40 Gy in ten fractions as a split course, 21 Gy in three fractions over three
weeks and 14 Gy in four fractions were not included in the Malthus decision tree. There is,
however, a lack of high-quality evidence in this area and the regimens listed in the report
are likely to reflect current practice from key opinion leaders in the UK.
Finally, it is important to emphasise that this is not a comprehensive text on radiotherapy.
Limited background has been included to give each section context and where appropriate
some detail of the evidence base from which the recommendations are derived has been
given. We have deliberately avoided giving specific recommendations on treatment fields,
volume or technique, which are considered to be outside the scope of this document.
References 1. Borras JM, Lievens Y, Dunscombe P et al. The optimal utilization proportion of external beam
radiotherapy in European countries: An ESTRO-HERO analysis. Radiother Oncol 2015; 116(1): 38–44.
2. Borras JM, Barton M, Grau C et al. The impact of cancer incidence and stage on optimal utilization of
radiotherapy: Methodology of a population based analysis by the ESTRO-HERO project. Radiother
Oncol 2015; 116(1): 45–50.
3. Borras JM, Lievens Y, Barton M. How many new cancer patients in Europe will require radiotherapy by
2025? An ESTRO-HERO analysis. Radiother Oncol 2016; 119(1): 5–11.
4.
www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009
(last accessed 22/9/16)
5. Jena R, Round C, Mee T et al. The Malthus programme – a new tool for estimating radiotherapy
demand at a local level. Clin Oncol (R Coll Radiol) 2012; 24(1): 1–3.
6. Haviland JS, Owen JR, Dewar JA et al. START Trialists' Group. The UK Standardisation of Breast
Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-
year follow-up results of two randomised controlled trials. Lancet Oncol 2013; 14(11): 1086–1094.
Oxford Centre for Grades of recommendation

Evidence-based A Consistent level 1 studies C Level 4 studies or extrapolations from
Medicine1 level 2 or 3 studies
B Consistent level 2 or 3 studies or
extrapolations from level 1 studies D Level 5 evidence or troublingly
inconsistent or inconclusive studies
of any level
‘Extrapolations’ are where data is used in a situation that has potentially clinically important
differences than the original study situation.
Levels of evidence
1a SR (with homogeneity*) of RCTs 3a SR (with homogeneity*) of case-
control studies
1b Individual RCT (with narrow
confidence interval) 3b Individual case-control study
1c All or none§ 4 Case-series (and poor-quality cohort
and case-control studies§§)
2a SR (with homogeneity*) of
cohort studies 5 Expert opinion without explicit critical
appraisal, or based on physiology,
2b I ndividual cohort study (including
bench research or ‘first principles’
low quality RCT; for example, <80%
follow-up) SR: systematic review
2c ‘Outcomes’ research; ecological studies RCT: randomised controlled trial
* In this context, homogeneity means a systematic review that is free of worrisome
variations (heterogeneity) in the directions and degrees of results between individual
studies. Not all systematic reviews with statistically significant heterogeneity need be
worrisome, and not all worrisome heterogeneity need be statistically significant. As
noted above, studies displaying worrisome heterogeneity should be tagged with a ‘-’
at the end of their designated level.
§ Met when all patients died before the treatment became available, but some now
survive on it; or when some patients died before the Rx became available, but none
now die on it.
§§ In this context, poor-quality cohort study means one that failed to clearly define
comparison groups and/or failed to measure exposures and outcomes in the same
(preferably blinded), objective way in both exposed and non-exposed individuals
and/or failed to identify or appropriately control known confounders and/or failed to
carry out a sufficiently long and complete follow-up of patients. In this context, poor
quality case-control study means one that failed to clearly define comparison groups
and/or failed to measure exposures and outcomes in the same (preferably blinded),
objective way in both cases and controls and/or failed to identify or appropriately
control known confounders.
References 1. w
ww.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009
1. Background
There are approximately 1,000–1,200 registrations of squamous carcinoma of the anus
Anal cancer per year in the UK. Despite its rarity, a succession of phase III trials have been conducted
which have established the standard treatment of this disease; radical treatment with
chemoradiotherapy allowing sphincter preservation.
Radical treatment
Both the United Kingdom Co-ordinating Committee on Cancer Research (UKCCCR) anal
cancer trial (45 Gray [Gy] in 20 or 25 fractions with a boost) and an European Organisation
for Research and Treatment of Cancer (EORTC) trial demonstrated improved outcome
for concomitant chemoradiotherapy using mitomycin C and 5-fluorouracil (5-FU) when
compared with radiotherapy alone.1,2 A statistically significant reduction in locoregional
failure was demonstrated in both trials. A further phase III trial performed by the
Radiotherapy Oncology Group (RTOG) demonstrated improved colostomy-free survival
when mitomycin C was added to 5-FU chemoradiation.3 Chemoradiotherapy improves
outcome in anal cancer compared to radiotherapy alone (Level 1b).4
The UKCCCR ACT2 trial compared concomitant mitomycin C and 5-FU with cisplatin and
5-FU when combined with a two-phase radiotherapy technique delivering a total dose of
50.4 Gy in 28 fractions.5 A second randomisation tested the role of two subsequent cycles
of cisplatin 5-FU chemotherapy against no further treatment. There was no significant
difference between concurrent chemotherapy regimens, and no progression-free survival
benefit to the addition of adjuvant chemotherapy (Level 1b).4
The EXTRA trial was a phase II study substituting capecitabine for 5-FU chemotherapy
that reported minimal toxicity and acceptable compliance.6 Substitution of 5-FU with
capecitabine has been thoroughly investigated in other tumour sites and the two drugs
have been proven to be equally effective (Level 2b).4
Treatment technique
The phase 2 RTOG 0529 trial treated patients with inverse planned intensity-modulated
radiotherapy (IMRT) and reported reduced toxicity to that seen in the RTOG 9811 trial where
standard conformal radiotherapy techniques were used (Level 2b).4,7,8
It is recommended that a standard atlas for delineating volumes is used for IMRT or
arc radiotherapy. Expert opinion was sought from a number of UK clinicians to create a
consensus guideline which is based on ACT II volumes but adapted for inverse planning.9,10
Recommendations
For standard planned two-phase radical chemoradiation for anal cancers:
50.4 Gy in 28 daily fractions (Grade A)
Phase 1: 30.6 Gy in 17 fractions over 3.5 weeks
Phase 2: 19.8 Gy in 11 fractions over 2.2 weeks
The types of evidence and the grading of recommendations used within this review are based on
those proposed by the Oxford Centre for Evidence-based medicine.4
Node positive patients

Analyses of both the UKCCR ACT II and RTOG 9811 trial have highlighted that locally
advanced and node-positive tumours have a significantly reduced disease-free survival and
overall survival.5,8 As a result, current guidance and recent trials have used a higher dose for
these patients when using IMRT or arc radiotherapy.
However, due to the excellent outcomes in ACT II in node-negative cancers, the
recommended prophylactic nodal dose remains the same and has been calculated to
deliver the same biologically effective dose over 28 fractions with IMRT or arc radiotherapy
which was previously delivered over 17 fractions during standard 2-phase radiotherapy
(Level 5).4,11
Recommendations
For radical inverse planned IMRT or arc radiotherapy (chemoradiotherapy) of
anal cancers
Dose to primary (early stage):
50.4 Gy in 28 fractions over 5.5 weeks (Grade D)
Dose to primary and involved nodes (advanced stage):
Dose to uninvolved nodes (prophylactic):
40 Gy in 28 fractions over 5.5 weeks (Grade D)
The Personalising Anal Cancer Radiotherapy Dose (PLATO) trial looking at dose escalation
in locally advanced anal cancers and dose de-escalation in early small-node negative
tumours is currently in set up in the UK and will inform dose fractionation for anal cancers in
the future.12
Palliative treatment
There are no good-quality trials evaluating different dose fractionation schedules for
palliative treatment. An appropriate regime should be chosen after considering the patient’s
likely prognosis, disease burden, symptoms and performance status.
Recommendations
For palliative treatment of anal cancer (Grade D):
30 Gy in 10 fractions over 2 weeks
20 Gy in 5 fractions over 2 weeks
References 1. The UKCCCR Anal Cancer Trial Working Party. Epidermoid anal cancer: results from the UKCCCR
randomised trial of radiotherapy alone versus radiotherapy, 5-fluorouracil and mitomycin. Lancet 1996;
348(9034): 1049–1054.
2. Bartelink H, Roelofsen F, Eschwege F et al. Concomitant radiotherapy and chemotherapy is superior to

radiotherapy alone in the treatment of locally advanced anal cancer: results of a phase III randomized
trial of the European Organisation for Research and Treatment of Cancer Radiotherapy and
Gastrointestinal Cooperative Groups. J Clin Oncol 1997; 15(5): 2040–2049.
3. Flam M, John M, Pajak TF et al. Role of mitomycin in combination with fluorouracil and radiation, and
of salvage chemoradiation in the definitive nonsurgical treatment of epidermoid carcinoma of the anal
canal: results of a phase III randomised intergroup study. J Clin Oncol 1996; 14(9): 2527–2539.
4. w
5. James RD, Glynne-Jones R, Meadows HM et al. Mitomycin or cisplatin chemoradiation with or

without maintenance chemotherapy for treatment of squamous cell carcinoma of the anus (ACT II): a
randomised phase 3 open-label, 2x2 factorial trial. Lancet Oncolo 2013; 14(6): 516–524.
6. Glynne-Jones R, Meadows H, Wan S et al. EXTRA – a multicenter phase II study of chemoradiation

using a 5 day per week oral regimen of capecitabine and intravenous mitomycin C in anal cancer. Int J
Radiat Oncol Biol Phys 2008; 72(1): 119–126.
7. Kachnic LA, Winter K, Myerson RJ et al. RTOG 0529: a phase 2 evaluation of dose-painted intensity
modulated radiation therapy in combination with 5-fluorouracil and mitomycin-C for the reduction of
acute morbidity in carcinoma of the anal canal. Int J Radiat Oncol Biol Phys 2013; 86(1): 27–33.
8. Gunderson LL, Winter KA, Ajani JA et al. Long-term update of US GI intergroup RTOG 98-11 phase
III trial for anal carcinoma: survival, relapse, and colostomy failure with concurrent chemoradiation
involving fluorouracil/mitomycin versus fluorouracil/cisplatin. J Clin Oncol 2012; 30(35): 4344–4351.
9. Muirhead R, Adams RA, Gilbert DC et al. Anal cancer: developing an intensity-modulated radiotherapy
solution for ACT2 fractionation. Clin Oncol 2014; 26(11): 720–721.
10. www.analimrtguidance.co.uk (last accessed 22/9/16)
11. Pettit L, Meade S, Sanghera P et al. Can radiobiological parameters derived from squamous
cell carcinoma of the head and neck be used to predict local control in anal cancer treated with
chemoradiation? Br J Radiol 2013; 86(1021): 20120372.
12. www.ukctg.nihr.ac.uk/trials/trial-details/trial-details?trialId=36181 (last accessed 13/10/16)

2. Radical treatment
Conventional fractionation (dose per fraction 1.8–2.0 Gray [Gy])
Bladder cancer
The radiotherapeutic regimens used in studies comparing radiotherapy and surgery for
bladder cancer have been delivered using either a conventional regimen of 60–64 Gy in
30–32 fractions over 6–6.5 weeks or hypofractionated radiotherapy of 52.5–55 Gy in 20
fractions (Level 2b).1–5
Hyperfractionation
Two published trials compare hyperfractionation with doses of 1–1.2 Gy per fraction to
conventionally fractionated treatment.6,7 Pooled analysis suggests a significant benefit from
hyperfractionation with a 17% (95% confidence interval, 6–27%) improvement in the rate
of local control.8 However, the regimens in both arms of these studies used split courses
with overall treatment times of eight weeks. This approach would no longer be considered
acceptable in a control arm (Level 1b).5
Accelerated fractionation
There was no evidence of clinical benefit from 60.8 Gy in 32 fractions given using two
fractions per day of 1.9 Gy over a treatment time of 26 days when compared to a standard
regime of 64 Gy in 32 fractions over 45 days.9 The shorter regimen was associated with a
higher rate of intestinal toxicity (Level 1b).5
Hypofractionation
The two UK-based randomised controlled trials published in the last five years allowed the
use of both conventional (60 Gy in 30 fractions) and hypofractionated radiotherapy (55 Gy
in 20 fractions).10,11 Although neither study was powered to detect a difference in outcome
based on dose and fractionation, there was no difference seen between conventional and
hypofractionated radiotherapy (Level 2b).5
Partial bladder irradiation

Partial bladder radiotherapy has been studied in two UK-based trials. A trial from
Manchester compared whole bladder radiotherapy 52.5 Gy in 20 fractions with partial
bladder irradiation of 57.5 Gy in 20 fractions and 55 Gy in 16 fractions.12 There was no
significant difference in local control at five years between the three groups, and late toxicity
was similar in all three arms. The BC2001 sub-study compared whole bladder high-dose
irradiation with reduced high-dose volume radiation therapy.13 There was no difference in
locoregional recurrence, late toxicity or overall survival between the two groups (Level 1b).5
Radical radiotherapy with radiosensitisation

Two UK-based randomised control trials have demonstrated that radical radiotherapy with a
radiosensitiser improves outcomes compared to radiotherapy alone.10,11 BC2001 compared
radical radiotherapy alone with radical radiotherapy given concurrently with mitomycin
C and 5-fluorouracil (5-FU), with the chemoradiotherapy arm showing significantly better
two-year locoregional recurrence rates of 67% versus 54% (Level 1b).5,10 The Bladder
Carbogen Nicotinamide (BCON) investigators compared radical radiotherapy alone to
radical radiotherapy given concurrently with carbogen and nicotinamide with a significant
improvement in three-year overall survival of 13% in the experimental arm (Level 1b).5,11
Some centres within the UK use a weekly gemcitabine chemoradiation protocol based on a
multicentre phase II study which has shown acceptable toxicity and comparable outcomes
to those in the literature with a three-year overall survival of 75% and 88% achieving a
complete endoscopic response at first check cystoscopy (Level 2b).5,14
Treatment technique
The size of the planning target volume (PTV) is critical to any discussion of dose and
fractionation.15,16 Some centres use a two-phase (large pelvic volume/small bladder volume)
approach, although there is no robust evidence for this approach improving survival
outcomes for patients (Level 5).5 There is no published evidence using fraction sizes other
than 1.8–2 Gy for this approach. All of the dose-fractionation regimens discussed below are
based on the assumption that the PTV is <1,000 mililitres (ml) and that three-dimensional
(3-D) image-based planning techniques are used. There is also increasing use of adaptive
radiotherapy techniques for bladder treatment using a ‘plan of the day’ based on imaging
prior to delivery of each fraction. The fractionation evidence has not been tested in this
setting, but there is no reason to believe that the recommendations below do not apply to
the adaptive setting also.
Recommendations
For radical radiotherapy to the bladder:
52.5–55 Gy in 20 fractions over 4 weeks
60–64 Gy in 30–32 fractions over 6–6.5 weeks (Grade B)
There is robust evidence that radiotherapy with a radiosensitiser using carbogen and
nicotinamide or chemotherapy improves outcomes for patients with organ-confined
muscle-invasive bladder cancer (Grade A)10,11
Palliative radiotherapy
The Medical Research Council (MRC) randomised trial BA09 clearly established that 21 Gy
in three fractions on alternate weekdays in one week (4–6 elapsed days) is as effective as
35 Gy in ten fractions in two weeks in palliating symptoms in patients with bladder cancer.17
There was no statistically significant difference in the rate of symptom relief (64% versus
71%; p=0.192; 95% confidence interval for the 7% rate difference, –2% to +13%), nor was
there any significant difference in the duration of symptomatic relief (Level 1b).5 Other
palliative regimes which are in use in the UK are 20 Gy in five fractions and 30–36 Gy in 5–6
fractions over 5–6 weeks (Level 2-).5 These regimes are also used for frail patients not fit for
radical radiotherapy treatment.
In the hypofractionated bladder radiotherapy with or without image-guided adaptive
planning (HYBRID) trial, a dose of 30–36 Gy in 5–6 fractions given weekly has been used.
For very frail patients, a 6–8 Gy single fraction of pelvic radiotherapy often provides
symptomatic relief (Level 4).5
Recommendations
For the palliation of local symptoms from bladder cancer:
21 Gy in 3 fractions on alternate days in 1 week is the regimen of choice (Grade A)
30–36 Gy in 5-6 fractions weekly has also been used in this setting (Grade D)
A single fraction of 6–8 Gy may provide useful palliation in patients who are unfit for the
recommended regimen (Grade D)
References 1. Shelley MD, Barber J, Mason MD. Surgery versus radiotherapy for muscle invasive bladder cancer.
Cochrane Database Syst Rev 2001; 2001(3): CD002079.
2. Booth CM, Siemens DR, Li G et al. Curative therapy for bladder cancer in routine clinical practice: a
population-based outcomes study. Clin Oncol (R Coll Radiol) 2014; 26(8): 506–514.
3. Gray PJ, Fedewa SA, Shipley WU et al. Use of potentially curative therapies for muscle-invasive
bladder cancer in the United States: results from the National Cancer Data Base. Eur Urol 2013; 63(5):
823–829.
4. Kotwal S, Choudhury A, Johnston C, Paul AB, Whelan P, Kiltie AE. Similar treatment outcomes for
radical cystectomy and radical radiotherapy in invasive bladder cancer treated at a United Kingdom
specialist treatment center. Int J Radiat Oncol Biol Phys 2008; 70(2): 456–463.
5.
6. Edsmyr F, Andersson L, Esposti PL, Littlebrand B, Nilsson B. Irradiation therapy with multiple small
fractions per day in urinary bladder cancer. Radiother Oncol 1985; 4(3): 197–203.
7. Näslund I, Nilsson B, Littbrand B. Hyperfractionated radiotherapy of bladder cancer. A ten-year follow-

up of a randomized clinical trial. Acta Oncol 1994; 33(4): 397–402.
8. Goldobenko GV, Matveev BP, Shipilov VI, Kilmakov BD, Tkachev S. Radiation treatment of bladder
cancer using different fractionation regimens. Med Radiol (Mosk) 1991; 36(5): 14–16.
9. Horwich A, Dearnaley D, Huddart R et al. A randomised trial of accelerated radiotherapy for localised
invasive bladder cancer. Radiother Oncol 2005; 75(1): 34–43.
10. James ND, Hussain SA, Hall E et al. Radiotherapy with or without chemotherapy in muscle-invasive
bladder cancer. N Engl J Med 2012; 366(16): 1477–1488.
11. Hoskin PJ, Rojas AM, Bentzen SM, Saunders MI. Radiotherapy with concurrent carbogen and
nicotinamide in bladder carcinoma J Clin Oncol 2010; 28(33): 4912–4918.
12. Cowan RA, McBain CA, Ryder WD et al. Radiotherapy for muscle-invasive carcinoma of the bladder:
results of a randomized trial comparing conventional whole bladder with dose-escalated partial
bladder radiotherapy. Int J Radiat Oncol Biol Phys 2004; 59(1): 197–207.
13. Huddart RA, Hall E, Hussain SA et al. Randomized noninferiority trial of reduced high-dose volume
versus standard volume radiation therapy for muscle-invasive bladder cancer: results of the BC2001
trial (CRUK/01/004). Int J Radiat Oncol Biol Phys 2013; 87(2): 261–269.
14. Choudhury A, Swindell R, Logue JP et al. Phase II study of conformal hypofractionated radiotherapy
with concurrent gemcitabine in muscle-invasive bladder cancer. J Clin Oncol 2011; 29(6): 733–738.
15. Muren LP, Ekerold R, Kvinnsland Y, Dahl O. On the use of margins for geometrical uncertainties around
the rectum in radiotherapy planning. Radiother Oncol 2004; 70(1): 11–19.
16. Muren LP, Smaaland R, Dahl O. Conformal radiotherapy of urinary bladder cancer. Radiother Oncol
2004; 73(3): 387–398.
17. Duchesne GM, Bolger JJ, Griffiths GO et al. A randomized trial of hypofractionated schedules of
palliative radiotherapy in the management of bladder carcinoma: results of medical research council
trial BA09. Int J Radiat Oncol Biol Phys 2000; 47(2): 379–388.
3. Background
Breast cancer is the most common cancer in women in the UK and most patients are
Breast cancer diagnosed at an early stage due the NHS Breast Screening Programme. Radiotherapy has
long been established as an important treatment modality in the adjuvant and palliative
setting in breast cancer. Technological advances and results of pivotal trials have led to
significant changes in practice in the UK in the last few years.
Adjuvant radiotherapy to the breast or chest wall

Radiotherapy increases both local control and overall survival in the conservation
management of primary breast cancer in selected patients after mastectomy (Level 1a).1–3 It
also reduces ipsilateral breast tumour recurrence following breast conservation in patients
with a diagnosis of ductal carcinoma in situ (DCIS).4,5
Although radiotherapy reduces the risk of recurrence for both DCIS and invasive disease
for all patient groups, given the small benefits of adjuvant radiotherapy following breast-
conserving surgery in low-risk patient groups, it is reasonable to consider omission of
radiotherapy in patients with oestrogen receptor positive, node negative tumours which
are less than 3 centimetres (cm) in maximum diameter and who are aged over 70 years,
with low-risk biological features such as low-grade, no lymphovascular invasion and HER-2
negativity (Level 1b).3,6,7
The previous standard breast fractionation was a regimen of 50 Gray (Gy) in 25 fractions
over five weeks as reported in the National Surgical Adjuvant Breast and Bowel Project
(NSABP) breast cancer trials.8 Currently the most widely used UK regimen is the
hypofractionated regimen of 40 Gy in 15 fractions over three weeks as used in the UK
START Study B.9 Mature data from the START B trial and a Canadian study demonstrate
the equivalence of hypofractionationed regimens to the previous standard of 2 Gy daily
fractionation (Level 1b).3,10
There are no trials comparing 40 Gy in 15 fractions versus 50 Gy in 25 fractions following
breast reconstruction, but there is no radiobiological reason to recommend 50 Gy in 25
fractions in this situation. The results of the START B trial demonstrate that 40 Gy in 15
fractions leads to fewer late effects.9
Recommendation
For adjuvant radiotherapy of breast or chest wall:
40 Gy in 15 daily fractions of 2.67 Gy over 3 weeks (Grade A)
Further hypofractionation for breast radiotherapy is currently under investigation. In the

FAST study, 915 women aged ≥50 years with node negative early breast cancer were
randomly assigned after microscopic complete tumour resection to 50 Gy in 25 fractions
versus 28.5 or 30 Gy in five, once-weekly fractions of 5.7 or 6.0 Gy respectively, to the whole
breast. The primary endpoint was two-year change in photographic breast appearance.
At three years median follow-up, 28.5 Gy in five fractions was comparable to 50 Gy in 25
fractions, and significantly milder than 30 Gy in five fractions, in terms of adverse effects in
the breast. There were two local recurrences which were both in the 50 Gy in 25 fractions
arm. Mature local recurrence and late effects data are awaited.11
The FAST Forward trial is investigating 40 Gy in 15 fractions vesus 26 or 27 Gy in five
fractions over one week. The main trial closed in 2014. Five-year local control data will
be available in 2019. The FAST Forward nodal study opened in 2015 with normal tissue
endpoints.12 In 2018, this was modified to a two-arm study comparing 40 Gy in 15 fractions
over three weeks against 26 Gy in five fractions over one week.
Partial breast irradiation

It is recognised that whole-breast radiation (WBI) can cause significant toxicity in patients
with large breasts. Partial breast radiation may improve this outcome, though accelerated
partial breast irradiation (APBI) could reduce acute and late side-effects. A meta-analysis
has shown that APBI is associated with a higher local recurrence rate, albeit still low,
compared to WBI (Level 1a).13 However, this meta-analysis included studies covering
a broad range of APBI techniques and selection criteria. The UK Intensity Modulated
and Partial Organ Radiotherapy Following Breast Conservation Surgery for Early Breast
Cancer (IMPORT LOW) Trial compared two schedules of partial breast radiation versus
whole-breast 40 Gy in 15 fractions and was presented at the European Breast Cancer
Conference in March 2016.14 For each of the test groups, non-inferiority, assessed against
the prespecified 2.5% threshold, was demonstrated. Local relapse (LR) rates were very
low across all groups, as were moderate/marked normal tissue events, with a statistically
significant improvement for breast appearance and breast hardness (median follow-up 72
months) for partial breast radiotherapy.
Two trials of intraoperative radiation therapy (IORT) have reported: the External
Radiotherapy for Early Breast Cancer (ELIOT) trial reported an ipsilateral breast tumour
recurrence rate of 4.4% at five years with IORT and 0.4% with WBI.15 This gave a hazard ratio
for ipsilateral relapse with IORT of 9.3 (95% confidence interval [CI] 3.3–26.3) compared
to WBI. The TARGIT A trial has insufficient median follow up to draw firm conclusions
(Level 2b).3,16
Multicatheter interstitial brachytherapy is an alternative approach to APBI. One large
non-inferiority trial has shown equivalence at five years with a predefined 3% difference
comparing APBI with interstitial brachytherapy and whole-breast radiotherapy to 50 Gy in
25 fractions.17
Breast boost
Delivery of a boost to the tumour bed following whole-breast radiotherapy reduces the risk
of ipsilateral breast cancer recurrence (Level 1b).3,18 However, there is no impact on overall
survival and it doubles the risk of moderate or severe fibrosis.
The proportional benefit is similar across all age groups but the absolute benefit falls with
increasing age and hence the biggest absolute benefit is in women under 50 years of age.
There is also a greater absolute benefit of boost in high-grade (G3) cancer.
Incomplete resection margins, where further surgery is not possible, are an indication for
breast boost regardless of age. A boost dose of 16 Gy in eight fractions or equivalent is
most commonly prescribed.18
A multidisciplinary consensus meeting held at The Royal College of Radiologists

(RCR) in March 2016 concluded that it would be reasonable for the boost dose to
be hypofractionated, as given in 40 Gy in 15 fractions breast dose, rather than 2 Gy
fractionation. A dose of 16 Gy in eight fractions is equivalent to a hypofractionated dose of
13.35 Gy in five fractions of 2.67 Gy or 12 Gy in four fractions of 3 Gy assuming an alpha/
beta value for breast carcinoma of 3 Gy.
Appreciation of the volume of the boost and the need for accurate delivery was emphasised.
It is recognised that there is no direct clinical trial evidence for this approach.
The UK dose-escalated, intensity-modulated radiotherapy (IMRT) for women treated by
breast conservation surgery and appropriate systemic therapy for early breast cancer
(IMPORT-HIGH) trial closed in 2015. Patients were randomised to sequential versus
simultaneous integrated boost (IMRT and image-guided radiotherapy [IGRT]) including
dose escalation.19
The breast boost volume should be defined by localising the tumour bed. Surgical clips
should be routinely placed during a wide local excision to aid localisation of the tumour bed.
There is currently insufficient evidence to recommend IORT for tumour bed boost; the
TARGIT B trial is currently recruiting (Clinical Trials Group, University College London, UK
Clinical Research Network ID 14208) and randomising to convention external beam boost
versus IORT boost in high-risk disease.20
Radiotherapy technique
Two-dimensional (2-D) computed tomography-based planning is no longer recommended
for adjuvant radiotherapy to the breast or chest wall.
Simple, forward-planned, field-in-field IMRT reduces the late toxicity and improves cosmetic
outcome following adjuvant whole-breast radiotherapy (Level 1b).3,21
Breast radiotherapy may increase the risk of heart disease.22,23 For most women irradiated
in the UK, the absolute risk of developing radiation-induced heart disease is less than 1% at
20 years, but risk varies according to a woman’s pre-existing risk of heart disease and her
heart radiation dose. Techniques to limit heart dose without reducing target dose should
be considered for women with left-sided breast cancer. These include multileaf collimation
(MLC) cardiac shielding and voluntary breath holding (Level 2b).3,24
Recommendations
For boost after whole-breast radiotherapy in women with a higher risk of
local recurrence:
16 Gy in 8 daily fractions of 2 Gy (Grade A) or an equivalent hypofractionated
schedule:3
13.35 Gy in five fractions of 2.67 Gy or 12 Gy in four fractions of 3 Gy (Grade C)
Regional nodal irradiation

