Radiation Therapy for Sarcomas and Skin Cancers: A Practical Guide on Treatment Techniques

Contents
1: Extremity Soft Tissue Sarcoma
1.1 Introduction
1.2 Staging System
1.3 Treatment Strategies to Be Discussed in this Chapter
1.4 Management Principles
1.4.1 Workup
1.4.2 Staging
1.4.3 Treatment Planning
1.4.4 Integration of Primary Surgery with Multimodality Treatment
1.4.5 Areas of Controversy
1.5 Radiation Therapy Techniques
1.5.1 Technical Considerations
1.5.1.1 CT Simulation
1.5.1.2 Target Definitions
1.5.1.3 Radiation Planning
1.5.2 Preoperative External Beam Radiation Therapy
1.5.2.1 Hypofractionation
1.5.3 Postoperative External Beam Radiation Therapy
1.5.4 Brachytherapy
1.5.5 Intraoperative Radiation Therapy (IORT)
1.6 Chemotherapy
1.6.1 Overview
1.6.2 Combinations of Radiation Therapy and Chemotherapy
1.6.3 Role of Biologic Therapy in Combination with Radiation Therapy
1.7 Sequelae of Treatment and Dose Constraints
1.7.1 Follow-Up/Surveillance
References
2: Retroperitoneal Sarcoma
2.1 Introduction to Retroperitoneal Sarcoma
2.2 Historical Outcomes
2.3 Management Principles
2.4 Surgery
2.5 Radiotherapy
2.5.1 Intraoperative Radiotherapy and Postoperative Brachytherapy
2.6 Systemic Therapy
2.7 Radiotherapy Techniques and Planning
2.8 CT Simulation
2.9 Target Volumes
2.10 Prescription Dose
2.11 Boosts to High-Risk Margin and GTV
2.12 Target Coverage
2.13 Radiation Technique
2.13.1 Image-Guided Radiation Therapy (IGRT)
2.14 Organs at Risk and Radiation Tolerance Doses
2.14.1 DVH (Dose Volume Histogram) Considerations
2.15 Current Trials
2.15.1 STRASS EORTC 62092-22092 (ClinicalTrials.gov NCT01344018), Ref [54]
2.15.2 Phase I/Phase II Trial of Preoperative IG-IMPT or IMRT with Simultaneous Integrated Boost (SIB) for Retroperitoneal Sarcomas (ClinicalTrials.gov NCT01659203), Ref [64]
2.15.3 NRG-DT001 (ClinicalTrials.gov NCT03217266), Ref [50]
2.16 Future Directions
2.17 Treatment Algorithm
2.18 Summary
References
3: Gynecologic Sarcomas
3.1 Introduction
3.1.1 Epidemiology and Risk Factors
3.1.2 Histopathology of Gynecologic Sarcomas
3.1.3 General Management Strategy
3.1.4 Current Staging for Gynecologic Sarcomas
3.1.5 Prognosis by Tumor Stage
3.2 Management Principles
3.2.1 Presentation, Diagnosis, and Staging Workup
3.2.2 Uterine Sarcoma
3.2.3 Cervical Sarcoma
3.2.4 Vaginal/Vulvar Sarcoma
3.2.5 Ovarian Sarcoma
3.2.6 Management of Gynecologic Sarcomas
3.2.7 Uterine Sarcoma
3.2.8 Cervical Sarcoma
3.2.9 Vaginal/Vulvar Sarcoma
3.2.10 Ovarian Sarcoma
3.2.11 Recurrent Disease/Palliation
3.3 Radiation Therapy Techniques and Planning
3.3.1 Uterine and Cervical Sarcoma
3.3.1.1 Adjuvant Radiotherapy
3.3.1.2 Simulation
3.3.1.3 Volume Delineation
3.3.1.4 Treatment Planning Considerations
3.3.1.5 Definitive Radiotherapy/Chemoradiotherapy
3.3.1.6 Simulation
3.3.1.7 Volume Delineation
3.3.1.8 Treatment Planning Considerations
3.3.2 Vulvar/Vaginal Sarcoma
3.3.2.1 Adjuvant Radiotherapy
3.3.2.2 Simulation
3.3.2.3 Volume Delineation
3.3.2.4 Treatment Planning Considerations
3.3.2.5 Definitive Radiotherapy/Chemoradiotherapy
3.3.3 Ovarian Sarcoma
3.3.3.1 Radiation-Related Toxicities and Radiotherapy Dose Constraints for Organ at Risk Volumes
3.3.4 Recurrent and Metastatic Disease
