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Radiotherapy Protocols

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					  CCO, Radiotherapy Quality System                                                 2007
  Quality Procedure                                               Radiotherapy Protocols




Clatterbridge Centre for Oncology
             NHS Foundation Trust




                 Radiotherapy
                  Protocols




 Issue Date: 13-Aug-10    Page 1 of 59     Filename:    CCO Radiotherapy   Issue No: 1.2
                                           Protocol.doc
 Author:    A Melbourne   Authorised by:                                   Copy No:
CCO, Radiotherapy Quality System                                                                                    2007
Quality Procedure                                                                                  Radiotherapy Protocols

                                                                                                                    Page
Breast.................................................................................................................. 3
Bladder................................................................................................................ 6
Prostate............................................................................................................... 8
Testicular…………………………………………………………………………………10
Anal Canal………………………………………………………………………………. 11
Anal Margin………………………………………………………………………………12
Pancreas (protocol under development).............................................................. 13
Stomach…………………………………………………………………………………. 13
Oesophagus……………………………………………………………………………...14
Colon .................................................................................................................. 15
Rectum................................................................................................................ 16
Soft tissue Sarcoma (protocol under development)……………………….. ........... 18
Non-Small Cell Lung………………………………………………….…………………19
Small Cell Lung (protocol under development) ………………………………………20
Mesothelioma...................................................................................................... 21
Cervix.................................................................................................................. 22
Vulva…………………………………………………………………………………….. 24
Ovary (protocol under development) ................................................................... 27
Endometrium (protocol under development)………………………………………… 27
Head and Neck Cancer-General ......................................................................... 28
Oropharynx           Buccal Mucosa ........................................................................... 29
                     Floor of Mouth ............................................................................ 30
                     Base of Tongue .......................................................................... 31
                     Oral Tongue................................................................................ 32
Larynx              Glottic Larynx............................................................................... 33
                     Sub-Glottic Larynx ...................................................................... 34
                     Supraglottic Larynx ..................................................................... 36
Lower Alveolus.................................................................................................... 38
Nasopharynx ....................................................................................................... 39
Parotid Gland                                                      ...................................................... 40
Pyriform Fossa .................................................................................................... 41
Retromolar Trigone ............................................................................................. 42
Maxillary Sinus/Nasal Cavity ............................................................................... 43
Soft Palate .......................................................................................................... 44
Tonsil .................................................................................................................. 46
Thyroid ................................................................................................................ 48
Cervical Oesophagus .......................................................................................... 48
Skin – Non melanoma / melanoma / Merkel Cell ................................................. 49
Glioma – Low grade/ High Grade ........................................................................ 50
Optic Nerve Glioma (protocol under development)………………………………….51
Germinoma ......................................................................................................... 51
Primary CNS Lymphoma..................................................................................... 52
Ependymoma ...................................................................................................... 53
Pituitary ............................................................................................................... 53
Acoustic Neuroma............................................................................................... 54
Meningioma………………………………………………………………………………54
Malignant Spinal cord compression..................................................................... 55
Brain Metastases ................................................................................................ 55
Craniopharyngioma (protocol under development) …………………………………55
Orbital Tumours………………………………………………………………………….56
Hodgkins / Non-Hodgkins Disease / Spleen (under development)....................... 57
Paediatric Tumours…………………………………………………………… ............ 58
Bone Metastases ................................................................................................ 59

Issue Date: 13-Aug-10                    Page 2 of 59                   Filename:    CCO Radiotherapy               Issue No: 1.2
                                                                        Protocol.doc
Author:        A Melbourne               Authorised by:        Dr B J Haylock                                       Copy No:
CCO, Radiotherapy Quality System                                                          2007
Quality Procedure                                                        Radiotherapy Protocols


                                        BREAST

DCIS
Policy is to treat patients according to risk of recurrence.

    •     Low risk patients i.e. <1.5cm, low-grade lesions and margins >1cm

             o Wide local excision only.

    •     High risk patients i.e. patients with more than 1 of; >4cm, high grade
          histology, <1mm margin.

             o Mastectomy.

    •     All other patients

             o Wide local excision and post-operative radiotherapy.
             o PTV whole breast + margin only. Technique, dose and # as per
               invasive carcinoma.

Invasive Breast Cancer

    •     Post breast conserving surgery

                o All patients unless within clinical trial
                o PTV is whole breast with margin +/- regional lymph nodes
                  (see below).

    •     Post mastectomy

                o T3/4 with >4 lymph nodes +ve or involved margins
                o T2 with 2 or more minor risk factors i.e. 1-3 lymph nodes
                  +ve, vascular invasion. G3.
                o PTV chest wall with margin +/- regional lymph nodes [see
                  below]


Lymph node radiotherapy

Axilla not irradiated if:

    •     Level 3 axillary dissection regardless of lymph node status [normally
          level 2 clearance is performed and upper axilla included in SCF field]
    •     N0 [minimum of 4 nodes sampled]
    •     T1a/T1b Nx and low grade tumours [lower axilla included in tangential
          fields]
Issue Date: 13-Aug-10          Page 3 of 59           Filename:    CCO Radiotherapy   Issue No: 1.2
                                                      Protocol.doc
Author:     A Melbourne        Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                          2007
Quality Procedure                                                        Radiotherapy Protocols

    •     There is a single node with micrometastasis
    •     Using a hypo-fractionated weekly regime

    Sentinel lymph node biopsy – discuss with local surgeon

Axilla XRT considered if:
    •     <4 nodes removed and N1 – risk of residual disease is high
    •     All removed lymph nodes +ve [e.g. 10/10]


Axilla is usually irradiated if;
    •     N1 disease and limited axillary sampling
    •     Nx disease [this includes patients with <4 nodes sampled and all
          negative]

Supra Clavicular Fossa irradiated if:
    •     >4 nodes +ve

Internal Mammary Chain:
    •     not routinely treated


Locally advanced or Inflammatory Breast Cancer
Patients who have had a good response to primary therapy and whose
disease is operable (i.e. no SCF disease) should be offered mastectomy and
axillary dissection followed by radiotherapy to the chest wall and SCF.

Recurrent Disease

Useful palliation for local/regional recurrence                  after    hormones       or
chemotherapy. Requires individual treatment.

Timing of Radiotherapy and integration of Chemotherapy

Surgery + XRT
                                                    -   Start within 8 weeks of surgery
Surgery + Chemotherapy + XRT
                                                    -   Concurrent or sequential with
                                                        CMF
                                                    -   Sequential with Anthracyclines
                                                        / Taxanes after a 21-35 day
                                                        gap




Issue Date: 13-Aug-10        Page 4 of 59           Filename:    CCO Radiotherapy   Issue No: 1.2
                                                    Protocol.doc
Author:     A Melbourne      Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

Radiotherapy Techniques
Breast/Chest Wall only – tangentials. PTV - breast tissue/chest wall + margin.
Monobloc – extended tangentials. PTV - breast tissue/chest wall+ margin and
            axillary nodes in continuity.
3 field – PTV - breast tissue/chest wall + margin and SCF.
4 field – PTV - breast tissue/chest wall + margin, SCF and posterior axillary
         boost where axillary separation > 14 cm.