Axilla and supraclavicular fossa

Axillary sentinel lymph node biopsy (SLNB) is now the British Association of Surgical
Oncologists (BASO) recommended standard procedure for axillary staging in early breast
cancer with clinically negative lymph nodes. For most patients with clinically positive nodes
a level III axillary lymph node dissection (ALND) remains the standard procedure.
Nodal irradiation is not recommended following a negative SLNB.
Following a positive SLNB, the AMAROS trial demonstrated an axillary recurrence rate
of 0.43% for ALND versus 1.19% for axillary radiotherapy after a median follow-up of 6.1
years.25 The trial was underpowered for the planned non-inferiority test due to the low
number of events. Axillary radiotherapy produced lower long-term toxicity compared
to ALND (Level 2b), though the effects of RT on cardiovascular health and second
malignancies in this study are not known.3,25
The American College of Surgeons Oncology Group (ACOS-OG) Z0011 trial demonstrated
a low axillary recurrence rate of 0.9% versus 0.5% for SLNB + standard breast RT compared
to SLNB followed by ALND + standard breast RT in a RCT comparing ANLD versus no
axillary treatment in women with T1/T2 N0 breast cancer undergoing breast-conserving
treatment.27 Most patients were over 50 years of age and had grade 1 or 2, T1, oestrogen
receptor positive, ductal cancer with no LVI (Level 2b).3,26 However, there are significant
methodological concerns about the Z0011 trial, including the statistical power of the
study. There was a potential for bias in this study as the radiation oncologists were aware
of the treatment allocation and it is unclear whether this influenced their decision about
how much of the axilla to treat with tangential radiotherapy. Generalisability of the results
is limited as some centres recruited fewer than five patients, axillary recurrence was not
a prespecified endpoint, mastectomy patients were excluded and preoperative axillary
ultrasound was not performed in contrast to standard UK practice.
The UK pragmatic, randomised, multicentre, non-inferiority trial (POSNOC) trial is currently
recruiting patients with 1–2 positive sentinel lymph nodes and randomising them to
standard adjuvant therapy and axillary treatment (ALND or axillary radiotherapy) versus
standard adjuvant therapy alone. The primary endpoint is axillary recurrence at five
years. When available, the results will provide a more definitive answer to the question of
managing a positive SLNB axilla.27
Radiotherapy to the ipsilateral supraclavicular fossa (SCF) is recommended for N2 or
N3 disease following ALND. Axillary radiotherapy following ALND produces significant
toxicity and should only be recommended in women with very high risk of recurrence (high
proportion of involved nodes, extensive extra-nodal disease or biologically aggressive
cancer). There is no evidence that radiotherapy to the axilla following ALND improves
overall survival from breast cancer.
The North American MA20 trial randomised node positive or high-risk node-negative
patients to WBI versus WBI plus regional nodal irradiation (RNI) including the ipsilateral
axilla, SCF and internal mammary chain, dose 50 Gy in 25 fractions.28 It demonstrated
improved disease-free survival (DFS) in the RNI group (82% versus 77%, hazard ratio [HR]
0.76, p=0.01) after a median follow-up of 9.5 years. The primary end point of improved
overall survival was not met. There was a small absolute increase in the risk of acute
pneumonitis and late lymphoedema in the RNI group (Level 1b).3,28
The EORTC 22922/10925 trial randomised patients with medial or centrally located breast
cancers irrespective of nodal status or node-positive lateral tumours to WBI/chest wall
irradiation versus WBI/chest wall irradiation plus RNI defined as ipsilateral medial SCF and
internal mammary nodes, dose 50 Gy in 25 fractions.29 After a median follow-up of ten years,
it demonstrated an improvement in DFS in the RNI group (72.1% versus 69.1%, HR 0.89,
p=0.04). The primary end point of improved overall survival was not met (Level 1b).3,29
Both the MA20 and EORTC 22922/10925 trials demonstrated improved distant-disease-
free survival, but this did not translate to improved overall survival and the long-term effects
of RNI on cardiovascular morbidity and mortality and second cancer rates in these trials
is not known. However a meta-analysis of these studies published before the full results
became available suggests an improvement in overall survival (Level 1a-), although this
analysis was not conducted with patient level data. A Danish population based non-
randomised cohort study has shown improved survival with internal mammary nodal
(IMN) irradiation especially in women with larger (>50 millimetres [mm]) tumours or with
more than four involved nodes (Level 2b).3,30,31 Hence RNI to include the internal mammary
chain along with ipsilateral axilla and SCF may be considered for patients fitting the MA20
and EORTC 22922/10925 criteria to reduce breast cancer recurrence, but careful patient
selection is advised and the lack of data on cardiac effects of IMN irradiation and second
cancers should be taken into account.28–31
Data for hypofractionated nodal irradiation is limited to small subsets of patients from RCTs
(14% in START A, 7% in START B) but shows no increase in toxicity compared to standard
fractionation nodal irradiation (Level 1b-).3,32
Recommendation
Where indicated, for regional nodal irradiation:
40 Gy in 15 daily fractions (Grade B)
There are no good-quality head-to-head trials evaluating the optimum schedules for
palliative radiotherapy to the breast, chest wall or regional nodes. The most common doses
range from 20 Gy to 40 Gy over 5–15 fractions. Weekly treatments over 5–6 weeks to a total
of 30–36 Gy are also commonly used (Grade D).3
References 1. Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Darby S, McGale P et al. Effect of
radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death:
meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 2011;
378(9804): 1707–1716.
2. BCTCG (Early Breast Cancer Trialists' Collaborative Group), McGale P, Taylor C et al. Effect of
radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer
mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet
2014; 383(9935): 2127–2135.
3.
4. Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Correa C, McGale P et al. Overview of the
randomized trials of radiotherapy in ductal carcinoma-in-situ of the breast. J Natl Cancer Inst Monogr
2010; 2010(41): 162–177.
5. Nilsson C, Valachis A. The role of boost and hypofractionation as adjuvant radiotherapy in patients with
DCIS: A meta-analysis observational studies. Radiother Oncol 2015; 114(1): 50–55.
6. Kunkler IH, Williams LJ, Jack WJ, Cameron DA, Dixon JM, PRIME II investigators. Breast-conserving
surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II):
a randomised controlled trial. Lancet Oncol 2015; 16(3): 266–273.
7. McCormick B, Winter K, Hudis C et al. RTOG 9804: a prospective randomized trial for good-risk ductal
carcinoma in situ comparing radiotherapy with observation. J Clin Oncol 2015; 33(7): 709–715.
8. Fisher B, Anderson S, Bryant J et al. Twenty-year follow-up of a randomized trial comparing total
mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.
N Engl J Med 2002; 347(16): 1233–1241.
9. Haviland JS, Owen JR, Dewar JA et al. The UK standardisation of breast radiotherapy (START) trials of
radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two
randomised controlled trials. Lancet Oncol 2013; 14(11): 1086–1094.
10. Whelan TJ, Pignol JP, Levine MN et al. Long-term results of hypofractionated radiation therapy for
breast cancer. N Engl J Med 2010; 362(6): 513–520.
11. FAST Trialists Group, Agrawal RK, Alhasson A et al. First results of the randomised UK FAST Trial of
radiotherapy hypofractionation for treatment of early breast cancer. Radiother Oncol 2011; 100(1):
93–100.
12. Yarnold J, Bentzen S, Coles C, Haviland J. Hypofractionated radiotherapy for women with early breast
cancer: myths and realities. Int J Radiation Oncology Biol Phys 2011; 79(1): 1–9.
13. Marta GN, Macedo CR, Carvalho Hde A, Hannah San, da Silva JL, Riera R. Accelerated partial
irradiation for breast cancer: systematic review and meta-analysis of 8653 women in eight randomized
trials. Radiother Oncol 2015; 114(1): 42–29.
14. Coles CE, Griffin CL, Kirby AM et al. Partial-breast radiotherapy after breast conservation surgery
for patients with early breast cancer (UK IMPORT LOW trial). 5-year results from a multicentre,
randomised, controlled, phase 3 non-inferiority trial. Lancet 2017; 390(10099): 1048–1060.
15. Veronesi U, Orecchia R, Maisonneuve P et al. Intraoperative radiotherapy versus external radiotherapy
for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol 2013; 14(13):
1269–1277.
16. Vaidya JS, Wenz F, Bulsara M et al. Risk-adapted targeted intraoperative radiotherapy versus whole-
breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the
TARGIT-A randomised trial. Lancet 2014; 383(9917): 603–613.
17. Strnad V, Ott OJ, Hildebrandt G et al. 5-year results of accelerated partial breas irradiation using
sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-
conserving surgery for low-risk invasive and in-situ carcinoma of the female breast; a randomised,
phase 3, non-inferiority trial. Lancet 2016; 387(10015): 229–238.
18. Bartelink H, Maingon P, Poortmans P et al. Whole-breast irradiation with or without a boost for patients
treated with breast-conserving surgery for early breast cancer: 20-year follow-up of a randomised
phase 3 trial. Lancet Oncol 2015; 16(1): 47–56.
19. Donovan EM, Ciurlionis L, Fairfoul J et al. Planning with intensity-modulated radiotherapy and
tomotherapy to modulate dose across breast to reflect recurrence risk (IMPORT High trial). Int J Radiat
Oncol Biol Phys 2011; 79(4): 1064–1072.
29. www.ukctg.nihr.ac.uk/trials/trial-details/trial-details?trialId=4633 (last accessed 4/1/19)
21. Mukesh MB, Barnett GC, Wilkinson JS et al. Randomized controlled trial of intensity-modulated
radiotherapy for early breast cancer: 5-year results confirm superior overall cosmesis. J Clin Oncol
2013; 31(36): 4488–4495.
22. Taylor C, Kirby A. Cardiac side-effects from breast cancer radiotherapy. Clin Oncol (R Coll Radiol) 2015;
27(11): 621–629.
23. Chan EK, Woods R, Virani S et al. Long-term mortality from cardiac causes after adjuvant
hypofractionated vs. conventional radiotherapy for localized left-sided breast cancer. Radiother Oncol
2015; 114(1): 73–78.
24. Donovan E, Coles C, Westbury C, Yarnold J. Breast In: Hoskin PJ (ed). External beam therapy, 2nd edn.
Oxford: Oxford University Press, 2012: 49–100.
25. Donker M, van Tienhoven G, Straver ME et al. Radiotherapy or surgery of the axilla after a positive
entinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label,
phase 3 non-inferiority trial. Lancet Oncol 2014; 15(12): 1303–1310.
26. Giulliano AE, McCall L, Beitsch P et al. Locoregional recurrence after sentinel lymph node dissection
with or without axillary dissection in patients with sentinel lymph node metastases: the American
College of Surgeons Oncology Group Z0011 randomized trial. Ann Surg 2010; 252(3): 426–432.
27. www.posnoc.co.uk (last accessed 23/9/16)
28. Whelan TJ, Olivotto IA, Parulekar WR et al. Regional nodal irradiation in early-stage breast cancer:
results of the MA20 prospective randomised controlled trial. N Eng J Med 2015; 373(4): 307–316.
29. Poortmans P, Collette S, Kirkove C et al. Internal mammary and medial supraclavicular irradiation in
breast cancer. N Eng J Med 2015; 373(4): 317–327.
30. Budach W, Kammers K, Boelke E, Matuschek C. Adjuvant radiotherapy of regional lymph nodes in
breast cancer – a meta-analysis of randomized trials. Radiat Oncol 2013; 8: 267.
References 31. Thorsen LB, Offersen BV, Danø H et al. DBCG-IMN: a population-based cohort study on the effect
of internal mammary node irradiation in early node-positive breast cancer. J Clin Oncol 2016; 34(4):
314–320.
32. Badiyan SN, Shah C, Arthur D et al. Hypofractionated regional nodal irradiation for breast cancer:
examining the data and potential for future studies. Radiother Oncol 2014; 110(1): 39–44.
4. Background
Three important considerations underpin the choice of treatment fractionation in neuro-
Central nervous oncology. First, the results of treatment vary widely and, second, the brain and spinal cord
system (CNS) tumours are susceptible to late radiation damage which is strongly dependent on radiation dose
per fraction. The Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC)
papers published in 2010 provide details of normal tissue tolerances for brain, brainstem,
optic nerves and chiasm, hearing and spinal cord.1–9 Patients with a life expectancy of more
than 12–18 months are rarely treated with doses per fraction greater than 2 Gray (Gy). With
increased use of inverse planned intensity-modulated radiotherapy (IMRT), consideration
must be given to appropriate dose constraints to serial structures, balancing tumour control
against risk of toxicity. Finally, our understanding of tumours, in particular the gliomas, has
changed substantially recently, and there is clearly a key role for isocitrate dehydrogenase
(IDH) mutations and chromosomal (1p/19q) codeletions. This is likely to further evolve over
time.
High-grade glioma
Radical treatment
Retrospective analyses and one randomised trial have demonstrated a dose–response
relationship for high-grade glioma up to, but not beyond, 60 Gy in 30 fractions.10–12 This
has led to the adoption of the dose regimen of 60–65 Gy delivered in 1.8–2.0 Gy fractions
as standard in the therapy of better prognosis patients with high-grade malignant
glioma. Further attempts to improve response through hyperfractionation or accelerated
fractionation have not demonstrated a significant survival benefit.13,14 The addition of
temozolomide to radiotherapy for newly diagnosed glioblastoma has been shown to
improve overall and progression-free survival.15 The first trial only included patients under
the age of 70. However, a subsequent study included older patients and found similar
benefits from the addition of temozolomide.16
For World Health Organization (WHO) grade III gliomas with 1p and 19q chromosomal co-
deletion, the addition of procarbazine, lomustine and vincristine (PCV) chemotherapy, either
before or after radiotherapy, has recently been shown to improve overall survival.17,18 The
addition of temozolomide after radiotherapy has been shown to improve survival in patients
with grade III non-1p 19q co-deleted tumours and final results of this trial are still awaited.
Recent trials for grade III glioma (anaplastic oligodendroglioma and oligoastrocytoma, and
non-1p19q co-deleted WHO grade III glioma) have all used a radiotherapy dose of 59.4 Gy
in 33 fractions, providing Level 2a evidence for this regimen in WHO grade III glioma.19–22
Previous dose determination studies in high-grade gliomas used a dose of 60 Gy in 30
fractions for grade III gliomas.11,20
Recommendations
For patients of good performance status:
WHO Grade IV glioma (GBM)
60 Gy in 30 daily fractions over 6 weeks (Grade A)
WHO Grade III glioma
59.4 Gy in 33 fractions over 6.5 weeks (Grade A)
60 Gy in 30 fractions over 6 weeks (Grade B)
Increasing age is a significant negative prognostic factor for patients with glioblastoma.
Several trials in older patients have evaluated shorter courses of radiotherapy. One
randomised trial which recruited patients aged ≥60 of Karnofsky Performance Status
(KPS) ≥50 showed similar survival for 40 Gy in 15 fractions over three weeks compared
to 60 Gy in 30 fractions.21 In another randomised trial in patients aged ≥60 principally of
WHO performance status 0–2, 34 Gy in ten fractions appeared to have similar survival
rates in patients over 60 and better survival in patients over 70 than 60 Gy in 30 fractions
of radiotherapy alone.23 Shorter fractionations are therefore an option in elderly patients
unsuitable for chemo-radiotherapy. The recent results using 40 Gy in 15 fractions in older
patients combined with concurrent and adjuvant temozolomide suggest that this may be
the best option in fit, older patients.16
For patients with high-grade glioma and poor performance status, when treatment is
indiciated, hypofractionated treatments are used.24,25 The most commonly adopted regimen
in the UK is 30 Gy in six fractions over two weeks.
Recommendations
Elderly patients with glioblastoma unsuitable for chemo-radiotherapy:
40 Gy in 15 fractions over 3 weeks (Grade A)
30 Gy in 6 fractions over 2 weeks (Grade C)
For patients of poor performance status being treated for high-grade glioma:
Low-grade glioma
For low-grade glioma, two prospective randomised dose comparison trials have
demonstrated no difference in outcome between 45 Gy in 25 fractions and 59.4 Gy in 33
fractions and between 50.4 Gy in 28 fractions and 64.8 Gy in 36 fractions.26,27 As a result, a

standard dose of 50.4 Gy in 28 fractions of 1.8 Gy is accepted practice in the UK and
internationally. A dose of 54 Gy in 30 fractions over six weeks was used in a randomised
study of the timing of radiotherapy and also in the Radiation Therapy Oncology Group
(RTOG) 9802 randomised trial which showed an overall survival benefit for the addition of
adjuvant procarbazine, lomustine and vincristine (PCV) chemotherapy after radiotherapy for
high-risk low-grade glioma (age 18–39 and incompletely resected, or age ≥40 with any
extent of resection).28,29 This provides Level 2b evidence for this regimen.19
Recommendations
50.4 Gy in 28 daily fractions over 5.5 weeks (Grade A)
54 Gy in 30 daily fractions over 6 weeks (Grade B)
Finally, data from molecular pathology are likely to further refine these guidelines.
Meningioma
For benign meningioma (WHO grade I), radiotherapy may be used as radical treatment
or postoperatively after incomplete resection or recurrence. Radiological surveillance is
often an appropriate option for benign meningioma, depending on tumour growth, location
and the risk to the patient from further tumour growth. Randomised clinical trial evidence
is lacking, but generally excellent rates of local control are reported with radiotherapy
doses of 50–54 Gy in 25–30 fractions. Small-volume benign tumours away from critical
structures (for example, optic apparatus) may also be treated with stereotactic radiosurgery
(SRS). Multiple series confirm long-term local control rates in excess of 80% using both
fractionation and SRS. Lower doses have been used in more recent series with similar local
control rates.
Radiotherapy should be considered for recurrent or incompletely resected meningioma
of atypical histology. As for other benign intracranial tumours, fractionation has been
governed by tolerance of local structures and adjacent brain tissue. There is an absence
of prospective randomised clinical trial evidence for the use of adjuvant radiation therapy.
However, multiple institutional series have demonstrated an improvement in local control
and overall survival with adjuvant radiotherapy doses of 50.4–59.4 Gy in 28–33 fractions.30–33
There is some evidence to suggest that local control is enhanced at doses greater than
52 Gy.30–33
Patients with grade 2 meningiomas are at higher risk of relapse, and standard practice
has historically been to give radiotherapy. The role of adjuvant radiotherapy, balanced
against the neuro-cognitive side-effects, in patients with completely resected meningioma
are being explored in the ROAM study (EORTC 1308). In patients who have incompletely
resected tumours, radiotherapy has been offered at a dose of 60 Gy in 30 fractions.
Attempts at dose escalation using radiosurgery boost and accelerated hyperfractionation
have failed to achieve improved local control.32 The EORTC 26021-22021 phase II trial
(NCT00626730) of postoperative radiotherapy for atypical and malignant meningiomas
which treated Simpson stage 1–3 to 60 Gy and Simpson stages 4–5 to 70 Gy closed in 2013
and is in follow-up.34
Special consideration should be given to meningioma of the optic nerve sheath. There is
now evidence from multiple institutional series that radiotherapy should be considered as a
primary treatment option to achieve tumour control and consequentially prevent visual
deterioration and symptomatic proptosis.35,36
Recommendations
Tumour grade 1:
50.4–54 Gy in 28–30 fractions over 5.5–6 weeks (Grade C)
50–55 Gy in 30–33 fractions over 6–6.5 weeks (Grade C)
Grade 2:
54–60 Gy in 30 fractions over 6 weeks (Grade D)
Grade 3:
60 Gy in 30 fractions over 6 weeks (Grade D)
Pituitary tumours
Fractionation has been governed by tolerance of the local structures and prospective
data is lacking. There are consistent reports of high local control when using 45 Gy in 25
fractions for non-functioning pituitary adenomas.37 This is commonly accepted as the
standard dose for tumours without adverse features including suprasellar extension.
There is data to suggest that the dose response may increase up to about 50 Gy, however,
higher doses are generally reserved for tumours with adverse features.38 Small inoperable
pituitary tumours away from optic apparatus may be suitable for single fraction stereotactic
treatment which offers a similar local control rate.39
Although radiological control rates are high, biochemical remission rates for functional
tumours vary considerably using conventional doses of 45–54 Gy (1.8–2 Gy per fraction).
No clear dose response has been defined using fractionated treatment, however, higher
marginal doses are used when using single fraction stereotactic treatment.
Recommendation
Craniopharyngioma
Radiation therapy is typically used as an adjunct to surgery after maximal tumour
resection. Doses between 50–60 Gy in 30 fractions have been used. Historical studies of
postoperative radiotherapy showed a dose of 55 Gy to be a threshold dose in terms of local
disease control, though concern over the risk of radiation induced optic neuropathy has
resulted in median doses of 50–52.2 Gy in more recently published series.40–42
Recommendations
50–55 Gy in 30–33 fractions over 6–6.5 weeks (Grade D)
52.2–54 Gy in 27–28 fractions over 5.5 weeks (Grade D)
References 1. Kramer S. The hazards of therapeutic irradiation of the central nervous system. Clin Neurosurg
1968,15: 301–318.
2. Marks JE, Baglan RJ, Prassa SC, Blank WF. Cerebral radionecrosis: incidence and risk in relation to
dose, time, fractionation and volume. Int J Radiat Oncol Biol Phys 1981; 7(2): 243–252.
3. Sheline GE, Wara WM, Smith V. Therapeutic irradiation and brain injury. Int J Radiat Oncol Biol Phys
1980; 6(9): 1215–1228.
4. Leibel SA, Sheline GE. Tolerance of the brain and spinal cord to conventional radiation. In: Gutin PH,
Leibel SA, Sheline GE (eds). Radiation Injury to the Nervous system. New York: Raven Press, 1991:
239–256.
5. Corn BW, Yousem DM, Scott CB et al. White matter changes are correlated significantly with radiation
dose. Observations from a randomized dose-escalation trial for malignant glioma (Radiation Therapy
Oncology Group 83-02). Cancer 1994; 74(10): 2828–2835.
6. Emami B, Lyman J, Brown A et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat
Oncol Biol Phys 1991; 21(1): 109–122.
7. Berg G, Blomquist E, Cavallin-Ståhl E. A systematic overview of radiation therapy effects in brain

tumours. Acta Oncologica 2003; 42(5–6): 582–588.
8. Marks LB, Ten Haken RK, Martel MK. Guest editor's introduction to QUANTEC: a users guide. Int J
Radiat Oncol Biol Phys 2010; 76(3 Suppl): S1–S2.
9. Marks LB, Yorke ED, Jackson A et al. Use of normal tissue complication probability models in the clinic.
Int J Radiat Oncol Biol Phys 2010; 76(3 Suppl): S10–9.
10. Walker MD, Strike TA, Sheline GE. An analysis of dose-effect relationship in the radiotherapy of
malignant gliomas. Int J Radiat Oncol Biol Phys 1979; 5(10): 1725–1731.
11. Bleehan NM, Stenning SP. A Medical Research Council trial of two radiotherapy doses in the
treatment of grades 3 and 4 astrocytoma. Br J Cancer 1991; 64(4): 769–774.
12. Salazar OM, Rubin P, McDonald JV, Feldstein ML. High dose radiation therapy in the treatment of
glioblastoma multiforme: a preliminary report. Int J Radiat Oncol Biol Phys 1976; 1(7–8): 717–727.
13. Werner-Wasik M, Scott CB, Nelson DF et al. Final report of a phase I/II trial of hyperfractionated
and accelerated hyperfractionated radiation therapy with carmustine for adults with supratentorial
malignant gliomas: Radiation Therapy Oncology Group Study 83-02. Cancer 1996; 77(8): 1535–1543.
14. González DG, Menten J, Bosch DA et al. Accelerated radiotherapy in glioblastoma multiforme: a dose
searching prospective study. Radiother Oncol 1994; 32(2): 98–105.
15. Stupp R, Hegi ME, Mason WP et al. Effects of radiotherapy with concomitant and adjuvant
temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study:
5-year analysis of the EORTC-NCIC trial. Lancet Oncol 2009; 10(5): 459–466.
16. Perry JR, Laperriere N, O’Callaghan J et al. Short-course radiation plus temozolomide in elderly patients
with glioblastoma. N Eng J Med 2017; 376(11): 1027–1037.
17. Cairncross G, Wang M, Shaw E et al. Phase III trial of chemoradiotherapy for anaplastic
oligodendroglioma: long-term results of RTOG 9402. J Clin Oncol 2013; 31(3): 337–343.
18. van den Bent MJ, Brandes AA, Taphoorn MJ et al. Adjuvant procarbazine, lomustine, and vincristine
chemotherapy in newly diagnosed anaplastic oligodendroglioma: long-term follow-up of EORTC brain
tumor group study 26951. J Clin Oncol 2013; 31(3): 344–350.
19. www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009
20. Mulvenna P, Nankivell M, Barton R et al. Dexamethasone and supportive care with or without
whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases
unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority,
randomised trial. Lancet 2016; 388(10055): 2004–2014.
21. Roa W, Brasher PM, Bauman G et al. Abbreviated course of radiation therapy in older patients with
glioblastoma multiforme: a prospective randomized clinical trial. J Clin Oncol 2004; 22(9): 1583–1588.
22. van den Bent MJ, Baumert B, Erridge SC et al. Interim results from the CATNON trial (EORTC study
26053-22054) of treatment with concurrent and adjuvant temozolomide for 1p/19q non-co-deleted
anaplastic glioma: a phase 3, randomised, open-label intergroup study. Lancet 2017; 390(10103):
1645–1653.
23. Malmström A, Grønberg BH, Marosi C et al. Temozolomide versus standard 6-week radiotherapy
versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic
randomised, phase 3 trial. Lancet Oncol 2012; 13(9): 916–926.
24. McAleese JJ, Stenning SP, Ashley S et al. Hypofractionated radiotherapy for poor prognosis malignant
glioma: matched pair survival analysis with MRC controls. Radiother Oncol 2003; 67(2): 177–182.
25. Thomas R, James N, Guerrero D, Ashley S, Gregor A, Brada M. Hypofractionated radiotherapy as

palliative treatment in poor prognosis patients with high grade glioma. Radiother Oncol 1994; 33(2):
113–116.
26. Karim AB, Maat B, Hatlevoll R et al. A randomized trial on dose-response in radiation therapy of low-
grade cerebral glioma: European Organisation for Research and Treatment of Cancer (EORTC) Study
22845. Int J Radiat Oncol Biol Phys 1996; 36(3): 549–556.
27. Karim AB, Afra D, Cornu P et al. Randomized trial on the efficacy of radiotherapy for cerebral low-grade
glioma in the adult: European Organisation for Research and Treatment of Cancer Study 22845 with
the Medical Research Council study BR04: an interim analysis. Int J Radiat Oncol Biol Phys 2002; 52(2):
316–324.
28. van den Bent MJ, Afra D, de Witte O et al. Long-term efficacy of early versus delayed radiotherapy for
low-grade astrocytoma and oligodendroglioma in adults: the EORTC 22845 randomised trial. Lancet
2005; 366(9490): 985–990.
29. Shaw E, Arusell R, Scheithauer B et al. Prospective randomised trial of low- versus high-dose radiation
therapy in adults with supratentorial low-grade glioma: initial report of a North Central Cancer
Treatment Group/Radiation Therapy Oncology Group/astern Cooperative Oncology Group Study. J
Clin Oncol 2002; 20(9): 2267–2276.
30. Adeberg S, Hartmann C, Welzel T et al. Long-term outcome after radiotherapy in patients with atypical
and malignant meningiomas – clinical results in 85 patients treated in a single institution leading to
optimized guidelines for early radiation therapy. Int J Radiat Oncol Biol Phys 2012; 83(3): 859–864.
31. Aghi MK, Carter BS, Cosgrove GR et al. Long-term recurrence rates of atypical meningiomas after
gross total resection with or without postoperative adjuvant radiation. Neurosurgery 2009; 64(1):
56–60; discussion 60.
32. Goldsmith BJ, Wara WM, Wilson CB, Larson DA. Postoperative irradiation for subtotally resected
meningiomas. A retrospective analysis of 140 patients treated from 1967 to 1990. J Neurosurg 1994;
80(2): 195–201.
References 33. Milosevic MF, Frost PJ, Laperriere NJ, Wong CS, Simpson WJ. Radiotherapy for atypical or malignant
intracranial meningioma. Int J Radiat Oncol Biol Phys 1996; 34(4): 817–822.
34. https://clinicaltrials.gov/ct2/show/NCT00626730 (last accessed 13/10/16)
35. Brower JV, Amdur RJ, Kirwan J, Mendenhall WM, Friedman W. Radiation therapy for optic nerve sheath
meningioma. Pract Radiat Oncol 2013; 3(3): 223–288.
36. Roser F, Nakamura M, Martini-Thomas R, Samii M, Tatagiba M. The role of surgery in meningiomas
involving the optic nerve sheath. Clin Neurol Neurosurg 2006; 108(5): 470–406.
37. Erridge SC, Conkey DS, Stockton D et al. Radiotherapy for pituitary adenomas: long-term efficacy and
toxicity. Radiother Oncol 2009; 93(3): 597–601.
38. Grigsby PW, Simpson JR, Emami BN, Fineberg BB, Schwartz HG. Prognostic factors and results of
surgery and postoperative irradiation in the management of pituitary adenomas. Int J Radiat Oncol Biol
Phys 1989; 16(6): 1411–1417.
39. Sheehan JP, Starke RM, Mathieu D et al. Gamma Knife radiosurgery for the management of
nonfunctioning pituitary adenomas: a multicenter study. J Neurosurg 2013; 119(2): 446–456.
40. Varlotto JM, Flickinger JC, Kondsiolk D et al. External beam irradiation of craniopharyngiomas: long-
term analysis of tumor control and morbidity. Int J Radiat Oncol Biol Phys 2002; 54(2): 492–499.
41. Masson-Cote L, Masucci GL, Atenafu EG et al. Long-term outcomes for adult craniopharyngioma
following radiation therapy. Acta Oncol 2013; 52(1): 153–158.
42. Harrabi SB, Adeberg S, Welzel T et al. Long term results after fractionated stereotactic radiotherapy
(FSRT) in patients with craniopharyngioma: maximal tumor control with minimal side effects. Radiat
Oncol 2014; 9: 203.
5. Cervix cancer
Background
Gynaecological
cancers Patients presenting with small volume International Federation of Gynaecologists
and Obstetricians (FIGO) stage IB1 and IIA disease can be treated either by radical
hysterectomy and lymphadenectomy or radical radiotherapy as primary procedures. The
two approaches have equivalent survival rates (Level 1b).1,2
The combination of surgery and radiotherapy increases morbidity and should be avoided
if possible.1,3 Postoperative chemoradiotherapy is indicated for patients with poor
prognostic features discovered at surgery (positive nodes, positive margins or extensive
lymphovascular space involvement) (Level 1b).2–4
Local control and survival are increased by the addition of concomitant chemotherapy in
all stages, although the benefit may be smaller when only one node is positive or when the
tumour size is <2 centimetres (cm) (Level 1b).2–11
Randomised studies of radiotherapy have used fractionation regimens of 40–50.4 Gray (Gy)
in daily 1.8–2 Gy fractions over 4–5.5 weeks (Level 1b).1–3,12,13 Both early and late toxicity are
increased when chemotherapy is added (Level 1b).2,12,14
Overall treatment time, including intracavitary brachytherapy (ICBT), should not exceed 56
days for squamous carcinoma (Level 1b).2,15–19 Haemoglobin levels during treatment are
prognostic, with the best outcomes in those whose haemoglobin remains greater than 12
grams per decilitre (g/dl) throughout treatment (Level 2b).2,20
Small-volume parametrial disease can be often be encompassed within the brachytherapy
dose-envelope using a combination of interstitial and intracavitary brachytherapy (ISBT
and ICBT) (Level 2b).2 Alternatively, a simultaneous integrated intensity-modulated
radiotherapy (IMRT) planned external beam radiotherapy (EBRT) boost can be considered
(Level 2b).2 Boosting parametrial disease conventionally with three-dimensional conformal
radiotherapy (3D-CRT) or parallel opposed fields with midline blocking does not usually
allow organs at risk (OAR) constraints to be met and is not recommended (Level 1b).2,21,22
Evidence from cohort series supports the use of image-guided brachytherapy (IGBT) to
reduce late toxicities and facilitate delivery of >80–85 Gy (combined external beam and
brachytherapy equivalent dose in 2 Gy per fraction [EQD2]).23,24 Dose constraints to OARs
have been published based on organ volume rather than point doses (Level 2b).2,25 These
doses can only be achieved within normal tissue constraints when doses of <50 Gy are
delivered by external beam radiotherapy.
Currently, there is no evidence of improvements in survival to support the routine use of
neoadjuvant or adjuvant chemotherapy in addition to primary chemoradiotherapy. This
question is being addressed by two international trials: Cisplatin and Radiation Therapy
with or without Carboplatin and Paclitaxel in Patients with Locally Advanced Cervical
Cancer (OUTBACK) and Induction Chemotherapy Plus Chemoradiation as First Line
Treatment for Locally Advanced Cervical Cancer (INTERLACE).26,27
Treatment technique
The planning target volume (PTV) for treating pelvic malignancy normally encompasses the
lymphatic drainage of the true pelvis and may be extended further, depending on the extent
and type of malignancy, to include the para-aortic nodes, the inguinal nodes or the vagina.28
Nodal atlases have been developed to assist in the outlining of the female pelvis.29,30
Significantly less toxicity is seen if EBRT is delivered using IMRT or volumetric-modulated
arc therapy (VMAT) rather than 3D-CRT (Level 2b).2,31
Recommendations
Post-operative external beam:
Delivered with weekly concurrent cisplatin 40 milligrams per metre squared (mg/m2)
(Grade A)
Definitive primary treatment
External beam radiotherapy:
Delivered with weekly concurrent cisplatin 40 mg/m2 (Grade A)
Involved pelvic and para-aortic lymph nodes should receive:
57–60 Gy in 28 fractions over 5.5 week using a simultaneous integrated boost (Grade C)
Parametrial disease that cannot be encompassed by ICBT and ISBT may receive:
57–60 Gy in 25–28 fractions over 5–5.5 weeks
65 Gy in 28 fractions over 5.5 weeks using a simultaneous integrated boost (Grade C)
EBRT should be followed by image-guided brachytherapy so that a total dose of
80–85 Gy EQD2 is delivered to the high-risk clinical target volume (CTV) (Level 2b).
This is achieved with:
45 Gy in 25 fractions over 5 weeks external beam followed by high-dose rate (HDR) 28
Gy in 4 fractions (Grade B)
Other fractionation schedules in use for brachytherapy after the external beam
schedules given above are:
HDR: 6–7.5 Gy per fraction for 3–5 fractions (Grade C)
Pulsed dose rate (PDR): 17 Gy per fraction at 1 Gy per hour for 2 fractions, 7–10 days
apart (Grade C)
Overall treatment time, including brachytherapy should be no more than 56
days for squamous cancers (Level 1b)
Endometrial cancer
Adjuvant therapy in operable disease
The majority of patients present with organ-confined disease and surgery is the
primary treatment.
Trials of pelvic radiotherapy consistently show a reduction in local recurrences but no
overall survival benefit.32–37 The Vaginal Brachytherapy Versus Pelvic External Beam
Radiotherapy for Patients with Endometrial Cancer of High–Intermediate Risk (PORTEC
2) trial showed equivalent outcome for patients with some intermediate risk features who
received either adjuvant vaginal brachytherapy (VBT) or external beam radiotherapy.35
The long-term pelvic side-effects in the brachytherapy group were less than with external
beam. The PORTEC 3 trial has investigated the benefit of concurrent chemoradiotherapy
and adjuvant chemotherapy compared to adjuvant radiotherapy alone, which has been the
current standard of care. This shows an advantage for the combined approach in stage III
patients after hysterectomy.36,37
Recommendations
High-risk patients
Postoperative adjuvant external beam radiotherapy:
46 Gy in 23 fractions over 4.5 weeks (Grade A)
Other schedules in use include 45 Gy in 25 fractions (Grade D) and 50.4 Gy in 28
fractions (Grade D)
Stage III patients should receive chemoradiation with cisplantin followed by adjuvant
carboplantin and paclitaxel (Grade A)
Vault brachytherapy may follow the above schedules in patients with cervical
involvement although there is no strong evidence base for this practice:
HDR: 8 Gy at 5 milimetres (mm) in 2 fractions (Level 1b)
PDR: 19 Gy at 5 mm at 1 Gy per hour given in 1 fraction (Level 1b)
Intermediate risk patients
Vaginal vault brachytherapy:
HDR:
21 Gy at 5mm in 3 fractions over 3 weeks (Grade A)
12–30 Gy at 5 mm in 3–8 fractions (Grade C)
PDR: 28 Gy at 5 mm in 1 Gy pulse per hour given in 2 fractions delivered in 7–10 days
(Level 1b)
Definitive radiotherapy for inoperable disease

Endometrial carcinoma may be inoperable because of medical co-morbidity or advanced
disease stage. Accurate staging can be achieved using magnetic resonance imaging (MRI).
Radiotherapy can control stage I and II disease and may have a role in more advanced
cases (Level 2a).38,39
Recommendations
Brachytherapy alone
HDR:
36 Gy in 5 fractions (Grade C) prescribed to the uterine serosa
37.5 Gy in 6 fractions (Grade C) prescribed to the uterine serosa
Combination therapy
External beam:
Brachytherapy:
HDR:
Endometrial carcinoma: salvage

Recurrent uterine corpus carcinoma in a previously unirradiated pelvis can be treated,
and sometimes salvaged, with radiotherapy (external beam alone, external beam
combined with brachytherapy or brachytherapy alone). Data of any sort are sparse, with no
randomised trials. Doses of greater than 60 Gy EQD2 including brachytherapy should be
delivered, provided rectal and bladder constraints are respected (Level 2c).40,41
Vulva
Adjuvant therapy in operable disease
For those with operable vulval cancer, surgical resection of the primary with inguinal
lymphadenectomy remains the treatment of choice.42
Adjuvant radiotherapy may be considered for those with incomplete resection, two or
more positive lymph nodes or any extracapsular spread. Concurrent chemotherapy with
cisplatin is used, but without a strong evidence base to support it (Grade C).2 The Gronigen
International Study on Sentinel Nodes in Vulvar Cancer (GROINSS – II) study is comparing
surgery with either definitive radical radiotherapy or radical chemoradiotherapy where
sentinel lymph node metastases <2 mm are detected.43
Recommendation
Postoperative radiotherapy to vulva, pelvic and inguinal nodes:
Inoperable vulval carcinoma