3.3.4.1 Interstitial Brachytherapy
3.3.4.2 Stereotactic Body Radiotherapy
3.3.4.3 Palliative Radiotherapy Treatments
3.3.4.4 Physics and Quality Assurance Considerations
3.3.4.5 Treatment Algorithm
3.4 Summary
References
4: Radiation Therapy for Oligometastatic Sarcomas
4.1 Systemic Therapy for Oligometastatic Sarcoma
4.1.1 Standard Chemotherapy
4.1.2 Targeted Therapies and Emerging Systemic Treatments
4.2 Metastasectomy of Sarcoma Oligometastases
4.3 Stereotactic Body Radiation Therapy (SBRT) of Oligometastases
4.4 SBRT Technique
4.4.1 Spine SBRT
4.4.1.1 Image Guidance
4.4.1.2 Treatment Delivery
4.4.1.3 Imaging and Planning
4.4.1.4 Target Volumes
4.4.1.5 Patient Selection
4.4.1.6 Treatment Dose
4.4.2 Lung SBRT
4.4.2.1 Simulation
4.4.2.2 Motion Management
4.4.2.3 Image Guidance
4.4.2.4 Target Volumes
4.4.2.5 Dose
4.5 Concluding Remarks
References
5: Radiotherapy for Pediatric Sarcomas
5.1 Introduction
5.2 Management Principles
5.2.1 Workup for Pediatric Sarcomas
5.2.2 Staging for Pediatric Sarcomas
5.2.3 Treatment Algorithm for Pediatric Bone and Soft Tissue Sarcoma
5.2.3.1 Ewing Sarcoma
5.2.3.2 Rhabdomyosarcoma
5.2.3.3 Non-RMS Soft Tissue Sarcoma
5.2.3.4 Osteosarcoma
5.2.4 Radiation Therapy Techniques and Planning
5.2.4.1 Preparing to Treat the Patient
5.2.4.2 Simulation
5.2.4.3 Target Definitions
5.2.5 Curative Dose Recommendations
5.2.5.1 Ewing Sarcoma
5.2.5.2 RMS
5.2.5.3 Non-RMS Soft Tissue Sarcoma
5.2.5.4 Osteosarcoma
5.2.6 Treatment Planning Considerations
5.2.7 Modalities of Radiation
5.2.7.1 Physics/Quality Assurance
5.3 Summary
References
6: Concurrent Chemoradiation Therapy for Soft Tissue Sarcoma
6.1 Introduction
6.2 Concurrent Radiotherapy with Anthracycline-Based Chemotherapy
6.3 Improvements in Concurrent CRT
6.4 Concurrent Radiotherapy and Immunotherapy
6.5 Concurrent Radiotherapy and MDM2 Inhibitor, AMG-232
6.6 Concurrent Radiotherapy and Taxanes for Angiosarcoma
6.7 Adjuvant Chemotherapy for Resectable Soft Tissue Sarcomas (STS)
6.8 Systemic Therapy in Advanced/Metastatic STS
6.9 Progression After First-Line Chemotherapy for Metastatic Disease
6.10 Summary
References
7: Particle Therapy for Head and Neck Sarcomas
7.1 Introduction
7.2 Essentials of Particle Beam Radiotherapy
7.2.1 Characteristics of Charged Particle Beams
7.2.2 Delivery Technologies of PBRT
7.3 Registration and Planning
7.3.1 Patient Registration and Immobilization
7.3.2 Definition and Delineation of Target Volumes
7.3.2.1 Beam Directions
7.3.3 Dose and Fractionation of PBRT
7.3.3.1 Soft Tissue Sarcoma and Osteosarcoma
7.3.3.2 Rhabdomyosarcoma
7.3.3.3 Chordoma and Chondrosarcoma
7.3.4 Dose Constrains for Organs at Risk (OARs)
7.3.5 Reirradiation
7.3.6 Setup Verification
7.4 The Use of Chemotherapy with PBRT
7.5 Clinical Outcomes
7.5.1 Soft Tissue Sarcomas and Osteosarcoma
7.5.2 Rhabdomyosarcoma
7.5.3 Chordoma and Chondrosarcoma
7.6 Future Direction
References
8: Desmoid Tumors
8.1 Introduction
8.2 Management Principles
8.2.1 Workup
8.2.2 Observation
8.2.3 Surgery
8.2.4 Radiation Therapy
8.2.5 Systemic Therapy
8.2.6 Follow-Up Guidelines Based on Recurrence Patterns and Prognosis
8.2.7 Management of Recurrent Disease
8.3 Radiation Therapy Techniques and Planning
8.3.1 Simulation