Radiotherapy schedules

Radical:

40Gy/15#/3 weeks
45Gy/20#/4 weeks
50Gy/25#/5 weeks

Palliative:

30Gy/5-6#/weekly
39Gy/13#/5a fortnight
45Gy/12#/3 a week

Electron Boost
Indications:

 •  Use is variable, consider if:risk of local recurrence is high (eg high
    grade,T3/4 or lymphovascular invasion)
 • Close margins < 1mm
 • < 50 – 60 years
NB – Oncoplastic incisions require clip localization and CT planning on
AQSim and planned PHOTON treatment

Boost schedules:
This should be discussed with consultant.
 • 16Gy/8#
 • 15Gy/5#
 • 10Gy/3#
 • 10Gy/5#
 • 12.5/5#
 • 9Gy/3#
 • 8Gy/4#

Ovarian Ablation:
See under ‘Ovary’



Issue Date: 13-Aug-10     Page 5 of 59           Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                       2007
Quality Procedure                                                     Radiotherapy Protocols

                                   BLADDER
Superficial bladder cancer
Tis, Ta/T1, G1/2 – no routine role

T1 G3 Unifocal and Multifocal+/-Tis relapse – consider radiotherapy or
cystectomy

Muscle invasive bladder cancer
T2-T4a, N0, M0
Good performance status: Radical cystectomy or radical radiotherapy
                         Consider concurrent cisplatin/RT
Poor performance status: Palliative radiotherapy

N+, M0
Good performance status: Neoadjuvant chemotherapy
                         For responders radical radiotherapy
Poor performance status: Palliative radiotherapy

T4b, M+
Any performance status:       Palliative radiotherapy

Radical treatment : Clinical target volume and planning target volume

    •     include whole bladder with a 1.5 cm, and a 2 cm margin for a superior
          tumour
    •     include prostatic urethra in men, particularly for inferior tumours
    •     treat with a phase I (whole bladder) and phase II (10-14Gy, partial
          bladder volume) in small localized tumours, in patients with a large
          residual volume or diverticulum
    •     for patients with large residual volume consider indwelling catheter or
          treatment of small volume throughout
    •     pelvic lymph nodes are not routinely treated

Schedule (Grade B evidence)
   • Conventional:60-64Gy / 30-32# / 6.5 weeks / 8-10 MV or
Hypofractionated:
   • 50-55Gy / 20# / 4 weeks / 8-10 MV for volume < 11x11x11

Treatment Delays for TCC Bladder

NB TCC Bladder are category 1 patients therefore do not prolong overall
treatment and avoid split courses.




Issue Date: 13-Aug-10       Page 6 of 59           Filename:    CCO Radiotherapy   Issue No: 1.2
                                                   Protocol.doc
Author:     A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                       2007
Quality Procedure                                                     Radiotherapy Protocols


Palliative treatment : Clinical target volume and planning target
                                volume

    •     CT planning (urgent RT may be done without CT planning)
    •     2,3,or 4 field plan
    •     include whole bladder, margin can be tighter

Schedule

    •     21 Gy / 3# / 1 week / 8-10 MV or
    •     30-35 Gy / 10-15# / 2-3 weeks 8-10 MV or
    •     30-36 Gy / 6# / 6 weeks 8-10 MV

Concurrent cisplatin/ radiotherapy

Schedule

    •     Start chemotherapy during week 1 on Delamere as outpatient
    •     Cisplatin 30 mg/m2 in 1l N/S over one hour, maximal dose 60 mg, for
          4-6 weeks
    •     Concurrent radiotherapy 64 Gy / 32# or 50-55 Gy / 20#
    •     Weekly U+E, FBC before each chemotherapy course
    •     Chemotherapy can be given before or after RT; there is no evidence
          that the timing makes a difference.




Issue Date: 13-Aug-10       Page 7 of 59           Filename:    CCO Radiotherapy   Issue No: 1.2
                                                   Protocol.doc
Author:     A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

                                 PROSTATE

Early disease: T1, T2, Gleason 2-7, N0, M0 and PSA < 10 ng/ml
(Risk score PSA + [ (Gleason score –6)x10] <30)
                                           ]

•   Watch and wait policy
•   Radical radiotherapy +/- 3-6 month neo-adjuvant hormone therapy
•   I131 brachytherapy
•   Radical prostatectomy

Locally advanced disease: T1, 2 Gleason 8-10, any T3, N0, M0 and/or
PSA >10 ng/ml (Risk score PSA + [ (Gleason score –6)x10] 30 – 60)
                                                        ]

•   Watch and wait
•   Immediate hormone therapy
•   Neo-adjuvant/adjuvant hormone therapy and local radiotherapy only or
    pelvic radiotherapy and boost to prostate

Suitable patients for dose escalation

•   Fit and < 70 years for Grade 2 or <75 years for Grade 3
•   PSA 10 - 30
•   and/or: Gleason 7-10
•   and T1c, T2, early T 3a/b on MRI only

Planning Radical treatment

For normal dose RT
       • PTV1 = GTV1 + 1cm 3D margin
For concurrent dose escalation
       • Large volume and lower dose; PTV1 = GVT1 + 1cm
       • Smaller volume and high dose; PTV2=GTV2

Volume to be treated depends on the risk of lymph node involvement (risk
score) = PSA + [(Gleason score –6) x 10


Early disease

P = prostate SV = Seminal vesicles
T1/ T2 with risk score <15:                          GTV1 P and base of SV
                                                     GTV2 P only
T1/ T2 with risk score >15:                          GTV1 P and SV
                                                     GTV2 P and base of SV




Issue Date: 13-Aug-10     Page 8 of 59           Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

Locally advanced disease

T2c/T3a risk score <40                               GTV1 P and SV
                                                     GTV2 P and base of SV
T1,2 risk score >40, T3b :                          Ph I: PTV1 P and SV + 1cm
                                                    Phase II: pelvis (including
                                                    obturator, hypogastric,
                                                    external and internal iliac
                                                    lymph nodes up to sacral
                                                    promontory) plus as above);
                                                    outline lymph node on CT if
                                                    possible PTV: lymph nodes
                                                    (margin 0.5 cm) + prostate

Schedule

•   Standard schedules:
    • 64Gy / 32# / 6 weeks
    • 66Gy / 33# / 7 weeks
•   Dose escalated schedule;(IMRT and CHHIP)
    • Inverse IMRT – PTV1 64Gy / 32# , PTV2 70 Gy / 32# / 6.5 weeks
    • Forward planned IMRT – PTV1 64Gy / 32# , 72 Gy / 32# / 6.5. weeks
    • Acceptable include: 74-78Gy / 37 –39 # / 7.5 – 8.0 weeks (Grade A)
    • Also 50 Gy / 16 # (Grade C)
•   Phase I: Prostate boost – 20 Gy / 10# / 12 days
    Phase II: Pelvis – 44 Gy / 22 # / 29 days or 45 Gy / 25# / 35 days



Palliative treatment

•   T3 tumour: three or four field planning technique
•   T4 tumour require parallel-opposed fields
•   The whole pelvis radiotherapy for symptomatic enlarged lymph nodes

Schedules
•   20 Gy / 5# / 1 week
•   30 Gy / 10 # / 2 weeks
•   35 Gy / 15 # / 3 weeks or
•   30-36 Gy / 5-6# / 5-6 weeks once a week




Issue Date: 13-Aug-10    Page 9 of 59           Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

                         TESTICULAR TUMOURS
Radiotherapy as adjuvant treatment for Stage 1 seminoma is only used if there is a
contraindication for adjuvant single agent carboplatin.

Stage I with no risk factors for pelvic node disease
• Para-aortic node from D10/ 11 to L5/S1 with POP,.20 Gy / 10# / 2 weeks

Stage I and Stage llA or llB Seminoma with Risk of Pelvic Node Disease
Where there has been previous inguino-scrotal surgery, the field should be
extended to include the ipsilateral pelvic nodes (“dog-leg”).
• 30 Gy / 15# / 3 weeks




Issue Date: 13-Aug-10    Page 10 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
 CCO, Radiotherapy Quality System                                                      2007
 Quality Procedure                                                    Radiotherapy Protocols

                                 ANAL CANAL
 The preferred treatment is external irradiation Abdomino-perineal resection is
 reserved for patients who have intractable pain or have persistent or recurrent
 disease following radiotherapy, and is also the treatment of choice for patients
 with tumours that have destroyed the anal sphincter. (+/ - pre- or post-op RT ).