Data in this area are sparse with no randomised studies. Potential therapeutic options
include definitive chemo-radiotherapy, treating the primary and nodes. Consideration
should then be given to surgical removal of residual disease or a second phase of
radiotherapy with electrons or brachytherapy.44
Recommendation
Inoperable vulval cancer:
50.4 Gy in 28 fractions over 5.5 weeks (Grade C)
External beam radiotherapy may be given with weekly cisplatin 40 mg/m2 (Grade C)
The primary and involved nodes should be boosted using electrons,
simultaneous integrated boost (SIB) with IMRT or brachytherapy to deliver a
total dose of 60–65 Gy EQD2 (Grade C)
Vaginal carcinoma
The rarity of vaginal carcinoma has led to therapy recommendations being derived from
single institution series accrued over many years and extrapolation from cervical carcinoma
data with no randomised trials. Therapy with EBRT in combination with either ISBT or ICBT
is accepted practice with doses of between 70–80 Gy EQD2 appearing to confer survival
advantage (Level 4).45 The addition of concurrent chemotherapy appears to deliver a
survival advantage (Level 4).46
Recommendation
Definitive therapy of vaginal carcinoma:
45–50 Gy in 25 fractions over 5 weeks (Grade C)
Followed by ISBT or ICBT HDR 18.75–20 Gy in 5 fractions (Grade C)
References 1. Landoni F, Maneo A, Colombo A et al. Randomised study of radical surgery versus radiotherapy for
stage Ib–IIa cervical cancer. Lancet 1997; 350(9077): 535–540.
2. w
3. Sedlis A, Bundy BN, Rotman MZ, et al. A randomized trial of pelvic radiation therapy versus no further
therapy in selected patients with stage IB carcinoma of the cervix after radical hysterectomy and pelvic
lymphadenectomy: A Gynecologic Oncology Group Study. Gynaecol Oncol 1999; 73(2): 177–183.
4. Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration (CCCMAC). Reducing

uncertainties about the effects of chemoradiotherapy for cervical cancer: individual patient data meta-
analysis. Cochrane Database Syst Rev 2010; (1): CD009285.
5. Whitney CW, Sause W, Bundy BN et al. Randomized comparison of fluorouracil plus cisplatin versus
hydroxyurea as an adjunct to radiation therapy in stage IIB–IVA carcinoma of the cervix with negative
para-aortic lymph nodes: a Gynecologic Oncology Group and Southwest Oncology Group study. J Clin
Oncol 1999; 17(5): 1339–1348.
6. Rose PG, Bundy BN, Watkins EB et al. Concurrent cisplatin-based radiotherapy and chemotherapy for
locally advanced cervical cancer. N Engl J Med 1999; 340(15): 1144–1153. [erratum in N Engl J Med
1999; 341(9): 708]
7. Morris M, Eifel PJ, Lu J et al. Pelvic radiation with concurrent chemotherapy compared with pelvic and
para-aortic radiation for high-risk cervical cancer. N Engl J Med 1999; 340(15): 1137–1143.
8. Keys HM, Bundy BN, Stehman FB et al. Cisplatin, radiation, and adjuvant hysterectomy compared
with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma. N Engl J Med 1999;
340(15):1154–1161. [erratum in N Engl J Med 1999; 341(9): 708].
9. Thomas GM. Improved treatment for cervical cancer – concurrent chemotherapy and radiotherapy. N
Engl J Med 1999; 340(15): 1198–1200.
10. Rose PG, Bundy BN. Chemoradiation for locally advanced cervical cancer: does it help? J Clin Oncol
2002; 20(4): 891–893.
11. Eifel PJ, Winter K, Morris M et al. Pelvic irradiation with concurrent chemotherapy versus pelvic and
para-aortic irradiation for high-risk cervical cancer: an update of radiation therapy oncology group trial
(RTOG) 90-01. J Clin Oncol 2004; 22(5): 872–880.
12. Peters WA 3rd, Liu PY, Barrett RJ 2nd et al. Concurrent chemotherapy and pelvic radiation therapy
compared with pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk
early-stage cancer of the cervix. J Clin Oncol 2000; 18(8): 1606–1613.
13. Monk BJ, Wang J, Im S et al. Rethinking the use of radiation and chemotherapy after radical
hysterectomy: a clinical-pathologic analysis of a Gynecologic Oncology Group/Southwest Oncology
Group/Radiation Therapy Oncology Group trial. Gynecol Oncol 2005; 96(3): 721–728.
14. Vale CL, Tierney JF, Davidson SE, Drinkwater KJ, Symonds P. Substantial improvement in UK cervical
cancer survival with chemoradiotherapy: Results of a Royal College of Radiologists’ audit. Clin Oncol
(R Coll Radiol) 2010; 22(7): 590–601.
15. The Royal College of Radiologists. The timely delivery of radical radiotherapy: standards and
guidelines for the management of unscheduled treatment interruptions, Third edition. London: The
Royal College of Radiologists, 2008
16. Chatani M, Makayoshi Y, Masaki N, Inoue T. High-dose rate intracavitary irradiation for carcinoma
of the uterine cervix. The adverse effect of treatment prolongation. Strahlenther Onkol 1997; 73(7):
379–384.
17. Perez CA, Grigsby PW, Castro-Vita H, Lockett MA. Carcinoma of the uterine cervix part I. Impact of
prolongation of overall treatment time and timing of brachytherapy on outcome of radiation therapy. Int
J Radiat Oncol Biol Phys 1999; 32(5): 1275–1288.
18. Fyles A, Keane TJ, Barton M, Simm J. The effect of treatment duration in the local control of cervix
cancer. Radiother Oncol 1992; 25(4): 273–279.
19. Delaloye JF, Coucke PA, Pampallona S, De Grandi P. Effect of total treatment time on event-free survival
in carcinoma of the cervix. Gynecol Oncol 1996; 60(1): 42–48.
20. Winter WE 3rd, Maxwell GL, Tian C et al. Association of hemoglobin level with survival in cervical
carcinoma patients treated with concurrent cisplatin and radiotherapy: A Gynecologic Oncology
Group study. Gynecologic Oncol 2004; 94(2): 495–501.
21. Mohamed S, Kallehauge J, Fokdal L, Lindegaard JC, Tanderup K. Parametrial boosting in locally
advanced cervical cancer: combined intracavitary/interstitial brachytherapy versus intracavitary
brachytherapy plus external beam radiotherapy. Brachytherapy 2015; 14(1): 23–28.
22. Huang E-Y, Lin H, Hsu HC et al. High external parametrial dose can increase the probability of radiation
proctitis in patients with uterine cervix cancer. Gynecol Oncol 2000; 79(3): 406–410.
23. Mazeron R, Castelnau-Marchand P, Dumas I et al. Impact of treatment time and dose escalation on
local control in locally advanced cervical cancer treated by chemoradiation and image-guided pulsed-
dose rate adaptive brachytherapy. Radiother Oncol 2015; 114(2): 257–263.
24. Rijkmans EC, Nout RA, Rutten IH et al. Improved survival of patients with cervical cancer treated with
image-guided brachytherapy compared with conventional brachytherapy. Gynecol Oncol 2014;
135(2): 231–238.
25. Potter R, Georg P, Dimopoulos JC et al. Clinical outcome of protocol based image (MRI) guided
adaptive brachytherapy combined with 3D conformal radiotherapy with or without chemotherapy in
patients with locally advanced cervical cancer. Radiother Oncol 2001; 100(1): 116–123.
27. https://clinicaltrials.gov/ct2/show/NCT01566240?term=interlace&rank=2 (last accessed 13/10/16)
28. Yap ML, Cuartero J, Yan J et al. The role of elective para-aortic lymph node irradiation in patients with
locally advanced cervical cancer. Clin Oncol (R Coll Radiol) 2014; 26(12): 797–803.
29. Taylor A, Rockall AG, Powell ME. An atlas of the pelvic lymph node regions to aid radiotherapy target
volume definitions. Clin Oncol (R Coll Radiol) 2007; 19(7): 542–550.
30. Small W Jr, Mell LK, Anderson P et al. Consensus guidelines for delineation of the clinical target volume
for intensity-modulated pelvic radiotherapy in the postoperative treatment of endometrial and cervical
cancer. Int J Radiat Oncol Biol Phys 2008; 71(2): 428–434.
31. Hasselle MD, Rose BS, Kochanski JD et al. Clinical outcomes of intensity-modulated pelvic radiation
therapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2011; 80(5): 1436–1445.
32. ASTEC study group, Kitchener H, Swart AM, Qian Q et al. Efficacy of systematic pelvic
lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet 2009;
373(9658): 125–136.
References 33. Creutzberg CL, Nout RA, Lybeert ML et al. Fifteen-year radiotherapy outcomes of the randomised
PORTEC-1 trial for endometrial carcinoma. Int J Rad Oncol Biol Phys 2011; 81(4): e631–e638.
34. Keys HM, Roberts JA, Brunetto VL et al. A phase III trial of surgery with or without adjunctive external
pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: A Gynecologic Oncology
Group study. Gynecol Oncol 2004; 92(3): 744–751.
35. Nout RA, Smit VT, Putter H et al. Vaginal brachytherapy versus pelvic external beam radiotherapy for
patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority,
randomised trial. Lancet 2010; 375(9717): 816–823
36. https://clinicaltrials.gov/ct2/show/NCT00411138?term=PORTEC+3&rank=1 (last accessed 26/9/16)
37. de Boer SM, Powell ME, Mileshkin L et al. PORTEC study group: Adjuvant chemoradiotherapy versus
radiotherapy alone for women with high-risk endometrial cancer (PORTEC-3): final results of an
international, open-label, multicentre, randomised, phase 3 trial. Lancet Oncol 2018; 19(3): 295–309.
38. Churn M, Jones B. Primary radiotherapy for carcinoma of the endometrium using external beam
radiotherapy and single line source brachytherapy. Clin Oncol 1999; 11(4): 255–262.
39. Gill BS, Kim H, Houser C et al. Image-based three-dimensional conformal brachytherapy for medically
inoperable endometrial carcinoma. Brachytherapy 2014; 13(6): 542–547.
40. Vargo JA, Kim H, Houser CJ et al. Definitive salvage for vaginal recurrence of endometrial cancer: the
impact of modern intensity-modulated-radiotherapy with image-based HDR brachytherapy and the
interplay of the PORTEC 1 risk stratification. Radiother Oncol 2014; 113(1): 126–131.
41. Jereczek-Fossa B, Badzio A, Jassem J. Recurrent endometrial cancer after surgery alone: results of
salvage radiotherapy. Int J of Radiat Oncol Biol Phys 2000; 48(2); 405–413.
42. Van der Velden J, Fons G, Lawrie TA. Primary groin irradiation versus primary groin surgery for early
vuval cancer. Cochrane Database Syst Rev 2011; 5: CD002224.
43. https://clinicaltrials.gov/ct2/show/NCT01500512?term=GROINSS&rank=1 (last accessed 26/9/16)
44. Moore DH, Ali S, Koh WJ et al. A phase II trial of radiation therapy and weekly cisplatin chemotherapy
for the treatment of locally-advanced squamous cell carcinoma of the vulva: a gynaecological
oncology group study. Gynecol Oncol 2012; 124(3): 529–533.
45. Beriwal S, Bhatnagar A, Heron DE et al. High-dose-rate interstitial brachytherapy for gynecological
malignancies. Brachytherapy 2006; 5(4): 218–222.
46. Rajagopalan MS, Xu KM, Lin JF, Sukumvanich P, Krivak TC, Beriwal S. Adoption and impact of
concurrent chemoradiation therapy for vaginal cancer: A National Cancer Data Base (NCDB) Study.
Gynecol Oncol 2014; 135(3): 495–502.
6. Background
Intensity-modulated radiotherapy (IMRT) is the accepted standard radiotherapy for
Head and neck cancer patients undergoing primary and adjuvant radiotherapy for head and neck squamous cell
carcinomas; exceptions are T1/T2N0 glottic cancer and the use of low-dose palliative
radiotherapy. The international standard for definitive treatment remains 70 Gray (Gy) in
daily fractions of 2 Gy over seven weeks, although altered fractionation regimens have been
widely used. In the UK, many centres have adopted 65–66 Gy in 30 fractions over six weeks
as a standard regimen. Most centres employ a simultaneous integrated boost technique
with IMRT to treat all target volumes and elective lymph node regions to varying dose levels
in each fraction (rather than the use of multiple phases or a matched neck field). This has
led to altered fractionation regimens for either high-dose or elective treatment volumes.1
T1/2N0 glottic carcinoma

Hypofractionated regimens are recommended.2 A randomised trial demonstrated the
superiority of modest hypofractionation with 2.25 Gy per fraction and, in large retrospective
series, fraction sizes of ≥2.25 Gy compared favourably with other reported series.2–4 Several
UK series have reported high rates of local control with shorter more hypofractionated
schedules including 50–52.5 Gy in 16 fractions over three weeks for T1 disease and 55 Gy
in 20 fractions for T1 and T2 disease.5–8 Hyperfractionated schedules have not shown a
significant improvement compared with conventional fractionation.9
Recommendations
63 Gy in 28 fractions over 5.5 weeks (Grade B)
50 Gy in 16 fractions over 3 weeks (T1 disease only) (Grade C)
Role of modified fractionation in head and neck squamous cell

carcinoma (HNSCC) (non-nasopharyngeal)
A meta-analysis of 15 trials of altered fractionation without chemotherapy in non-
nasopharyngeal head and neck squamous cell carcinoma (predominantly oropharynx
and larynx cancers) showed a modest benefit in overall survival (3.4% at five years)
and local control (6.4% at five years).11 The overall survival benefit was mainly seen
with hyperfractionation (8.2% at five years) although these schedules are difficult to
implement and are not widely used (Level 1a).10 The Danish Head and Neck Cancer
Group (DAHANCA) regimen of six fractions per week showed an improvement of 10% in
five-year locoregional control in patients treated without chemotherapy with transiently
increased acute toxicity.12 In the meta-analysis the overall survival benefit of acceleration
without a total dose reduction was 2% at five years, and 1.7% at five years with a total dose
reduction.11 There was no benefit of altered fractionation for patients age >70 years old
(Level 1b).10,11
Elective lymph node and mucosal doses with IMRT

A biological equivalent dose (EQD2) of 50 Gy in 25 fractions is a standard dose to electively
treat lymph node regions. Although there is no direct evidence of the need for higher doses
for microscopic disease, some centres favour the use of an additional ‘intermediate’ risk
higher elective dose, such as a biological equivalent to 60 Gy in 30 fractions, to regions
deemed to be at higher risk of harbouring disease, particularly radiologically equivocal
areas for nodal disease (Level 4).10,13
In the management of head and neck carcinomas of unknown primary, commonly used
mucosal doses are the biological equivalent of 50–60 Gy in 25–30 fractions.14–17 Several
series have suggested that doses at the lower end of this dose range are associated with
very low rates of subsequent emergence of a mucosal primary (Level 4).10,15–17
To incorporate elective lymph node and mucosal doses into a single phase IMRT plan, two
approaches to dose fractionation can be adopted: i) accept moderate hypofractionation to
sites of known disease while retaining a conventional fraction size (1.8–2 Gy) for elective
lymph node treatment or ii) retain a conventional fraction size to known disease and deliver
a reduced fraction size to the elective lymph node regions (for example, 1.5–1.6 Gy). An
increasing number of series suggest that elective lymph node irradiation may be safely
delivered with a reduced fraction size (Level 4).11,18
Recommendations
For elective nodal treatment using IMRT with a matched lower neck technique:
50 Gy in 25 fractions over 5 weeks to the matched neck (Grade C)
Elective treatment within the IMRT plan, the following dose levels
are appropriate:
60 Gy in 30 fractions over 6 weeks or 63 Gy in 35 fractions over 7 weeks may be
additionally used for ‘intermediate’ risk regions (Grade D)
Radiotherapy alone for early stage (I/II) oropharynx/hypopharnx/larynx

cancer (excluding T1/2 glottic carcinoma)
Single modality treatment with surgery or radiotherapy is the standard of care. The relative
merits of conventional versus altered fractionation remain unclear. IMRT with modest
acceleration has shown high rates of local control with low rates of late toxicity.19 Patients
with early stage disease accounted for >50% of patients in the DAHANCA 6 and 7 trial
which demonstrated a substantial benefit of shortening overall treatment time without
reduction in total dose (66–68 Gy in 33–34 fractions delivered at five versus six fractions
per week).12 In a meta-analysis, there was no clear benefit for altered fractionation for the
subgroup with stage I/II disease (Level 1a).10,11
Recommendations
Stage I/II oropharynx, hypopharynx or non-glottic larynx cancer:
66 Gy in 33 fractions or 70 Gy in 35 fractions, 6 fractions per week over 6 weeks (Grade B)
Radiotherapy with concomitant chemotherapy for stage III/IVa/b

HNSCC (excluding nasopharyngeal carcinoma)
Radiotherapy with concurrent cisplatin is the current standard of care for the definitive
management of stage III/IV patients <70 years of age with adequate performance
status.20 The international standard schedule is 70 Gy in 35 fractions.20 Although not
directly compared, a modestly hypofractionated schedule of 65–66 Gy in 30 fractions
has been adopted as standard practice in a number of UK trials and centres.21 There has
been considerable interest in combining perceived benefits of altered fractionation with
concurrent chemotherapy. However, the Radiation Therapy Oncology Group (RTOG)
0129 trial compared 72 Gy in 42 fractions delivered over six weeks with two cycles of
concurrent chemotherapy with a standard arm of 70 Gy in 35 fractions over seven weeks
with three cycles of concurrent chemotherapy with no difference seen between the arms.22
The three arm Groupe d’Oncologie Radiothérapie Tête et Cou (GORTEC) 99-02 phase
III trial compared 70 Gy in 35 fractions over seven weeks with three cycles of concurrent
chemotherapy with 70 Gy over six weeks with two cycles of concurrent chemotherapy and
a very accelerated radiotherapy alone arm of 64.8 Gy in 3.5 weeks; there was no benefit of
modest acceleration with concurrent chemotherapy while the accelerated radiotherapy
alone arm was inferior (Level 1b).10,23 These data support a hypothesis that concurrent
cisplatin may suppress tumour repopulation during radiotherapy, leading to a lower than
expected tumour biologically equivalent dose with modestly accelerated schedules.24
Reported outcomes for hypofractionated IMRT schedules with concomitant chemotherapy
(65 Gy in 30 fractions over six weeks or 55 Gy in 20 fractions over four weeks) do not as yet
support this hypothesis (Level 2b).10,21,25
In patients with oropharyngeal cancer, the tumour human papilloma virus (HPV) status
has been identified as a strong and independent prognostic factor for survival.26 In the
anticipation of robust evidence from ongoing de-escalation studies, radiotherapy dose and
fractionation for HPV positive oropharyngeal carcinomas should be no different to that for
HPV negative oropharyngeal tumours (Grade D).10
Recommendations
Radiotherapy with concomitant chemotherapy:
those proposed by the Oxford Centre for Evidence-based Medicine.10
Radiotherapy alone for stage III/IVa/b HNSCC (excluding

nasopharyngeal carcinoma)
The meta-analysis does not show a benefit of concomitant chemotherapy in patients >70
years old (Level 1a).10,20 Concomitant chemotherapy or cetuximab may not be appropriate
for some patients <70 years old due to co-morbidity, fitness or patient choice. Altered
fractionation is an option for fit patients <70 years old treated with radiotherapy alone with
superior local control and no increase in late toxicity; meta-analysis of altered fractionation
studies did not show a benefit for alterated fractionation in patients ≥70 years old
(Level 1a).10,11,12,27
Recommendations
Radiotherapy without concomitant radiotherapy:
66 Gy in 33 fractions or 70 Gy in 35 fractions, 6 fractions per week, over 6 weeks (Grade A)
Postoperative radiotherapy
There are few studies of radiation dose with postoperative radiotherapy with or without
chemotherapy. Historical studies suggest that for adjuvant radiotherapy alone, patients
with extracapsular extension benefitted from doses of 63 Gy and for other patients there
was no benefit >57.6 Gy (Level 2b).10,28 Adjuvant doses of 60–66 Gy in 30–33 fractions were
used in the RTOG and European Organisation for Research and Treatment of Cancer
(EORTC) trials investigating the role of concurrent chemotherapy.29,30 A pooled analysis
identified subgroups with close/positive margins and/or extracapsular spread as benefiting
from concurrent cisplatin (Level 2a).10,31 Based on limited evidence of a dose-effect in the
adjuvant setting, a dose of 66 Gy in 33 fractions is considered standard in the presence of
high-risk pathological findings, and 60 Gy in 30 fractions is widely used in the absence of
high-risk features.32,33 Doses equivalent to 50–54 Gy in 2 Gy per fraction are commonly used
for lower risk areas at risk of microscopic disease (Level 4).10,33
Recommendation
Postoperative radiotherapy:
A dose of up to 66 Gy in 33 fractions over 6.5 weeks may be delivered to high-risk
subvolumes (areas surrounding extracapsular spread and/or positive/close margins)
(Grade B)
Nasopharyngeal carcinoma
Radiotherapy alone is used for early stage nasopharyngeal carcinoma.34 For locally
advanced disease, conventionally fractionated radiotherapy combined with chemotherapy
is currently recommended. RTOG phase 2 trials have used a high, intermediate and elective
three dose level approach of 70 Gy, 59.4 Gy and 54 Gy in 33 fractions (Level 2b).10,35 A case
series of altered fractionation using 65 Gy in 30 fractions with an elective dose level of 54 Gy
in 30 fractions has reported disease outcomes and toxicity (Level 4).10,36 Doses biologically
equivalent to 50–60 Gy in 2 Gy per fraction are commonly used to treat at-risk sites.34
Recommendations
Nasopharyngeal cancer:
Palliative radiotherapy schedules

Palliative radiotherapy is used in a very heterogenous group of patients, and may range
from the use of a single fraction to stop bleeding/fungation to the use of high doses to
achieve longer-term disease control while accepting that a cure is not possible. Decisions
with regard to palliative radiotherapy dose fractionation take into account symptoms,
disease extent and co-morbidity. When higher doses are delivered, three-dimensional (3D)
conformal radiotherapy or IMRT are often required due to proximity to critical structures.
There is no consensus for palliative radiotherapy for locally advanced head and neck
Recommendations
cancer.37
Examples of appropriate dose fractionations include:
40 Gy in 10 fractions over 4 weeks ‘split course’ (Level C)38
21 Gy in 3 fractions over 3 weeks (Level C)39
20 Gy in 5 fractions over 1 week (Level C)40
14 Gy in 4 fractions which may be repeated 2 further times every 4 weeks (Level C)41
Re-irradiation
Re-irradiation with curative intent can be an option for selected patients with limited local
recurrence or new primary disease who are unsuitable for surgical treatment/decline
surgery. Re-irradiation may also be considered following salvage surgery with adverse
histological features (for example, positive margins, extracapsular spread). Patient
selection, choice of dose fractionation and dose constraints are individualised dependent
on the extent of recurrence, time from previous radiotherapy, sequalae of prior treatment,
proximity to organs at risk, performance status, co-morbidity and nutritional status.
Radiotherapy target volumes are limited to high-risk areas only and do not include elective
regions. Ideally the aim should be to deliver a dose equivalent of ≥60 Gy in 2 Gy per fraction,
although the dose may need to be reduced on an individual basis if organ at risk tolerances
are exceeded.40,41 Hyperfractionation with bi-daily irradiation at approximately 1.2 Gy per
fraction can be considered (Grade C).10,41 The use of concomitant radiosensitising agents
should only be used with extreme caution.
References 1. Ho KF, Fowler JF, Sykes AJ, Yap BK, Lee LW, Slevin NJ. IMRT dose fractionation for head and neck
cancer: variation in current approaches will make standardisation difficult. Acta Oncol 2009; 48(3):
431–439.
2. Le QT, Fu KK, Kroll S et al. Influence of fraction size, total dose, and overall time on local control of T1-T2
glottic carcinoma. Int J Radiat Oncol Biol Phys 1997; 39(1): 115–126.
3. Yamazaki H, Nishiyama K, Tanaka E, Koizumi M, Chatani M. Radiotherapy for early glottic carcinoma
(T1N0M0): results of prospective randomized study of radiation fraction size and overall treatment
time. Int J Radiat Oncol Biol Phys 2006; 64(1): 77–82.
4. Chera BS, Amdur RJ, Morris CG, Kirwan JM, Mendenhall WM. T1N0 to T2N0 squamous cell carcinoma
of the glottic larynx treated with definitive radiotherapy. Int J Radiat Oncol Biol Phys 2010; 78(2):
461–466.
5. Gowda RV, Henk JM, Mais KL, Sykes AJ, Swindell R, Slevin NJ. Three weeks radiotherapy for T1 glottic
cancer: the Christie and Royal Marsden Hospital Experience. Radiother Oncol 2003; 68(2): 105–111.
6. Cheah NL, Lupton S, Marshall A, et al. Outcome of T1N0M0 squamous cell carcinoma of the larynx
treated with short-course radiotherapy to a total dose of 50 Gy in 16 fractions: the Birmingham
experience. Clin Oncol (R Coll Radiol) 2009; 21(6): 494–501.
7. Ermis E, Teo M, Dyker KE, Fosker C, Sen M, Prestwich RJ. Definitive hypofractionated radiotherapy for
early glottic carcinoma: experience of 55 Gy in 20 fractions. Radiat Oncol 2015; 10: 203.
8. Short S, Krawitz H, Macann A et al. TN/TN glottic carcinoma: a comparison of two fractionation
schedules. Australas Radiol 2006; 50(2): 152–157.
9. Trotti A 3rd, Zhang Q, Bentzen SM et al. Randomized trial of hyperfractionation versus conventional
fractionation in T2 squamous cell carcinoma of the vocal cord (RTOG 9512). Int J Radiat Oncol Biol
Phys 2014; 89(5): 958–963.
11. Bourhis J, Overgaard J, Audry H et al. Hyperfractionated or accelerated radiotherapy in head and neck
cancer: a meta-analysis. Lancet 2006; 368(9538): 843–854.
12. Overgaard J, Hansen HS, Specht L et al. Five compared with six fractions per week of conventional
radiotherapy of squamous-cell carcinoma of head and neck: DAHANCA 6 and 7 randomised
controlled trial. Lancet 2003; 362(9388): 933–940.
13. Pettit L, Hartley A, Bowden SJ et al. Variation in volume definition between UK head and neck
oncologists treating oropharyngeal carcinoma. Clin Oncol (R Coll Radiol) 2011; 23(9): 654–655.
14. Sher DJ, Balboni TA, Haddad RI et al. Efficacy and toxicity of chemoradiotherapy using intensity-
modulated radiotherapy for unknown primary of head and neck. Int J Radiat Oncol Biol Phys 2011;
80(5): 1405–1411.
15. Chen AM, Farwell DG, Lau DH, Li BQ, Luu Q, Donald PJ. Radiation therapy in the management of
head-and-neck cancer of unknown primary origin: how does the addition of concurrent chemotherapy
affect the therapeutic ratio? Int J Radiat Oncol Biol Phys 2011; 81(2): 346–352.
16. Frank SJ, Rosenthal DI, Petsuksiri J et al. Intensity-modulated radiotherapy for cervical node squamous
cell carcinoma metastases from unknown head-and-neck primary site: M. D. Anderson Cancer Center
outcomes and patterns of failure. Int J Radiat Oncol Biol Phys 2010; 78(4): 1005–1010.
References 17. Shoushtari A, Saylor D, Kerr KL et al. Outcomes of patients with head-and-neck cancer of unknown
primary origin treated with intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys 2011; 81(3):
e83–e91.
18. Bedi M, Firat S, Semenenko VA et al. Elective lymph node irradiation with intensity-modulated
radiotherapy: is conventional dose fractionation necessary? Int J Radiat Oncol Biol Phys 2012; 83(1):
e87–e92.
19. Eisbruch A, Harris J, Garden AS et al. Multi-institutional trial of accelerated hypofractionated intensity-
modulated radiation therapy for early-stage oropharyngeal cancer (RTOG 00-22). Int J Radiat Oncol
Biol Phys 2010; 76(5): 1333–1338.
20. Pignon JP, le Maitre A, Maillard E, Bourhis J, MACH-NC Collaborative Group. Meta-analysis of
chemotherapy in head and neck cancer (MACH-NC): an update on 93 randomised trials and 17,346
patients. Radiother Oncol 2009; 92(1): 4–14.
21. Nutting CM, Morden JP, Harrington KJ et al. Parotid-sparing intensity modulated versus conventional
radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial.
Lancet Oncol 2011;12(2): 127–136.
22. Nguyen-Tan PF, Zhang Q, Ang KK et al. Randomized phase III trial to test accelerated versus standard
fractionation in combination with concurrent cisplatin for head and neck carcinomas in the Radiation
Therapy Oncology Group 0129 trial: long-term report of efficacy and toxicity. J Clin Oncol 2014; 32(34):
3858–3866.
23. Bourhis J, Sire C, Graff P et al. Concomitant chemoradiotherapy versus acceleration of radiotherapy
with or without concomitant chemotherapy in locally advanced head and neck carcinoma (GORTEC
99-02): an open-label phase 3 randomised trial. Lancet Oncol 2012; 13(2): 145–153.
24. Meade S, Sanghera P, McConkey C et al. Revising the radiobiological model of synchronous
chemotherapy in head-and-neck cancer: a new analysis examining reduced weighting of accelerated
repopulation. Int J Radiat Oncol Biol Phys 2013; 86(1): 157–163.
25. Benghiat H, Sanghera P, Cashmore J et al. Four week hypofractionated accelerated intensity
modulated radiotherapy and synchronous carboplatin or cetuximab in biologically staged
oropharyngeal carcinoma. Cancer and Clinical Oncology 2014; 3(2): 2.
26. Ang KK, Harris J, Wheeler R et al. Human papillomavirus and survival of patients with oropharyngeal
cancer. N Engl J Med 2010; 363(1): 24–35.
27. Beitler JJ, Zhang Q, Fu KK et al. Final results of local-regional control and late toxicity of RTOG 9003:
a randomized trial of altered fractionation radiation for locally advanced head and neck cancer. Int J
28. Peters LJ, Goepfert H, Ang KK et al. Evaluation of the dose for postoperative radiation therapy of head
and neck cancer: first report of a prospective randomized trial. Int J Radiat Oncol Biol Phys 1993; 26(1):
3–11.
29. Cooper JS, Pajak TF, Forastiere AA et al. Postoperative concurrent radiotherapy and chemotherapy for
high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 2004; 350(19): 1937–1944.
30. Bernier J, Domenge C, Ozsahin M et al. Postoperative irradiation with or without concomitant
chemotherapy for locally advanced head and neck cancer. N Engl J Med 2004; 350(19): 1945–1952.
31. Bernier J, Cooper JS, Pajak TF et al. Defining risk levels in locally advanced head and neck cancers: a
comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC
(#22931) and RTOG (# 9501). Head Neck 2005; 27(10): 843–850.
32. Langendijk JA, Ferlito A, Takes RP et al. Postoperative strategies after primary surgery for squamous
cell carcinoma of the head and neck. Oral Oncol 2010; 46(8): 577–585.
33. Expert Panel on Radiation Oncology-Head and Neck, Salama JK, Saba N et al. ACR appropriateness
criteria® adjuvant therapy for resected squamous cell carcinoma of the head and neck. Oral Oncol
2011; 47(7): 554–559.
34. Lee AW, Lin JC, Ng WT. Current management of nasopharyngeal cancer. Semin Radiat Oncol 2012;
22(3): 233–244.
35. Lee N, Harris J, Garden AS et al. Intensity-modulated radiation therapy with or without chemotherapy
for nasopharyngeal carcinoma: radiation therapy oncology group phase II trial 0225. J Clin Oncol 2009;
27(22): 3684–3690.
36. Boon CS, Hartley A, Sanghera P. Initial efficacy of hypofractionated accelerated chemo-tomotherapy(r)
for nasopharyngeal carcinoma. Clin Oncol (R Coll Radiol) 2015; 27(8): 484–485.
37. Shahid Iqbal M, Kelly C, Kovarik J et al. Palliative radiotherapy for locally advanced non-metastatic head
and neck cancer: A systematic review. Radiother Oncol 2018; 126: 558–567.
38. Kancherla KN, Oksuz DC, Prestwich RJ et al. The role of split-course hypofractionated palliative
radiotherapy in head and neck cancer. Clin Oncol (R Coll Radiol) 2011; 23(2): 141–148.
39. Nguyen NT, Doerwald-Munoz L, Zhang H et al. 0-7-21 hypofractionated palliative radiotherapy: an
effective treatment for advanced head and neck cancers. Br J Radiol 2015; 88(1049): 20140646.
40. Mohanti BK, Umapathy H, Bahadur S, Thakar A, Pathy S. Short course palliative radiotherapy of 20 Gy
in 5 fractions for advanced and incurable head and neck cancer: AIIMS study. Radiother Oncol 2004;
71(3): 275–280.
41. Corry J, Peters LJ, Costa ID et al. The ‘QUAD SHOT’ – a phase II study of palliative radiotherapy for
incurable head and neck cancer. Radiother Oncol 2005; 77(2): 137–142.
42. Strojan P, Corry J, Eisbruch A et al. Recurrent and second primary squamous cell carcinoma of the
head and neck: when and how to reirradiate. Head Neck 2015; 37(1): 134–150.
43. McDonald MW, Lawson J, Garg MK et al. ACR appropriateness criteria retreatment of recurrent head
and neck cancer after prior definitive radiation expert panel on radiation oncology-head and neck
cancer. Int J Radiat Oncol Biol Phys 2011; 80(5): 1292–1298.
7. Background
Overall survival has increased in lung cancer in the past ten years, with the vast majority of
Lung cancer the gains occurring in disease stages I–III. There has been very little, if any improvement
seen in outcomes for stage IV patients.1,2 Several publications have looked at access to
radiotherapy treatments (Level 2a).3–5 Although many of these do not distinguish between
radical and palliative treatment, it appears that the proportion of lung cancer patients in the
UK accessing radiotherapy remains lower than expected.
Lung cancer staging has improved with routine use of positron emission tomography-
computed tomography (PET-CT) and endobronchial ultrasound (EBUS). Routine use
of intravenous (IV) contrast in planning has improved mediastinal target delineation.
Significant technological advances have taken place in the delivery of radiotherapy. For
radical radiotherapy, four-dimensional computed tomography (4DCT) planning is replacing
three-dimensional conformal radiotherapy (3DCRT) as the standard of care. Bulky tumours
in certain anatomical locations, such as the paravertebral gutter, have improved dosimetry
with intensity-modulated radiotherapy (IMRT) and can more often meet normal tissue
constraints (NTC) than those planned conformally (Level 2c).5–7 However, as with many
tumour types, there is insufficient evidence to determine the efficacy of IMRT (Level 4).5,7,8
Non-small cell lung cancer (NSCLC): curative therapy

Background
For patients with stage I and II lung cancer, anatomically based surgical resection remains
the treatment of choice. There is an emerging body of literature to support ablative
therapies in node-negative patients, of which stereotactic ablative radiotherapy (SABR)
has the most mature evidence base. There are, as yet, no completed randomised studies.
The two international randomised studies, which closed due to poor accrual, have been
published in pooled form (Level 2b).5,9 There are a number of multi-institutional prospective
as well as retrospective series. Most concentrate on medically inoperable patients who are,
by definition, less well than their surgical counterparts. Published outcomes both in terms
of overall survival (OS) and disease-free survival (DFS) approach surgical series. Two-year
survival has been reported as 70% and five-year survival 43%.10,11
For medically inoperable patients with node negative tumours less than 5 centimetres (cm)
and in a favourable anatomical position, stereotactic ablative radiotherapy (SABR) is the
treatment of choice. The best outcomes occur when the tumour receives >100 Gray (Gy)
equivalent dose in 2 Gy per fraction EQD2 biologically equivalent dose (BED). Treatment
should be delivered with an interfraction interval of greater than 40 hours but less than four
days (Level 2a).5,12
Stage III NSCLC is an extremely heterogeneous group in terms of tumour size and extent
of nodal involvement. Concurrent chemoradiotherapy has been demonstrated in meta-
analyses to give superior outcomes when compared with sequential chemoradiotherapy
or radiotherapy alone, but the optimum dose fractionation schedule has yet to be defined
(Level 1a).5,13–15 Concurrent schedules have an increased incidence of grade three
oesophageal toxicities (Level 1b) and elderly patients with good performance status and
few co-morbidities derive as much benefit from concurrent therapy as their younger
counterparts (Level 1b).5,16
Although trimodality therapy remains an option, there is no evidence of benefit over
definitive chemoradiotherapy. The only tumour group where there is some evidence to
support the use of trimodality therapy is Pancoast tumours (Level 1b).5,17
There is no evidence of benefit for chemotherapy delivered either neoadjuvantly or
adjuvantly to those receiving concurrent regimes (Level 1b).5
Dose escalation has been investigated in many studies. The recently published Radiation
Therapy Oncology Group (RTOG) 0617 trial did not demonstrate a survival benefit in the
escalated arm. This trial has received significant interest and review of individual data. The
quality assurance of the radiotherapy delivered may have been the cause of the lack of a
positive outcome so it is likely that this issue will be revisited (Level 1b).5,18
For those unable to tolerate concurrent chemoradiotherapy, a sequential approach
demonstrates survival benefit over radiotherapy alone.15 The optimum therapy schedule
has yet to be defined (Level 1a).5
Patients unfit for systemic therapy should be treated with radiotherapy alone. Accelerated
fractionation schedules seem to improve outcomes (Level 1b) and can be safely combined
with concurrent and neoadjuvant approaches (Level 1b).5,15,19–22
Recommendations
Medically inoperable T1–3 (≤5 cm) N0:
SABR using:
54 Gy in 3 fractions over 5–8 days (Grade B)
Medically inoperable stage I and II:
54 Gy in 36 fractions treating thrice daily over 12 consecutive days continuous,
hyperfractionated, accelerated radiotherapy (CHART) (Grade A)
55 Gy in 20 fractions (Grade C)
STAGE III:
Concurrent:
55 Gy in 20 fractions over 4 weeks with cisplatin and vinorelbine (Grade A)
60 Gy in 30 fractions over 6 weeks with cisplatin and etoposide (Grade A)
66 Gy in 33 fractions over 6.5 weeks with cisplatin and etoposide (Grade A)
Sequential:
54 Gy in 36 fractions treating thrice daily over 12 consecutive days (CHART) (Grade B)
Radiotherapy alone:
54 Gy in 36 fractions treating thrice daily over 12 consecutive days (CHART) (Grade A)
55Gy in 20 fractions over 4 weeks (Grade B)
Pancoast tumours (T3–4 N0–1):
45 Gy in 25 fractions over 5 weeks with cisplatin and etoposide followed by surgery
(Level 2b)
Non-small cell lung cancer (NSCLC): palliative radiotherapy

Background
The early trials were undertaken predominantly in patients unexposed to chemotherapy.
Current practice would see a significant proportion of patients receiving sequential
chemoradiotherapy, with good performance status (PS) stage III patients managed with
radical concurrent chemoradiotherapy.
Overall the trials demonstrate that short-course radiotherapy can palliate intrathoracic
symptoms as well as long-course, but for those with good PS, higher doses confer a
moderate survival advantage at the expense of extra toxicity (Level 1a).5,23
Recommendations
For those with good PS:
39 Gy in 13 fractions over 2.5 weeks with cord dose limited to 36 Gy (Grade A)
20 Gy in 5 fractions over 1 week (Grade A)
For those with poor PS:
17 Gy in 2 fractions over 8 days (Grade A)
10 Gy in 1 fractions (Grade A)
Small cell lung cancer (SCLC)

Background
The evidence base now favours integration of chemotherapy and radiotherapy at all disease
stages (Level 1a).5
Concurrent chemoradiotherapy (stages I–III)

For patients with T1–4 and N0–3 SCLC, there is evidence for concurrent
chemoradiotherapy with radiotherapy starting no later than day one cycle three of
chemotherapy (Level 1a).5,24 The UK-led phase III Concurrent Once-Daily Versus Twice Daily
Radiotherapy (CONVERT) trial has compared the internationally accepted standard of 45
Gy in 30 fractions treating twice daily over three weeks with 66 Gy in 33 daily fractions over
six weeks, finding no difference between the two schedules.25,26 In addition, a US intergroup
study is currently recruiting, which compares three fractionation schedules (45 Gy in 30
fractions treating twice daily; 70 Gy in 35 daily fractions and 61.2 Gy over five weeks treating
once daily until day 21 and twice daily thereafter) (Level 1b).5
One trial of early versus late concurrent thoracic radiotherapy used 40 Gy in 15 daily
fractions using a simple parallel opposed pair with cord shielding (Level 1b).5,24 This can
shield the tumour and, in the modern era, cord constraints would be met using 3DCRT.
Sequential chemoradiotherapy (stages I–III)