8.3.2 Treatment Volumes
8.3.3 Treatment Techniques
8.3.4 Dose
8.3.5 Dose Constraints
8.4 Treatment Algorithm
References
9: Solitary Fibrous Tumors/Hemangiopericytoma
9.1 Introduction
9.1.1 Nomenclature and Historical Perspective
9.1.2 Epidemiology and Clinical Manifestations
9.1.2.1 Pleural/Intrathoracic SFTs
9.1.2.2 Hemangiopericytoma
9.1.2.3 Extrathoracic/Soft Tissue SFTs
9.2 Diagnosis
9.2.1 Initial Evaluation
9.2.2 Imaging
9.2.3 Pathology
9.2.4 Risk Stratification and Staging
9.2.4.1 Intrathoracic SFTs
9.2.4.2 Intracranial SFTs
9.2.4.3 Extrathoracic SFTs
9.3 Treatment Strategies
9.3.1 Surgery
9.3.2 Radiotherapy
9.3.2.1 Indications for Adjuvant Radiation
9.3.2.2 Indications for Definitive Radiation
9.3.3 Systemic Therapy
9.4 Posttreatment and Future Direction
9.4.1 Surveillance
9.4.2 Management of Recurrence
9.4.3 Future Directions
9.5 Clinical Treatment Planning Considerations
9.5.1 Patient Setup and Immobilization
9.5.2 Simulation
9.5.3 Image Guidance and Motion Management for Optimized Treatment Delivery
9.5.4 Radiation Modalities/Plan Optimization
9.5.4.1 Intrathoracic SFTs
9.5.4.2 Intracranial HPCs
9.5.4.3 Extrathoracic SFTs
9.5.5 Dosimetric Treatment Planning Considerations
9.5.5.1 Target Volumes
Intrathoracic SFTs
Gross Tumor Volume (GTV)
Clinical Target Volume (CTV)
Internal Target Volume (ITV)
Planning Target Volume (PTV)
Intracranial HPCs
Gross Tumor Volume (GTV)
Clinical Target Volume (CTV)
Planning Target Volume (PTV)
Extrathoracic SFTs
Gross Tumor Volume (GTV)
Clinical Target Volume (CTV)
Planning Target Volume (PTV)
9.5.5.2 Dose Prescription
General Dose Guidelines
9.5.5.3 Organs-at-Risk (OAR) Tolerances
9.5.6 Physics and Quality Assurance
9.5.6.1 Equipment-Specific QA
9.5.6.2 Patient-Specific QA
9.5.6.3 Procedure-Specific QA
9.6 Summary of Radiotherapy Treatment Algorithm
9.7 Conclusion
References
10: Radiation Therapy for Angiosarcomas
10.1 Introduction
10.2 Epidemiology
10.3 Etiology
10.4 Imaging
10.5 Pathology
10.6 Clinical Subtypes
10.6.1 Primary Cutaneous Angiosarcoma
10.6.1.1 Diagnosis
10.6.1.2 Management
Surgery
Radiation Therapy
Simulation
Target Delineation Including Organs at Risk (OAR)
Treatment Planning
Treatment Delivery
Safety/Quality Assurance (QA)
Systemic Therapy
10.6.2 Angiosarcoma Associated with Lymphedema
10.6.2.1 Diagnosis
10.6.2.2 Management
10.6.3 Breast Angiosarcoma
10.6.3.1 Diagnosis
10.6.3.2 Management
10.6.4 Soft Tissue Angiosarcoma
10.6.5 Radiation-Induced Angiosarcoma
10.6.5.1 Diagnosis
10.6.5.2 Management
10.7 Summary
References
11: Radiation for Dermatofibrosarcoma Protuberans
11.1 Introduction
11.1.1 Staging
11.2 Management Principles
11.2.1 Workup
11.2.2 Treatment Options
11.2.2.1 Surgery
11.2.2.2 Radiotherapy
11.2.2.3 Systemic Therapy
11.2.2.4 Follow-Up
11.3 Radiation Therapy Techniques and Planning
11.3.1 Choice of Modality
11.3.2 Simulation
11.3.3 Target Definition
11.3.4 Dose
11.4 Physics/QA
11.5 Treatment Algorithm
11.6 Summary
References
12: Radiation Therapy in the Management of Cutaneous Squamous Cell Carcinomas
12.1 Early Stage Disease
12.1.1 Surgical Management of Early Stage cSCCs
12.1.2 Indications for Adjuvant Radiation After Surgery for Early Stage cSCCs
12.1.3 Radiation as Primary Management of Early Stage cSCCs