 Radical Treatment Options:

                                                   -   Small Tumours : Grade 1-2 /
                                                       T1NOMO*, T2 <3cm NOMO
     •  Prone 3 Fields – post and 2 laterals
     •  CTV = Primary tumour + margin (ing. Nodes are not included in PTV)
     •  Chemo/RT using Mitomycin C and 5FU of Cisplatin and 5FU see below
     •  45Gy / 20# / 4weeks (as per ACT I).
     •  50Gy / 25# / 5weeks (as per ACT II)
     •  Boost – Consider Iridium implant (15-20Gy) in patients with residual
        tumour at 4-6 weeks assessment – EUA preferred.
 * N.B. Chemotherapy in very small selected T1NOMO patients may be
 omitted and small volumes taken to a dose of 50G / 20# / 4 weeks

                                                   -   Standard Regime (Bulky and
                                                       High Grade Tumours):
 First consider trial entry into:
 ACT II or EXTRA trial of radiochemotherapy (RT details as below)

 a) All Grades: T2 >3cm ; T3/T4NOMO and G3 T1
Node negative
 •   Phase 1:Supine: 30.6Gy/17#/23 days
     • Ant and post – large parallel opposed fields
     • CT/SIM planned to include the inguinal nodes
     • CTV = Tumour + inguinal + lower pelvic nodes;
     • PTV = CTV +planning Margin
     •     Phase 2: Prone preferred (may be supine for comfort or to facilitate
           nodal treatments phase II): 19.8Gy /11# / 15days
     •     CT/SIM: 3 Fields– post and two laterals.
     •     CTV = Tumour + 3 cm margin
     •     PTV = CTV +planning Margin
 b) T3 , T4 / N1 / M1
 Young fit patients with bulky primary tumour + nodes.
    • Radiotherapy as above + inguinal node boost on effected side using
        appropriate energy electrons.
    • Prescribed at 3cm depth or depending on CT
    • 19.8Gy / 11# / 15 days
 N.B.: In cases with residual tumour at 4-6 weeks assessment (EUA
 preferred) consider Iridium implant boost 15Gy
 Issue Date: 13-Aug-10      Page 11 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                   Protocol.doc
 Author:     A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

Radical Palliative Treatments: ‘Split course’ Vancouver technique.
  • For older or very frail patients
  • Phase 1: as above:26Gy /13# / 17days 5FU/Mito wk 1
  • proceed only if well enough to phase 2 after 3.5 weeks
     Phase 2: as above: 24Gy / 12# 16 days 5FU/Mito repeat


                             ANAL MARGIN
Radical Treatment. Only carcinoma in situ and early invasive carcinoma
should be treated by a local excision alone, providing adequate margins can
be obtained without endangering sphincter function.

Early Carcinoma: Grade 1 or 2 / T1NOMO*, T2 <3cm NOMO
    • Concurrent RT/CT (Mitomycin/5FU see anal canal)
    • Patient treated prone lying over rectal board.
    • 2 Fields (post and direct perineal).
    • Target volume: PTV = Primary tumour + margin (ing. nodes are not
      included in PTV).
    • 45Gy / 20# / 4wks
    • 50Gy / 25# / 5wks.
*in small selected T1NOMO patients chemotherapy may be omitted and small
volumes taken to a dose of 50Gy / 20# / 4weeks


Standard Regime: T1 G3 only, ALL Grades T2 >3cm; T3/T4NOMO
•   Concurrent RT/CT (Mitomycin/5FU see anal canal)
• Phase 1:Supine
  • Ant and post – large parallel opposed fields
  • CT/SIM planned to include the inguinal nodes
  • 30.6Gy /17# / 23days
  • Target volume :     CTV = Tumour + inguinal and lower pelvic nodes
                        PTV = CTV +planning Margin
• Phase 2: Prone
  • CT/SIM: 3 Fields– post and two laterals.
  • 19.8Gy /11# / 15days
  • Target volume :     CTV = Tumour + 3 cm margin
                        PTV = CTV +planning Margin
Advanced: T3 T4 / N1 / M1
High risk patients are encouraged to enter into ongoing trials:
ACT II Trial; EXTRA Trial see Anal Canal

Older or Frail patients:
Consider ‘Split course’ Vancouver treatment – after B Cummings Toronto


Issue Date: 13-Aug-10     Page 12 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

Palliative Treatments:
Most palliation of the primary involves ‘radical palliation’ much as above
although Chemotherapy may be omitted if contraindicated because of
extreme age or cardiac morbidity. Simple palliation of secondary lesions
requires few fractions of simple set ups.



                                  PANCREAS
Protocol under development




                 GASTRIC CARCINOMA (stomach)
Adjuvant postoperative radiotherapy or chemo-radiotherapy is only
recommended for high risk patients with a clear margin of resection.
Techniques as per MacDonald et al NEJM 2003.
This treatment can be very toxic and requires a pt with good performance
status and intensive support during and after treatment.

Palliative treatment can be useful in selected cases.
POP 30Gy/10 /2wks or 20Gy/5 /1wk




Issue Date: 13-Aug-10     Page 13 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols


                            OESOPHAGUS

Radical Options:

    a)    Small Operable Tumours (e.g.T1/T2 N0 – at or below the carina)
                Surgery alone
    b)    Other Operable Tumours (e.g. T3 N0/N1)
                 Neoadjuvant Chemotherapy/Surgery
    c) Doubtful Operability – young and fit e.g. T3N1
    Long course RT/CT – 50Gy / 25# / 5 weeks (plus 5FU on weeks 1 and 5)
     + Surgery    (or 45Gy / 25# / 5 weeks plus 5FU on weeks 1 and 5 plus
    brachytherapy boost* esp if surgery declined. *10Gy @ 1 cm from central
    axis. N.B.This has potential for toxicity)
    d)  Doubtful Operability – medically unfit for Chemotherapy +
         Surgery
    3 weeks radiotherapy 40Gy/15/3wks CT planned plus a brachytherapy
    boost*.

    e) Locally Advanced (but disease within treatable volume)
    Long course RT/CT as above plus 2 cycles chemo.(Cisplatin anad 5FU to
    follow)

Radical Treatments:
a) Standard long course
Phase 1 – ant and post parallel opposed fields 30 Gy / 15# / 3 weeks
Phase 2 – ant and 2 post obliques 20 Gy / 10# / 2 weeks
Or One phase CT planned 50Gy/25/5wks.
Critical Structure: Spinal cord and lung parenchyma

b) Short Course
40Gy /15# /3 weeks
40Gy /15# /3 weeks intensified with HDR brachytherapy boost *(after
Vancouver). May be used where chemotherapy is contraindicated.
N.B. Palliation:
    o 30Gy / 10#/ 2 weeks +/- HDR brachytherapy boost palliative option via
       pop for long tumours or larger volumes.
    o 24Gy / 6 # / 2 weeks
    o 20Gy / 5 # 1 week

Definition of radical volumes:
CTV: information from barium swallow and the CT scan establishes the upper
and lower borders.
PTV: extends 4.0 cm above and below all known tumour. The lower margin
will usually be slightly less than this for tumours at the gastro-oesophageal

Issue Date: 13-Aug-10    Page 14 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

junction. The width of the fields depends on the CT findings, with a 1.5 cm
margin between all known disease and the 95% isodose.

Adjuvant post-operative radiotherapy
Not recommended. However, in selected cases it may be used if a definite site
of residual disease can be identified and encompassed in an appropriately small
volume.
    • 40Gy / 15# / 3 weeks
    • 50Gy / 20# / 4 weeks
    • Intra-cavitary therapy is not usually recommended for these patients.