For those patients who, due to tumour size or co-morbidities, cannot be treated with
concurrent chemoradiotherapy, sequential chemoradiotherapy is the best alternative (Level
1a).5 There is no definitive evidence to indicate the optimal schedule in this patient group,
although many use 40 Gy in 15 daily fractions (Level 2b).5
Recommendations
Concurrent chemoradiotherapy with cisplatin and etoposide should be
delivered with either:
45 Gy in 30 fractions treating twice daily over 3 weeks (Grade A)
Sequential chemoradiotherapy:
SCLC: palliative thoracic radiotherapy

Background
A recent European Organisation for Research and Treatment of Cancer (EORTC) trial
randomised 498 patients with metastatic SCLC, who had not progressed during primary
chemotherapy to prophylactic cranial irradiation (PCI), with or without thoracic radiotherapy
with 30 Gy in ten daily fractions in addition. The trial did not meet its primary endpoint of
improved OS at one year, but OS at two years was in favour of mediastinal consolidation
(Level 1b).5,27 Further data analysis has confirmed the OS and DFS benefits are limited to
those with persistent intrathoracic disease (Level 1b).5,28
Recommendation
Those patients with metastatic SCLC who respond to primary chemotherapy but
have persistent intrathoracic disease or thoracic symptoms should be considered for
thoracic consolidation radiotherapy with 30 Gy in 10 fractions over 2 weeks (Grade A).
Prophylactic cranial irradiation (PCI) (stages I–III)

Meta-analysis of patients with stages I–III SCLC in complete or near complete thoracic
remission following primary chemoradiotherapy have an increased OS and decreased
incidence of intracerebral relapse when PCI is delivered (Level 1a).5,29,30
25 Gy in ten fractions over 14 days carries the same disease relapse rate but lower mortality
when compared with 36 Gy in 18 fractions over 24 days (Level 1a).5,30
Recommendations
Selected patients with locally advanced metastatic SCLC who respond to
primary chemotherapy should be offered PCI. Acceptable schedules are:
Prophylactic cranial irradiation (PCI) (stage IV)

Patients with stage IV SCLC who had any response to primary chemotherapy were
randomised to either PCI with one of five schedules (20–30 Gy in 5–12 daily fractions) or no
PCI. The treatment arms had an increased OS and reduced symptomatic incidence of brain
metastases (Level 1b).5 85% of patients were treated with either 30 Gy in ten fractions or 20
Gy in five fractions. Two thirds received 20 Gy in five fractions. The trial excluded patients
above 75 years of age.31
Recommendations
Selected patients with metastatic SCLC who respond to primary chemotherapy
should be offered PCI. Acceptable schedules are:
Mesothelioma
Background
The use of prophylactic irradiation of tracts of pleural interventions has been thought to
reduce the incidence of chest wall recurrence. Three small randomised studies have
been reported, one demonstrating benefit, two not (Level 1b).5,32–34 Currently in the UK, two
studies are addressing this issue. The Prophylactic Irradiation of Tracts (PIT) trial (closed
to recruitment in December 2015) randomises those with a visible scar following minor
pleural interventions between 21 Gy in three daily fractions using electrons or no treatment.
The Simultaneous Modulated Accelerated Radiation Therapy (SMART) trial randomised
those with larger pleural interventions between immediate radiotherapy with 21 Gy in
three daily fractions or treatment deferred until tract metastases occurred. The SMART
trial has been verbally presented (January 2016), with no benefit of immediate radiotherapy
demonstrated.35
For those patients with a diagnosis of mesothelioma and chest wall pain, controversy exists
about the utility of radiotherapy, especially where the pain is poorly localised. A recently
published non-randomised study demonstrates a 35% response rate when chest wall
radiotherapy is delivered to patients with localised pain (Level 2c).5,36
Recommendation
Routine prophylactic irradiation of tracts is not recommended (Level 1b)
Selected patients with chest wall pain may benefit from radiotherapy with either:
20 Gy in 5 fractions over 1 week (Grade C)
36 Gy in 6 fractions treating twice per week (Grade D)
References 1. www.hqip.org.uk/ncapop-library/#cancer (last accessed 28/9/16)
2. National Cancer Intelligence Network Survival by stage (NCIN) 2014:

www.ncin.org.uk/publications/survival_by_stage (last accessed 28/9/16)
3. Koning CC, Aarts MJ, Struikmans H et al. Mapping use of radiotherapy for patients with non-small cell
lung cancer in the Netherlands between 1997 and 2008. Clin Oncol (R Coll Radiol) 2012; 24(2): e46–
e53.
4. Delaney GP and Barton MB. Evidence-based estimates of the demand for radiotherapy. Clin Oncol (R
Coll Radiol) 2015; 27(2): 70–76.
5. w
6. Harris JP, Murphy JD, Hanlon AL, Le QT, Loo BW Jr, Diehn M. A population-based comparative
effectiveness study of radiation therapy techniques in stage III non-small cell lung cancer. Int J Radiat
Oncol Biol Phys 2014; 88(4): 872–884.
7. Chan C, Lang S, Rowbottom C et al. Intensity-modulated radiotherapy for lung cancer: current status
and future developments. J Thorac Oncol 2014; 9(11): 1598–1608.
8. Bezjak A, Rumble RB, Rodrigues G, Hope A, Warde P, Members of the IMRT Indications Expert Panl.
Intensity-modulated radiotherapy in the treatment of lung cancer. Clin Oncol (R Coll Radiol) 2012;
24(7): 508–520.
9. Chang JY, Senan S, Paul MA et al. Stereotactic ablative radiotherapy versus lobectomy for operable
stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol 2016;
16(6): 630–637.
10. Zheng X, Schipper M, Kidwell K et al. Survival outcome after stereotactic body radiation therapy and
surgery for stage I non-small cell lung cancer: a meta-analysis. Int J Radiat Oncol Biol Phys 2011; 90(3):
603–611.
11. Shirvani SM, Jiang J, Chang JY et al. Comparative effectiveness of 5 treatment strategies for early-stage
non-small cell lung cancer in the elderly. Int J Radiat Oncol Biol Phys 2012; 84(5): 1060–1070.
12. SABR UK Consortium. Stereotactic ablative radiotherapy (SABR): A resource. Version 5.0. Manchester:
SABR UK Consortium, 2015.
13. Aupérin A, Le Péchoux C, Pignon JP et al. Concomitant radio-chemotherapy based on platin

compounds in patients with locally advanced non-small cell lung cancer (NSCLC): a meta-analysis of
individual data from 1764 patients. Ann Oncol 2006; 17(3): 473–483.
14. O’Rourke N, Roqué i Figuls M, Farré Bernadó N, Macbeth F. Concurrent chemoradiotherapy in non-
small cell lung cancer. Cochrane Database Syst Rev 2010; 16(6): CD002140.
15. Maguire J, Khan I, McMenemin R et al. SOCCAR: A randomised phase II trial comparing sequential
versus concurrent chemotherapy and radical hypofractionated radiotherapy in patients with
inoperable stage III non-small cell lung cancer and good performance status. Eur J Cancer 2014;
50(17): 2939–2949.
16. Jalal SI, Riggs HD, Melnyk A et al. Updated survival and outcomes for older adults with inoperable
stage III non-small-cell lung cancer treated with cisplatin, etoposide, and concurrent chest radiation
with or without consolidation docetaxel: analysis of a phase III trial from the Hoosier Oncology Group
(HOG) and US Oncology. Ann Oncol 2012; 805(23): 1730–1738.
17. Rusch VW, Giroux DJ, Kraus MJ et al. Induction chemoradiation and surgical resection for superior
sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416
(Intergroup trial 0160). J Clin Oncol 2007; 25(3): 313–318.
18. Bradley JD, Paulus R, Komaki R et al. Standard-dose versus high-dose conformal radiotherapy with
concurrent and consolidation carboplatin plus paclitaxel with or without cetuximab for patients with
stage IIIA or IIIB non-small cell lung cancer (RTOG 0617): a randomised, two-by-two factorial phase 3
study. Lancet Oncol 2015; 16 (2): 187–199.
19. Saunders M, Dische S, Barrett A, Harvey A, Gibson D, Palmar M. Continuous hyperfractionated

accelerated radiotherapy (CHART) versus conventional radiotherapy in non-small cell lung cancer: a
randomised multicentre trial. CHART Steering Committee. Lancet 1997; 350(9072): 161–165.
20. Mauguen A, Le Péchoux C, Saunders MI et al. Hyperfractionated or accelerated radiotherapy in lung

cancer: an individual patient data meta-analysis. J Clin Oncol 2102; 30(22): 2788–2297.
21. Hatton M, Nankivell M, Lyn E et al. Induction chemotherapy and continuous hyperfractionated
accelerated radiotherapy (CHART) for patients with locally advanced inoperable non-small-cell lung
cancer: the MRC INCH randomized trial. Int J Radiat Oncol Biol Phys 2011; 81(3): 712–718.
22. Price A, Yellowlees A, Keerie C et al. Radical radiotherapy with or without gemcitabine in patients with
early stage medically inoperable non-small cell lung cancer. Lung Cancer 2012; 77(3): 532–536.
23. Lester JF, Macbeth F, Toy E, Coles B. Palliative radiotherapy regimens for non-small-cell lung cancer.
Cochrane Database Syst Rev 2006; 18(4): CD002143.
24. Murray N, Coy P, Pater JL et al. Importance of timing for thoracic irradiation in the combined modality
treatment of limited-stage small-cell lung cancer. The National Cancer Institute of Canada Clinical
Trials Group. J Clin Oncol 1993; 11(2): 336–344.
25. Faivre-Finn C, Snee M, Ashcroft L et al. CONVERT: An international randomised trial of concurrent
chemo-radiotherapy (cCTRT) comparing twice-daily (BD) and once-daily (OD) radiotherapy schedules
in patients with limited stage small cell lung cancer (LS-SCLC) and good performance status (PS). J
Clin Oncol 2016; 34: (suppl; abstr 8504).
26. Turrisi AT 3rd, Kim K, Blum R et al. Twice-daily compared with once-daily thoracic radiotherapy in
limited small cell lung cancer treated concurrently with cisplatin and etoposide. N Engl J Med 1999;
340(4): 265–271.
27. Slotman BJ, van Tinteren H, Praag JO et al. Use of thoracic radiotherapy for extensive stage small-cell
lung cancer: a phase 3 randomised controlled trial. Lancet 2015; 385(9962): 36–42.
28. Slotman BJ, van Tinteren H, Praag JO et al. Which patients with extensive-stage small cell lung cancer
(ES-SCLC) are most likely to benefit from routine thoracic radiotherapy (TRT) following chemotherapy?
Lancet (in press).
29. Aupérin A, Arriagada R, Pignon JP et al. Prophylactic cranial irradiation for patients with small-cell lung
cancer in complete remission. Prophylactic Cranial Irradiation Overview Collaborative Group. N Engl J
Med 1999; 341(7): 476–484.
30. Le Péchoux C, Dunant A, Senan S et al. Prophylactic Cranial Irradiation (PCI) Collaborative Group.
Standard-dose versus higher-dose prophylactic cranial irradiation (PCI) in patients with limited-stage
small-cell lung cancer in complete remission after chemotherapy and thoracic radiotherapy (PCI 99-
01, EORTC 22003-08004, RTOG 0212, and IFCT 99-01): a randomised clinical trial. Lancet Oncol 2009;
10(5): 467–474.
References 31. Slotman B, Faivre-Finn C, Kramer G et al. Prophylactic cranial irradiation in extensive small-cell lung
cancer. N Engl J Med 2007; 357(7): 664–672.
32. Boutin C, Rey F, Viallat JR. Prevention of malignant seeding after invasive diagnostic procedures in
patients with malignant pleural mesothelioma. A randomised trial of local radiotherapy. Chest 1995;
108(3): 754–758.
33. Bydder S, Phillips M, Joseph DJ et al. A randomised trial of single dose radiotherapy to prevent
procedure tract metastases by malignant pleural mesothelioma. Br J Cancer 2004; 91(1): 9–10.
34. O’Rourke N, Garcia JC, Paul J, Lawless C, mcMenemin R, Hill J. A randomised controlled trial of
intervention site radiotherapy in malignant pleural mesothelioma. Radiother Oncol 2007; 84(1): 18–22.
35. Clive AO, Wilson P, Taylor H et al. Protocol for the surgical and large bore procedures in malignant
pleural mesothelioma and radiotherapy trial (SMART Trial): an RCT evaluating whether prophylactic
radiotherapy reduces the incidence of procedure tract metastases. BMJ Open 2015; 5(1): e006673.
36. MacLeod N, Chalmers A, O’Rourke N et al. Is radiotherapy useful for treating pain in mesothelioma?: A
phase II trial. J Thorac Oncol 2015; 10(6): 944–950.
8. Hodgkin lymphoma
Background
Lymphoma
Over the last 30 years, combination chemotherapy has become integral to the standard of
care for both early and late stage Hodgkin lymphoma. Previous techniques employing the
traditional mantle and inverted Y fields are no longer practiced. Involved field radiotherapy
(IFRT), which has been the standard until recently, is being replaced by involved node
radiotherapy (INRT) or involved-site radiotherapy (ISRT), further reducing the treated
volume for consolidation or residual disease after chemotherapy.1,2 There should be every
effort to reduce cardiac and lung doses when treating the mediastinum with good evidence
to support the use of intensity-modulated radiotheray (IMRT) and deep inspiration beath
hold (DIBH) in this setting.3
Early Hodgkin lymphoma

Studies by the German Hodgkin Disease Study Group have shown no difference in
outcome between two cycles of Adriamycin bleomycin vinblastine dacarbazine (ABVD)
and 20 Gray (Gy) in ten fraction IFRT in the favourable subgroup or four cycles of ABVD and
30 Gy IFRT in the unfavourable subgroup (Level 1b).4–6 Radiotherapy after chemotherapy
in PET-negative patients reduces the later risk of relapse, but the absolute reduction in
progression-free survival (PFS) was only 4% at three years in the RAPID trial (Level 1b).8,7
Recommendations
For patients with early Hodgkin lymphoma:
Favourable group: 2 cycles of ABVD chemotherapy followed by 20 Gy in 10 fractions
over 2 weeks (Grade A)
Unfavourable group: 4 cycles of ABVD followed by 30 Gy in 15 fractions over 3 weeks
(Grade A)
For selected patients who are PET negative after thee cycles of ABVD, the relative risks
of relapse from omitting radiotherapy and the late toxicity from giving radiotherapy
should be considered and discussed with the patient (Grade A)
Advanced Hodgkin lymphoma

The role of radiotherapy in advanced Hodgkin disease after full-dose combination
chemotherapy is controversial. One overview showed that combined-modality therapy
conferred no survival benefit but did increase the risk of long-term fatal complications
(cardiac and second cancer), while another, using UK National Cancer Research Institute
(NCRI) study data, has shown an improved survival in patients with Hodgkin lymphoma who
received radiotherapy compared to those who did not (Level 1a).6,8,9 A European
Organisation for Research and Treatment of Cancer (EORTC) study demonstrated that
radiotherapy did not improve the outcome for patients who had a complete remission after
mustine, vincristine, procarbazine, prednisolone-adriamycin bleomycin vinblastine (MOPP-
ABV) chemotherapy, but that irradiation may benefit patients with a partial response after
chemotherapy (Level 1b).5,9
Recommendation
In advanced Hodgkin lymphoma, radiotherapy for residual disease is indicated after
partial response to chemotherapy.
30–34 Gy in 15–20 fractions over 3 to 4 weeks (Grade B)
Relapsed Hodgkin lymphoma

High-dose chemotherapy and stem cell transplantation remain the international standard of
care for many younger patients with relapsed Hodgkin lymphoma.
In some patients with a single site of relapse, particularly occurring late, after previous
treatment, re-induction as for early disease combined with IFRT may be appropriate, using
a dose of 30–34 Gy in 15–20 fractions over 3–4 weeks.
If the site has not previously been irradiated, radiotherapy alone has been used for selected
patients (Grade D).6,11
Recommendations
For palliative treatments no definitive recommendations can be made and dose will
depend on the clinical situation. The following may be used:
20 Gy in 5 fractions over 1 week (Grade D)
Single doses of 7–8 Gy (Grade D)
Nodular lymphocyte Hodgkin lymphoma

IFRT alone, without chemotherapy, results in high PFS and overall survival (OS) rates and is
considered an adequate treatment for early stage disease.12 A dose of 30 Gy in 15 fractions
over three weeks is recommended (Grade D).6
Aggressive non-Hodgkin lymphoma (NHL)

In aggressive lymphomas, radiotherapy alone is not recommended except in palliative
situations or where the patient is too frail for chemotherapy.
Consolidation IFRT in aggressive non-Hodgkin lymphoma

Following the landmark study comparing eight cycles of cyclophosphamide, doxorubicin,
vincristine and prednisone (CHOP) chemotherapy to three cycles of CHOP followed by
IFRT with 40–45 Gy in 1.8–2 Gy fractions, combined modality therapy was established
as the standard of care.13 Longer term follow-up has shown convergence of the survival
curves, as a result of an excess of relapses and deaths from lymphoma in the group given
CHOP plus radiotherapy (Level 1b).14,6 In a further study, patients who received eight
cycles of CHOP chemotherapy and achieved complete remission, 30 Gy in daily 2 Gy
fractions improved local control (Level 1b).15,16 A further trial in patients aged <61 years
with no adverse prognostic factors has shown improved event-free and overall survival
rates with doxorubicin, cyclophosphamide, vindesine, bleomycin and prednisone (ACVBP)
chemotherapy over those achieved by CHOP plus IFRT (Level 1b).6,16
There are therefore two treatment approaches to the patient with early aggressive NHL:
short-course immunochemotherapy rituximab, cyclophosphamide, doxorubicin, vincristine
and prednisone (R-CHOP) followed by IFRT or full-course R-CHOP with six to eight cycles
alone. The relative merits should be discussed with the patient. There is no evidence to
suggest that early PET response can be used to individualise treatment the schedule
at present.
Recent evidence from the rituximab with CHOP over age 60 years (RICOVER) trial suggests
that there may be a role for radiotherapy in advanced stage diffuse large B-cell lymphoma
(DLBCL) given to bulky sites of disease at presentation after chemotherapy (Level 2b).6,17
Radiotherapy is also considered for mediastinal B-cell lymphoma and extranodal sites after
full-course chemotherapy.18
A randomised trial of radiotherapy dose comparing 30 Gy to 40–45 Gy (all in daily two Gy
fractions) has demonstrated that in aggressive NHL 30 Gy is equivalent to a higher dose for
local PFS and OS. All patients with aggressive NHL receiving radiotherapy should therefore
be given 30 Gy in 15 fractions over three weeks (Level 1b).6,19
Recommendation
For patients with aggressive non-Hodgkin lymphoma:
30 Gy in 15 fractions over 3 weeks is recommended as part of planned combined
modality therapy (Grade B).
Mantle cell lymphoma

This disease has a poor prognosis. The vast majority of patients require systemic treatment,
although the standard of care is not yet established. In combined modality treatment, there
is no evidence that mantle cell lymphomas respond differently to radiation compared to
other aggressive lymphomas. A recent retrospective multi-institutional study of stage 1–2
patients reported favourable outcomes with combined modality or radiotherapy alone with
two-thirds and half of the patients being free of disease at five and ten years respectively.
Median dose was 35 Gy (range 12–45 Gy) (Grade C).6,20
Natural killer (NK)/T-cell lymphoma

This is a rare entity in Western countries but is common in East Asia and Latin America.20
Chemoradiation using cisplatin-based schedules and l-asparaginase are now standard,
followed by consolidation chemotherapy. This type of lymphoma requires a higher dose
than other T-cell lymphomas and a dose of at least 50 Gy in 25 fractions over five weeks
should be given (Grade C).6,22
Central nervous system lymphoma (CNS) lymphoma

The role of radiotherapy in CNS lymphoma is controversial in view of the significant late
effects on cognitive function. It may be indicated after chemotherapy, particularly where
there is an incomplete response and also in relapsed disease. Standard lymphoma doses
are considered inadequate in the CNS and recommended doses would be 40–45 Gy in
20–25 fractions over four to five weeks (Grade C).6,23
Mycosis fungoides
This will typically be a widespread skin infiltration with radiotherapy used for palliation of
thicker plaques. Doses of 8 Gy in two fractions or 12 Gy in three fractions are recommended
(Grade C).6,24
Indolent lymphoma
Indolent lymphoma includes follicular lymphoma, small lymphocytic lymphoma and
marginal zone lymphoma. Stage I indolent lymphoma has, for many years, been treated with
radical IFRT. In advanced stage indolent lymphoma, IFRT may be indicated for control of
local symptomatic disease.
A randomised trial comparing 24 Gy to 40 Gy (all in 2 Gy fractions) included patients with
early stage indolent lymphoma. There was no difference in local PFS or OS between these
two dose arms. A subsequent study randomised patients with follicular and marginal zone
lymphoma to receive either 24 Gy in 12 fractions or 4 Gy in two fractions. At 12 weeks,
the complete response rate was 68% after 24 Gy and 49% after 4 Gy. Local PFS was also
strongly in favour of the 24 Gy arm with a hazard ratio for local progression of 3.42 (95%
confidence interval [CI]: 2.10–5.57).Toxicity was low in both arms (Level 1b).6,25
Recommendation
For the radical treatment of stage I, indolent lymphoma, or durable palliation in
more advanced stages:
Palliative treatment of non-Hodgkin lymphoma

In patients with follicular lymphoma, high response rates have been achieved after low-
dose IFRT (4 Gy in 1 or 2 fractions), however, the randomised trial comparing 4 Gy to
24 Gy showed that, while effective in many patients, 4 Gy was inferior for local control
(Level 1b).6,25,26 Where short-term palliation is the aim of treatment, 4 Gy in 2 fractions may
be considered.
For aggressive lymphoma, a single dose of 8 Gy or short-course palliation such as 20 Gy
in five fractions or 30 Gy in ten fractions are effective and appropriate for the palliative
treatment of many patients with a limited prognosis (Grade D).6
Recommendations
In the palliative management of lymphoma, there is evidence to support the
following regimens:
Indolent lymphoma:
24 Gy in daily 2 Gy fractions over 2.5 weeks (Grade A)
For short-term palliation in follicular or marginal zone lymphoma:
4 Gy in 2 fractions (Grade A)
Intermediate/high-grade lymphoma:
Single dose 8–10 Gy (Grade D)
References 1. Hoskin PJ, Díez P, Williams M et al. Recommendations for the use of radiotherapy in nodal lymphoma.
Clin Oncol (R Coll Radiol) 2013; 25(1): 49–58.
2. Specht L, Yahalom J, Illidge T et al. Modern radiation therapy for Hodgkin lymphoma: field and dose
guidelines from the International Lymphoma Radiation Oncology Group (ILROG). Int J Radiat Oncol
Biol Phys 2014; 89(4): 854–862.
3. Aznar MC, Maraldo MV, Schut DA et al. Minimizing late effects for patients with mediastinal Hodgkin
lymphoma: deep inspiration breath-hold, IMRT, or both? In J Radiat Oncol Biol Phys 2015; 92(1):
169–174.
4. Engert A, Plutschow A, Eich HT et al. Reduced treatment intensity in patients with early-stage
Hodgkin’s lymphoma. N Engl J Med 2010; 363(7): 640–652.
5. Eich HT, Diehl V, Görgen H et al. Intensified chemotherapy and dose-reduced involved-field
radiotherapy in patients with early unfavourable Hodgkin’s lymphoma: Final analysis of the German
Hodgkin Study Group HD11 trial. J Clin Oncol 2010; 28(27): 4199–4206.
6.
7. Radford J, Illidge T, Counsell N et al. Results of a trial of PET-directed therapy for early-stage Hodgkin’s
lymphoma. N Eng J Med 2015; 372(17): 1598–1607.
8. Loeffler M, Brosteanu O, Hasenclever D et al. Meta-analysis of chemotherapy versus combined

modality treatment trials in Hodgkin’s disease. International database on Hodgkin’s Disease Overview
Study Group. J Clin Oncol 1998; 16(3): 818–829.
9. Johnson PW, Sydes MR, Hancock BW et al. Consolidation radiotherapy in patients with
advanced Hodgkin’s lymphoma: survival data from the UKLG LY09 randomized controlled trial
(ISRCTN97144519). J Clin Oncol 2010; 28(20): 3352–3359.
10. Aleman BM, Raemaekers JM, Tirelli U et al. Involved-field radiotherapy for advanced Hodgkin’s
lymphoma. N Engl J Med 2003; 348(24): 2396–2406.
11. Josting A, Nogová L, Franklin J et al. Salvage radiotherapy in patients with relapsed and refractory
Hodgkin’s lymphoma: A retrospective analysis from the German Hodgkin’s Lymphoma Study Group. J
Clin Oncol 2005, 23(7): 1522–1529
12. McKay P, Fielding P, Gallop-Evans E et al. Guidelines for the investigation and management of nodular
lymphocyte predominant Hodgkin lymphoma. Br J Haematol 2015; 172(1): 32–43.
13. Miller TP, Dahlberg S, Cassady JR et al. Chemotherapy alone compared with chemotherapy plus
radiotherapy for localized intermediate- and high-grade non-Hodgkin’s lymphoma. N Engl J Med 1998;
339(1): 21–26.
14. Miller TP, LeBlanc M, Spier CM et al. CHOP alone compared to CHOP plus radiotherapy for early
stage aggressive non-Hodgkin’s lymphomas: update of the South-West Oncology Group (SWOG)
randomised trial. Blood 2001; 98: 742a–743a (abstract).
15. Horning SJ, Weller E, Kim K et al. Chemotherapy with or without radiotherapy in limited-stage diffuse
aggressive non-Hodgkin’s lymphoma: Eastern Cooperative Oncology Group study 1484. J Clin Oncol
2004; 22(15): 3032–3038.
16. Reyes F, Lepage E, Ganem G et al. ACVBP versus CHOP plus radiotherapy for localized aggressive
lymphoma. N Engl J Med 2005; 352(12): 1197–1205.
17. Held G, Murawski N, Ziepert M et al. Role of radiotherapy to bulky disease in elderly patients with
aggressive B-cell lymphoma. J Clin Oncol 2014; 32(11): 1112–1118.
18. Phan J, Mazloom A, Medeiros LJ et al. Benefit of consolidative radiation therapy in patients with diffuse
large B-cell lymphoma treated with R-CHOP chemotherapy. J Clin Oncol 2010; 28(27): 4170–4176.
19. Lowry L, Smith P, Qian W et al. Reduced dose radiotherapy for local control in non-Hodgkin lymphoma:
a randomised phase III trial. Radiother Oncol 2011; 100(1): 86–92.
20. Dabaja B, Tsang RW, Qi S et al. Favorable outcome in stage I-II mantle cell lymphoma: a report of 160
patients from the International Lymphoma Radiation Oncology Group (ILROG). Innt J Rad Oncol Biol
Phys 2014; 90(1): S151–S152.
21. Li YX, Tao B, Jin J et al. Radiotherapy as primary treatment for stafe IE and IIE nasal natural killer/T-cell
lymphoma. J Clin Oncol 2006, 24(1): 181–189.
22. Wu X, Li P, Zhao J et al. A clinical study of 115 patients with extranodal natural killer/T-cell lymphoma,
nasal type. Clin Oncol (R Coll Radiol) 2008; 20(8): 619–625.
23. Korfel A, Thiel E, Martus P et al. Randomized phase III study of whole-brain radiotherapy for primary
CNS lymphoma. Neurology 2015; 84(12): 1242–1248.
24. Morris SL. Skin lymphoma. Clin Oncol (R Coll Radiol) 2012; 24(5): 371–385.
25. Hoskin PJ, Kirkwood AA, Popova B et al. 4 Gy versus 24 Gy radiotherapy for patients with indolent
lymphoma (FORT): a randomised phase 3 non-inferiority trial. Lancet Oncol 2014; 15(4): 457–463.
26. Haas RLM, Poortmans D, de Jong BM et al. High response rates and lasting remissions after low-dose
involved field radiotherapy in indolent lymphomas. J Clin Oncol 2003; 21(13): 2474–2480.
9. Background
Radiotherapy (RT) is an important modality of therapy in the local control of paediatric
Paediatric cancer malignancies and the majority of paediatric tumours are radiosensitive. However, for many
children, long-term survival comes at the price of long-term effects of treatment. Long-term
effects of radiotherapy include soft tissue hypoplasia, impaired bone growth, endocrine
dysfunction, impaired fertility, neuropsychological effects of irradiation of the central
nervous system (CNS) and radiation-induced malignancy.
Currently, 40–50% of children with cancer receive radiotherapy as part of their initial
treatment. It is extremely important that radiotherapy for children should be undertaken only
in specialised centres associated with the Children’s Cancer and Leukaemia Group (CCLG)
paediatric oncology centres. The paediatric radiotherapy team should include a specialist
paediatric therapy radiographer, specialist nurse and play specialist. The components of
the paediatric multidisciplinary team are described in The Royal College of Radiologists’
Good practice guidance for paediatric radiology.1
Wherever possible parents of children requiring radiotherapy should be offered the
opportunity for their child to have treatment within an appropriate National Cancer
Research Institute (NCRI) portfolio or international trial.
Radiotherapy for children should only be carried out in designated departments associated
with CCLG centres. The current document summarises typical dose-fractionation policies
as applied in CCLG centres in the UK.
Leukaemia
The leukaemias account for the largest group of paediatric malignancies, with
approximately 80% having acute lymphoblastic leukaemia (ALL). The remainder have acute
non-lymphoblastic leukaemia (ANLL), usually acute myeloid leukaemia (AML) or, rarely,
chronic myeloid leukaemia (CML). Currently more than 85% with ALL and 65% with AML
are long-term survivors. During the 1960s and 1970s, the routine use of prophylactic whole-
brain radiotherapy (WBRT) and intrathecal methotrexate reduced the risk of CNS relapse
to less than 10%. In current protocols, the use of WBRT is no longer standard but may be
employed for patients who present with CNS involvement.2
Recommendation
Whole brain radiotherapy childhood leukaemia:
24 Gray (Gy) in 15 fractions of 1.6 Gy daily over 3 weeks (Level B)
Boys who suffer a testicular relapse may be treated with testicular radiotherapy, generally
with electrons, encompassing a clinical target volume (CTV) which includes both testes,
scrotum and the inguinal canal supero-laterally as far as the deep inguinal ring.4
Recommendation
Testicular irradiation in childhood leukaemia:
24 Gy in 12 fractions of 2.0 Gy daily over 2.5 weeks (Level B)
Total body irradiation (TBI)

As in the treatment of adults with haematological malignancies, TBI is an important
technique usually used together with high-dose cyclophosphamide (cyclo-TBI) as the
conditioning regimen prior to bone marrow transplantation (BMT). Individual techniques
for TBI have evolved in different departments, often depending on availability of
treatment machines. TBI planning may use CT and dosimetry is usually based on in vivo
measurements. For such a large and complex target volume, it is not feasible to adhere to
the International Commission on Radiation Units and Measurements (ICRU) 50 guidelines
of a range of -5% to +7%; a range of -10% to +10% is more realistic.5–7
For children with CNS relapse in ALL, a cranial boost may be advised in addition to the TBI.8
Recommendations
TBI in childhood leukaemia:
14.4 Gy in 8 fractions of 1.8 Gy twice daily with a minimum interfraction interval of 6
hours over 4 days (Level C)
12 Gy in 6 fractions of 2 Gy twice daily with a minimum interfraction interval of 6 hours
over 4 days (Level C)
Cranial boost where indicated after TBI:
5.4 Gy in 3 fractions of 1.8 Gy over 3 days (Level D)
TBI for bone marrow transplant (BMT) in benign haematological disorders, for
example, Fanconi’s anaemia and thalassaemia:
2–3 Gy single dose (Level D)
Hodgkin lymphoma
The survival rate for children with Hodgkin lymphoma is approximately 90%. In current
protocols, the aims are to maintain this good overall survival rate and reduce long-term
effects.9–11 Typically patients are selected for radiotherapy if their disease does not respond
well on 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed
tomography (PET-CT) reassessment after initial chemotherapy. All sites initially involved are
usually treated.
Recommendations
Hodgkin lymphoma: sites of initial involvement:
19.8 Gy in 11 fractions over 2.2 weeks. Where there is significant residual disease
(Level B)
Hodgkin lymphoma: residual disease following chemotherapy or bulky sites:
Boost of 10 Gy in 5 fractions over 1 week (Level B)
Neuroblastoma
Patients with neuroblastoma are risk-stratified at presentation by age, stage and molecular
pathology. External-beam radiotherapy to the primary tumour bed is indicated for all
patients with ‘high risk’ disease (for example, aged greater than one year with stage
M4 disease at presentation, patients with localised disease and MYCN amplification
at presentation, and selected patients with intermediate-risk disease). The intent is to
maximise the probability of local tumour control following chemotherapy and surgical
resection of the primary tumour.12–14
Recommendation
Neuroblastoma: postoperative radiotherapy to the tumour bed:
21 Gy in 14 fractions over 3 weeks (Level B)
Wilms’ tumour (nephroblastoma)

In Europe, the series of International Society of Paediatric Oncology (SIOP) studies have
been based on preoperative chemotherapy to ‘downstage’ the primary, reducing the
surgical morbidity, particularly the number who have tumour rupture at surgery and the
number who require flank radiotherapy. Initial treatment is with preoperative chemotherapy
with actinomycin-D and vincristine, with delayed nephrectomy after six weeks of
preoperative chemotherapy. Postoperative adjuvant therapy is based on subsequent
pathological staging and allocation of risk status (good risk versus intermediate risk versus
poor risk histology).
Postoperative chemotherapy is given using the drugs vincristine, actinomycin D and
sometimes other drugs; the number of drugs and duration are dependent upon the staging.
Postoperative flank radiotherapy is employed for stage III patients, that is, those with
incompletely resected primary tumours, pre- or perioperative tumour rupture or
histologically involved lymph nodes. Patients with gross pre- or perioperative tumour
rupture or disseminated intra-abdominal disease should receive whole abdominal

radiotherapy.15 Patients with lung metastases who do not achieve a complete response to
chemotherapy should receive whole lung radiotherapy.16
Recommendations
Wilms’ tumour: postoperative radiotherapy to flank:
Intermediate risk: 14.4 Gy in 8 fractions of 1.8 Gy daily over 1.5 weeks (Level B)
High risk: 25.2 Gy in 14 fractions of 1.8 Gy over 2 weeks (Level B)
Wilms’ tumour: whole abdominal radiotherapy
Depending upon histopathological risk group:
15 Gy in 10 fractions over 2 weeks (Level B) or
21 Gy in 14 fractions of 1.5 Gy over 2 weeks (Level B)
Wilms’ tumour: whole lung radiotherapy
15 Gy in 10 fractions of 1.5 Gy over 2 weeks (Level B)
Rhabdomyosarcoma
The basis of treatment has generally involved the use of intensive chemotherapy with
the aim of improving survival, and reducing the use of local therapy with surgery and/or
radiotherapy, thus minimising long-term effects. Treatment is stratified according to risk
groups based on parameters such as histological subtype (embryonal versus alveolar
histology), stage of disease and primary tumour site. Patients in the ‘low-risk’ category, that
is, those with localised tumours which are microscopically completely resected, are treated
with chemotherapy using actinomycin-D and vincristine for nine weeks.17–19 Standard
risk tumours are those which are locally more extensive but at selected favourable sites,
for example, the vagina, uterus or paratestis, and are treated with ifosfamide, vincristine
and actinomycin-D. Poor responders switch to a six-drug combination. High-risk tumours
include other incompletely resected tumours, including all those arising in parameningeal
sites (nasopharynx, middle ear) and those with involved lymph nodes. These are treated
with further chemotherapy.
Brachytherapy, typically in conjunction with conservative surgery, may be considered for
very carefully selected patients such as those with localised embryonal bladder/prostate
and female genital tract rhabdomyosarcoma. Such patients should be referred to a
specialist centre with experience in this type of treatment.
Recommendations
Embryonal rhabdomyosarcoma:
Post-chemotherapy, no surgery:
41.4 Gy in 23 fractions of 1.8 Gy following complete response to chemotherapy and
50.4 Gy in 28 fractions of 1.8 Gy for incomplete response (Level B)
Consider boost of 5.4 Gy in 3 fractions of 1.8 Gy for large tumours and/or poor
response to chemotherapy
Postoperative:
36 Gy in 20 fractions of 1.8 Gy (Level B)
Alveolar rhabdomyosarcoma:
Post-chemotherapy, no surgery:
50.4 Gy in 28 fractions of 1.8 Gy (Level B)
Consider boost of 5.4 Gy in 3 fractions of 1.8 Gy for large tumours and/or poor
response to chemotherapy
Postoperative:
41.4 Gy in 23 fractions of 1.8 Gy (Level B)
Ewings sarcoma/peripheral primitive neuroectodermal tumour