12.1.4 Radiation Dose and Fractionation Schemes for the Management of Early Stage cSCCs
12.1.5 Radiation Techniques for the Management of Early Stage cSCCs
12.2 Advanced Disease
12.2.1 Surgical Management of Advanced Stage cSCCs
12.2.2 Indications for Adjuvant Radiation After Surgery for Advanced Stage cSCCs
12.2.3 Radiation as the Primary Management of Advanced Stage cSCCs
12.2.4 Radiation Dose and Fractionation Schemes for the Management of Advanced Stage cSCCs
12.2.5 Radiation Techniques for the Management of Advanced Stage cSCCs
12.3 Conclusion
References
13: Basal Cell Carcinoma
13.1 Epidemiology
13.2 Natural History
13.3 Subtypes
13.3.1 Risk Stratification
13.3.2 Management Options
13.3.2.1 Excision
13.3.2.2 MOHS Micrographic Surgery (MMS)
13.3.2.3 Curettage and Electrodesiccation (C&E)
13.3.2.4 Superficial Therapies
13.3.3 Radiation Therapy
13.3.3.1 Patient Selection
13.3.3.2 Modality Comparison
13.3.3.3 Treatment Recommendations
13.3.4 Radiation Techniques
13.3.5 External Beam Radiation
13.3.5.1 Orthovoltage/Supervoltage
13.3.5.2 Electron Beam
13.3.5.3 Patient Setup
13.3.5.4 Prescription
13.3.5.5 Electron Arc Therapy
13.3.5.6 Photon Beam Therapy
13.3.5.7 Brachytherapy
13.3.6 Applicators
13.3.6.1 Contact BT
13.3.6.2 Surface Flaps
13.3.6.3 Custom Applicators
13.3.6.4 Treatment Planning and Prescription
13.3.6.5 Treatment Toxicity and Patient Management
13.3.6.6 Palliation
13.4 Systemic Therapy
13.4.1 Targeted Therapy: Hedgehog Pathway
13.4.2 Non-Targeted Agents
References
14: Melanoma
14.1 Pathology
14.1.1 Epidemiology
14.1.2 Aetiology
14.1.2.1 Environmental
14.1.2.2 Genetic
14.1.3 Radial and Vertical Growth
14.1.4 Subtypes
14.1.4.1 Superficial Spreading Melanoma
14.1.4.2 Nodular Melanoma
14.1.4.3 Lentigo Maligna Melanoma
14.1.4.4 Desmoplastic Melanoma
14.1.4.5 Acral Lentiginous Melanoma
14.2 Staging
14.2.1 T Category
14.2.2 N Category
14.2.3 M Category
14.2.4 Clinical and Pathologic Prognostic Stage Groups
14.3 Initial Assessment
14.3.1 Approach to Pigmented Lesion
14.3.1.1 History
14.3.1.2 Examination
14.3.1.3 Investigations
14.3.2 Workup of Biopsy-Confirmed Melanoma
14.3.2.1 All Patients
14.3.2.2 Patients with No Clinical Evidence of Regional Nodal or Distant Metastases
14.3.2.3 Patients with Clinical Evidence of Regional Nodal or Distant Metastases
14.4 Treatment: Primary Cutaneous Melanoma
14.4.1 Invasive Malignant Melanoma
14.4.1.1 Wide Local Excision
14.4.1.2 Radiation Therapy
14.4.1.3 Adjuvant Therapy
14.4.2 In Situ Melanoma
14.5 Treatment: Regional Lymphatics
14.5.1 Approach to the Clinically Involved Nodal Basin
14.5.1.1 Surgery for Resectable Regional Nodal Metastases
14.5.1.2 Adjuvant Therapy Following Regional Lymph Node Dissection
14.5.1.3 Neoadjuvant Therapy Prior to Regional Lymph Node Dissection
14.5.1.4 Unresectable Regional Nodal Metastases
14.5.2 Approach to the Clinically Uninvolved Nodal Basin
14.5.2.1 Sentinel Lymph Node Biopsy
14.5.2.2 Adjuvant Therapy Following Sentinel Lymph Node Biopsy
14.5.2.3 Approach to Satellite Lesions or in-Transit Metastases
14.6 Treatment: Distant Metastases and Unresectable Regional Nodal Metastases
14.6.1 Systemic Therapy
14.6.1.1 Cytotoxic Chemotherapy
14.6.1.2 Targeted Therapies