Other Palliative Options:
                                           - Metastatic disease:
RT alone or chemotherapy (Cisplatin/5FU or ECF for adenocarcinomas)
                                              - Dysphagia:
Stent +/- RT; Laser +/- RT see palliative fractionations




                                    COLON
Routine adjuvant radiotherapy or chemo-radiotherapy is not recommended
outside a randomised trial.
N.B. For patient at high risk of a local recurrence e.g. following a localised
perforation or for areas of residual small volume disease marked with surgical
clips e.g Abdominal wall or pelvic side wall consider localised planned
radiotherapy

Volume:         CTV defined by clips
                PTV = CTV + 1.5 cms margin
Dose:           45Gy/20# in 4 wks or 45Gy/25# in 5 wks with adjuvant
                chemotherapy
CT Planning aiming to minimise small bowel in the volume. Verification with
oral contrast to facilitate blocking of non motile small bowel




Issue Date: 13-Aug-10     Page 15 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                        2007
Quality Procedure                                                      Radiotherapy Protocols

                                      RECTUM
Definitive Radical Irradiation
Considered if surgical resection is not feasible (e.g. age, poor condition,
patient choice).

LOCAL TREAMENT OPTIONS: Lead Dr Sun Myint

    a)     T1NoMo < 3cms (excluding high grade)

    •     ‘TEM’ (Advice from specialist surgeon via Dr Myint)
    •     ‘Papillon’ techniques of radiotherapy (Dr Sun Myint)

    b)  T1,T2 (or occasional early T3) tumour, >3cms <5cms and < half
      the circumference
    • Consider down staging with long course XRT followed by Trans Anal
       Resection or ‘Papillon’ style boost.

Preoperative Radiotherapy:

This ideally employs MRI assessment of the any mesorectal fascial breech or
close lymph node involvement which may prevent the achievement of a clear
circumferential resection margin (< or = 1mm)

Clinically ‘Mobile’ Tumours (or where a clear margin likely)
We await the results of CRO7. Some low tumours in large patients where
complete clearance may not be possible and in older patients with disease
close to mesorectal envelop where post op long course RT is contraindicated.
Offer short course RT
Schedule: 25Gy / 5# / 5 days precludes further radiotherapy treatment.

Clinically ‘Fixed’ or ‘Tethered’ Tumours:
Or where MR predicts a high risk of positive or close margin, anterior tumours
and very low tumours where margins are narrow.
Long course RT/CT (with 5FU inf. Weeks 1 and 5 or oral Capecitabine)
Trial entry NWWCOG (RICE trial) if advanced tumour

N.B. Patients who are considered at risk of developing obstruction (e.g.
circumferential tight tumour; narrow caliber stools; abdominal bloating) should
be considered for surgical defunctioning prior to any RT.


RT Schedules:
Short course (25Gy / 5#) Mon – Fri (With surgery within 7 days)
Long course:
    1. Unfit for chemo.(e.g. Ischaemic heart disease; older pts):
       • 45Gy/20#/4wks alone

Issue Date: 13-Aug-10        Page 16 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                    Protocol.doc
Author:     A Melbourne      Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                        2007
Quality Procedure                                                      Radiotherapy Protocols

          •   39Gy / 13# / 3wks . +/- additional papillon boost : 30-60Gy / 1-2# /
              14days or HDR brachytherapy boost 10Gy @ 10mm from surface
    2. Fit patients:
       • 45Gy / 25# / 5 weeks with concurrent chemotherapy
           5FU (1g/m2/750mg if less robust days 1-4 and 29-33)
           or oral Capecitabine
          •   Optional boost 5.4 – 9Gy / 3-5# / 3-5 days to a reduced volume for
              high risk patients – must exclude small bowel.
                                Or
          •   Consider HDR boost as above
    Target volumes: Post Pelvis. Full Bladder
      • Use Simulator with rectal barium to delineate tumour and include
         pelvis nodes to define PTV.
      • CT planned: CTV grown to PTV
      • 3 field prone

Post operative RT:
Tumours at high risk of local failure, which depends on involved CRM, bulky
T3, G3:
Long course RT as above for gross residual disease in fit patients 45Gy /25# /
5 weeks +/- boost of 10-15Gy to gross macroscopic residual disease or
consider HDR boost as above
Target volume: Gross tumour or tumour bed and pelvic lymph nodes
Technique : Prone 3 field technique.
This is excluded by any pre operative RT (long or short course).

Palliative Treatment (Local Disease)
Palliative radiotherapy can be considered for the rectal cancer to help control
pain or bleeding. It is particularly useful for perineal or pelvic pain from local
recurrence of rectal cancer.
Patients with obstructive symptoms are NOT candidates for palliative RT.
Instead consider a defunctioning stoma or intraluminal stent.
Schedules
a). Patients with a good PS, and long life expectancy
    ‘Radical’ palliation: 45Gy / 20# / 4 wks or 45Gy / 25# / 5 wks +/- chemo
    +/- boost as above

b). Patients with poor PS and/or wide spread distant metastases
    • 10Gy / 1#
    • 20Gy / 5# / 1week
    • 30Gy / 10# / 2 weeks
    • 30-36Gy / 5- 6# / 1 x weekly
    • 24Gy / 3# - days 0,7,21
    • 39Gy / 13# / 17 days

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Author:       A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

                         SOFT TISSUE SARCOMA

Protocol under development




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Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                        2007
Quality Procedure                                                      Radiotherapy Protocols


                          NON-SMALL CELL LUNG
Radical Treatment
It is recommended to use conformal planning techniques. Tumour mobility can
be large, particular in small peripheral tumours. Use slow CT scans, breathing
control and fluoroscopy to avoid a geographical miss. Use mean lung dose
and V20 to assess risk of toxicity.

Schedule
    •     52.5-50Gy / 20# / 4 weeks if spinal cord in field
    •     55 – 57.5 Gy / 20# / 4 weeks
    •     64 Gy / 32# / 6.5 weeks
    •     68 Gy / 34# / 7 weeks

Intraluminal radiotherapy (ILT)

Radical ILT
    •     7.5 Gy at 1 cm x 3 weekly, over 3 weeks

Palliative ILT
The clinician should specify the specific indications for using
   • First treatment 10-15 Gy at 1 cm
   • Re-treatment 7.5-10 Gy at 1 cm

Chemo-Radiotherapy
•   Radiotherapy – 55 Gy / 20# / 26 days
•   Chemotherapy – Cisplatin 20 mg/m2 concurrent with fractions 1-4 and 16-
    20 plus Vinorelbine 15mg/ m2 days 1-8 and 16-20


If there is evidence of response and the patient’s performance status is
maintained, this is followed by –
• Cisplatinum 80 mg/m2 day 1 and Vinorelbine 30mg/ m2 day 1,8 at 21 day
    intervals,
• commencing 4 weeks after completion of concurrent treatment.

Palliative Treatment

Symptomatic local disease with PS 3-4 and/or metastatic spread

    •     Large single fraction not advised if there is a substantial amount of
          myocardium within the treatment volume.



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Author:     A Melbourne      Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                       2007
Quality Procedure                                                     Radiotherapy Protocols

Thoracic RT – moderate / high dose palliative schedules

    •     10Gy mid plane dose 1# – only for PS poor 3 or 4
    •     Consider – 20Gy / 5# / 1week
    •     27 Gy / 6# / 2 weeks
    •     30-32 Gy / 10# / 2 weeks
    •     36 Gy / 12# / 16 days
    •     NB – if cord and oesophagus are not in field – 39 Gy / 13# / 17 days
    •     40Gy / 15# / 3 weeks
    •     20–25 Gy / 4-5 # 1 week




                  SMALL CELL LUNG CARCINOMA
Protocol under development




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Author:     A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                       2007
Quality Procedure                                                     Radiotherapy Protocols


                             MESOTHELIOMA
Radiation fields should be limited to the site of painful disease but whole lung
radiotherapy may be employed for widespread disease causing extensive
pain.


Schedule
    •     Painful area – 20 Gy / 5# / 1 week
    •     Hemi-thorax – 20-30 Gy / 10# / 2weeks.