(PPNET)
Initial treatment is with chemotherapy in conjunction with the appropriate use of local
therapy. The decision as to whether surgery, radiotherapy or both should be employed
for local control of the primary tumour demands careful multidisciplinary discussion. In
previous series, patients’ survival has been better following local treatment with surgery
compared with radiotherapy alone. However, these series are confounded by selection bias
with patients with smaller tumours selected for surgery.20,21
Recommendations
Ewings and PPNET:
Phase 1 and postoperative volume:
45 Gy in fractions of 1.8 Gy over 5 weeks (Level B)
Phase 2 for macroscopic disease:
9.6 Gy in fractions of 1.8–2.0 Gy (Level B)
Ewings and PPNET:
Whole lung radiotherapy:
Central nervous system tumours

Low-grade astrocytoma
These comprise the most common group of paediatric CNS tumours. Modern
management is based on the recognition that low-grade gliomas may undergo long
periods of ‘quiescence’ even when not completely resected. The current five-year survival
rate is 85%, but late relapse is not uncommon.
Treatment is initially with surgical resection, as complete as is considered safe.
In the recently closed SIOP Low-Grade Glioma (LGG2) study, those over the age of seven
were treated with radiotherapy. Those aged seven or under received chemotherapy with
the aim of delaying radiotherapy.22
Recommendation
Low-grade astrocytoma:
54 Gy in 30 fractions of 1.8 Gy daily over 6 weeks (Level B)
For patients who present with spinal cord primary low-grade glioma, the management
policy will be similar.
Recommendation
Low-grade spinal astrocytoma:
50.4 Gy in 28 fractions of 1.8 Gy over 5.5 weeks (Level B)
High-grade astrocytoma
Unlike adults, high-grade astrocytomas are uncommon in childhood. However, in
common with adults, the outlook is generally poor. Survival is currently approximately
20% at five years. Current management is based on surgical resection and postoperative
chemoradiotherapy with temozolomide.23
Recommendation
High-grade astrocytoma:
Under 14 years: 54 Gy in 30 fractions over 6 weeks (Level B)
Over 14 years: 60 Gy in 30 fractions over 6 weeks (Level B)
Ependymoma
The overall five-year survival rate is approximately 50–60%. In the majority of studies,
prognostic factors include tumour grade and extent of resection. The predominant
site of relapse is within the local tumour bed. The majority of collaborative groups now
recommend an increased radiotherapy dose (59.4 Gy with conformal techniques) taking
care to limit the dose to the brainstem and other adjacent critical structures.24
Recommendation
Ependymoma:
59.4 Gy in 33 fractions in 6.5 weeks (Level B)
Medulloblastoma
Medulloblastoma is a primitive neuronal tumour which arises in the cerebellum. It is
notable for its propensity for metastatic spread via the craniospinal fluid (CSF) and its
radiosensitivity. PNET arises elsewhere in the CNS, usually the supratentorial cerebral
cortex, where they are referred to as supratentorial PNET (StPNET). PNET arising in the
pineal area are referred to as pineoblastoma.
Standard therapy for medulloblastoma/PNET is initial maximal surgical resection followed
by craniospinal radiotherapy and a ‘boost’ to the primary site.
Current studies are based on the allocation of risk status. Standard-risk disease refers
to non-metastatic medulloblastoma with complete or near-complete surgical resection.
High-risk disease includes patients with medulloblastoma with metastases or postsurgical
residue and StPNET.
It is standard practice to employ adjuvant chemotherapy (vincristine, CCNU, cisplatin)
following radiotherapy for patients with standard-risk disease and more intensive
chemotherapy for high-risk disease.25–27
Recommendations
Medulloblastoma/PNET:
Standard-risk craniospinal:
23.4 Gy in 13 fractions over 2.5 weeks (Level B) followed by boost to tumour bed or
whole posterior fossa
30.6 Gy in 17 fractions in 3.5 weeks (Level B)
High-risk medulloblastoma and StPNET craniospinal
36.0 Gy in 20 fractions over 4 weeks (Level B)
39.6 Gy in 22 fractions over 4.4 weeks (St Jude’s regimen for M2–3) (Level B)
Followed by boost to primary site to a total of 54.0–55.8 Gy in 1.8 Gy fractions (Level B)
Boost to sites of metastases to a total of 50.4 Gy (spinal) and 54–55.8 Gy (intracranial)
in 1.8 Gy fractions (Level B)
Intracranial germ cell tumours

Intracranial germ cell tumours account for approximately 30% of paediatric germ cell
tumours. For germinoma, although in the past craniospinal radiotherapy has been standard,
future trials will explore the role of chemotherapy and whole ventricular radiotherapy.
Patients with non-germinoma receive platinum based chemotherapy and radiotherapy,
either focal for non-metastatic disease or craniospinal for metastatic disease.28,29
Recommendations
Germinoma – craniospinal radiotherapy, no chemotherapy:
24 Gy in 15 fractions over 3 weeks followed by boost to primary site (Level B)
16 Gy in 10 daily fractions over 2 weeks (Level B)
Germinoma – post-chemotherapy: whole ventricular radiotherapy:
24 Gy in 15 fractions over 3 weeks followed by boost to residual disease (Level B)
16 Gy in 10 daily fractions over 2 weeks (Level B)
Non-germinomatous tumours – primary tumour:
Meningeal metastases – craniospinal axis:
Brain stem glioma

This includes tumours arising in the midbrain, pons and medulla. Historically they were
regarded as a single entity. However, it is now clear that they can be subdivided into focal
(5–10%), dorsal exophytic (10–20%), cervico-medullary (5–10%) and diffuse intrinsic
tumours (75–85%).
The majority of children with brain stem gliomas have diffuse intrinsic pontine glioma
(DIPG), which are usually high-grade astrocytomas. Their prognosis is very poor with a
median survival of approximately nine months and very few long-term survivors.30
Recommendation
Brain stem glioma:
Further reading Halperin EC, Constine LS, Tarbell NJ, Kun LE (eds). Pediatric Radiation Oncology. Philadelphia: Lippincott
Williams & Wilkins, 2011.
Thorp N. Basic principles of paediatric radiotherapy. Clin Oncol (R coll Radiol) 2013; 25(1): 3–10.
Thorp N, Taylor RE. Management of central nervous system tumours in children. Clin Oncol (R Coll Radiol)
2014; 26(7): 438–445.
References 1. The Royal College of Radiologists. Good practice guide for paediatric radiotherapy. London: The Royal
College of Radiologists, 2012.
2. Pui CH, Howard SC. Current management and challenges of malignant disease in the CNS in
paediatric leukaemia. Lancet Oncol 2008; 9(3): 257–268.
3. w
ww.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009 (last accessed
30/9/16)
4. Bowman WP, Aur RJ, Hustu H, Rivera G. Isolated testicular relapse in acute lymphocytic leukaemia of
childhood: categories and influence on survival. J Clin Oncol 1984; 2(8): 924–929.
5. International Commission on Radiation Units and Measurements. ICRU report 50: Prescribing,
recording, and reporting photon beam therapy. Washington, DC: International Commission on
Radiation Units and Measurements, 1993.
6. Cosset JM, Girinsky T, Malaise E, Chaillet MP, Dutriex J. Clinical basis for TBI fractionation. Radiother
Oncol 1990; 18(Suppl 1): 60–67.
7. Gerrard G, Vail A, Taylor RE et al. Toxicity and dosimetry of fractionated total body irradiation prior to
allogeneic bone marrow transplantation using a straightforward radiotherapy technique. Clin Oncol (R
Coll Radiol) 1998; 10(6): 379–383.
8. Alexander BM, Weschler D, Braun TM et al. Utility of cranial boost in addition to total body irradiation
in the treatment of high risk acute lymphoblastic leukaemia. Int J Radiat Oncol Biol Phys 2005; 63(4):
1191–1196.
9. Ruhl U, Albreacht M, Dieckmann K et al. Response-adapted radiotherapy in the treatment of Pediatric

Hodgkin’s Disease: an interim report at 5 years of the German GPOH-HD 95 trial. Int J Radiat Oncol Biol
Phys 2001; 51(5): 1209–1218.
10. Frew JA, Lewis J, Lucraft HH. The management of children with lymphomas. Clin Oncol (R Coll Radiol)
2013; 25(1): 11–18.
11. Mauz-Körholz C, Metzger ML, Kelly KM et al. Pediatric Hodgkin lymphoma. J Clin Oncol 2015; 33(27):
2975–2985.
12. Wolden SL, Gollamudi SV, Kushner BH et al. Local control with multimodality therapy for stage 4
neuroblastoma. Int J Radiat Oncol Biol Phys 2000; 46(4): 969–974.
13. Gatcombe HG, Marcus RB, Katzenstein HM, Tighouart M, Esiashvili N. Excellent local control from
radiation therapy for high-risk neuroblastoma. Int J Radiat Oncol Biol Phys 2009; 74(5): 1549–1554.
14. Robbins JR, Krasin MJ, Atmaram S et al. Radiation therapy as part of local control of metastatic
neuroblastoma: the St. Jude Children’s Research Hospital experience. J Pediatr Surg 2010; 45(4):
678–686.
15. Kalapurakal JA, Dome JS, Perlman EJ et al. Management of Wilms’ tumour: current practice and future
goals. Lancet Oncol 2004; 5(1): 37–46.
References 16. Nicolin G, Taylor RE, Baughan C et al. Outcome after pulmonary radiotherapy in Wilms’ tumour
patients with pulmonary metastases at diagnosis: A UK Children’s Cancer Study Group, Wilms’
Tumour Working Group Study. Int J Radiat Oncol Biol Phys 2008; 70(1): 175–180.
17. Terezakis SA, Wharam MD. Radiotherapy for rhabdomyosarcoma: indications and outcome. Clin
Oncol (R Coll Radiol) 2013; 25(1): 27–35.
18. Raney RB, Walterhouse DO, Meza JL et al. Results of the Intergroup Rhabdomyosarcoma Study Group
D9602 protocol, using vincristine and dactinomycin with or without cyclophosphamide and radiation
therapy, for newly diagnosed patients with low-risk embryonal rhabdomyosarcoma: a report from the
Soft Tissue Sarcoma Committee of the Children’s Oncology Group. J Clin Oncol 2011; 29(10): 1312–
1318.
19. Michalski JM, Meza J, Breneman JC et al. Influence of radiation therapy parameters on outcome in
children treated with radiation therapy for localized parameningeal rhabdomyosarcoma in Intergroup
Rhabdomyosarcoma Study Group trials II through IV. Int J Radiat Oncol Biol Phys 2004; 59(4): 1027–
1038.
20. Bölling T, Hardes J, Dirksen U. Management of bone tumours in paediatric oncology. Clin Oncol (R Coll
Radiol) 2013; 25(1): 19–26.
21. Lopez JL, Cabrera P, Ordonez et al. Role of radiation therapy in the multidisciplinary management of
Ewing’s sarcoma of bone in pediatric patients: an effective treatment for local control. Rep Pract Oncol
Radiother 2011; 16(3): 103–109.
22. Merchant TE, Kun LE, Wu S et al. Phase II trial of conformal radiation therapy for pediatric low-grade
glioma. J Clin Oncol 2009; 27(22): 3598–3604.
23. Stupp R, Mason WP, van den Bent MJ et al. Radiotherapy plus concomitant and adjuvant
temozolomide for glioblastoma. N Engl J Med 2005; 352(10): 987–996.
24. Merchant TE, Li C, Xiong X et al. Conformal radiotherapy after surgery for paediatric ependymoma: a
prospective study. Lancet Oncol 2009 10(3): 258–266.
25. Packer RJ, Gajjar A, Vezina G et al. Phase III study of craniospinal radiation therapy followed by
adjuvant chemotherapy for newly diagnosed average-risk medulloblastoma. J Clin Oncol 2006; 24(25):
4202–4208.
26. Lannering B, Rutkowski S, Doz F et al. Hyperfractionated versus conventional radiotherapy followed by
chemotherapy in standard-risk medulloblastoma: results from the randomized multicenter HIT-SIOP
PNET 4 trial. J Clin Oncol 2012; 30(26): 3187–3193.
27. Gajjar, A, Chintagumpala M, Ashley D et al. Risk-adapted craniospinal radiotherapy followed by high-
dose chemotherapy and stem-cell rescue in children with newly diagnosed medulloblastoma (St Jude
Medulloblastoma-96): long-term results from a prospective, multicentre trial. Lancet Oncol 2006; 7(10):
813-820.
28. Calaminus G, Kortmann R, Worch J et al. SIOP CNS GCT 96: final report of outcome of a prospective,
multinational nonrandomized trial for children and adults with intracranial germinoma, comparing
craniospinal irradiation alone with chemotherapy followed by focal primary site irradiation for patients
with localized disease. Neuro Oncol 2013; 15(6): 788–796.
29. Murray MJ, Bartels U, Nishikawa R et al. Consensus on the management of intracranial germ-cell
tumours. Lancet Oncol 2015; 16(9): e470–e477.
30. Hargrave D, Bartels U, Bouffet E. Diffuse brainstem glioma in children: critical review of clinical trials.
Lancet Oncol 2006; 7(3): 241–248.
10. Background
Squamous cell carcinoma of the penis is rare; treatment needs to consider both the primary
Penile cancer lesion and the potential for lymphatic dissemination. Bilateral lymph node involvement is
common due to the rich penile lymphatic drainage. Lymph node spread generally occurs
in a predictable manner, involving superficial inguinal, then deep inguinal and then pelvic
lymph nodes.1,2 Approximately 20–30% of patients with positive inguinal nodes have
positive pelvic nodes.1 Lymph node status is a major prognostic factor for penile cancer.1
Surgery is the mainstay of locoregional treatment.3 There is a lack of high level evidence to
guide management.
Radical radiotherapy for primary lesion

Primary disease is rarely managed non-surgically in the current era, with the development
of penile-preserving and reconstruction surgical techniques and the need for surgical
lymph node management.4 Radiotherapy remains an effective penile-sparing alterative
and may be delivered with external beam radiotherapy (EBRT) with tissue equivalent
bolus (Level 3) or brachytherapy (Level 3).5 Brachytherapy provides good control rates with
acceptable morbidity and can be considered for T1/2 and selected T3 lesions according to
the 2013 Americal Brachytherapy Society-Groupe Eurpoeén de Curiethérapie-European
Society of Theraputic Radiation Oncology (ABS-GEC-ESTRO) guidelines.6,7 Only a limited
number of series have reported outcomes with EBRT; a higher risk of local failure has been
associated with a total dose <60 Gray (Gy) (dose per fraction <2 Gy, treatment time >45
days), T3 or greater disease and higher tumour grade.8–12
Lymph nodes are managed with either a sentinel lymph node biopsy or dissection.4 Elective
irradiation of clinically and radiologically N0 inguinal lymph nodes is of unproven efficacy
and is not performed.4
If a primary penile cancer is treated non-surgically, either interstitial brachytherapy or EBRT
are appropriate.
Recommendations
50 Gy in 16 fractions over 3 weeks (Grade C)11
60 in 30 fractions over 6 weeks (Grade C)10
66 in 33 fractions over 6.5 weeks (Grade C)10
Unresectable primary and lymph node disease or locoregionally

recurrent tumour
For patients with resectable primary and lymph node disease, up front surgery is the
standard approach. For unresectable disease, there is interest in the use of multimodality
treatment, although there is no standard approach. Neoadjuvant chemotherapy is an
option with a view to downstaging the disease to facilitate surgery.13,14 The use of either
neoadjuvant or definitive radiotherapy or radiotherapy with concomitant chemotherapy are
alternative approaches.4 The radiotherapy target volume is individualised, but may include
the whole pelvis with a boost to sites of gross disease; intensity-modulated radiotherapy
(IMRT) may have a role in improving the tolerability of treatment (Grade D).5 One reported
schedule is 45 Gy in 20 fractions to the whole pelvis and inguinal regions followed by a
12 Gy in five fraction boost to gross disease.15 Combining radiotherapy with concurrent
chemotherapy can be considered, although there is no direct evidence to support the
combination in penile cancer (Level 4).5
Recommendations
Dose to pelvis/inguinal regions:
Boost dose to gross disease: up to a total of 55–66 Gy depending on tumour volume/
site (Grade D)
Adjuvant radiotherapy
The current European Society for Medical Oncology (ESMO) guidelines recommendation
for patients with mobile inguinal lymph nodes is an inguinal dissection with a subsequent
pelvic lymph node dissection if ≥2 inguinal lymph nodes are positive or in the presence of
extracapsular spread (ECS).4 The subsequent role of adjuvant radiotherapy is controversial
based on limited data (Level 2, Grade D), with the rationale provided by the observation of
a significant rate of lymph node recurrence in patients treated with lymphadenectomy with
positive lymph node rates varying between 25% and 77%.5,16–18
Two recent series have reported on the use of adjuvant radiotherapy for ≥2 lymph nodes
or extracapsular spread.15,19 In the series of 161 patients from The Netherlands Cancer
Institute, 67 patients received adjuvant radiotherapy to a dose of 50 Gy in 25 fractions,
delivered to the involved inguinal lymph nodes ± involved pelvic lymph node regions;
analysis identified high-risk patients as having ≥3 unilateral inguinal lymph nodes,
extracapsular spread or pelvic lymph node involvement.19 In a series from Leeds, the
target volume include the whole pelvis and inguinal regions to a dose of 45 Gy in 20
fractions followed by a boost to gross disease of 12 Gy in five fractions.15 In both of these
series, outcomes were superior to a series which reported on ECS without adjuvant
radiotherapy.2 One small series reported the adjuvant treatment of nine patients to a
conventionally fractionated dose of 54 Gy after dissection of pathological lymph nodes,
with only one regional recurrence compared with three of five patients who did not receive
adjuvant radiotherapy.20
The role of concurrent chemotherapy remains an important unanswered question,
extrapolated from other disease sites, with the caution that toxicity will be increased
in a cohort of patients who are usually elderly. A forthcoming trial of chemoradiation,
(International Advanced Penile Cancer Trial, InPACT) will provide more data.21
The use of IMRT can be considered (Grade D).5
Recommendations
Based on the forthcoming InPACT chemoradiotherapy trial are:21
54 Gy in 25 fractions over 5 weeks to inguinal regions
Boost sites of residual disease to 57 Gy (Grade D)
Pelvic dose:
45 Gy in 25 fractions over 5 weeks with the option of a boost up to 54 Gy in 25 fractions
to sites of residual disease or external iliac lymph nodes in high-risk patients (Grade D)
Other schedules in use include:
45 Gy in 25 fractions over 5 weeks or
50.4 Gy in 28 fractions over 5.5 weeks
to pelvis/inguinal regions, with the option of a boost in 1.8–2 Gy per fraction to high-
risk areas up to total of 55–66 Gy depending upon the size of boost volume/risk factors
(Grade D).
45 Gy in 20 fractions over 4 weeks to pelvis/inguinal regions with 10–12 Gy in 5
fraction boost (Grade D)
References 1. Horenblas S. Lymphadenectomy for squamous cell carcinoma of the penis. Part 2: the role and
technique of lymph node dissection. BJU Int 2001; 88(5): 473–483.
2. Pandey D, Mahajan V, Kannan RR. Prognostic factors in node-positive carcinoma of the penis. J Surg
Oncol 2006; 93(2): 133–138.
3. Pizzocaro G, Algaba F, Horenblas S et al. EAU penile cancer guidelines 2009. Eur Urol 2010; 57(6):
1002–1012.
4. Van Poppel H, Watkin NA, Osanto S et al. Penile cancer: ESMO Clinical Practice Guidelines for
diagnosis, treatment and follow-up. Ann Oncol 2013; 24(Suppl 6): vi115–vi124.
5. w
6. Crook J, Ma C, Grimard L. Radiation therapy in the management of the primary penile tumor: an
update. World J Urol 2009; 27(2): 189–196.
7. Crook JM, Haie-Meder C, Demanes DJ et al. American Brachytherapy Society-Groupe Européen de

Curiétherapie-European Society of Therapeutic Radiation Oncology (ABS-GEC-ESTRO) consensus
statement for penile brachytherapy. Brachytherapy 2013;12(3): 191–198.
8. Zouhair A, Coucke PA, Jeanneret W et al. Radiation therapy alone or combined surgery and radiation
therapy in squamous-cell carcinoma of the penis? Eur J Cancer 2001; 37(2): 198–203.
9. Gotsadze D, Matveev B, Zak B, Mamaladze V. Is conservative organ-sparing treatment of penile

carcinoma justified? Eur Urol 2000; 38(3): 306–312.
10. Sarin R, Norman AR, Steel GG, Horwich A. Treatment results and prognostic factors in 101 men
treated for squamous carcinoma of the penis. Int J Radiat Oncol Biol Phys 1997; 38(4): 713–722.
11. Azrif M, Logue JP, Swindell R, Cowan RA, Wylie JP, Livsey JE. External-beam radiotherapy in T1-2 N0
penile carcinoma. Clin Oncol (R Coll Radiol) 2006; 18(4): 320–325.
12. Soria JC, Fizazi K, Piron D et al. Squamous cell carcinoma of the penis: multivariate analysis of
prognostic factors and natural history in monocentric study with a conservative policy. Ann Oncol
1997; 8(11): 1089–1098.
13. Pagliaro LC, Williams DL, Daliani D et al. Neoadjuvant paclitaxel, ifosfamide, and cisplatin
chemotherapy for metastatic penile cancer: a phase II study. J Clin Oncol 2010; 28(24): 3851–3857.
14. Nicholson S, Hall E, Harland SJ et al. Phase II trial of docetaxel, cisplatin and 5FU chemotherapy in
locally advanced and metastatic penis cancer (CRUK/09/001). Br J Cancer 2013; 109(10): 2554–2559.
15. Franks KN, Kancherla K, Sethugavalar B, Whelan P, Eardley I, Kiltie AE. Radiotherapy for node positive
penile cancer: experience of the Leeds teaching hospitals. J Urol 2011; 186(2): 524–529.
16. Culkin DJ, Beer TM. Advanced penile carcinoma. J Urol 2003; 170(2 Pt 1): 359–365.
17. Ozsahin M, Jichlinski P, Weber DC et al. Treatment of penile carcinoma: to cut or not to cut? Int J Radiat
Oncol Biol Phys 2006; 66(3): 674–679.
18. Horenblas S, van Tinteren H, Delemarre JF et al. Squamous cell carcinoma of the penis. III. Treatment
of regional lymph nodes. J Urol 1993; 149(3): 492–497.
19. Graafland NM, Moonen LM, van Boven HH, van Werkhoven E, Kerst JM, Horenblas S. Inguinal
recurrence following therapeutic lymphadenectomy for node positive penile carcinoma: outcome and
implications for management. J Urol 2011; 185(3): 888–893.
20. Chen MF, Chen WC, Wu CT, Chuang Ck, Ng KF, Chang JT. Contemporary management of penile
cancer including surgery and adjuvant radiotherapy: an experience in Taiwan. World J Urol 2004; 22(1):
60–66.

11. Background
Early prostate cancer is being diagnosed more frequently because of prostate-specific
Prostate cancer antigen (PSA) screening. This change in natural history poses new management
opportunities and external-beam radiotherapy (EBRT) is only one of several options, which
include active surveillance and monitoring, radical surgery and brachytherapy.
Hormonal therapy and radiation dose

There is Grade A evidence in favour of neoadjuvant or adjuvant androgen deprivation
therapy (ADT) for patients with intermediate or high-risk (PSA >10 or Gleason score >7 or
T2C–T3) prostate cancer treated with radical radiotherapy, although with the likelihood of
significant toxicity reducing quality of life.1 A systematic review of 14 randomised phase III
clinical trials showed benefit which increases as the risk factors of stage, PSA and Gleason
score increase.2 The National Institute for Health and Care Excellence (NICE) guidelines
recommend six months of ADT for intermediate-risk patients, which may be extended for
up to three years in high-risk localised prostate cancer.3
There are now five randomised dose escalation studies which have demonstrated superior
biochemical relapse-free survival (bRFS) with doses from 74–80 Gray (Gy) compared to
lower doses. As yet, however, this has not translated into an overall survival advantage.4–8
Fractionation
A full discussion of the radiobiology of prostate cancer is outside of the remit of this
guideline. There is consistent evidence from large retrospective series to support the
hypothesis that prostate cancer has a low αβ ratio.9,10 Hypofractionation, using fraction sizes
>2 Gy per day, may therefore be radiobiologically advantageous.
Conventional fractionation (doses-per-fraction in the range 1.8–2 Gy)

The results of conventional fractionation have been comprehensively reviewed and
reported. Dose escalation has been shown to improve bRFS in randomised controlled trials
(RCT) (64 Gy versus 74 Gy , 68 Gy versus 78 Gy, 70 Gy versus 78 Gy, 70.2 Gy versus 79.2 Gy)
as well as meta-analysis.4–8,11 Unfortunately, this has not translated into improved overall
survival as yet.
There is evidence (Grade B) that doses beyond 80 Gy can now be delivered safely with
image-guided intensity-modulated radiotherapy (IMRT).1 There are no reported randomised
trials of higher levels of dose escalation, but results from the Memorial Sloan Kettering
Cancer Center have shown that the late grade II gastrointestinal toxicity rates of patients
treated to 86.4 Gy in fraction sizes of 1.8 Gy was 3%, with <1% developing late grade III
gastrointestinal toxicity.12 Analysis of outcomes from this series showed that the ten-year
failure free survival (bNED) was significantly improved by dose escalation: 84% (>75.6 Gy)
versus 70% for low-risk disease (p=0.04), 76% (>81 Gy) versus 57% for intermediate-risk
disease (p=0.0001) and 55% (>81 Gy) versus 41% for high-risk patients (p=0.0001).13 In a
multivariate analysis including the use of six-months ADT, a dose >81 Gy (p=0.027) and ADT
(p=0.052) were found to be predictive factors for distant metastasis-free survival, but not
overall survival.
Hypofractionation (doses of 2.5 Gy per fraction and above)

Two historical randomised trials which compared hypofractionation (52.5–55 Gy in 20
fractions) with control arms of 60–66 Gy in 33 fractions in 6.5 weeks, doses that, by current
standards, are low. The results show a trend towards a lower four-year bNED rate with
hypofractionation.14,15
The Christie Hospital has reported their experience using 50 Gy in 16 fractions with
a conformal technique. The overall bNED rates at five years were 82% for low grade;
56% for intermediate and 39% for high risk. These outcomes are comparable to those
achieved using more protracted regimens (Level 2b) with toxicity greater than or equal
to Radiation Therapy Oncology Group (RTOG) grade 2 in 5% for bladder and 9% for
gastrointestinal (GI).1,16
Nearly 8,000 patients have been randomised into completed and ongoing trials of
hypofractionation; including the Conventional or Hypofractionated High Dose Intensity
Modulated Radiotherapy for Prostate Cancer (CHHiP) trial, the Hypofractionated versus
Conventionally Fractionated Radiotherapy for Patients with Localised Prostate Cancer
(HYPRO) trial, the Scandinavian-led Phase III Study of HYPOfractionated Radiotherapy of
Intermediate Risk Localised Prostate Cancer (HYPO) study, the Canadian PROFIT study
and the North American RTOG 0415 study.4,17–21 Toxicity of moderate hypofractionation
at two-year follow-up (based on physician reported outcomes) was as low as with
conventional fractionation in the CHHiP study, which compared 74 Gy in 37 fractions to 60
Gy in 20 fractions and 57 Gy in 19 fractions.4 There is a suggestion that equivalent disease-
free survival (DFS) can be obtained at the expense of increased genitourinary (GU) or GI
toxicity although overall toxicity remains acceptable.17,22,23
Results, in terms of disease control, from three of the hypofractionation trials have now
been presented in abstract form. The CHHiP trial showed non-inferiority between 60 Gy in
20 fractions and 74 Gy in 37 fractions; the HYPRO study showed non-inferiority between
78 Gy in 39 fractions and 64.6 Gy in 19 fractions; PROFIT showed non-inferiority between
78 Gy in 39 fractions and 60 Gy in 20 fractions and the RTOG 0415 study showed non-
inferiority between 73.8 Gy in 41 fractions and 70 Gy in 28 fractions.24,25
High-dose-rate (HDR) brachytherapy is an alternative means of delivering hypofractionated
radiation as a boost to achieve dose escalation after 45–46 Gy in 1.8–2 Gy daily fractions
or 37.5 Gy in 15 fractions.26–28 The ASCENDE-RT trial shows that low dose rate (LDR)
brachytherapy as a boost after 46 Gy in 23 fractions is superior to external-beam 76 Gy in 38
fractions.28
Profound hypofractionation (defined as 6 Gy per fraction or more) has been shown to be
feasible and safe in cohort studies, with high levels of disease control in low-risk patients.
The Prostate Advances in Comparative Evidence (PACE) trial is randomising between
standard of care (surgery or image-guided intensity-modulated radiotherapy [IG-IMRT]),
and stereotactic radiotherapy (36.25 Gy in five fractions); HYPO compares 78 Gy in 39
fractions versus 42.7 Gy in seven fractions and has recruited 1,000 patients in Scandinavia
with a target recruitment of 1,920 patients.18,269
There is evidence (Grade A) from three randomised trials, that adjuvant postoperative
radiotherapy using 60–64 Gy and 2 Gy per fraction improves recurrence rates in
postoperative patients considered to be at high risk of recurrence.1,30–29 The optimal timing
of postoperative radiotherapy in this group, whether immediate or at first evidence of PSA
recurrence, is not known; this and the benefit of adjuvant ADT in the postoperative setting
are the two primary questions being addressed in the ongoing Medical Research Council
(MRC) Radiotherapy and Androgen Deprivation in Combination After Local Surgery
(RADICALS) trial, using either 66 Gy in 33 fractions or 52.5 Gy in 20 fractions.33
Radiotherapy technique
Dose escalation increases the side-effects of treatment. This can be mitigated by
using IMRT or arc techniques (volumetric modulated arc therapy [VMAT] or Rapidarc®)
to minimise dose to the organs at risk. The role of lymph node irradiation remains
uncertain.34,35 It is possible to identify patients who have a significant risk of lymph node
involvement, but the results of randomised trials to address the value of elective nodal
irradiation are equivocal. It may be considered for high-risk patients, recognising that the
larger volume is associated with higher toxicity.
IMRT or arc techniques (VMAT or Rapidarc) with appropriate IGRT are the standard of care
when delivering high-dose radiation to the prostate. Fiducial markers or cone beam images
should be used for verification to minimise interfraction variation.36,37
Recommendations
Radical radiotherapy to the prostate should be delivered using IMRT
or arc (VMAT or Rapidarc) techniques with IGRT verifation. Acceptable
regimens include:
74–78 Gy to the prostate in 37–39 fractions over 7.5 weeks (Grade A)
Or using a brachytherapy boost:
37.5 GY in 15 fractions over 3 weeks followed by 15 Gy HDR brachytherapy boost
(Grade B)
46 Gy in 23 fractions over 4.5 weeks followed by 115 Gy LDR brachytherapy boost
(Grade B)
Nodal irradiation:
55–60 Gy in 37 fractions over 7.5 weeks or equivalent (Grade D)
Postoperatively:
66 Gy in 33 fractions over 6.5 weeks or
52.5 Gy in 20 fractions over 4 weeks (Grade C)
Palliative radiotherapy may be indicated in the event of troublesome haemorrhage, outflow
obstruction or pressure symptoms. There is no evidence to guide fractionation.
Recommendations
For palliation standard schedules are used as follows:
21 Gy in 3 fractions, alternate days over 1 week (Grade D)
8–10 Gy single dose (Grade D)
References 1. w
2. Schmidt-Hansen M, Hoskin P, Kirkbride P, Hasler E, Bromham N. Hormone and radiotherapy versus

hormone or radiotherapy alone for non-metastatic prostate cancer: a systematic review with meta-
analyses. Clin Oncol (R Coll Radiol) 2014; 26(10): e21–e46.
3. National Institutue for Health and Care Excellence. Prostate cancer: diagnosis and management.
Clinical Guideline. Cardiff: National Institutue for Health and Care Excellence, 2014.
4. Dearnaley DP, Sydes MR, Graham JD et al. Escalated-dose versus standard-dose conformal
radiotherapy in prostate cancer: first results from the MRC RT01 randomised controlled trial. Lancet
Oncol 2007; 8(6): 475–487.
5. Creak A, Hall E, Eeles R et al. Randomised pilot study of dose escalation using conformal radiotherapy
in prostate cancer: long-term follow-up. Br J Cancer 2013; 109(3): 651–657.
6. Peeters ST, Heemsbergen WD, Koper PC et al. Dose-response in radiotherapy for localized prostate
cancer: results of the Dutch multicenter randomized phase III trial comparing 68 Gy of radiotherapy
with 78 Gy. J Clin Oncol 2006; 24(13): 1990–1996.
7. Pollack A, Zagars GK, Starkschall et al. Prostate cancer radiation dose response: results of the M. D.
Anderson phase III randomized trial. Int J Radiat Oncol Biol Phys 2002; 53(5): 1097–1105.
8. Michalski JM, Moughan J, Purdy J et al. A randomized trial of 79.2 Gy versus 70.2 Gy radiation therapy
(RT) for localized prostate cancer. J Clin Oncolo 2015; 33(suppl 7; abstr 4).
9. Dasu A, Toma-Dasu I. Prostate alpha/beta revisited – an analysis of clinical results from 14 168
patients. Acta Oncol 2012; 51(8): 963–974.
10. Proust-Lima C, Taylor JM, Sécher et al. Confirmation of a low alpha/beta ratio for prostate cancer
treated by external beam radiation therapy alone using a post-treatment repeated-measures model for
PSA dynamics. Int J Radiat Oncol Biol Phys 2011; 79(1): 195–201.
11. Viani GA, Stefano EJ, Afonso SL. Higher-than-conventional radiation doses in localized prostate
cancer treatment: a meta-analysis of randomized, controlled trials. Int J Radiat Oncol Biol Phys 2009;
74(5): 1405–1418.
12. Cahlon O, Zelefsky MJ, Shippy A et al. Ultra-high dose (86.4 Gy) IMRT for localized prostate cancer:
toxicity and biochemical outcomes. Int J Radiat Oncol Biol Phys 2008; 71(2): 330–337.
13. Zelefsky MJ, Pei X, Chou JF et al. Dose escalation for prostate cancer radiotherapy: predictors of long-
term biochemical tumor control and distant metastases-free survival outcomes. Eur Urol 2011; 60(6):
1133–1139.
14. Lukka H, Hayter C, Julian JA et al. A randomized trial comparing two fractionation schedules for
patients with localized prostate cancer. J Clin Oncol 2005; 23(25): 6132–6138.
15. Yeoh EE, Fraser RJ, McGowan RE et al. Evidence for efficacy without increased toxicity of
hypofractionated radiotherapy for prostate carcinoma: early results of a Phase III randomized trial. Int J
16. Livsey JE, Cowan RA, Wylie JP et al. Hypofractionated conformal radiotherapy in carcinoma of the
prostate: five-year outcome analysis. Int J Radiat Oncol Biol Phys 2003; 57(5): 1254–1259.
17. Aluwini S, Pos G, Schimmel E et al. Hypofractionated versus conventionally fractionated radiotherapy
for patients with prostate cancer (HYPRO): acute toxicity results from a randomised non-inferiority
18. www.controlled-trials.com/ISRCTN45905321 (last accessed 3/10/16)