14.6.1.3 Immunotherapy
14.6.2 Local Therapy for Extracranial Oligometastases
14.6.2.1 Surgical Metastasectomy
14.6.2.2 Radiation Therapy
14.6.3 Approach to Brain Metastases
14.7 Head and Neck Mucosal Melanoma
14.7.1 Pathology, Epidemiology and Staging
14.7.2 Treatment
14.8 Other Mucosal Melanoma
14.8.1 Pathology, Epidemiology and Staging
14.8.2 Treatment
14.9 Ocular Melanoma
14.9.1 Pathology, Epidemiology and Staging
14.9.2 Treatment
14.10 Radiation Therapy Techniques
14.10.1 Considerations in Selecting a Radiation Technique
14.10.2 Simulation
14.10.3 Daily Treatment Position and Image Verification
14.10.4 Treatment Planning, Volume Delineation and Recommended Dose
14.10.4.1 Adjuvant Radiation Therapy for High-Risk Nodal Metastases
14.10.4.2 Adjuvant Radiation Therapy for High-Risk Primary Cutaneous Melanoma of the Head and Neck
14.10.4.3 Definitive Radiation Therapy for Lentigo Maligna
14.10.4.4 Definitive Radiation Therapy for Mucosal Melanoma of the Head and Neck
14.10.5 Dose Specification
14.10.5.1 Megavoltage (MV) Energy Photon Treatments (3DCRT, IMRT/VMAT)
14.10.5.2 Electron Treatments
14.10.5.3 Superficial (Kilovoltage Energy) Photon Treatments
14.11 Principles of Stereotactic Ablative Radiation Therapy for Extracranial Oligometastases
14.11.1 Highly Hypofractionated Treatment to Small Fields with Steep Dose Gradients
14.11.2 Motion Management
14.11.3 Image Guidance
14.11.4 Quality Assurance
14.12 Patient-Specific Radiation Quality Assurance for Modern Techniques
14.13 Normal Tissue Complications From Radiation Therapy for Melanoma
14.13.1 Factors Affecting Risk of Normal Tissue Complications
14.13.1.1 Patient Factors
14.13.1.2 Tumour Factors
14.13.1.3 Treatment Factors
14.13.2 Early Radiation Toxicity Following Radiation Therapy for Melanoma
14.13.2.1 Head and Neck
14.13.2.2 Axilla
14.13.2.3 Groin
14.13.3 Late Toxicities Following Radiation Therapy for Melanoma
14.13.3.1 General
14.13.3.2 Head and Neck
14.13.3.3 Adjuvant Treatment of Axilla
14.13.3.4 Adjuvant Treatment of Groin
14.13.4 Strategies to Minimize Radiation Toxicity
14.13.4.1 Patient Factors
14.13.4.2 Treatment Factors
14.14 Summary for Role of RT in Melanoma
References
15: Merkel Cell Carcinoma
15.1 Introduction
15.1.1 Clinical Presentation
15.1.2 Risk Factors and Pathogenesis
15.1.3 Staging
15.2 Management Principles
15.2.1 Initial Diagnosis
15.2.2 Treatment
15.2.3 Current Role of Adjuvant Therapy in MCC
15.2.3.1 Radiation Therapy
15.2.3.2 Adjuvant Systemic Therapy
15.2.3.3 Metastatic Disease
15.2.3.4 Role of Radiation
15.3 Radiation Therapy Techniques and Planning
15.3.1 Radiation Technical Considerations
15.3.2 Target Delineation
15.3.3 Dose Treatment Recommendations
15.4 Summary
References
16: Treatment of Cutaneous Lymphomas: Topical, Systemic, and Radiation Therapies
16.1 Introduction
16.2 Management Approaches
16.2.1 Primary Cutaneous B-Cell Lymphomas
16.2.1.1 Radiotherapy
16.2.1.2 Other Therapies
16.2.2 Cutaneous T-Cell Lymphoma (CTCL) Including Primary Cutaneous CD30-Positive Lymphomas (Such as pcALCL and LyP) and Mycosis Fungoides (MF)
16.2.2.1 Radiation Therapy (RT)
16.2.2.2 Mycosis Fungoides
16.2.2.3 Topical Therapies
16.2.2.4 Phototherapy
16.2.2.5 Systemic Therapies for CTCL
References