RT to site of intrathoracic drains, biopsy sites etc (unless life
expectancy is thought to be <3 months).
    •     10-12Gy / 1# (MV or HVX))
    •     10-12.5 Gy / 1# (Cobalt)
Chemotherapy plus Extra Pleural Pneumonectomy followed by
Radiotherapy
    •     Radiotherapy – 50 Gy / 25# / 5 weeks
             •   Left sided tumour – conformal RT
             •   Right sided tumour – IMRT
    •     Chemotherapy – Alimta 500mg/m2 and Cisplatinum 80mg/ m2
    •     B12 and Folate mandatory




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Author:     A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

                                     CERVIX

Stage 1a disease
These patients are generally managed surgically but those unsuitable for surgery
can be treated with intracavity brachytherapy.

Stage 1b1 and 11a disease (non bulky)
There is agreement that for these patients either radical radiotherapy (XRT) or
Wertheims Hysterectomy (WH) are equally effective treatments.

 Bulky stage disease and stages Iib – Iva
These patients are best treated with radical course of radiotherapy consisting of
external beam treatment followed by intracavity treatment. Concurrent weekly
cisplatin chemotherapy is recommended in patients with good performance status.

Stage I and II patients with a high risk of para-aortic nodal metastases
This includes patients with either bulky disease or involved pelvic lymph nodes.
Chemo-radiation is the treatment of choice. Selected patients are considered for
extended field radiotherapy.

Patients with known para-aortic nodal metastases
For stage I and II disease with microscopic or small volume nodal disease consider
extended field radiotherapy.

Patients with isolated local failure in the pelvis after Wertheims
Hysterectomy
Treatment includes both external beam and intracavity radiotherapy. Patients with
bulky recurrences have a poor prognosis and may be considered for neoadjuvant or
concurrent chemotherapy. Decisions regarding the use of chemotherapy are made
on an individual basis.


Chemo-radiation
Neoadjuvant chemotherapy – for bulky pelvic and para-aortic lymphadenopathy
Concurrent Chemotherapy – considered for either locally advanced or bulky
disease.
Integrated chemotherapy – considered for persistently bulky disease after external
beam XRT or disease extending to pelvic side-wall

Postoperative radiotherapy
This is considered for patients at high risk for disease recurrence. These include the
following groups of patients;
    • Patients with involved pelvic lymph nodes
Consider adjuvant radiotherapy and concurrent chemotherapy for patients with more
than one involved pelvic lymph node
    • Patients with involved resection margins after WH
Post-operative external beam ± intracavity treatment ± concurrent chemotherapy.

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Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

Patients with gross residual disease after WH do badly. To optimise local control
higher radiation doses may be used than for patients with residual microscopic
disease.
    • High-risk node negative patients
Radiotherapy not recommended for these patients.
    • Patients treated inadvertently with simple hysterectomy
For those patients treated with radiotherapy a combination of external beam and
intracavity treatment is used

Improving Effectiveness of Radiotherapy: Hb Levels
All patients with cervical carcinoma undergoing radical radiotherapy should have
weekly FBC and would require blood transfusion if Hb is <12g/dl. Selected patients
may benefit from prophylactic use of growth factors (Erythropoetin).

Radical Planning
  • Patient should be lying supine
  • Upper Border top of sacrum
  • Lower Border at bottom of Obturator foramen. In case of vaginal involvement,
     2-3 Cm below the lower extent of disease.
  • Lateral Border 1 – 1.5 c m lateral to the pelvic brim
  • Posterior Border at junction of S2 and S3 vertebrae or 2 cm anterior to the
     most concave part of anterior sacrum. Take into account the sagittal view of
     MRI scan films. Treat with parallel opposed field if Uterosacral ligament
     involved.
  • Consider appropriate lead shielding – usually superior corners of all fields to
     shield small bowel / sacrum.

Radical Schedule
Stage I B1 and non-bulky Iia:
   • XRT: 45 Gy / 25# / 35 days or 46Gy / 23#
   • Brachytherapy: LDR: 25 Gy to point “A”
   • HDR: 7Gy x 2 to point “A”:
NB – the brachytherapy doses may be modified depending upon response and
    normal tissue dosimetry

Stage I B2, IIB, III and IVA:
   • XRT: 45-50.4 Gy / 25-28# / 33-38 days
   • Brachytherapy:
          o LDR: 25 Gy to point “A”
          o HDR: 7Gy x 2 to point “A”
   • Consider Parametrial Boost if the disease is extending to parametrium –
   5.4 Gy / 3# / 3 days
NB – the brachytherapy doses may be modified depending upon response and
normal tissue dosimetry




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Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                       2007
Quality Procedure                                                     Radiotherapy Protocols


Palliative Planning
Fields generally include gross tumour and margin.

Palliative Schedule
   • 30 Gy / 10# / 14 days
   • 20 Gy / 5# / 7 days
   • 8-10 Gy / 1 # - this can be repeated if necessary


                                      VULVA
For early stage, surgery is the treatment of choice. Radiotherapy given alone
or in conjunction with chemotherapy may be used in advanced stage to
downstage the tumour prior to surgery or as a primary treatment if there is
complete response. The use of radiotherapy prior to surgery will of course be
determined by clinical factors relating to the extent and site of the disease.

Primary Radiotherapy
    •     Very small lesions with poor performance status
    •     Young patients with clitoral lesions where surgery would be associated
          with major psychosexual problems.
    •     Patients with advanced disease who are unfit for surgery – radical
          radiotherapy alone or in combination with concurrent chemotherapy
          may be considered.

Adjuvant Radiotherapy
Considered for patients;
  •
      with close or involved margins – if the excision margin is positive but both
      re-excision or surveillance with surgical salvage of recurrence are equally
      valid approaches in view of the morbidity of irradiating the vulva post-
      operatively and the reasonable salvage rates with localised vulvar failure.
  •
      with presence of an infiltrative growth pattern and lymphovascular space
      involvement (both are associated with an increased risk of local
      recurrence though not of nodal metastasis)

Pre-operative Radiotherapy
Preoperative radiotherapy ± concurrent chemotherapy is useful in fit patients
with inoperable large tumours in an attempt to downstage the tumours and
facilitate ‘viscera-preserving’ surgery.

Palliative Radiotherapy
For patients with poor performance status and advanced tumours.

Irradiation of Inguinal Nodes
Surgical dissection remains the treatment of choice. Radiotherapy may be
inferior to groin dissection and its use alone should be reserved for the less fit
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Author:     A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                       2007
Quality Procedure                                                     Radiotherapy Protocols

patients.

Chemo-radiation

The morbidity of chemo-radiation is the major issue and patients have to be
carefully selected for this aggressive approach. Ideal patients are those who are
young and fit with large tumours where surgery would need to be extensive.

Radical Treatment
  • Patient supine
  • Radio-opaque markers used to indicate extent of palpable disease
  • Initial volume – gross tumour and sites of potential microscopic disease
  • Usually parallel opposed fields
  • Sup border – bottom of SIJ
  • Inferior border – 2cm below inferior extent of disease
  • Lateral border – to include all of femoral head
  • Fields can be weighted anteriorly to improve dose distribution
  • Electrons can be used to treat groin nodes
  • Appropriate shielding

Radical schedules

    •     45 Gy / 25# / 5 weeks followed by boost: 15Gy / 5#
    •     50.4 Gy / 28# / 5.5 weeks with chemo

Implants
   • 60Gy over 5-6 days, or
   • HDR 36 Gy in 6 fractions, or
   • Part Brachytherapy after fractionated XRT 40-45 Gy


Concurrent Chemoradiation
    •     50.4 Gy / 28# / 5.5 weeks with concurrent 5 Fluorouracil infusion plus
          Mitomycine C on week 1 and 5 Fluorouracil infusion on week 5. A
          small volume boost taking the dose to 60 Gy can be considered
          (photons, electrons or brachytherapy)
    •     NB – A split course is recommended in patients with severe acute skin
          reactions.