19. Radiation Therapy Oncology Group. RTOG 0415. A phase III randomized study of hypofractionated
3D-CRT/IMRT versus conventionally fractionated 3D-CRT/IMRT in patients with favorable-risk
prostate cancer. Philadelphia: Radiation Therapy Oncology Group, 2007.
20. Arcangeli S, Strigari L, Gomellini S et al. Updated results and patterns of failure in a randomized
hypofractionation trial for high-risk prostate cancer. Int J Radiat Oncol Biol Phys 2012; 84(5): 1172–
1178.
21. Pollack A, Walker G, Horwitz EM et al. Randomized trial of hypofractionated external-beam

radiotherapy for prostate cancer. J Clin Oncol 2013; 31(31): 3860–3868.
22. Catton CN, Lukka H, Gu C-S et al. Randomized trial of a hypofractionated radiation regimen for the
treatement of localized prostate cancer. J Clin Oncol 2017; 35: 1884–1890.
23. Dearnaley D, Syndikus I, Mossop H et al. Conventional versus hypofractionated high-dose intensity-
modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority,
phase 3 CHHiP trial. Lancet Oncol 2016; 17: 1047–1060.
24. Incrocci L, Wortel RC, Alemayehu WG et al. Hypofractionated versus conventionally fractionated
radiotherapy for patients with localised prostate cancer (HYPRO: final efficacy results from a
randomised, multicentre, open label, phase 3 trial. Lancet Oncol 2016; 17(8): 1061–1069.
25. Lee W R, Dignam JJ, Amin M et al. Randomized phase III noninferiority study comparing two
radiotherapy fractionation scheduled in patients with low-risk prostate cancer. J Clin Oncol 2016;
34(20): 2325–2332.
26. Hoskin PJ, Rojas AM, Bownes PJ, Lowe GJ, Ostler PJ, Bryant L. Randomised trial of external beam
radiotherapy alone or combined with high-dose-rate brachytherapy boost for localised prostate
cancer. Radiother Oncol 2012; 103(2): 217–222.
27. Helou J, D’Alimonte L, Loblaw A et al. High dose-rate brachytherapy boost for intermediate risk
prostate cancer: long-term outcomes of two different treatment schedules and early biochemical
predictors of success. Radiother Oncol 2015; 115(1): 84–89.
28. Morris WJ, Tyldesley S, Rodda S et al. Androgen suppression combined with elective nodal and dose
escalated radiation therapy (the ASCENDE-RT Trial): an analysis of survival endpoints for a randomized
trial comparing low-dose-rate brachytherapy boost to a dose-escalated external beam boost for high-
and intermediate-risk prostate cancer. Int J Radiat Oncol Biol Phys 2017; 98(2): 275–285.
29. www.isrctn.com/ISRCTN45905321 (last accessed 3/10/16)
30. Wiegel T, Bottke D, Steiner U et al. Phase III postoperative adjuvant radiotherapy after radical
prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with postoperative
undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95. J Clin Oncol 2009; 27(18): 2924–
2930.
31. Thompson IM, Tangen CM, Paradelo J et al. Adjuvant radiotherapy for pathological T3N0M0 prostate
cancer significantly reduces risk of metastases and improves survival: long-term follow-up of a
randomized clinical trial. J Urol 2009; 181(3): 956–962.
32. Bolla M, van Poppel H, Tombal B et al. Postoperative radiotherapy after radical prostatectomy for high-
risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911). Lancet
2012; 380(9858): 2018–2027.
33. Parker C, Sydes MR, Catton C et al. Radiotherapy and androgen deprivation in combination after local
surgery (RADICALS): a new Medical Research Council/National Cancer Institute of Canada phase III
trial of adjuvant treatment after radical prostatectomy. BJU Int 2007; 99(6): 1376–1379.
34. Pommier P, Chabaud S, Lagrance JL et al. Is there a role for pelvic irradiation in localized prostate
adenocarcinoma? Preliminary results of GETUG-01. J Clin Oncol 2007; 25(34): 5366–5373.
35. Lawton CA, DeSilvio M, Roach M 3rd et al. An update of the phase III trial comparing whole pelvic to
prostate only radiotherapy and neoadjuvant to adjuvant total androgen suppression: updated analysis
of RTOG 94-13, with emphasis on unexpected hormone/radiation interactions. Int J Radiat Oncol Biol
Phys 2007; 69(3): 646–655.
36. Zelefsky MJ, Kollmeier M, Cox B et al. Improved clinical outcomes with high-dose image guided
radiotherapy compared with non-IGRT for the treatment of clinically localized prostate cancer. Int J
37. Singh J, Greer PB, White MA et al. Treatment-related morbidity in prostate cancer: a comparison of
3-dimensional conformal radiation therapy with and without image guidance using implanted fiducial
markers. Int J Radiat Oncol Biol Phys 2013; 85(4): 1018–1023.
12. Background
Rectal cancer is less common than colon cancer but presents difficult treatment decisions
Rectal cancer because, while it is frequently curable, treatment may involve radical surgery including the
need for a colostomy, which can have a profound effect on a survivor’s quality of life.
Equally, recurrent rectal cancers produce distressing symptoms and are difficult to treat
and frequently require re-irradiation for symptom control, exenterative surgery or both.
The aim of radiotherapy in rectal cancers is to allow radical treatment to take place for more
advanced cancers or to reduce the risk of relapse for early stage cancers (neoadjuvant
therapy). In recurrent or incurable disease, radiotherapy can reduce the disease burden and
help control symptoms.
Neoadjuvant therapy
Operable tumours
Preoperative radiotherapy is preferred to postoperative treatment as the preoperative
technique is more effective and less toxic (Level 1a).1–3
For operable rectal cancers, as defined by preoperative pelvic magnetic resonance (MR)
scan and staging chest, and abdomen and pelvis computed tomography (CT) scans,
preoperative short-course rectal radiotherapy (SCRT) has been evaluated in several
prospective randomised controlled trials (RCTs). The Dutch total mesorectal excision (TME)
versus SCRT (25 Gray [Gy] in five fractions) + TME trial demonstrated a reduction in local
recurrence rate, though with a longer median follow-up of 6.1 years the benefit appears
to decrease (10.9% versus 5.6%; 49% relative reduction in risk).4,5 The overall survival was
same in both groups (Level 1b).3 The MRC-07 trial demonstrated the advantage of SCRT
(25 Gy in five fractions) for operable rectal cancer over selective postoperative (chemo-)
radiation, in terms of reducing the relative risk of local recurrence after a median follow-up
of four years by 61% (HR 0.39, CI 0.27–0.58). This translates to an absolute reduction in risk
of local relapse of 6.2% at three years. There is also an absolute improvement in disease
free survival of 6% at three years with no effect on overall survival (Level 1b).3,6
SCRT, however, increases long-term toxicity, with poorer functional outcomes especially in
terms of continence (Level 1b).3,7 The benefit seems to be mainly for cancers in the mid-
rectum and ‘intermediate-risk’ cancers as defined in the National Institute of Health and
Care Excellence (NICE) guidance (Level 1b).3,8
Recommendation
Short course preoperative radiotherapy:
25 Gy in 5 daily fractions (Grade A)
Followed by definitive surgery within a week
Inoperable tumours
For inoperable cancers, cancers which involve or threaten the circumferential margin
or for cancers deemed to be at high risk of relapse (NICE guidance), down-staging
treatment is recommended.8 If not otherwise contraindicated, concurrent chemotherapy is
recommended to improve response rates.
Doses of >30 Gy improve the response rate and long-course chemo-radiotherapy (LCCRT)
has been shown to improve response rate and the likelihood of a R0 resection compared to
long-course radiotherapy alone (Level 1a), though the sphincter preservation rate and long-
term outcomes appear to be similar.1,3,9,10 A dose of 45–50.4 Gy in 1.8 Gy per fraction with
concurrent chemotherapy is commonly used in the UK, though there is little good quality
RCT research underpinning this.
Fluorouracil (5-FU)-based chemotherapy has been used in all major trials since the 1980s
and more recently, capecitabine has been shown to have similar efficacy in several phase
2 studies (Level 2b); it has replaced infusional 5-FU as the drug of choice for LCCRT to
the rectum.3,11,12 The UK ARISTOTLE trial (EUDRACT No. 2008-005782-59) is currently
investigating the effect of the addition of intravenous (IV) irinotecan to capecitabine on local
control rates in advanced rectal cancers.13 Some authors have reported a ‘boost’ of 5.4 Gy in
three fractions to the gross tumour volume plus margin following 45 Gy in 25 fractions to a
larger volume.12 The efficacy and toxicity of this remains unknown (Level 2b).3
Retrospective series from Sweden and the UK, looking at patients with locally advanced
unresectable rectal cancer who are unfit for standard LCCRT, treated with 25 Gy in five
fractions, have reported significant tumour regression, with 60–80% of patients going on to
have delayed surgery (Level 2c).3,14,15
Recommendations
For downstaging LCCRT:
45 Gy in 25 daily fractions with concurrent chemotherapy (Grade A)
Optional boost of 5.4 Gy in 3 (Grade C) fractions to smaller volume
50.4 Gy in 28 daily fractions with concurrent chemotherapy (Grade A)
For patients not fit for chemotherapy:
45 Gy in 25 daily fractions (Grade A) with or without boost
50.4 Gy in 28 daily fractions (Grade A)
For elderly patients or those with significant co-morbidities:
25 Gy in 5 daily fractions (Grade B)
Brachytherapy
Low-energy contact brachytherapy (Papillion technique) and high-dose rate (HDR)
brachytherapy have both been used, generally in combination with external beam
radiotherapy (EBRT), for the treatment of rectal cancers. The aim of treatment has been
either palliative or as part of neoadjuvant treatment to improve response. In patients unfit for
surgery, these techniques can be used to improve local control.
Apart from one RCT (Level 1b), most of the evidence for the Papillion technique comes
from case series and retrospective analyses.3,16 Similarly, there is only one published RCT
evaluating a neoadjuvant 10 Gy in two fractions HDR brachytherapy boost (endoluminal)
along with 50.4 Gy in 28 fractions of EBRT (Level 1b).3,17 This trial showed no improvement
in pathological complete response (pCR) or long-term survival despite a better R0
resection rate for T3 tumours treated with HDR brachytherapy boost along with standard
chemoradiotherapy.17 There is increasing experience in the UK and worldwide of the use
of the Papillon technique, usually in combination with EBRT, for the radical treatment of
patients not suitable for surgery or those who refuse a stoma.18–22 It is also used for the
palliative treatment of patients with a recurrence or metastases not suitable for surgery.
Contact radiotherapy is also offered to patients with a resected pT1 malignant polyp in
combination with EBRT, though there is no randomised trial evidence comparing this
approach with radical surgery. It may be most appropriate for elderly, frail patients who
cannot undergo radical resection.
Dose recommendations are derived from published trials and current consensus among
UK centres offering brachytherapy.
Recommendations
Postoperative:
pT1 or pT2 with R1 resection if patient refuses further surgery
60 Gy in 2 weekly fractions followed by EBRT (Grade B)
Radical treatment (unfit patients or those who refuse surgery):
cT1/cNo (≤3 centimetres [cm]) 110 Gy in 4 fractions over 6 weeks (30 Gy every 2 weeks
x 3 and final boost 20 Gy) (Grade D)
cT1/cN1 or cT2 cNo/cN1 (≤3cm) low-energy contact brachytherapy should be
followed by EBRT (SCRT or external beam chemoradiotherapy (EBCRT)) (Grade D)
High-risk patients not fit for surgery cT1, cT2, cT3a, (>3 cm)
45 Gy in 25 fractions or 50.4 Gy in 28 fractions over 5–5.5 weeks with concurrent
chemotherapy (Grade D)
or 25 Gy in 5 daily fractions in 1 week in patients not fit for chemotherapy (Grade D)
followed by:
contact radiotherapy boost 90 Gy in 3 fractions over 4 weeks to responders (regression to
<3 cm) and consider final boost 20 Gy (total 110 Gy in 4 fractions over 6 weeks) (Grade D)
HDR brachytherapy 12 Gy in 2 fractions (Grade D)
Consider salvage surgery if no response after (EBCRT)
There are no good-quality trials evaluating different dose fractionation schedules for
palliative treatment. An appropriate regime should be chosen after considering the patient’s
likely prognosis, disease burden, symptoms and performance status.
Recommendations
30 Gy in 10 daily fractions (Level D)
20–25 Gy in 5 daily fractions (Level D)
HDR brachytherapy 10 Gy at 1 cm single dose (Level D)
Re-irradiation
Following previous SCRT or LCCRT, some patients will experience a local or regional
relapse. Such patients should be discussed in specialist multidisciplinary team meetings
(MDTMs) with the relevant expertise in treating recurrent rectal cancer.
Where possible, recurrences after neoadjuvant radiotherapy should be treated with surgery
or systemic therapy, avoiding further radiation. However, if surgery is not feasible with clear
margins or holds excess risks, re-irradiation should be considered for limited volumes,
including the use of stereotactic body radiotherapy (SABR) techniques. This may yield good
symptomatic relief as a palliative treatment and long-term control is possible.
When curative resection is to be considered but re-irradiation is required to achieve this,
currently, hyperfractionated chemoradiotherapy should be preferred to limit late toxic
(Grade D).3
References 1. Colorectal Cancer Collaborative Group. Adjuvant radiotherapy for rectal cancer: a systematic overview
of 8,507 patients from randomised trials. Lancet 2001; 358(9290): 1291–1304.
2. Frykholm GJ, Glimelius B, Påhlman L. Preoperative or postoperative irradiation in adenocarcinoma of

the rectum: final results of a randomised trial and an evaluation of late secondary effects. Dis Colon
Rectum 1993; 36(6): 564–572.
3. w
4. Kapiteijn E, Marijnen CA, Nagtegaal ID et al. Preoperative radiotherapy combined with total mesorectal
excision for resectable rectal cancer. N Engl J Med 2001; 345(9): 638–646.
5. Peeters KC, Marijnen CA, Nagtegaal ID et al. The TME trial after a median follow-up of 6 years:
increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma.
Ann Surg 2007; 246(5): 693–701.
6. Sebag-Montefiore D, Stephens RJ, Steele R. Preoperative radiotherapy versus selective postoperative

chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre,
randomised trial. Lancet 2009; 373(9666): 811–820.
7. Peeters KC, van de Velde CJ, Leer JW et al. Late side effects of short-course preoperative radiotherapy
combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated
patients – a Dutch colorectal cancer group study. J Clin Oncol 2005; 23(25): 6199–6206.
8. National Institutue for Health and Care Excellence. Colorectal cancer: diagnosis and management.
Clinical guideline 131. London: National Institute for Health and Care Excellence, 2011.
9. Braendengen M, Tveit KM, Berglund A et al. Randomised phase II study comparing preoperative
radiotherapy with chemoradiotherapy in nonresectable rectal cancer. J Clin Oncol 2008; 26(22):
3687–3694.
10. Ceelen WP, Van Nieuwenhove Y, Fierens K. Preoperative chemoradiation versus radiation alone for
stage II and III resectable rectal cancer. Cochrane Database Syst Rev 2009; 1: CD006041.
11. De Bruin AF, Nuyttens JJ, Ferenschild FT, Planting AS, Verhoef C, de Wilt JH. Preoperative
chemoradiation with capecitabine in locally advanced rectal cancer. Neth J Med 2008; 66(2): 71–76.
12. De Paoli A, Chiara S, Luppi G et al. Capecitabine in combination with preoperative radiation therapy
in locally advanced, resectable, rectal cancer: a multicentric phase II study. Ann Oncol 2006; 17(2):
246–251.
13. http://www.isrctn.com/ISRCTN09351447
14. Radu C, Berflund A, Påhlman L, Glimelius B. Short-course preoperative radiotherapy with delayed
surgery in rectal cancer – a retrospective study. Radiother Oncol 2008; 87(3): 343–349.
15. Hatfield P, Hingorani M, Radhakrishna G et al. Short-course radiotherapy, with elective delay prior to
surgery, in patients with unresectable rectal cancer who have poor performance status or significant
co-morbidity. Radiother Oncol 2008; 92(2): 210–214.
16. Ortholan C, Romestaing P, Chapet O, Ferard JP. Correlation in rectal cancer between clinical tumor
response after neoadjuvant radiotherapy and sphincter or organ preservation: 10-year results of the
Lyon R 96-02 randomized trial. Int J Rad Oncol Biol Phys 2012; 83(2): e65–e71.
17. Appelt AL, Vogelius IR, Pløen J et al. Long-term results of a randomized trial in locally advanced rectal
cancer: no benefit from adding a brachytherapy boost. Int J Rad Oncol Biol Phys 2014; 90(1): 110–118.
18. Sischy B, Hinson EJ, Wilkinson DR. Definitive radiation therapy for selected cancers of the rectum. Br J
Surg 1988; 75(9): 901–903.
19. Gerard JP, Romestaing P, Chapet O. Radiotherapy alone in the curative treatment of rectal carcinoma.
Lancet Oncol 2003; 4(3): 158–166.
20. Sun Myint A, Grieve RJ, McDonald AC et al. Combined modality treatment of early rectal cancer: the
UK experience. Clin Oncol (R Coll Radiol) 2007; 19(9): 674–681.
21. Dhadda A, Cast J, Hunter I. Organ preservation using contact radiotherapy for early rectal cancer:
outcomes of patients treated at a single centre in the United Kingdom. Ann Oncol 2014; 25(suppl 2):
ii12.
22. National Institutue for Health and Care Excellence. Low energy contact X-ray brachytherapy (the
Papillon technique) for early stage rectal cancer. London: National Institute for Health and Care
Excellence, 2015.
13. There are limited indications for radiotherapy in renal cancer, apart from the treatment of
bone and brain metastases, which are covered in the relevant sections of this document
Renal cancer (sections 18 and 19).
It has no role in neoadjuvant or primary treatment.
Adjuvant radiotherapy
Adjuvant radiotherapy is not currently recommended.
There is evidence (Grade C) of improvement in local control when radiotherapy is given
adjuvantly postoperatively in high-risk patients with T3 localised tumours using doses of
41.4–63 Gray (Gy) in 1.8–2 Gy fractions.1–6
Stereotactic body radiotherapy (SBRT) has been used for highly selected patients with
localised primary tumours (>T1a) who are not able to have surgery. Doses of 40–45 Gy in
five fractions have been used (Grade C).1 This is not recommended outside clinical trials
at present.7
Palliative radiotherapy may be considered for persistent haematuria or pain from large soft
tissue masses. Single doses of 8–10 Gy in poor performance status patients (Grade D)
for haematuria and 30 Gy in ten fractions for soft tissue masses and pain (Grade D) may
be used.1
References 1. w
2. Ulutin HC, Aksu G, Fayda M, Kuzhan O, Tahmaz L, Beyzadeoglu M. The value of postoperative
radiotherapy in renal cell carcinoma: a single-institution experience. Tumori 2006; 92(3): 202–206.
3. Stein M, Kuten A, Halpern J, Coachman NM, Cohen Y, Robinson E. The value of postoperative
irradiation in renal cell cancer. Radiother Oncol 1992; 24(1): 41–44.
4. Scherer E, Wirtz C. The role of postoperative radiotherapy in the treatment of hypernephroid

carcinoma. Strahlenther Onkol 1988; 164(7): 371–385.
5. Kao GD, Malkowicz SB, Whittington R, D’Amico AV, Wein AJ. Locally advanced renal carcinoma: low
complication rate and efficacy of postnephrectomy radiation therapy planned with CT. Radiology 1994;
193(3): 725–730.
6. Makarewicz R, Zarzycka M, Kulińska G, Windorbska W. The value of postoperative radiotherapy in

advanced renal cell cancer. Neoplasma 1998; 45(6): 380–383.
7. Kirkbride T, Cooper T. Stereotactic body radiotherapy. Guidelines for commissioners, providers and
clinicians: a national report. Clin Oncol (R Coll Radiol) 2011; 23(3): 163–164
14. Background
Radiotherapy is widely used as an adjunct to surgery in the management of soft tissue
Sarcoma sarcomas as the risk of failure in the surgical bed can be high. For bone sarcomas,
radiotherapy is only occasionally employed in the management of osteosarcomas;
indications include incompletely resected or unresectable primary disease.1 By contrast,
radiotherapy remains an integral part of multimodality treatment for Ewings’ sarcoma.
Clinical experience suggests that sarcomas vary widely in radiosensitivity. Radiotherapy
is delivered with conventional fractionation, with no established role for hypo- or
hyperfractionation in treatment with curative intent.2 Intensity-modulated radiotherapy
(IMRT) or proton therapy may be appropriate when optimal dose fractionationis not
achievable with conventional techniques.
Resectable extremity soft tissue sarcomas

Surgery is the primary treatment modality in the majority of soft tissue sarcomas. Adjuvant
radiotherapy is used to reduce the probability of local recurrence and facilitate surgical
sparing of function.3, 4 There are no randomised trials in soft tissue sarcomas dealing
purely with dose-fractionation. External beam radiotherapy (EBRT) can be delivered
pre- or postoperatively. The Canadian Sarcoma Group SR-2 trial randomised patients to
preoperative radiotherapy with 50 Gray (Gy) in 25 fractions compared with postoperative
radiotherapy with 66 Gy in 33 fractions.4 The results suggest that local control is similar
with pre- or postoperative radiotherapy, but that preoperative treatment is associated with
an increased rate of acute wound complications (predominantly in the lower limb) and
that postoperative treatment leads to increased limb fibrosis, joint stiffness, oedema and
bone fractures.
Local control is superior with total postoperative doses >64 Gy in the presence of high-risk
features for local failure or positive margins.5,6 If preoperative radiotherapy is delivered,
there is no evidence to support a role for a subsequent postoperative boost in the event of
positive resection margins.7,8
Recommendations
Preoperative radiotherapy:
Postoperative radiotherapy:
50 Gy in 25 fractions over 5 weeks plus a 10 Gy in 5 fraction boost over 1 week for
average risk (Grade C)
For post-operative treatment, a boost of up to 16 Gy in 8 fractions over 1.5 weeks is
recommended for disease considered at higher risk of local recurrence due to positive
margins (Grade C)
This boost may be limited to 10 Gy in 5 fractions at certain anatomical sites (for
example, across joints, Achilles tendon, brachial plexus)
Unresectable extremity soft tissue sarcomas

Where there are no metastases at presentation, patients may be considered for radical
radiotherapy with the aim of achieving local control. There is Level 2+ evidence to support a
total dose to tumour of ≥63 Gy.9,10
Recommendation
66 Gy in 33 fractions over 6.5 weeks (Grade C)
Retroperitoneal soft tissue sarcomas

Surgery is the mainstay of treatment for retroperitoneal sarcomas, however, locoregional
recurrence remains the predominant pattern of disease recurrence. The role of
radiotherapy remains unproven, with limited supporting data.11–13 Preoperative radiotherapy
is deliverable with minimal toxicity.11,12 An international expert consensus panel recently
concluded that preoperative radiotherapy is preferable to postoperative and provided
guidelines on which patients this may be appropriate for, while acknowledging the limited
evidence base (Level 4).9,13
Recommendations
Preoperative radiotherapy:
50 Gy in 25 fractions over 5 weeks or
50.4 Gy in 28 fractions over 5.5 weeks (Grade C)
Desmoid tumours
These rare tumours are locally aggressive but do not metastasise. Consensus now
supports a multidisciplinary specialist approach to management, with a period of
observation most frequently recommended as initial management.14 For patients with
inoperable disease for whom radiotherapy is judged to be indicated, there is evidence to
support the use of 56 Gy in 28 fractions in an attempt to delay progression (Level 4).9,15,16
Radiotherapy may also be used, at similar doses, to prevent or delay recurrence in patients
who have residual disease after surgical excision, if clinically indicated. However, it should
be noted that positive margins do not necessarily result in disease progression, so this is
not an absolute indication for radiotherapy.
Recommendation
Definitive or postoperative radiotherapy:
Ewing’s-type tumours and primitive neuroectodermal tumour (PNET)

When surgical resection is feasible or appropriate, this is usually carried out after
preliminary chemotherapeutic cytoreduction. Where a radical surgical margin is not
achieved, then there is evidence to suggest that postoperative radiotherapy at a dose of 54–
60 Gy in 28–30 fractions for gross disease, and at least 45 Gy in 25 fractions for microscopic
disease, might be beneficial. Surgical resection may not be feasible or appropriate for
certain anatomical sites (for example, spine, pelvis), in which case radiotherapy can be used
as a radical treatment, although evidence suggests that it is not quite as effective as surgery
in achieving local tumour control; evidence indicates that doses of 55–56 Gy in 1.8 Gy
fractions can be effective (Level 2b).9,17–20
Recommendations
Doses are based upon the current Euro Ewing 2012 radiotherapy protocol.21
For preoperative treatment:
50.4 Gy in 28 fractions as a single phase. Dose may be reduced to 45 Gy in 25 fractions
if necessary due to proximity to organs at risk (Grade C)
Unresectable disease or incomplete macroscopic clearance:
54 Gy in 30 fractions. A phase 2 boost of 5.4 Gy in 3 fractions may be used respecting
organ at risk constraints (Grade C)
For paraspinal tumours:
50.4 Gy in 30 fractions either as a single phase or an initial phase of 45 Gy in 25
fractions followed by a boost of 5.4 Gy in 3 fractions
For patients at risk of microscopic disease following surgery:
54 Gy in 30 fractions, delivered with an initial phase of 45 Gy in 25 fractions followed by
a 9 Gy in 5 fraction boost (Grade C)
Lung metastases
Curative intent multimodality treatment for patients with lung metastases includes whole-
lung radiotherapy (in patients who have not received busulphan).22 Recommended
doses for whole-lung radiotherapy in the EURO EWING 99 study were 15 Gy (for patients
<14 years of age) or 18 Gy (patients >14 years) delivered with 1.5 Gy daily fractions or
alternatively using bi-daily fractionation with 1.25 Gy per fraction.23,24 An appropriate
bi-daily fractionation schedule would be 17.5 Gy in 14 fractions of 1.25 Gy per fraction
over two weeks with a minimum of a six-hour inter-fraction interval. Other centres have
reported that a dose of 15 Gy in ten fractions over three weeks is well tolerated in an adult
population.22 Whole-lung radiotherapy should be computed tomography (CT) planned with
an inhomogeneity correction.
Recommendations
Whole-lung radiotherapy:
Doses are based on the current Euro Ewing 2012 radiotherapy protocol.21
<14 years of age:
≥14 years of age:
Palliation
Radiotherapy is used to palliate locally uncontrolled and distant disease. With little evidence
available, the selection of dose-fractionation schedules is individualised. Higher total doses
maybe appropriate for selected patients with local disease to obtain more durable local
control. In patients with metastatic soft tissue sarcoma, a recent series reported a high rate
of durable pain control with a dose of 39 Gy in 13 fractions (Level 4).9,25
Recommendations
8 Gy in a single fraction (Grade D)
References 1. DeLaney TF, Park L, Goldberg SI et al. Radiotherapy for local control of osteosarcoma. Int J Radiat
Oncol Biol Phys 2005; 61(2): 492–498.
2. Dickie CI, Haas R, O'Sullivan B. Adjuvant radiation for soft tissue sarcomas. Am Soc Clin Oncol Educ
Book 2015; e634–e642.
3. Yang JC, Chang AE, Baker AR et al. Randomized prospective study of the benefit of adjuvant radiation
therapy in the treatment of soft tissue sarcomas of the extremity. J Clin Oncol 1998; 16(1): 197–203.
4. O'Sullivan B, Davis AM, Turcotte R et al. Preoperative versus postoperative radiotherapy in soft-tissue
sarcoma of the limbs: a randomised trial. Lancet 2002; 359(9325): 2235–2241.
5. Zagars GK, Ballo MT. Significance of dose in postoperative radiotherapy for soft tissue sarcoma. Int J
6. Delaney TF, Kepka L, Goldberg SI et al. Radiation therapy for control of soft-tissue sarcomas resected
with positive margins. Int J Radiat Oncol Biol Phys 2007; 67(5): 1460–1469.
7. Al Yami A, Griffin AM, Ferguson PC et al. Positive surgical margins in soft tissue sarcoma treated with
preoperative radiation: is a postoperative boost necessary? Int J Radiat Oncol Biol Phys 2010; 77(4):
1191–1197.
8. Pan E, Goldberg SI, Chen YL et al. Role of post-operative radiation boost for soft tissue sarcomas with
positive margins following pre-operative radiation and surgery. J Surg Oncol 2014; 110(7): 817–822.
9.
10. Kepka L, DeLaney TF, Suit HD, Goldberg SI. Results of radiation therapy for unresected soft-tissue
sarcomas. Int J Radiat Oncol Biol Phys 2005; 63(3): 852–859.
11. Jones JJ, Catton CN, O'Sullivan B et al. Initial results of a trial of preoperative external-beam radiation
therapy and postoperative brachytherapy for retroperitoneal sarcoma. Ann Surg Oncol 2002; 9(4):
346–354.
12. Pisters PW, Ballo MT, Fenstermacher MJ et al. Phase I trial of preoperative concurrent doxorubicin and
radiation therapy, surgical resection, and intraoperative electron-beam radiation therapy for patients
with localized retroperitoneal sarcoma. J Clin Oncol 2003; 21(16): 3092–3097.
13. Baldini EH, Wang D, Haas RL et al. Treatment guidelines for preoperative radiation therapy for
retroperitoneal sarcoma: preliminary consensus of an international expert panel. Int J Radiat Oncol Biol
Phys 2015; 92(3): 602–612.
14. Kasper B, Baumgarten C, Bonvalot S et al. Management of sporadic desmoid-type fibromatosis: a

European consensus approach based on patients' and professionals' expertise – a sarcoma patients
EuroNet and European Organisation for Research and Treatment of Cancer/Soft Tissue and Bone
Sarcoma Group initiative. Eur J Cancer 2015; 51(2): 127–136.
15. Keus RB, Nout RA, Blay JY et al. Results of a phase II pilot study of moderate dose radiotherapy for
inoperable desmoid-type fibromatosis – an EORTC STBSG and ROG study (EORTC 62991-22998). Ann
Oncol 2013; 24(10): 2672–2676.
16. Kriz J, Eich HT, Haverkamp U et al. Radiotherapy is effective for desmoid tumors (aggressive
fibromatosis) – long-term results of a German multicenter study. Oncol Res Treat 2014; 37(5): 255–260.
17. Indelicato DJ, Keole SR, Shahlaee AH et al. Definitive radiotherapy for ewing tumors of extremities and
pelvis: long-term disease control, limb function, and treatment toxicity. Int J Radiat Oncol Biol Phys
2008; 72(3): 871–877.
18. La TH, Meyers PA, Wexler LH et al. Radiation therapy for Ewing's sarcoma: results from Memorial
Sloan-Kettering in the modern era. Int J Radiat Oncol Biol Phys 2006; 64(2): 544–550.
19. Casey DL, Meyers PA, Alektiar KM et al. Ewing sarcoma in adults treated with modern radiotherapy
techniques. Radiother Oncol 2014; 113(2): 248–253.
20. DuBois SG, Krailo MD, Gebhardt MC et al. Comparative evaluation of local control strategies in
localized Ewing sarcoma of bone: a report from the Children's Oncology Group. Cancer 2015; 121(3):
467–475.
21. http://www.isrctn.com/ISRCTN92192408 (last accessed 10/10/16)
22. Casey DL, Alektiar KM, Gerber NK, Wolden SL. Whole lung irradiation for adults with pulmonary
metastases from Ewing sarcoma. Int J Radiat Oncol Biol Phys 2014; 89(5): 1069–1075.
23. Ladenstein R, Pötschger U, Le Deley MC et al. Primary disseminated multifocal Ewing sarcoma:
results of the Euro-EWING 99 trial. J Clin Oncol 2010; 28(20): 3284–3291.
24. http://www.controlled-trials.com/ISRCTN61438620 (last accessed 10/10/16)
25. Soyfer V, Corn BW, Kollender Y et al. Radiation therapy for palliation of sarcoma metastases: a unique
and uniform hypofractionation experience. Sarcoma 2010; 2010: 927–972.
15. Background
Stage I seminoma has between a 15–20% risk of relapse; surveillance without treatment
Seminoma is one option. Relapses principally occur in the para-aortic nodes and the risk can be
quantifield using factors related to the primary tumour.1 A tumour >4 centimetres (cm)
in size is the most important of these; rete testis involvement may also be a predictor.2
Adjuvant treatment rather than surveillance may be offered in such cases.
A single dose of carboplatin has been shown to achieve results equal to radiotherapy in
terms of overall tumour control and early survival in the TE19 randomised trial.3 In the UK
this approach has now become the standard (Level 1b).4
If radiotherapy is considered in this setting then a dose of 20 Gray (Gy) in ten daily fractions
treating the para-aortic node chain only has been shown to be as effective as 30 Gy or larger
fields (Level 1b).4,5
Radiotherapy may also be considered for selected patients with stage IIA and IIB seminoma
where there are metastatic para-aortic nodes up to 5 cm.6 A dose of 30 Gy in 15 daily
fractions to the para-aortic nodal chain and ipsilateral iliac nodes is recommended. A boost
of 5 Gy to enlarged lymph nodes may be considered (Level 2b).4,7,8 An alternative approach
uses a single dose of carboplatin with radiation fields reduced to the involved para-aortic
region only (Level 1b).4,9
Radiotherapy carries an excess risk of death as a result of radiation-induced cardiac
disease or second cancer.5 Thirty-year follow-up shows that the relative risk of second
malignancy is 1.4; this translates into an increase in the risk of cancer from 15% for the
normal population to 25% for the seminoma cohort at 30 years (Level 2b).4,10
Recommendations
Single agent carboplatin will be the usual adjuvant treatment for high-risk stage I
disease seminoma (Grade B)
Stage I seminioma for which adjuvant para-aortic radiotherapy is indicated:
Stage IIA or IIB seminoma: para-aortic and ipsilateral iliac radiotherapy (dog leg)
or para-aortic radiotherapy alone after carboplatin:
References 1. Warde P, Specht L, Horwich A et al. Prognostic factors for relapse in stage I seminoma managed by
surveillance: a pooled analysis. J Clin Oncol 2002; 20(22): 448–452.
2. Chung P, Daugaard G, Tyldesley S et al. Evaluation of a prognostic model for risk of relapse in stage I
seminoma surveillance. Cancer Med 2015; 4(1): 155–160.
3. Oliver RT, Mead GM, Rustin GJ et al. Randomized trial of carboplatin versus radiotherapy for stage
I seminoma: mature results on relapse and contralateral testis cancer rates in MRC TE19/EORTC
30982 study (ISRCTN27163214). J Clin Oncol 2011; 29(8): 957–962.
4. w
5. Jones WG, Fossa SD, Mead GM et al. Randomised trial of 30 versus 20 Gy in the adjuvant treatment of
stage I testicular seminoma: a report on Medical Research Council Trial TE18, European Organisation
for the Research and Treatment of Cancer Trial 30942 (ISRCTN 18525328). J Clin Oncol 2005; 23(6):
1200–1208.
6. Giannatempo P, Greco T, Mariani L et al. Radiotherapy or chemotherapy for clinical stage IIA and
IIB seminoma: a systematic review and meta-analysis of patient outcomes. Ann Oncol 2015; 26(4):
657–656.
7. Oldenburg J, Fosså SD, Nuver J et al. Testicular seminoma and non-seminoma: ESMO Clinical Practice
Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013; 24(Suppl 6): vi125–vi132.
8. Tandstad T, Smaaland R, Solberg A et al. Management of seminomatous testicular cancer: a binational

prospective population-based study from the Swedish Norwegian testicular cancer study group. J Clin
Oncol 2011; 29(6): 719–725.
9. Horwich A, Dearnaley DP, Sohaib A, Pennert K, Huddart RA. Neoadjuvant carboplatin before
radiotherapy in stage IIA and IIB seminoma. Ann Oncol 2013; 24(8): 2104–2107.
10. Zagars GK, Ballo MT, Lee AK, Strom SS. Mortality after cure of testicular seminoma. J Clin Oncol 2004;
22(4): 640–647.
16. Squamous cell carcinoma and basal cell carcinoma

Background
Skin cancer
Surgery and radiotherapy are both highly effective curative treatment modalities for
squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). The choice of treatment
modality is determined by factors including age, tumour size and functional/cosmetic
outcomes. Surgery is generally preferred for younger patients. Primary radiotherapy is
often preferred for regions around the lower eyelids, nose and ear, where better functional/
cosmetic results can be achieved. Radiotherapy to the lower leg is often avoided in
elderly patients due to the risk of radionecrosis. There appears to be a slightly higher local
recurrence rate following radiotherapy for SCCs compared with BCCs.1 Postoperative
radiotherapy for SCC can be considered for high-risk features, for example, positive or close
margins, perineural invasion, tumour depth >4 millimetres (mm) and poor differentiation.2
Elective irradiation of first echelon lymph nodes can be considered for higher risk SCC.3
There are no randomised studies examining dose-fractionation; in addition, most series
report use of multiple dose-fractionation schedules in historical series.4 As a consequence,
there is wide variation in both total dose and dose per fraction in commonly used
schedules, with a variety of pragmatic hypofractionated schedules being widely used.4, 5
Similar doses are used for BCC and SCC, although some suggest higher doses for SCCs.6
More protracted treatment regimens may provide superior cosmetic results.
A large retrospective study of patients with SCC and BCC showed that schedules of 54
Gray (Gy) in 18 fractions or 44 Gy in ten fractions had similar efficacy with good cosmetic
outcomes.7 A schedule of 34 Gy in five fractions was shown to provide high rates of local
control for BCC (five-year recurrence rate of 7%).8 In a retrospective series employing
multiple schedules for BCC and SCC, including 35 Gy in five fractions, no difference in
control rates was found between different fractionation schedules.3 In a large retrospective
series of 1,005 predominantly small BCCs/SCCs, single fraction doses of 18, 20 and 22.5
Gy provided a five-year local control rate of 90%; the skin necrosis-free rate at five years was
only 84% and necrosis occurred more frequently with the 22.5 Gy dose (Level 4).9,10
The relative biological effectiveness of electrons and photons is around 10% less than that
for superficial X-rays; treatment with electrons or photons therefore, theoretically, requires a
corresponding increase in dose, although this is often not considered in practice.
Recommendations
The choice of dose fractionation takes into account patient factors, tumour and
field size. The following schedules are examples of those appropriate for the
treatment of skin SCCs and BCCs either definitively or adjuvantly:
Single fraction 18–20 Gy (usually in elderly patients with field size <3 cm) (Grade C)
32.5–35 Gy in 5 fractions over 1 week (usually small lesions <4 cm) (Grade C)
45 Gy in 10 fractions over 2–3 weeks (Grade C)
50 Gy in 15–20 fractions over 3–4 weeks (Grade C)
If large area and in area of poor radiation tolerance:
Squamous cell carcinoma and regional lymph node disease

Background
Surgical management of regional lymph node disease is regarded as the treatment of
choice. Relapse rates after therapeutic surgery alone to regional lymph node disease are
high.11 Several series have reported multiple factors predictive of regional relapse after
surgery, including lymph node >3 cm, multiple involved nodes, extracapsular spread.11,12
In the head and neck region, the use of adjuvant radiotherapy has been shown to reduce
regional recurrence rates and improve disease free survival.13 In a large retrospective series,
the median dose employed was 60 Gy in 30 fractions with a dose of 50 Gy in 25 fractions
to elective at risk regions (Level 4).10,13 Optimal adjuvant dose fractionation will depend
upon the anatomical site. In the head and neck region, doses of up to 66 Gy in 33 fractions
can be considered in the presence of extracapsular spread.14 Radical radiotherapy can be
considered if surgery is inappropriate or declined.
Recommendations
For adjuvant radiotherapy to nodal regions considered at high risk o frelapse
after theraputic lymphadenectomy:
50–60 Gy in 25–30 fractions over 5–6 weeks (Grade C)
Where there are high pathological risk features in the head and neck region:
Melanoma
Background
The primary treatment for cutaneous melanoma is complete local excision. Adjuvant
radiotherapy to the primary site is not usually indicated, other than in rare cases of
desmoplastic melanoma, which is a rare subtype associated with perineural spread and
increased risk of local failure. Adjuvant radiotherapy to the primary site can be considered
for desmoplastic melanoma resected with close margins, perineural invasion or lesions
thicker than 4 mm.14,15
For patients at high risk of regional recurrence after a therapeutic lymphadenectomy,
adjuvant hypofractionated radiotherapy with a dose of 48 Gy in 20 fractions over four weeks
has been shown in a Trans Tasmann Radiation Oncology Group (TROG) phase III trial to
reduce the risk of regional recurrence, although has no effect on overall survival (Level
1b).10,16 Hypofractionated schedules have commonly been used for melanoma although no
direct comparison with conventional 2 Gy per day fractionation has been performed. The
MD Anderson Cancer Centre has reported an alternative hypofractionated schedule of 30
Gy in five fractions (two fractions per week) with high rates of regional control (Level 4).10,17
Recommendations
Adjuvant radiotherapy to nodal regions:
Merkel cell carcinoma

Background
Merkel cell cancer is a rare, aggressive, neuroendocrine skin malignancy with a propensity
for locoregional and distant recurrence. The primary therapy for Merkel cell carcinoma is
surgery. Merkel cell cancer is considered radiosensitive and multiple retrospective series
provide evidence that adjuvant postoperative radiotherapy to the primary tumour bed and
draining lymphatics provides high rates of locoregional control for higher risk tumours;
wide margins are required due to a tendancy for edge recurrences (Level 4).10,18–20 A
prospective cohort study in patients with lymph node positive disease has demonstrated
that radiotherapy alone to the regional lymph nodes provides equally high rates of regional
control, comparable to surgical outcomes, with no overall survival difference (Level 2b).10,21
Elective lymph node treatment is not always feasible depending upon the anatomical
site of the primary tumour and patient fitness. There are no randomised trials to assess
the optimal dose fractionation. Radical radiotherapy can be considered in medically
inoperable patients or when the functional/cosmetic deficits due to surgery are considered
excessively morbid. Limited data suggest that definitive radiotherapy can be effective. In
a series of 43 patients an in-field control rate of 75% was achieved; doses of 50–55 Gy in
20–25 fractions were recommended.22 In a small series, a dose of 60 Gy was effective in the
definitive treatment of the primary lesion, while others have employed doses of up to 70 Gy
(Level 4).10,18,23 In most series, adjuvant doses of >50 Gy are used.18,19,21 For some patients,
such as frail elderly patients, a conventionally fractionated schedule may be considered
excessively burdensome and shorter hypofractionated schedules may be considered.
Consistent with the radiosensitivity of the disease, lower doses of 20 Gy in five fractions or
30 Gy in ten fractions have been reported to potentially eradicate low volume disease in
poor performance status patients (Level 4).10,22
Recommendations
Primary and/or draining lymph node regions:
For definitive treatment:
60–66 Gy in 30–33 fractions in 6–6.5 weeks (Grade C)
50–55 Gy in 20–25 fractions in 4–5 weeks (Grade C)
For adjuvant treatment:
References 1. Lovett RD, Perez CA, Shapiro SJ, Garcia DM. External irradiation of epithelial skin cancer. Int J Radiat
Oncol Biol Phys 1990; 19(2): 235–242.
2. Han A, Ratner D. What is the role of adjuvant radiotherapy in the treatment of cutaneous squamous
cell carcinoma with perineural invasion? Cancer 2007; 109(6): 1053–1059.
3. Kwan W, Wilson D, Moravan V. Radiotherapy for locally advanced basal cell and squamous cell
carcinomas of the skin. Int J Radiat Oncol Biol Phys 2004; 60(2): 406–411.
4. Cho M, Gordon L, Rembielak A, Woo TC. Utility of radiotherapy for treatment of basal cell carcinoma: a
review. Br J Dermatol 2014; 171(5): 968–973.
5. McPartlin AJ, Slevin NJ, Sykes AJ, Rembielak A. Radiotherapy treatment of non-melanoma skin cancer:
a survey of current UK practice and commentary. Br J Radiol 2014; 87(1043): 20140501.
6. Locke J, Karimpour S, Young G, Lockett MA, Perez CA. Radiotherapy for epithelial skin cancer. Int J
7. van Hezewijk M, Creutzberg CL, Putter H, et al. Efficacy of a hypofractionated schedule in electron
beam radiotherapy for epithelial skin cancer: Analysis of 434 cases. Radiother Oncol 2010; 95(2):
245–249.
8. Silverman MK, Kopf AW, Gladstein AH, Bart RS, Grin CM, Levenstein MJ. Recurrence rates of treated
basal cell carcinomas. Part 4: X-ray therapy. J Dermatol Surg Oncol 1992; 18(7): 549–554.
9. Chan S, Dhadda AS, Swindell R. Single fraction radiotherapy for small superficial carcinoma of the skin.
Clin Oncol (R Coll Radiol) 2007; 19(4): 256–259.
10. www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009 (last accessed

30/9/16)
11. Veness MJ, Porceddu S, Palme CE, Morgan GJ. Cutaneous head and neck squamous cell carcinoma
metastatic to parotid and cervical lymph nodes. Head Neck 2007; 29(7): 621–631.
12. Porceddu SV, Veness MJ, Guminski A. Nonmelanoma cutaneous head and neck cancer and merkel
cell carcinoma: current concepts, advances, and controversies. J Clin Oncol 2015; 33(29): 3338–3345.
13. Veness MJ, Morgan GJ, Palme CE, Gebski V. Surgery and adjuvant radiotherapy in patients with
cutaneous head and neck squamous cell carcinoma metastatic to lymph nodes: combined treatment
should be considered best practice. Laryngoscope 2005; 115(5): 870–875.
14. Strom T, Caudell JJ, Han D et al. Radiotherapy influences local control in patients with desmoplastic
melanoma. Cancer 2014; 120(9): 1369–1378.
15. Guadagnolo BA, Prieto V, Weber R, Ross MI, Zagars GK. The role of adjuvant radiotherapy in the local
management of desmoplastic melanoma. Cancer 2014; 120(9): 1361–1368.
16. Burmeister BH, Henderson MA, Ainslie J et al. Adjuvant radiotherapy versus observation alone for
patients at risk of lymph-node field relapse after therapeutic lymphadenectomy for melanoma: 6 year
follow-up. Lancet Oncol 2015; 16(9): 1049–1060.
17. Ballo MT, Bonnen MD, Garden AS et al. Adjuvant irradiation for cervical lymph node metastases from
melanoma. Cancer 2003; 97(7): 1789–1796.
18. Lok B, Khan S, Mutter R et al. Selective radiotherapy for the treatment of head and neck Merkel cell
carcinoma. Cancer 2012; 118(16): 3937–3944.
19. Fields RC, Busam KJ, Chou JF et al. Recurrence after complete resection and selective use of adjuvant
therapy for stage I through III Merkel cell carcinoma. Cancer 2012; 118(13): 3311–3320.
20. Lewis KG, Weinstock MA, Weaver AL, Otley CC. Adjuvant local irradiation for Merkel cell carcinoma.
Arch Dermatol 2006; 142(6): 693–700.
21. Fang LC, Lemos B, Douglas J, Iyer J, Nghiem P. Radiation monotherapy as regional treatment for lymph
node-positive Merkel cell carcinoma. Cancer 2010; 116(7): 1783–1790.
22. Veness M, Foote M, Gebski V, Poulsen M. The role of radiotherapy alone in patients with merkel cell
carcinoma: reporting the Australian experience of 43 patients. Int J Radiat Oncol Biol Phys 2010; 78(3):
703–709.
23. Mortier L, Mirabel X, Fournier C, Piette F, Lartigau E. Radiotherapy alone for primary Merkel cell
carcinoma. Arch Dermatol 2003; 139(12): 1587–1590.
17. Oesophagus
Upper gastrointestinal Radical treatment

cancer For patients with localised disease, the standard curative approach to treatment is either
surgery + perioperative chemotherapy, surgery ± neoadjuvant chemoradiotherapy or
definitive radiotherapy ± concomitant chemotherapy.
Radiation with concomitant chemotherapy

Radiation with concomitant chemotherapy is superior to radiotherapy alone.1 The landmark
Radiation Therapy Oncology Group (RTOG) 85-01 trial showed a survival advantage for
concomitant chemoradiation (50 Gray [Gy] in 25 fractions) with two concurrent and two
adjuvant cycles of cisplatin and fluorouracil (5-FU), compared with radiotherapy alone
(64 Gy in 32 fractions), with five-year survival rates of 27% versus 0%.1 The subsequent
INT0123 trial failed to show a benefit of dose escalation to 64.8 Gy compared with 50.4
Gy with the same cisplatin/5-FU chemotherapy in both arms.2 Treatment-related deaths
were increased in the dose-escalated arm, although the majority of these occurred prior
to the delivery of >50 Gy and cannot be attributed to dose escalation.3 A systematic review
of neoadjuvant concomitant chemoradiation confirmed a radiotherapy dose–response
relationship with a pathological complete response.4 An increasing body of evidence
is suggestive of the safety and feasibility of doses ≥60 Gy.3 Outcomes have improved
in modern trials using more conformal radiotherapy techniques with improved patient
selection and radiotherapy quality assurance; in a recent UK study, radiotherapy combined
with cisplatin and capecitabine showed two-year survival rates of 56%.5
Recommendations
Radiation with concomitant chemotherapy:
For upper third oesophageal carcinoma, moderate dose escalation with intensity-
modulated radiotherapy (IMRT) can be considered wherever possible, within the
context of a clinical trial (Grade C)
Definitive radiotherapy alone

In a series of 101 patients in whom the majority of tumours were <5 centrimeters (cm) in
length, radiotherapy alone to a dose of 45–52.5 Gy in 15–16 fractions achieved a five-year
survival of 21%.7 Radiotherapy is an option for patients in whom the use of concurrent
chemotherapy is contraindicated.
Recommendations
Radiotherapy alone:
50 Gy in 15–16 fractions over 3 weeks (Grade C)
Preoperative radiation with concomitant chemotherapy

Recent meta-analyses have demonstrated a significant improvement in overall survival
using multimodality treatment over surgery alone; an advantage for neoadjuvant
concomitant chemoradiotherapy over chemotherapy has not been established.8 A recent
trial of neoadjuvant radiotherapy with concomitant carboplatin and paclitaxel and 41.4 Gy in
23 fractions versus surgery alone demonstrated an increase in median survival from 24–49
months and no increase in perioperative mortality.9 A dose of 45 Gy in 25 fractions has been
selected for a randomised multicentre UK trial.10
Recommendations
Neoadjuvant radiation with concomitant chemotherapy:
Adjuvant (chemo)radiotherapy can be considered for patients with positive margins and
prognosis likely to be influenced by local relapse, although evidence for the benefit of
adjuvant (chemo)radiotherapy is uncertain.11 Based on a meta-analysis, radiotherapy
with concomitant chemotherapy is preferred to radiotherapy alone with conventionally
fractionated doses of 40–50 Gy.12
There is increasing evidence that intraluminal brachytherapy provides effective relief of
dysphagia, with improved quality of life. An updated Cochrane review on interventions for
dysphagia in oesophageal cancer has concluded that, when compared to self-expanding
metal stents, brachytherapy has fewer requirements for re-intervention, improved survival
and better quality of life.13
Recommendations
Palliative brachytherapy:
12 Gy in 1 fraction (Grade B)14
12–16 Gy in 2 fractions (Grade B)15,16
Palliative radiotherapy alone should be considered for symptom improvement in

oesophageal cancer. Concurrent chemoradiotherapy has not been shown to be
advantageous in a phase III trial in which radiotherapy doses were 35 Gy in 15 fractions or
30 Gy in ten fractions.17
Recommendations
Palliative external beam radiotherapy:
Gastric cancer
Adjuvant radiotherapy with concomitant chemotherapy
Perioperative chemotherapy represents a standard of care in the management of locally
advanced gastric cancer.18 Adjuvant radiotherapy with concomitant chemotherapy
represents an alternative approach. The INT0116 trial provided evidence of a survival
benefit for postoperative concomitant chemoradiotherapy, however, this trial had poor
surgical quality control with 54% of patients undergoing a D0 resection.19 In patients with
a high risk of relapse who did not undergo preoperative chemotherapy, especially in the
absence of a D2 resection, adjuvant radiotherapy with concomitant 5-FU or capecitabine
can be considered (Level 2b).6,20
Recommendation
Adjuvant radiotherapy with concomitant chemotherapy:
Palliative radiotherapy is an effective treatment for bleeding due to gastric carcinoma, with
no clear benefit for more protracted fractionation schedules.21
Recommendations
6–8 Gy in 1 fraction (Grade D)
Pancreas cancer
Radical treatment
Chemoradiotherapy
Based on a very limited evidence base, adjuvant radiotherapy with concomitant
chemotherapy is occasionally used in some centres for patients who are resection margin
positive; a dose of 45 Gy in 25 fractions is appropriate for adjuvant treatment.22
Standard treatment options for patients with locally advanced inoperable pancreas
cancer include chemotherapy alone or induction chemotherapy followed by radiotherapy
and concomitant chemotherapy in responding or stable disease after induction
chemotherapy.23–25 One randomised study showed a small survival benefit in favour
of consolidation radiotherapy with concomitant chemotherapy, although this was not
confirmed in a subsequent study (Level 1b).6,23,24
Recommendations
Radiotherapy with concomitant chemotherapy following induction chemotherapy:
50.4 Gy in 28 fractions over 5.5 weeks (Grade B)
References 1. Herskovic A, Martz K, al-Sarraf M et al. Combined chemotherapy and radiotherapy compared with
radiotherapy alone in patients with cancer of the esophagus. N Engl J Med 1992; 326(24): 1593–1598.
2. Minsky BD, Pajak TF, Ginsberg RJ et al. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III
trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation
therapy. J Clin Oncol 2002; 20(5): 1167–1174.
3. Rackley T, Leong T, Foo M, Crosby T. Definitive chemoradiotherapy for oesophageal cancer – a

promising start on an exciting journey. Clin Oncol (R Coll Radiol) 2014; 26(9): 533–540.
4. Geh JI, Bond SJ, Bentzen SM, Glynne-Jones R. Systematic overview of preoperative (neoadjuvant)
chemoradiotherapy trials in oesophageal cancer: evidence of a radiation and chemotherapy dose
response. Radiother Oncol 2006; 78(3): 236–244.
5. Crosby T, Hurt CN, Falk S et al. Chemoradiotherapy with or without cetuximab in patients with
oesophageal cancer (SCOPE1): a multicentre, phase 2/3 randomised trial. Lancet Oncol 2013; 14(7):
627–637.
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7. Sykes AJ, Burt PA, Slevin NJ, Stout R, Marrs JE. Radical radiotherapy for carcinoma of the oesophagus:
an effective alternative to surgery. Radiother Oncol 1998; 48(1): 15–21.
8. Gwynne S, Wijnhoven BP, Hulshof M, Bateman A. Role of chemoradiotherapy in oesophageal cancer

-- adjuvant and neoadjuvant therapy. Clin Oncol (R Coll Radiol) 2014; 26(9): 522–532.
9. Zheng B, Zheng W, Zhu Y, Lin XY, Xu BH, Chen C. Role of adjuvant chemoradiotherapy in treatment of
resectable esophageal carcinoma: a meta-analysis. Chin Med J (Engl) 2013; 126(6): 1178–1182.
10. Sjoquist KM, Burmeister BH, Smithers BM et al. Survival after neoadjuvant chemotherapy or
chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis. Lancet Oncol
2011; 12(7): 681–692.
11. van Hagen P, Hulshof MC, van Lanschot JJ et al. Preoperative chemoradiotherapy for esophageal or
junctional cancer. N Engl J Med 2012; 366(22): 2074–2084.
12. Mukherjee S, Hurt CN, Gwynne S et al. NEOSCOPE: a randomised Phase II study of induction
chemotherapy followed by either oxaliplatin/capecitabine or paclitaxel/carboplatin based
chemoradiation as pre-operative regimen for resectable oesophageal adenocarcinoma. BMC Cancer
2015; 15: 48.
13. Dai Y, Li C, Xie Y et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev
2014;10: CD005048.
14. Homs MY, Steyerberg EW, Eijkenboom WM et al. Single-dose brachytherapy versus metal stent
placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial.
Lancet 2004; 364(9444): 1497–1504.
15. Sur RK, Levin CV, Donde B, Sharma V, Miszczyk L, Nag S. Prospective randomized trial of HDR
brachytherapy as a sole modality in palliation of advanced esophageal carcinoma – an International
Atomic Energy Agency study. Int J Radiat Oncol Biol Phys 2002; 53(1): 127–133.
16. Sharma V, Mahantshetty U, Dinshaw KA, Deshpande R, Sharma S. Palliation of advanced/recurrent

esophageal carcinoma with high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys 2002; 52(2):
310–315.
17. Penniment M. Full report of the TROG 03.01, NCIC CTG ES2 multinational phase III study in advanced
esophageal cancer comparing palliation of dysphagia and quality of life in patients treated with
radiotherapy or chemoradiotherapy. J Clin Oncol 2015; 33: 3: abstract 6.
18. Cunningham D, Allum WH, Stenning SP et al. Perioperative chemotherapy versus surgery alone for
resectable gastroesophageal cancer. N Engl J Med 2006; 355(1): 11–20.
19. Macdonald JS, Smalley SR, Benedetti J et al. Chemoradiotherapy after surgery compared with surgery
alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001; 345(10):
725–730.
20. Foo M, Crosby T, Rackley T, Leong T. Role of (chemo)-radiotherapy in resectable gastric cancer. Clin
Oncol (R Coll Radiol) 2014; 26(9): 541–550.
21. Chaw CL, Niblock PG, Chaw CS, Adamson DJ. The role of palliative radiotherapy for haemostasis in
unresectable gastric cancer: a single-institution experience. Ecancermedicalscience 2014; 8: 384.
22. Stocken DD, Büchler MW, Dervenis C et al. Meta-analysis of randomised adjuvant therapy trials for
pancreatic cancer. Br J Cancer 2005; 92(8): 1372–1381.
23. Huguet F, André T, Hammel P et al. Impact of chemoradiotherapy after disease control with
chemotherapy in locally advanced pancreatic adenocarcinoma in GERCOR phase II and III studies. J
Clin Oncol 2007; 25(3): 326–331.
24. Hammel P, Huguet F, van Laethem J et al. Randomized multicentre phase III study in patients with
locally advanced adenocarcinoma of the pancreas:gemcitabine with or without chemoradiotherapy
and with or without Erlotinib-LAP 07 study. J Clin Oncol 2011; 29: abstract e14619.
25. Mukherjee S, Hurt CN, Bridgewater J et al. Gemcitabine-based or capecitabine-based

chemoradiotherapy for locally advanced pancreatic cancer (SCALOP): a multicentre, randomised,
18. Localised bone pain in established metastatic disease

Background
Bone metastases
Uncomplicated local bone pain responds well with response rates of 70–80% after
localised external beam treatment. Since response may take 4–6 weeks to achieve, it is
recommended that consideration be given to the patient’s prognosis before treatment. A
number of large randomised controlled trials have been undertaken to explore the optimal
dose. Three reviews have been completed using the Cochrane methodology. On the basis
of this information, the recommended fractionation is a single dose of 8 Gray (Gy) (Level
1a).1–4
Bone metastases may give rise to pain with neuropathic features rather than simple bone
pain. One randomised controlled trial specifically addressed this question, comparing
single-dose 8 Gy to multifraction treatment, for most patients 20 Gy in five fractions.
No major advantage for the multifraction arm was identified, and the recommendation
therefore is that these patients should also receive a single dose of 8 Gy.5
Recommendation
For the initial therapy of pain from bone metastases:
8 Gy single dose (Grade A)
Bone metastases in oligometastatic disease

In the context of oligometastatic disease, stereotactic body radiotherapy (SBRT) can
achieve local control rates of 80% and treatment has been shown to be well tolerated, with
low rates of spinal cord myelopathy (see section 20).
Retreatment
Retreatment should be considered in patients still having clinically significant pain after 4–6
weeks despite optimal analgesic. After a single dose, around 25% of patients may need
re-treatment at some point.6 Limited evidence suggests that response rates are similar to
those after primary treatment.7 There are no data to guide optimal dose fractionation for
retreatment; a randomised trial compared 8 Gy single dose with 20 Gy in five fractions (eight
fractions over the spinal cord) and showed no significant difference (Level 1b).4,8 Both may
be considered acceptable treatments for re-irradiation.
Recommendations
For the re-irradiation of bone metastases:
8 Gy single dose (Grade B)
20 Gy in 5 daily fractions (or 8 fractions over the spinal cord) over 1 week (Grade B)
Scattered bone pain

For metastatic bone pain at several sites despite adequate analgesia, wide-field or
hemibody external beam radiotherapy (EBRT) may be effective. Appropriate pre-
medication, such as dexamethasone and a 5HT3 antagonist is advised to reduce radiation-
induced nausea and vomiting. There are no randomised data to compare such treatment
to isotope therapy, but case–control comparisons suggest that all are equally effective.
However, EBRT is associated with more toxicity in terms of gastrointestinal and bone
marrow side-effects.9 A large international study tested two, four and five fraction regimens,
but there is no evidence to suggest that any of these are superior to giving the treatment in a
single-dose (Level 4).4,10
Recommendation
For patients with scattered bone pain:
Upper hemibody 6 Gy single dose (Grade C)
Lower hemibody 8 Gy single dose (Grade C)
Pathological fracture
Prophylaxis
Bone metastases with high risk of pathological fracture can be identified from their
radiological appearances. Suggested parameters include: those with > 50% cortical
destruction, >3 centimetre (cm) maximum diameter, axial cortical involvement >3 cm and
multifocal lytic disease.11 Surgical fixation should be considered.
If radiotherapy is to be used, there is no consensus on the best fractionation in this setting.
Higher risk lesions were in general excluded from fractionation trials. Common practice
would be for these patients to receive a fractionated regimen such as 20 Gy in five fractions
or 8 Gy single dose (Level 5).4
Recommendation
To prevent pathological fracture:
8 Gy single dose (Level 4) or
20 Gy in 5 fractions over 1 week (Level 4)
Established fracture
Bones such as ribs, vertebrae and pelvic and shoulder girdle bones are not amenable
to surgical fixation and can be treated with local radiotherapy. There is no consensus on
optimal fractionation.
Recommendation
For inoperable pathological fractures:
8 Gy single dose (Grade D) or
After internal fixation of a fracture or prophylactic pinning of a high-risk lesion, postoperative
radiotherapy is often recommended. There is limited literature to support its efficacy and no
consensus on dose. Treatment should be considered for all patients with persisting bone
pain after surgery. In cases where treatment is given with the aim of enabling bone healing
and long-term rehabilitation, consideration should be given to performance status and
predicted survival.
Recommendations
Postoperative radiotherapy after fixation of bone metastases:
8 Gy single dose (Grade D) or
References 1. McQuay H, Carroll D, Moore RA. Radiotherapy for painful bone metastases: a systematic review. Clin
Oncol 1997; 9(3): 150–154.
2. Wu JS, Wong R, Johnston M et al. Meta-analysis of dose-fractionation radiotherapy trials for the
palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 2003; 55(3): 594–605.
3. Sze WM, Shelley MD, Held I, Wilt TJ, Mason MD. Palliation of metastatic bone pain: single fraction
versus multifraction radiotherapy – a systematic review of randomised trials. Clin Oncol (R Coll Radiol)
2003; 15(6): 345–352.
4. w
5. Roos DE, Turner SL, O’Brien PC et al. Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of
radiotherapy for neuropathic pain due to bone metastases. Radiother Oncol 2005; 75(1): 54–63.
6. van der Linden YM, Lok YJ, Steenland E et al. Single fraction radiotherapy is efficacious: a further
analysis of the Dutch Study controlling for the influence of retreatment. Int J Radiat Oncol Biol Phys
2004; 59(2): 528–537.
7. Mithal NP, Needham PR, Hoskin PJ. Retreatment with radiotherapy for painful bone metastases. Int J of
Rad Oncol Biol Phys 1994; 29(5): 1011–1014.
8. Chow E, van der Linden YM, Roos D et al. Single versus multiple fractions of repeat radiations for
painful bone metastases: a randomised, controlled, non-inferiority trial. Lancet Oncol 2014; 15(2):
164–171.
9. Dearnaley DP, Bayley RJ, A’Hern RP, Gadd J, zivanovic MM, Lewington VJ. Palliation of bone
metastases in prostate cancer. Hemibody irradiation or strontium-89. Clin Oncol (R Coll Radiol) 1992;
4(2): 101–107.
10. Salazar OM, Sandhu T, da Motta NW et al. Fractionated half-body irradiation (HBI) for the rapid
palliation of widespread, symptomatic, metastatic bone disease: a randomised Phase III trial of the
International Atomic Energy Agency (IAEA). Int J Radiat Oncol Biol Phys 2001; 50(3): 765–775.
11. van der Linden YM, Kroon HM, Dijkstra SP et al. Simple radiographic parameter predicts fracturing in
metastatic femoral bone lesions: results from a randomised trial. Radiother Oncol 2003; 69(1): 21–31.
19. Background
This is a heterogeneous population of patients with diverse underlying histologies,
Brain metastases differences in disease burden outside the central nervous system (CNS) and differing
systemic therapy options. As such, it is helpful to classify patients according to a simplified
system. The original recursive partitioning analysis (RPA) based system of the Radiation
Therapy Oncology Group (RTOG) is simple and robust, but has now been replaced by the
Graded Prognostic Assessment (GPA) and the disease-specific GPA (dsGPA).1–9 These
prognostic scores continue to evolve, and still do not fully reflect the latest systemic
therapies.5,10
Patients can be divided into three groups according to disease specific factors, but in
general these three of importance:
• Karnofsky Performance Status (KPS) (at least 70)
• Control of the primary tumour
• Brain as the only site of disease.
Patients who fail to meet all three criteria tend to have a very poor prognosis, and may not
benefit from treatment.
The regimens most commonly used for the whole-brain radiotherapy (WBRT) treatment of
cerebral metastases are 30 Gy in ten fractions over two weeks or 20 Gy in five fractions over
one week. For patients with limited disease, other approaches, including gamma knife or
stereotactic radiosurgery (SRS) and intraoperative radiotherapy are feasible. The following
discussion draws heavily on a systematic review performed as part of the Cancer Care
Ontario programme in evidence-based care.11
Solitary or oligo-metastases
The evidence from one systematic review and three randomised trials suggests benefit
from adding surgery to whole brain radiotherapy (WBRT) for patients of good performance
status with a solitary metastasis (Level 1a).11–14 Stereotactic radiosurgery (SRS) added to
WBRT offers a survival benefit for selected patients with a solitary metastasis, as well as
for patients of RPA Class I with up to three metastases.15 In patients with up to three brain
metastases and KPS ≥70, adding SRS to WBRT improves functional independence and
reduces steroid requirements at six months (Level 1b).15,16
Patients with more than three brain metastases were not included in these trials.
Moreover, it is recognised that the number of brain metastases detected on magnetic
resonance imaging (MRI) is technique dependent. For small-volume disease, a
prospective observational study (Level 2+) in patients with up to ten metastases (largest
<10 centimetres3 [cm3] , total volume ≤15 cm3) has suggested that overall survival is
equivalent for patients with five to ten as compared to two to four metastases and therefore
the number of metastases treated using SRS without WBRT may not correlate with
outcome.16,17 Several retrospective studies (Level 3) have shown that the total volume
of brain metastases correlates better with outcomes, including local control, distant
intracranial relapse and overall survival after SRS than number of brain metastases.7,16,18–20
Recommendations
Solitary metastases:
Surgery or SRS:
Lesion diameter
<20 millimetres (mm) – 24 Gy single dose (Grade B)
21–30 mm – 18 Gy single dose (Grade B)
31–40 mm – 15 Gy single dose (Grade B)
Multiple metastases up to total volume of 20 cm3 with good performance status
(Karnofsky Performance Status ≥70) and controlled extra-cranial disease:2
SRS:
Lesion diameter
<20 mm – 24 Gy single dose (Grade C)
21–30 mm – 18 Gy single dose (Grade C)
31–40 mm – 15 Gy single dose (Grade C)
Whole-brain radiotherapy with SRS

While WBRT was part of the initial treatment of patients in the above-mentioned trials of
surgery or SRS, three randomised trials have now investigated the addition of WBRT to
surgery or SRS for patients with one to four brain metastases.21–24 A meta-analysis of these
trials has also been published.25 Adding WBRT to local therapy by surgery or SRS appears
to improve intracranial control and reduce neurological deaths without influencing overall
survival (Level 1a).16 However, the addition of WBRT to SRS has been shown in one small
randomised trial to result in a significantly greater risk of neurocognitive deficits at three
months, and for this reason many groups now choose to defer WBRT.26 Post-treatment
MRI surveillance was used in all three trials and is recommended by some expert groups,
but high-level evidence about the value of MRI surveillance is lacking.27 Avoidance of the
hippocampus has been suggested as a method to limit the neurocognitive effects of WBRT,
but as yet there is little data to support this.
Recommendation
WBRT with SRS:
Adjuvant postoperative SRS and hypofractionation

While WBRT reduces the risk of intra-cranial relapse postoperatively, the lack of impact
on overall survival has led to the exploration of SRS to the stereotactic cavity.16 In line
with previous data, radiotherapy after surgery reduces the risk of intra-cranial relapse,
and radiotherapy restricted to the tumour bed appears to be non-inferior to whole brain
radiotherapy.28,29 However, technical problems and optimal dose and fractionation
schedules are as yet unclear. For patients with larger metastases >2 cm diameter, there has
been interest in hypofractionated SRS, delivered as 3–5 fractions. As yet, there is no data to
support an optimal dose-fractionation schedule.
Whole-brain radiotherapy for multiple metastases