Adjuvant Treatment
Positive Groin Nodes
   • Fields as for radical treatment but shield vulva if possible i.e. clear
      margins
   • Inguinal nodes – inferior border 2cm inf. To ischial tuberosity


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Author:     A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                       2007
Quality Procedure                                                     Radiotherapy Protocols

    •     If both groins dissected and +ve unilateral nodes – ipsilateral groin
          nodes and pelvic nodes treated with sup and inf borders as described

Close or +ve margins with –ve Groin Nodes
   • Treat tumour bed with 2cm margin
   • Nodal areas not treated
   • Direct electrons or photons can be used

Un-dissected Groin
   • Electrons can be used as an alternative to photons. When using
      electrons it is important to use CT/MRI images to chose appropriate
      energy to cover groin nodes. AcQsim can be used

Palliative volume
Small fields to cover gross tumour and margin.

Palliative schedules
    •     6Gy weekly over 3-6 weeks
    •     10 -20 Gy / 5# / 1 week
    •     8 Gy single fraction




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Author:     A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols


                                   OVARY
Protocol under development




                           ENDOMETRIUM

Protocol under development




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                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

HEAD AND NECK CANCER
Radical Radiotherapy – should commence within 4 weeks of the date of
biopsy confirming the diagnosis

Post – Operative Radiotherapy – must commence within 6 weeks of the
date of radical surgery / resection

Palliative Radiotherapy – often requires a high biological dose in order to
achieve adequate tumour regression as patient survival may be significant
even with locally advanced disease.

Clinical Target Volume (CTV) – only macroscopic disease with 2cm margin
 •   Good performance (WHO 0-2), young patients (prognosis >3 months)
      40.5Gy / 15# 21 days
      30Gy / 6# / 2 weeks (max cord dose = 27Gy / 6#)
      30Gy / 10#/ 2 weeks
 •   Poor performance (WHO 3-4), elderly, frail patients (prognosis <3
     months)
     Consider carefully whether radiotherapy is indicated.

Dose Prescriptions:
Computed volumes
 • To ICRU reference point or reference isodose (homogeneity within +/-
    5%)
 • ICRU reports 50 (1993) and 62 (1999)

Anterior neck fields only
 • An applied dose using 5/6 MV photons with midline shielding to cord
 • If significant lymphadenopathy in lower neck use AP opposing fields

Non-Computed Opposing Fields
 • Palliative treatment
 • Mid plane dose

Shielding
 • Consider all appropriate shielding requirements




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Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

                             OROPHARYNX
BUCCAL MUCOSA
T1 and T2
 • Radical radiotherapy or surgery
 • 2 phases maybe used to include prophylactic irradiation of 1st station
nodes (levels I &II)

T3 and T4
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
palliative radiotherapy

Techniques
Isocentric wedge pair – depending upon nodal status a half anterior split
field may be added
Isocentric lateral opposed pair – depending upon nodal status an anterior
split field may be added

Treatment Volume:
Isocentric wedge pair fields Phase 1 treatment volume
Superior –2.0 cm above tumour or 1.0 cm beyond graft
Inferior – hyoid
Medially – depends upon extent of tumour
Anteriorly – 2.0 cm above tumour or 1.0 cm beyond graft
Posteriorly – to include spinous process of C2.

Isocentric parallel opposed fields Phase 1 treatment volume
Superior –2.0 cm above tumour or 1.0 cm beyond graft
Inferior – hyoid
Anteriorly – 2.0 cm above tumour or 1.0 cm beyond graft
Posteriorly – to include spinous process of C2.

If nodes present add anterior split
Superior – to match lower border of lateral fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicle
Medial – lateral edge of vertebral bodies

If nodes present – Phase 2 treatment volume
Reduced off cord.
Add electron adjacent fields to boost area overlying cord.

Treatment Schedule
 •   50-55 Gy / 20# / 4 weeks
 •   Total – 63 Gy / 30# / 6 weeks
              Phase 1 – 42 Gy / 20#
              Phase 2 – 21 Gy / 10#
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Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

 •   Total – 66-70 Gy / 33-35# / 6-7 weeks
              Phase 1 – 44-46 Gy / 22-23#
              Phase 2 – 16-24 Gy / 8-12#
 •    Post RT to a total dose of 60-64 Gy / 30-32# / 6 weeks in one or two
      phases
 •   Anterior split field – 50 Gy / 25# / 5 weeks
                             40.5 Gy / 15# / 3 weeks
 •   Post boost off spinal cord–
                              10 Gy / 5# (non-involved contralateral neck +ve)
                              16 Gy / 8# (involved ipsilateral neck +ve)
                              16 Gy electrons / 8# (bilateral neck +ve)



FLOOR OF MOUTH

T1 and T2, N0
 • Early tumours usually treated with surgery
 • Indications for RT would be diffuse superficial tumours or patient refused
surgery
 • If lesion 1cm clear of midline
 • 2 phases maybe used to include prophylactic irradiation of 1st station
nodes (levels I &II)

T3 and T4
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
palliative radiotherapy

Techniques
Isocentric lateral opposed pair – For lesions at or crossing midline.
Depending upon disease extent an anterior split field may be added

Treatment Volume
Phase 1 treatment volume
Superior – through mouth bite
Inferior – hyoid
Anteriorly – to include palpable disease with a 2cm margin
Posteriorly – to include anterior 2/3rds of vertebral bodies or to include
spinous process of C2

If nodes present add anterior split field
Superior – to match lower border of lateral fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles

If nodes present phase 2 treatment volume:

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Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                         2007
Quality Procedure                                                       Radiotherapy Protocols

Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Treatment Schedule
 •   Total – 50-55 Gy / 20# / 4 weeks.
 •   Total – 66-70 Gy / 33-35# / 6-7 weeks.
              Phase 1 – 44-46 Gy / 22-23#.
              Phase 2 – 20-24 Gy / 10-13#

 •    Post RT to a total dose of 60-64 Gy / 30-32# / 6 weeks in one or two
      phases

 •   Anterior split field –50 Gy / 25# / 5 weeks
                           40.5 Gy / 15# / 3 weeks.
 •   Post Electron Boost – 10 Gy / 5# (non-involved contralateral neck +ve)
                           16 Gy / 8# (involved ipsilateral neck +ve)


BASE OF TONGUE
T1 and T2
 • Radical radiotherapy
 • 2 phases are used to include prophylactic irradiation of 1st station nodes
     (levels I &II)

T3 and T4
 • When operable, combined surgery and post-op radiotherapy (consider
     chemoradiation in suitable cases)
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy

Techniques
Isocentric lateral opposed pair – depending upon disease extent an anterior
split field may be added

Treatment Volume
Phase 1 treatment volume
Superior – 1cm above base of tongue
Inferior – level of glottis
Anteriorly – to include faucial pillar and a portion of oral tongue
Posteriorly – to include spinous process of C2.

If nodes present add anterior split field
Superior – to match lower border of lateral fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles


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Author:    A Melbourne        Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

If nodes present phase 2 treatment volume:
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Treatment Schedule
 • 50-55 Gy / 20# / 4 weeks
 • Total – 63 Gy / 30# / 6 weeks.
         o Phase 1 – 42 Gy / 20#.
         o Phase 2 – 21 Gy / 10#.
 • Total – 66-70 Gy / 33-35# / 6-7 weeks.
         o Phase 1 – 44-46 Gy / 22-23#.
         o Phase 2 – 20-26 Gy / 10-13#.
 • Anterior split field – 50 Gy / 25# / 5 weeks
                          40.5 Gy / 15# / 3 weeks.
 • Post Electron Boost – 10 Gy / 5# (if neck –ve)
                          16 Gy / 8# (involved ipsilateral neck +ve)



ORAL TONGUE

T1 and T2, N0
 • Early tumours usually treated with surgery
 • Indications for RT would be diffuse tumours or patient refused surgery
 • If lesion 1cm clear of midline
 • 2 phases are used to include prophylactic irradiation of 1st station nodes
     (levels I &II)

T3 and T4
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy

A mouth bite may be used to spare the hard palate, but care must be taken to
ensure that the posterior tongue base does not bulge above it.