Background
Several randomised trials have compared different radiotherapy regimens for patients with
multiple cerebral metastases. Most have used 30 Gy in ten fractions as the control arm and
have compared this regimen to either higher or lower doses.30–33 Only one small study of 70
patients has compared the six-month survival rate after 30 Gy in ten fractions to that after
20 Gy in five fractions. There was no significant difference.26 A Radiation Therapy Oncology
Group (RTOG) study reported in 1980 compared three regimens: 40 Gy in 15 fractions; 30
Gy in ten fractions; and 20 Gy in five fractions.34 The median survival in all three groups was
between 3.2 months and 3.5 months (P>0.05). There is, therefore, no clear evidence that 20
Gy in five fractions is inferior to, or better than, 30 Gy in ten fractions (Level 1b).16
Other regimens assessed in RTOG randomised trials included: 10 Gy single-dose and 30–
40 Gy in 10–20 fractions; 40 Gy in 20 fractions; 40 Gy in 15 fractions; 30 Gy in 15 fractions
and 30 Gy in ten fractions.34,35 There was no statistically significant difference in median
survival. The trial results suggest that regimens using only one or two fractions are inferior
to 30 Gy in ten fractions, but that there is no improvement in survival when dose is increased
beyond 30 Gy in ten fractions (Level 1b).16
Patients in RPA Class III have such a poor prognosis that it may be difficult to justify any
radiation treatment at all. Careful consideration should be given to patients with
non-small cell lung cancer. The Medical Research Council (MRC) QUARTZ study shows no
significant benefit in terms of survival or quality adjusted life years for WBRT over optimal
supportive care.36
Recommendation
Multiple cerebral metastases:
References 1. Gaspar L, Scott C, Rotman M et al. Recursive partitioning analysis (RPA) prognostic factors in
three Radiation Therapy Oncology Groups (RTOG) brain metastases trials. Int J Radiat Oncol
Biol Phys 1997; 37(4): 745–751.
2. Gaspar L, Scott C, Murray K, Curran W. Validation of the RTOG recursive partitioning analysis
(RPA) classification for brain metastases. Int J Radiat Oncol Biol Phys 2000; 47(4): 1001–1006.
3. Lock M, Chow E, Pond GR et al. Prognostic factors in brain metastases: can we determine
patients who do not benefit from whole-brain radiotherapy? Clin Oncol 2004; 16(5): 332–338.
4. Lutterbach J, Bartelt S, Stancu E, Guttenberger R. Patients with brain metastases: hope for
recursive partitioning analysis (RPA) class 3. Radiother Oncol 2002; 63(3): 339–345.
5. Sperduto PW, Kased N, Roberge D et al. Summary report on the graded prognostic
assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients
with brain metastases. J Clin Oncol 2012; 30(4): 419–425.
6. Chamberlain MC, Silbergeld DL. Is graded prognostic assessment an improvement compared

with radiation therapy oncology group’s recursive partitioning analysis classification for brain
metastases? J Clin Oncol 2012; 30(26): 3315–3316; author reply 3316–3317.
7. Likhacheva A, Pinnix CC, Parikh NR et al. Predictors of survival in contemporary practice after
initial radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys 2013; 85(3): 656–661.
8. Nieder C, Andratschke NH, Geinitz H, Grosu AL. Diagnosis-specific graded prognostic

assessment score is valid in patients with brain metastases treated in routine clinical practice
in two European countries. Med Sci Monit 2012; 18(7): CR450–CR455.
9. Villà S, Weber DC, Moretones C et al. Validation of the new Graded Prognostic Assessment
scale for brain metastases: a multicenter prospective study. Radiat Oncol 2011; 6: 23.
10. Sperduto PW, Yang TJ, Beal K, et al. Estimating Survival in Patients With Lung Cancer and
Brain MetastasesAn Update of the Graded Prognostic Assessment for Lung Cancer Using
Molecular Markers (Lung-molGPA). JAMA Oncol. 2017;3(6):827–831.
11. Tsao MN, Lloyd NS, Wong RK. Clinical practice guideline on the optimal radiotherapeutic
management of brain metastases. BMC Cancer 2005; 5: 34.
12. Mintz AH, Kestle J, Rathbone MP et al. A randomized trial to assess the efficacy of surgery
in addition to radiotherapy in patients with a single cerebral metastasis. Cancer 1996; 78(7):
1470–1476.
13. Noordijk EM, Vecht CJ, Haaxma-Reiche H et al. The choice of treatment of single brain
metastasis should be based on extracranial tumor activity and age. Int J Radiat Oncol Biol Phys
1994; 29(4): 711–717.
14. Patchell RA, Tibbs PA, Walsh JW et al. A randomized trial of surgery in the treatment of single
metastases to the brain. N Engl J Med 1990; 322(8): 494–500.
15. Andrews DW, Scott CB, Sperduto PW et al. Whole brain radiation therapy with or without
stereotactic radiosurgery boost for patients with one to three brain metastases: phase III
results of the RTOG 9508 randomised trial. Lancet 2004; 363(9422):1665–1672.
17. Yamamoto M, Serizawa T, Shuto T et al. Stereotactic radiosurgery for patients with multiple
brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet
Oncol 2014; 15(4): 387–395.
References 18. Baschnagel AM, Meyer KD, Chen PY et al. Tumor volume as a predictor of survival and local control in
patients with brain metastases treated with Gamma Knife surgery. J Neurosurg 2013; 119(5): 1139–
1144.
19. Bhatnagar AK, Flickinger JC, Kondziolka D, Lunsford LD. Stereotactic radiosurgery for four or more
intracranial metastases. Int J Radiat Oncol Biol Phys 2006; 64(3): 898–903.
20. Chen JC, Petrovich Z, O’Day S et al. Stereotactic radiosurgery in the treatment of metastatic disease to
the brain. Neurosurgery 2000; 47(2): 268–279; discussion 279–281.
21. Aoyama H, Shirato H, Tago M et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs
stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA
2006; 295(21): 2483–2491.
22. Aoyama H, Tago M, Kato N et al. Neurocognitive function of patients with brain metastasis who
received either whole brain radiotherapy plus stereotactic radiosurgery or radiosurgery alone. Int J
23. Chang EL, Wefel JS, Hess KR et al. Neurocognition in patients with brain metastases treated with
radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol
2009; 10(11): 1037–1044.
24. Kocher M, Soffietti R, Abacioglu U et al. Adjuvant whole-brain radiotherapy versus observation after
radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-
26001 study. J Clin Oncol 2011; 29(2): 134–141.
25. Tsao MN, Lloyd N, Wong RK et al. Whole brain radiotherapy for the treatment of newly diagnosed
multiple brain metastases. Cochrane Database Syst Rev 2012; 4: CD003869.
26. Tsao MN, Rades D, Wirth A et al. Radiotherapeutic and surgical management for newly diagnosed
brain metastasis(es): an American Society for Radiation Oncology evidence-based guideline. Pract
Radiat Oncol 2012; 2(3): 210–225.
27. Chatani M, Matayoshi Y, Masaki N, Inoue T. Radiation therapy for brain metastases from lung
carcinoma. Prospective randomized trial according to the level of lactate dehydrogenase. Strahlenther
Onkol 1994; 170(3): 155–161.
28. Brown PD, Ballmand KV, Cerhan JH et al. Postoperative stereotactic radiosurgery compared with
whole brain radiotherapy for resected metastatic brain disease (NCCTG N107C/CEC·3): a multicentre,
randomised, controlled, phase 3 trial. Lancet Oncol 2017; 18(8): 1049–1060.
29. Mahajan A, Ahmed S, McAleer MF et al. Post-operative stereotactic radiosurgery versus observation
for completely resected brain metastases: a single-centre, randomised, controlled, phase 3 trial.
Lancet Oncol 2017; 18(8):1040-1048.
30. Chatani M, Teshima T, Hata K et al. Whole brain irradiation for metastases from lung carcinoma. A
clinical investigation. Acta Radiol Oncol 1985; 24(4): 311–314.
31. Harwood AR, Simson WJ. Radiation therapy of cerebral metastases: a randomized prospective clinical
trial. Int J Radiat Oncol Biol Phys 1977; 2(11–12): 1091–1094.
32. Kurtz JM, Gelber R, Brady LW, Carella RJ, Cooper JS. The palliation of brain metastases in a favourable
patient population: a randomized clinical trial by the Radiation Therapy Oncology Group. Int J Radiat
Oncol Biol Phys 1981; 7(7): 891–895.
33. Murray KJ, Scott C, Greenberg HM et al. A randomized phase III study of accelerated hyper-
fractionation versus standard in patients with unresected brain metastases: a report of the Radiation
Therapy Oncology Group (RTOG) 9104. Int J Radiat Oncol Biol Phys 1997; 39(3): 571–574.
References 34. Borgelt B, Gelber R, Kramer S et al. The palliation of brain metastases: final results of the first
two studies by the Radiation Therapy Oncology Group. Int J Radiat Oncol Biol Phys 1980; 6(1):
1–9.
35. Borgelt B, Gelber R, Larson M, Hendrickson F, Griffin T, Roth R. Ultra-rapid high dose irradiation
schedules for the palliation of brain metastases: final results of the first two studies by the
Radiation Therapy Oncology Group. Int J Radiat Oncol Biol Phys 1981; 7(12): 1633–1638.
36. Mulvenna PM, Nankivell MG, Barton R et al. Dexamethasone and supportive care with or
without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain
metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a
phase 3, non-inferiority, randomised trial. Lancet 2016; 388(10055): 2004–2014..
20. Background
The oligometastatic state can be defined as 1–3 isolated metastatic sites, typically
Oligometastases occurring more than six months after successful treatment of primary disease.1
In colorectal cancer (in addition to sarcoma and other sites), surgical treatment of
oligometastatic disease (most frequently liver metastases) is associated with prolonged
overall survival.2 Multiple single-arm studies have shown that stereotactic radiotherapy is
effective and well tolerated in the oligometastatic setting, across multiple histologies and
anatomical sites. Thus, it may be deployed as an alternative to surgery or where surgery is
not possible.
There is no randomised data, and no established consensus for dose fractionation in
radiotherapy for oligometastatic disease. Recommendations have been derived from
systematic reviews of non-randomised studies (prospective and retrospective [Level 3a]),
along with expert consensus from the Comissioning through Evaluation (CtE) Service
Specification (Level 5).3,4 For all sites, it is recommended that the critical organ dose
constraints agreed by the UK Stereotactive Ablative Radiotherapy (SABR) consortium
should be followed.5
It is not possible to discuss dose fractionation without discussing treatment technique.
The majority of evidence comes from stereotactic body radiotherapy (SBRT or stereotactic
ablative radiotherapy [SABR]). Developments in radiotherapy technology have allowed
the safe delivery with high-precision of an ablative dose in five or fewer fractions. Patients
have been treated using dedicated stereotactic systems (such as Cyberknife) and using
conventional gantry-based systems with stereotactic capability. The optimal system for
delivery is unknown, but image guidance, either with implanted fiducials and/or soft tissue
tomography, is essential. Dose fractionation recommendations are, however, independent
of the stereotactic platform used.
Oligometastases: bone (including spine) and lymph nodes

In this setting, treatment can expect to achieve a local control around of 80% and
progression-free survival (PFS) of approximately 20% at 2–3 years.1 Doses delivering a
biologically equivalent dose (BED) at 2 Gray (Gy) per fraction (EQD2) >100 Gy, and those
tumours ≤3 centimetres (cm) have best outcomes. Treatment is, in general, well tolerated
with myelopathy rates for spinal treatments being less than 1% in most series.6,7
Contouring for spinal treatment should be based on the expert consensus guidelines by
Cox et al (Level 5).4,8
Recommendations
Initial treatment:
18–24 Gy single dose (Grade C)
30–45 Gy in 3 fractions over 1 week (10–15 Gy per fraction given on alternate days)
(Grade C)
Retreatment
Pelvis: 30 Gy in 5 fractions over 2 weeks, given on alternate days (Grade C)
Spine: 20–30 Gy in 2–5 fractions over 1–2 weeks, given on alternate days (Grade C)
In this setting, it is vital to take into account the dose previously received by critical organs.
As far as possible, cumulative doses to critical organs should be calculated and, allowing
for recovery, tolerances described in the UK SABR consensus document should not be
exceeded, if necessary modifying prescription doses to the planning target volume (PTV).5
In the specific case of remaining spinal cord tolerance, the method described by Sahgal is
recommended.7 Following this, the maximum cumulative dose to the thecal sac (similar to
cord planning organ at risk volume [PRV]), at a minimum of six months after initial irradiation,
should not exceed a BED of 140 Gy (αβ=2 Gy). For other organs, there is no consensus on
recovery of tolerance following radiation and clinical judgment, along with the available
literature, should be used.9
Oligometastases: lung
Lung oligometastases present a similar clinical problem to early-stage primary lung
cancer, for which stereotactic treatment is a standard of care.10 Specifically for patients with
oligometastases, an EQD2 >100 Gy is associated with approximately 90% local control
at 1–2 years.10,11 Although Timmerman et al found a significant increase in toxicity when
treating central lung tumours, other series have found no increase in toxicity when treating
with more than three fractions.12–15 These current recommendations are consistent with the
CtE Service Specification.3
Recommendations
48–54 Gy in 3 fractions over 1 week given on alternate days (Grade C)
Peripheral lung oligometastases in contact with chest wall or where three
fraction constraints cannot be met:
55–60 Gy in 5 fractions over 2 weeks given on alternate days (Grade C)
Lung oligometastases in the central lung/mediastinum:
60 Gy in 8 fractions over 1 week given on alternate days (Level 4)
Oligometastases: liver
The use of surgery and radiofrequency ablation to treat liver oligometastases is well
established. For colorectal liver tumours under 6 centimetres (cm) in diameter, local control
above 90% at one year can be achieved with stereotactic doses of at least 48 Gy in three
fractions.16 This analysis included patients who were heavily pre-treated with systemic
therapy. Further reviews have indicated this dose is effective in other tumour types, with
grade 3–4 toxicity of 1–10% (Level 3a).4,17,18
Recommendations
45–50 Gy in 3 fractions over 1 week, given on alternate days (Grade C)
For larger PTV volumes or where dose constraints cannot be met with a three-
fraction approach:
Oligometastases: adrenal
Due to a rich sinusoidal blood supply, adrenal metastases are frequently observed
in patients with melanoma, breast, lung, kidney and gastrointestinal tumours. Based
on observations of enhanced survival in patients undergoing adrenalectomy for
oligometastatic disease, stereotactic radiotherapy has also been been used. Local control
rates vary from 55% to 90% with doses ranging from 16 Gy in four fractions to 50 Gy in ten
fractions (Level 4).4,19,20
Recommendation
30–36 Gy in 3 fractions over 1 week (Grade C)
References 1. Tree AC, Khoo VS, Eeles RA et al. Stereotactic body radiotherapy for oligometastases. Lancet Oncol
2013; 14(1): e28–e37.
2. Weichselbaum RR, Hellman S. Oligometastases revisited. Nat Rev Clin Oncol 2011; 8(6): 378–382.
3.
www.england.nhs.uk/commissioning/spec-services/npc-crg/comm-eval
5.
www.sabr.org.uk/consortium (last accessed 13/10/16)
6. Bhattacharya IS, Hoskin PJ. Stereotactic body radiotherapy for spinal and bone metastases. Clin Oncol
(R Coll Radiol) 2015; 27(5): 298–306.
7. Sahgal A, Atenafu EG, Chao S et al. Vertebral compression fracture after spine stereotactic body
radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability
neoplastic score. J Clin Oncol 2013; 31(27): 3426–3431.
8. Cox BW, Spratt DE, Lovelock M et al. International Spine Radiosurgery Consortium consensus
guidelines for target volume definition in spinal stereotactic radiosurgery. Int J Radiat Oncol Biol Phys
2012; 83(5): e597–e605.
9. Mantel F, Flentje M, Guckenberger M. Stereotactic body radiation therapy in the re-irradiation situation
– a review. Radiat Oncol 2013; 8: 7.
10. Solda F, Lodge M, Ashley S, Whitington A, Goldstraw P, Brada M. Stereotactic radiotherapy (SABR) for
the treatment of primary non-small cell lung cancer; systematic review and comparison with a surgical
cohort. Radiother Oncol 2013; 109(1): 1–7.
11. Siva S, MacManus M, Ball D. Stereotactic radiotherapy for pulmonary oligometastases: a systematic
review. J Thorac Oncol 2010; 5(7): 1091–1099.
12. Timmerman R, McGarry R, Yiannoutsos C et al. Excessive toxicity when treating central tumors in a
phase II study of stereotactic body radiation therapy for medically inoperable early-stage lung cancer. J
Clin Oncol 2006; 24(30): 4833–4839.
13. Mangona VS, Aneese AM, Marina O et al. Toxicity after central versus peripheral lung stereotactic
body radiation therapy: a propensity score matched-pair analysis. Int J Radiat Oncol Biol Phys.2014;
91(1): 124–132.
14. Nuyttens JJ, van der Voort van Zyp NC, Praag J et al. Outcome of four-dimensional stereotactic
radiotherapy for centrally located lung tumors. Radiother Oncol 2012; 102(3): 383–387.
15. Chang JY, Balter PA, Dong L et al. Stereotactic body radiation therapy in centrally and superiorly
located stage I or isolated recurrent non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2008;
72(4): 967–971.
16. Chang DT, Swaminath A, Kozak M et al. Stereotactic body radiotherapy for colorectal liver metastases:
a pooled analysis. Cancer 2011; 117(17): 4060–4069.
17. Aitken KL, Hawkins MA. Stereotactic body radiotherapy for liver metastases. Clin Oncol (R Coll Radiol)
2015; 27(5): 307–315.
18. Høyer M, Swaminath A, Bydder S et al. Radiotherapy for liver metastases: a review of evidence. Int J
19. Chawla S, Chen Y, Katz AW et al. Stereotactic body radiotherapy for treatment of adrenal metastases.
Int J Radiat Oncol Biol Phys 2009; 75(1): 71–75.
20. Casamassima F, Livi L, Masciullo S et al. Stereotactic radiotherapy for adrenal gland metastases:
university of Florence experience. Int J Radiat Oncol Biol Phys 2012; 82(2): 919–923.
21. Background
Patients with symptoms suggestive of spinal cord compression, particularly severe back or
Metastatic spinal cord root pain, should be investigated urgently with whole spine magnetic resonance imaging
compression (MSCC) (MRI) to define sites and levels of compression accurately.1 Multiple levels of compression
are seen in up to one-third of patients.2–4
On clinical suspicion of MSCC or once a diagnosis has been established, all patients
should be started on steroids; the UK convention is to give dexamethasone in 16 miligrams
(mg) daily. There is evidence from one randomised trial that higher initial doses of 96 mg are
superior to no steroids (Level 2b).5,6 No dose comparison between 16 mg and higher doses
has been undertaken.
Systemic anti-cancer treatment may be more appropriate than radiotherapy for some
malignancies, for example, lymphomas, plasma-cell tumours, germ cell tumours or
untreated small cell cancers.
Long-term outcome from MSCC depends on the degree of paralysis and overall prognosis
for the cancer; with poorer outcomes associated with non-ambulatory status, poor
performance status, ≥3 involved vertebrae, presence of other bone metastases, presence
of visceral metastases and shorter time to developing motor deficits. Non-breast/prostate/
haematological primaries also confer a worse prognosis (Level 2c).7,8
Ideally, the prognosis of patients should be objectively assessed using validated scores
such as the Tokuhashi Score (Level 2b).6,8,9
Patients with a good expected prognosis, especially those who are ambulatory, should
be discussed with a spinal- or neurosurgeon to consider spinal decompression and
stabilisation surgery followed by radiotherapy. This intervention has been shown to improve
neurological status and overall survival in patients with MSCC (Level 1b) compared to
radiotherapy alone.6,10
For good prognosis or ambulatory patients who are not suitable for surgery, urgent
radiotherapy should be given before further neurological deterioration.3,4,8
For poor prognosis or non-ambulatory patients, radiotherapy should be considered either
to preserve neurological function (in ambulatory patients) or for pain relief only if paraplegia
has been established for >24 hours.3,4,8
Current evidence on dose and fractionation for MSCC largely consists of retrospective
series, prospective non-randomised studies looking at several different treatment
schedules or prospective randomised control trials (RCTs) using schedules not commonly
used in UK, including split course schedules (Level 2b).6,8,11–13
The current evidence suggests no benefit for doses higher than 30 Gray (Gy) in ten daily
fractions. More hypofractionated regimes (8 Gy in a single exposure, 20 Gy in five daily
fractions) are most commonly used in the UK and are as effective as longer schedules
in terms of pain relief, neurological benefit and survival. There may be fewer in-field
recurrences with longer schedules and fewer patients treated with longer courses are
treated with further radiotherapy to the same area for recurrent MSCC (Level 2b), however,
a recent randomised trial found that 20 Gy in five fractions was not inferior to 30 Gy in ten
fractions for motor function or ambulatory status.14–16
Ambulant patients with an expected better prognosis may, therefore, benefit from longer
courses of treatment to prevent recurrence and need for retreatment.
The SCORAD III prospective RCT is currently recruiting and randomising patients with an
expected prognosis of >12 weeks to either a single exposure of 8 Gy or 20 Gy in five daily
fractions. The results of this trial will inform decisions regarding the optimal schedule in the
future [UKCRN ID 7952].16
Recommendations
Metastatic spinal cord compression: non-ambulant patients or ambulant
patients with a poor prognosis:
8 Gy single dose (Grade B)
or
20 Gy in 5 daily fractions over 1 week (Grade B)
Metastatic spinal cord compression: ambulant patients with a good prognosis
or post-spinal surgery:
20 Gy in 5 daily fractions over 1 week (Grade B)
or
There is response to retreatment after initial benefit from radiotherapy for recurrent MSCC.
The absolute maximum retreatment dose has not been established, but a cumulative
biologically equivalent dose (BED) (initial + reirradiation) of 120 Gy2 appears to be safe
and effective. Evidence indicates that the effect of previous radiation, time to develop
motor deficit, presence of visceral metastases and performance status have an impact on
effectiveness of repeat treatment but schedule of treatment does not (Level 2c).6,17
Recommendation
Metastatic spinal cord compression: re-irradiation:
8 Gy single dose or 20 Gy in 5 daily fractions prescribed at depth.
Maximum cumulative BED <120 Gy2 (Grade C)
References 1. Levack P, Graham J, Collie D et al. Don’t wait for a sensory level – listen to the symptoms: a prospective
audit of the delays in diagnosis of malignant cord compression. Clin Oncol (R Coll Radiol) 2002; 14(6):
472–480.
2. Hoskin PJ, Grover A, Bhana R. Metastatic spinal cord compression: radiotherapy results and dose
fractionation. Radiother Oncol (R Coll Radiol) 2003; 68(2): 175–180.
3. Metastatic Spinal Cord Compression: Diagnosis and management of adults at risk of and with
metastatic spinal cord compression. NICE Clinical Guideline 75, November 2008
4. National Institute for Health and Care Excellence. Metastatic spinal cord compression in adults: risk
assessment, diagnosis and management. London: National Institute for Health and Care Excellence,
2008.
5. Sorensen PS, Helweg-Larsen SH, Mouridsen H, Hansen HH. Effect of high dose dexamethasone in
carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial. Eur J
Cancer 1994; 30A(1): 22–27.
6. w
7. Rades D, Fehlauer F, Schulte R et al. Prognostic Factors for local control and survival after radiotherapy
of metastatic spinal cord compression. J Clin Oncol 2006; 24(21): 3388–3393.
8. Prewett S, Venkitaraman R. Metastatic spinal cord compression: review of the evidence for a
radiotherapy dose fractionation schedule. Clin Onc (R Coll Radiol) 2010; 22(3): 222–230.
9. Tokuhashi Y, Matsuzaki H, Ods H, Oshima M, Ryu J. A revised scoring system for preoperative
evaluation of metastatic spine tumor prognosis. Spine 2005; 30(19): 2186–2191.
10. Patchell RA, Tibbs PA, Regine WF et al. Direct decompressive surgical resection in the treatment of
spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366(9486):
643–648.
11. Rades D, Stalpers LJ, Veninga T et al. Evaluation of five radiation schedules and prognostic factors for
metastatic spinal cord compression. J Clin Oncol 2005; 23(15): 3366–3375.
12. Maranzano E, Trippa F, Casale M et al. 8 Gy single-dose radiotherapy is effective in metastatic spinal
cord compression: results of a phase III randomized multicentre Italian trial. Radiotherapy Oncol 2009;
93(2): 174–179.
13. Maranzano E, Bellavita R, Rossi R et al. Short-course versus split-course radiotherapy in metastatic
spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol 2005; 23(15):
3358–3365.
14. Rades D, Rudat V, Veninga T, Stalphers LJ, Hoskin PJ, Schild SE. Prognostic factors for functional
outcome and survival after reirradiation for in-field recurrences of metastatic spinal cord compression.
Cancer 2008; 113(5): 1090–1096.
15. Rades D, Šegedin B, Conde-Moreno AJ et al. Radiotherapy With 4 Gy × 5 versus 3 Gy × 10 for

metastatic epidural spinal cord compression: final results of the SCORE-2 Trial (ARO 2009/01). J Clin
Oncol 2016; 34(6): 597–602.
16. www.ucl.ac.uk/cancertrials/trials/scorad (last accessed 13/10/16)
17. Rades D, Stalpers L, Veninga T, Hoskin PJ. Spinal re-irradiation after short-course RT for metastatic
spinal cord compression. Int J Radiat Oncol Biol Phys 2005; 63(3): 872–875.
Acknowledgements Working group

This review of Radiotherapy dose fractionation was undertaken by a working group
comprising the following members:
• Professor Peter Hoskin (Chair)
Mount Vernon Cancer Centre, Northwood, Middlesex
• Dr David Bloomfield~
Brighton and Sussex University Hospitals
• Dr Jeanette Dickson~~
Mount Vernon Cancer Centre, Northwood, Middlesex
• Dr Raj Jena
Addenbrooke’s Hospital, Cambridge
• Dr Vivek Misra
The Christie Hospital, Manchester
• Dr Robin Prestwich
St James’ University Hospital, Leeds
~ Medical Director, Professional Practice, Clinical Oncology, from September 2015
~~ Medical Director, Professional Practice, Clinical Oncology, until September 2015
Contributors
The working group would like to thank the following for their contributions to this
document in the form of comments on both the original draft and later revisions circulated
for consultation. Those who contributed on behalf of a stakeholder group are marked
with an asterisk (*).
Dr R Adams* Dr C Corner Dr S Falk*
Dr A Bahl Prof R Cowan* Dr C Featherstone
Dr S Ball Dr A Crellin Dr K Fife
Dr N Bayman Dr T Crosby Dr A Freebairn
Dr H Benghiat Dr C Crowley Dr B Foran*
Dr A Birtle* Dr S Davidson Dr E Gallop-Evans
Dr C Boon Dr N Davies Dr M Gaze
Dr M Brunt Prof D Dearnaley Dr K Geropantas
Dr S A R Challapalli Dr J Dewar Dr D Gilbert
Prof A Chalmers* Dr K Dyker Dr D Gilson
Dr N Charnley Dr A Elliott Dr J Glaholm
Dr A Choudhury Dr S Erridge Dr S Gwynne*
Dr C Coles Dr M Evans Dr G Hanna
Dr R Cooper Prof C Faivre-Finn Dr A Haridass
Acknowledgements Dr L Harris Dr L Moss Dr P L Shum

Dr M Harris Dr R Muirhead Dr N Sidek
Dr A Hartley Mr R Naik* Prof N Slevin
Dr M Hatton* Dr P Niblock Prof M Spittle OBE
Dr M Hawkins* Dr J Nicoll Dr J Staffurth
Dr A Henry Prof C Nutting* Prof A Sun Myint
Prof R Huddart* Dr N O’Rourke Dr I Syndikus
Prof T Illidge Dr P Ostler Dr L T Tan
Dr A Kiltie Dr C Parker* Dr C Taylor*
Dr P Kirkbride Dr L Pickering Prof R Taylor
Dr M Kosmin Dr H Phillips Dr A Thomson
Dr J Lester* Dr M Powell* Dr D Thomson
Dr J Lewis Prof A Price Dr A Tree*
Dr F Little Dr G Radhakrishna Ms J Troup*
Dr H Lord Dr G Read Dr N van As
Dr S Lupton Prof N Reed* Dr R Venkitaraman
Dr N MacLeod Dr M Robinson Dr A Weaver
Dr A Makris* Dr P Robson Ms S Welham*
Prof M Mason Dr S Rodda Dr G Whitfield*
Dr C McBain Dr T Roques Dr M Williams
Dr J McGrane Dr P Sanghera
Dr A Miah* Dr B Seddon
Dr G Mikhaeel Dr D Sheehan
Dr A Mitra Prof S Short
Stakeholder groups consulted in the development of Radiotherapy dose

fractionation, second edition
The following organisations contributed to the development of this document

by submitting comments during the consultation process.
• British Association of Head and Neck • Children’s Cancer and Leukaemia Group
Oncologists
• National Cancer Research Institute
• British Thoracic Society Clinical and Translational Radiotherapy
Research Working Group (CTRad)
• British Uro-Oncology Group
• Radiotherapy Clinical Reference Group
The following clinical oncology members of the National Cancer Research Institute (NCRI)
Clinical Studies Groups (CSG):
• Bladder and renal cancer • Lymphoma
• Breast cancer • Prostate cancer
• Brain tumour • Sarcoma
• Colorectal cancer • Skin cancer
• Gynaecological cancers • Testis cancer
• Head and neck cancer • Upper gastrointestinal
• Lung cancer
Approved by the Board of the Faculty of Clinical Oncology: 24 June 2016.

The Royal College of Radiologists. Radiology dose fractionation, third edition.
London: The Royal College of Radiologist, 2019.
© The Royal College of Radiologists, March 2019.
BFCO(19)3.
The Royal College of Radiologists For permission to reproduce any of the content contained herein, please email:
63 Lincoln’s Inn Fields [email protected]
London WC2A 3JW This material has been produced by The Royal College of Radiologists (RCR) for
use internally within the specialties of clinical oncology and clinical radiology in the
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[email protected] the making of any decision regarding the applicability and suitability of the material
www.rcr.ac.uk in any particular circumstance is subject to the user’s professional judgement.
@RCRadiologists The Royal College of Radiologists reviews its guidance to ensure it remains up to
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The Royal College of Radiologists is the latest version.
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Radiotherapy

Preparation of this document

First stage consultation

Second stage consultation

Third stage consultation

Update of guidance – third edition

Comparison with the Malthus model5

Oxford Centre for Grades of recommendation

Node positive patients

2. Bartelink H, Roelofsen F, Eschwege F et al. Concomitant radiotherapy and chemotherapy is superior to

5. James RD, Glynne-Jones R, Meadows HM et al. Mitomycin or cisplatin chemoradiation with or

6. Glynne-Jones R, Meadows H, Wan S et al. EXTRA – a multicenter phase II study of chemoradiation

10. www.analimrtguidance.co.uk (last accessed 22/9/16)

12. www.ukctg.nihr.ac.uk/trials/trial-details/trial-details?trialId=36181 (last accessed 13/10/16)

Partial bladder irradiation

Radical radiotherapy with radiosensitisation

7. Näslund I, Nilsson B, Littbrand B. Hyperfractionated radiotherapy of bladder cancer. A ten-year follow-

Adjuvant radiotherapy to the breast or chest wall

Further hypofractionation for breast radiotherapy is currently under investigation. In the

Partial breast irradiation

A multidisciplinary consensus meeting held at The Royal College of Radiologists

Regional nodal irradiation

Axilla and supraclavicular fossa

29. www.ukctg.nihr.ac.uk/trials/trial-details/trial-details?trialId=4633 (last accessed 4/1/19)

27. www.posnoc.co.uk (last accessed 23/9/16)

fractions and between 50.4 Gy in 28 fractions and 64.8 Gy in 36 fractions.26,27 As a result, a

7. Berg G, Blomquist E, Cavallin-Ståhl E. A systematic overview of radiation therapy effects in brain

25. Thomas R, James N, Guerrero D, Ashley S, Gregor A, Brada M. Hypofractionated radiotherapy as

34. https://clinicaltrials.gov/ct2/show/NCT00626730 (last accessed 13/10/16)

Definitive radiotherapy for inoperable disease

Endometrial carcinoma: salvage

Inoperable vulval carcinoma

4. Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration (CCCMAC). Reducing

26. https://clinicaltrials.gov/ct2/show/NCT01414608 (last accessed 26/9/16)

27. https://clinicaltrials.gov/ct2/show/NCT01566240?term=interlace&rank=2 (last accessed 13/10/16)

36. https://clinicaltrials.gov/ct2/show/NCT00411138?term=PORTEC+3&rank=1 (last accessed 26/9/16)

43. https://clinicaltrials.gov/ct2/show/NCT01500512?term=GROINSS&rank=1 (last accessed 26/9/16)

T1/2N0 glottic carcinoma

Role of modified fractionation in head and neck squamous cell

Elective lymph node and mucosal doses with IMRT

Radiotherapy alone for early stage (I/II) oropharynx/hypopharnx/larynx

Radiotherapy with concomitant chemotherapy for stage III/IVa/b

Radiotherapy alone for stage III/IVa/b HNSCC (excluding

Palliative radiotherapy schedules

Non-small cell lung cancer (NSCLC): curative therapy

Non-small cell lung cancer (NSCLC): palliative radiotherapy

Small cell lung cancer (SCLC)

Concurrent chemoradiotherapy (stages I–III)

Sequential chemoradiotherapy (stages I–III)

SCLC: palliative thoracic radiotherapy

Prophylactic cranial irradiation (PCI) (stages I–III)

Prophylactic cranial irradiation (PCI) (stage IV)

References 1. www.hqip.org.uk/ncapop-library/#cancer (last accessed 28/9/16)

2. National Cancer Intelligence Network Survival by stage (NCIN) 2014:

13. Aupérin A, Le Péchoux C, Pignon JP et al. Concomitant radio-chemotherapy based on platin

19. Saunders M, Dische S, Barrett A, Harvey A, Gibson D, Palmar M. Continuous hyperfractionated

20. Mauguen A, Le Péchoux C, Saunders MI et al. Hyperfractionated or accelerated radiotherapy in lung

Early Hodgkin lymphoma

Advanced Hodgkin lymphoma

2. Bartelink H, Roelofsen F, Eschwege F et al. Concomitant radiotherapy and chemotherapy is superior to

5. James RD, Glynne-Jones R, Meadows HM et al. Mitomycin or cisplatin chemoradiation with or

6. Glynne-Jones R, Meadows H, Wan S et al. EXTRA – a multicenter phase II study of chemoradiation

12. www.ukctg.nihr.ac.uk/trials/trial-details/trial-details?trialId=36181 (last accessed 13/10/16)

7. Näslund I, Nilsson B, Littbrand B. Hyperfractionated radiotherapy of bladder cancer. A ten-year follow-

7. Berg G, Blomquist E, Cavallin-Ståhl E. A systematic overview of radiation therapy effects in brain

25. Thomas R, James N, Guerrero D, Ashley S, Gregor A, Brada M. Hypofractionated radiotherapy as

4. Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration (CCCMAC). Reducing

26. https://clinicaltrials.gov/ct2/show/NCT01414608 (last accessed 26/9/16)

27. https://clinicaltrials.gov/ct2/show/NCT01566240?term=interlace&rank=2 (last accessed 13/10/16)

36. https://clinicaltrials.gov/ct2/show/NCT00411138?term=PORTEC+3&rank=1 (last accessed 26/9/16)

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2. National Cancer Intelligence Network Survival by stage (NCIN) 2014:

13. Aupérin A, Le Péchoux C, Pignon JP et al. Concomitant radio-chemotherapy based on platin

19. Saunders M, Dische S, Barrett A, Harvey A, Gibson D, Palmar M. Continuous hyperfractionated

20. Mauguen A, Le Péchoux C, Saunders MI et al. Hyperfractionated or accelerated radiotherapy in lung

8. Loeffler M, Brosteanu O, Hasenclever D et al. Meta-analysis of chemotherapy versus combined

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6. Makarewicz R, Zarzycka M, Kulińska G, Windorbska W. The value of postoperative radiotherapy in

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3. Rackley T, Leong T, Foo M, Crosby T. Definitive chemoradiotherapy for oesophageal cancer – a

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15. Rades D, Šegedin B, Conde-Moreno AJ et al. Radiotherapy With 4 Gy × 5 versus 3 Gy × 10 for