Techniques
Isocentric lateral opposed pair – depending upon nodal status an anterior
split field may be added
Isocentric right-angled wedge pair – depending upon nodal status a half
anterior split field may be added

Treatment Volume

Phase 1 treatment volume
Superior – 1.5cm above dorsum of tongue, sparing hard palate if possible
Inferior – vallecula

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Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

Anteriorly – to include palpable disease with a 2cm margin
Posteriorly – to mid vertebral unless node +ve when it should include
spinous process of C2.
If nodes present add anterior split field
Superior – to match lower border of lateral fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles
Medial – lateral edge of vertebral bodies

If nodes present phase 2 treatment volume:
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Treatment Schedule
 •   55Gy / 20# / 4 weeks
 •   Total – 60-70 Gy / 30-35# / 6-7 weeks.
           o Phase 1 – 44-46 Gy / 22-23#.
           o Phase 2 – 16-24 Gy / 8-12#.
 •   Anterior split field – 50 Gy / 25# / 5 weeks
                            40.5 Gy / 15# / 3 weeks.
 •   Post Electron Boost – 10 Gy / 5#.
                            16 Gy / 8#.



                                   LARYNX

GLOTTIC LARYNX
For the purposes of this protocol a glottic larynx tumour is defined as tumour
limited to the true vocal cords and 5mm below true vocal cords.

T1 and T2
 • Radical radiotherapy

T3
 • Always check airway and discuss role of surgery
 • Radical radiotherapy

T4
 • When operable, combined surgery and post-op radiotherapy using
   coronal fields if excision margins are close (<5mm) or positive or in the
   event of nodal disease
 • When inoperable, consider chemo-radiation, radical radiotherapy or
   palliative radiotherapy

Techniques
Isocentric lateral opposed fields
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Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

Anterior oblique fields – For patients with a short neck
Isocentric superior oblique fields. (Compensators would be used.)
NB – If the anterior commissure is involved, a 1cm thick strip of bolus should
be added to the front of the cast.


Treatment Volume
T1 or T2
Superior – hyoid bone
Inferior – 1cm below cricoid
Anteriorly – to clear the front of the cast
Posteriorly – the front of the vertebral bodies or to include the anterior 1/3 of
the vertebral bodies (dependent upon Consultant or if lesion is involving
posterior cord).

T3 orT
Superior – Arch of atlas
Inferior – root of neck
Anteriorly – as for T1 / T2
Posteriorly – posterior to vertebral bodies or spinous process

Treatment Schedule
Small volume
 • 55Gy / 20# / 4 weeks

Large volume
 • Total – 65 Gy / 30# / 6 weeks.
         o Phase 1 – 43 Gy / 20#.
         o Phase 2 – 22 Gy / 10#.
 • Total – 66-70 Gy / 33-35# / 6.5-7 weeks.
         o Phase 1 – 44 Gy / 22#.
         o Phase 2 – 22 Gy / 11#.
 • Post Electron Boost – 10 Gy / 5#.
                          16 Gy / 8# (involved ipsilateral neck +ve)


SUBGLOTTIC

T1 and T2 N0
 • Radical radiotherapy
 • 2 phases are used to include prophylactic irradiation of 1st station nodes
     (levels III & IV)

T3 and T4 Node +ve
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy
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Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols


Techniques
The technique is dependent upon the position of the lower border.
• Isocentric lateral opposed fields.
• Isocentric superior oblique fields. (Compensators would be used.)

Treatment Volume
Phase 1 treatment volume
Superior – 2cm above C1/C2 junction
Inferior – to include stoma or 1cm below SSN or 2cm margin and lower
cervical nodes (levels II & IV)
Anteriorly – to clear the front of the cast
Posteriorly – if nodes are present include spinous process of C2. If nodes –
ve, posterior border lies in front of the vertebral bodies.

If nodes present add anterior split field
Superior – to match lower border of lateral fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles

If nodes present phase 2 treatment volume:
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Treatment Schedule
 •   Total – 63 Gy / 30# / 6 weeks.
           o Phase 1 – 42 Gy / 20#.
           o Phase 2 – 21 Gy / 10#.
 •   Total – 65 Gy / 30# / 6 weeks.
           o Phase 1 – 41 Gy / 19#.
           o Phase 2 – 24 Gy / 11#.
 •   Total – 66-70 Gy / 33-35# / 6.5-7 weeks.
           o Phase 1 – 44 Gy / 22#.
           o Phase 2 – 22 Gy / 11#.
 •   Anterior split field – 50 Gy / 25# / 5 weeks
                            40.5 Gy / 15# / 3 weeks.
 •   Adjacent field dose (post neck off spinal cord)
                            10 Gy / 5#.
                            16 Gy / 8#.




Issue Date: 13-Aug-10     Page 35 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

SUPRAGLOTTIC LARYNX
T1 and T2 N0
 • Radical radiotherapy
 • 2 phases are used to include prophylactic irradiation of 1st station nodes
     (levels II & III)

T1 and T2 Node +ve
 • Small volume primary tumours and macroscopic disease may be treated
    by neck dissection and post-op RT, including the ipsilateral posterior
    triangle

T3 and T4
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy
Techniques
Isocentric lateral opposed fields pair – depending upon disease extent an
anterior split field may be added
Isocentric superior oblique fields – compensators would be used

Treatment Volume
Phase 1 treatment volume:

Superior – 2cm above C1/C2 junction
Inferior – lower border of cricoid or root of neck along clavicle
Anteriorly – to clear the front of the cast
Posteriorly – if nodes are present include spinous process of C2. If node-ve,
post. Border lies in front of the vertebral bodies.

If nodes present and using lateral fields add anterior split field
Superior – to match lower border of upper fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles

Phase 2 treatment volume if nodes present
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.
Treatment Schedule
 • Total – 63 Gy / 30# / 6 weeks.
          o Phase 1 – 42 Gy / 20#.
 • Phase 2 – 21 Gy / 10#.Total – 64 Gy / 32# / 6.5 weeks.
          o Phase 1 – 56 Gy / 28#.
          o Phase 2 – 8 Gy / 4#.
 • Total – 65 Gy / 30# / 6 weeks.
          o Phase 1 – 43 Gy / 20#.
          o Phase 2 – 22 Gy / 10#.
 • Total – 66 Gy / 33# / 6.5 weeks.

Issue Date: 13-Aug-10    Page 36 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

          o Phase 1 – 44 Gy / 22#.
          o Phase 2 – 22 Gy / 11#.
 •   Anterior split field – 50 Gy / 25# / 5 weeks
 •   Post Electron Boost – 10 Gy / 5#:16 Gy / 8#.




Issue Date: 13-Aug-10    Page 37 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

                         LOWER ALVEOLUS
T1 and T2
 • Radical radiotherapy
 • 2 phases maybe used to include prophylactic irradiation of 1st station
     nodes (levels I &II)

T3 and T4
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy

Techniques
Isocentric right-angled wedge pair – depending upon nodal status a half
anterior split field may be added
Isocentric lateral/anterior oblique wedge pair- depending upon nodal
status a half anterior split field may be added

Treatment Volume
Phase 1 treatment volume
Superior – 1.5 cm above tumour. For larger lesions, the pterygoids should be
covered
Inferior – hyoid
Anteriorly – symphysis
Posteriorly – to include spinous process of C2.

If nodes present add half anterior split field
Superior – to match lower border of lateral fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles
Medial – lateral edge of vertebral bodies

If nodes present phase 2 treatment volume:
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Treatment Schedule
 •   55 Gy / 20# / 4 weeks
 •   Total – 60-70 Gy / 30-35# / 6-7 weeks.
           o Phase 1 – 44-46 Gy / 22-23#.
           o Phase 2 – 16-24 Gy / 8-12#.
 •   Anterior split field – 50 Gy / 25# / 5 weeks
                            40.5 Gy / 15# / 3 weeks.
 •   Adjacent field dose (post neck off spinal cord)
                            10 Gy / 5#.
                            16 Gy / 8#.


Issue Date: 13-Aug-10     Page 38 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols


                            NASOPHARYNX
Techniques
Chemo-radiation – used for stage III / IV patients (1987 UICC) using the
Intergroup regime
Isocentric lateral opposed pair – depending upon disease extent an anterior
split field may be added. CT planned ph 2 if parapharyngeal extension
Offset 4 fields – 2 laterals, anterior and posterior fields for tumours involving
both the nasopharynx and the lower neck.

Treatment Volume
Phase 1 treatment volume
Superior – base of skull / above the clinoids
Inferior – bottom of C6
Anteriorly – posterior orbits
Posteriorly – to include spinous process of C2.

If nodes present add anterior split field
Superior – to match lower border of lateral fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles
NB – If positive nodes in the lower neck use anterior/posterior fields

If nodes present phase 2 treatment volume:
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Treatment Schedules
 •   Total - 64 – 70 Gy / 32-35# / 6.5-7 weeks
          o Phase 1 – 44-46Gy / 22-23#
          o Phase 2 – 20-24Gy / 10-12#
 •   Anterior split field – 50 Gy / 25# / 5 weeks
                            40.5 Gy / 15# / 3 weeks
                            60Gy / 30# / 6 weeks
 •   Post Electron Boost – 10 Gy / 5#.
                            16 Gy / 8# (involved ipsilateral neck +ve)




Issue Date: 13-Aug-10     Page 39 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

                           PAROTID GLAND

Post-Op RT is indicated for high grade carcinomas even where there has
been complete surgical excision and for recurrent pleomorphic adenoma

Inoperable Disease consider chemo-radiation, radical radiotherapy or
palliative radiotherapy

Techniques
Isocentric right-angled wedge pair – depending upon nodal status a half
anterior split field may be added
Isocentric anterior and posterior oblique wedge pair- depending upon
nodal status a half anterior split field may be added
NB Care must be taken to avoid exit of the posterior oblique field through the
contralateral eye.

Treatment Volume
Superior – zygomatic arch or 2cm above most superior extent of disease
(must be inferior to the eyes)
 Inferior – hyoid or 1cm inferior to the mandible
Anteriorly – anterior border of the masseter muscle
Posteriorly – through the mastoid process
Medially – the lateral pharyngeal wall or 2cm beyond the medial extent of the
tumour

If nodes present add anterior split field
Superior – to match lower border of lateral fields
Inferior –   to include heads of the clavicles
Lateral –    to include medial 2/3rds of clavicles
Medial –      lateral edge of vertebral bodies

If nodes present phase 2 treatment volume:
Reduced off cord.

Treatment Schedule

 •   Total – 66-70 Gy / 33-35# / 6-7 weeks.
           o Phase 1 – 44-46 Gy / 22-23#.
           o Phase 2 – 20-26 Gy / 10-13#.
 •   Anterior split field – 50 Gy / 25# / 5 weeks
                            40.5 Gy / 15# / 3 weeks.




Issue Date: 13-Aug-10     Page 40 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                      2007
Quality Procedure                                                    Radiotherapy Protocols

                           PYRIFORM FOSSA
T1 and T2 N0
 • Radical radiotherapy or surgery
 • 2 phases are used to include prophylactic irradiation of 1st station nodes
     (levels II &III)
T1 and T2 Node +ve
 • Small volume primary tumours and macroscopic disease may be treated
     by neck dissection and post-op RT, inc. the ipsilateral posterior triangle
T3 and T4
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy

Techniques
NB The technique is dependent upon the position of the lower border. If the
supraclavicular fossa needs treating, superior oblique fields should be used.
• Isocentric lateral opposed fields
• Isocentric superior oblique fields. (Compensators would be used.)

Treatment Volume
Small Treatment volume:
Superior – angle of jaw
Inferior – 1cm below cricoid cartilage
Anteriorly – to clear neck
Posteriorly – to lie in front of the spinal cord.

Large Treatment Volume:
Phase 1:Superior – 2cm above C1/C2 junction
Inferior – to include stoma or 1cm below SSN or root of neck – must be at
least 2cm below cricoid cartilage
Anteriorly – to clear the front of the cast
Posteriorly – if nodes are present include spinous process of C2. If no nodes,
post. Border is to lie in front of the vertebral bodies.

Phase 2 volume if nodes present
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Treatment Schedule
 • Total – 65 Gy / 30# / 6 weeks.
         o Phase 1 – 43 Gy / 20#.
         o Phase 2 – 22 Gy / 120#.
 • Total – 66-70 Gy / 33-35# / 6-7 weeks.
         o Phase 1 – 44-46 Gy / 22-23#.
         o Phase 2 – 20-26 Gy / 10-13#.
 • Post Electron Boost – 10 Gy / 5#; 16 Gy / 8#.
 • Post RT 60-64 Gy / 30-32# / 6.5 weeks in one or two phases
Issue Date: 13-Aug-10      Page 41 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                  Protocol.doc
Author:    A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                      2007
Quality Procedure                                                    Radiotherapy Protocols

                         RETROMOLAR TRIGONE
T1 and T2
 • Radical radiotherapy
 • 2 phases maybe used to include prophylactic irradiation of 1st station
     nodes (levels I &II)

T3 and T4
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy

Techniques
Isocentric right-angled wedge pair – depending upon nodal status a half
anterior split field may be added
Isocentric ipsilateral oblique fields – depending upon nodal status a half
anterior split field may be added

Treatment Volume
The CTV must extend superiorly to include the mandibular ramus because of
the high risk of microscopic spread. The temporomandibular joint should be
avoided if possible to minimise the risk of trismus.
Superior – temporomandibular junction
Inferior – hyoid
Anteriorly – masseter muscle
Posteriorly – mid vertebral body

If nodes present add half anterior split field
Superior – to match lower border of upper fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles
Medial – lateral edge of vertebral bodies

Treatment Schedule
 •   55 Gy / 20# / 4 weeks.
 •   Total – 66 Gy / 33# / 6.5 weeks.
           o Phase 1 – 44 Gy / 22#.
           o Phase 2 – 22 Gy / 11#.
 •   Half anterior split field :50 Gy / 25# / 5 weeks
                                40.5 Gy / 15# / 3 weeks.
 •   Post Electron Boost : 10 Gy / 5#.
                                16 Gy / 8#.




Issue Date: 13-Aug-10      Page 42 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                  Protocol.doc
Author:    A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

                MAXILLARY SINUS/NASAL CAVITY
NB – Patients are CT planned.

Operable Disease
 • Post-op RT

Inoperable Disease
 • consider chemo-radiation, radical radiotherapy or palliative radiotherapy

Technique
Isocentric anterior and 2 lateral fields.
NB the dose is biased from the anterior field with a weighting of 2 or 3 :1
NB A mouth bite may be used to spare the tongue

Treatment Volume
Anterior Field
Superior – 1cm above cribriform plate or supraorbital ridge
Inferior – upper alveolus through mouth bite
Medial – contralateral inner canthus
Lateral – to cover gingivo-buccal sulcus.
Lateral fields
Anterior – 2cm anterior to tumour
Posterior – to include the pterygoid fossa and lateral retrophayngeal node.

Treatment Schedule
 •   Total – 64-70 Gy / 32-35# / 6.5 weeks.
           o Phase 1 – 44-46 Gy / 22-23#.
           o Phase 2 – 20-22 Gy / 10-11#
NB – dose may need to be reduced to respect tolerance of critical normal
tissues (optic nerves, chiasm and brain stem)




Issue Date: 13-Aug-10     Page 43 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

                            SOFT PALATE
T1 and T2 N0 (1cm clear of midline)
 • Radical radiotherapy
 • 2 phases maybe used to include prophylactic irradiation of 1st station
     nodes (levels I &II)

T3 and T4 N0, any tumour involving the midline
 • When operable, combined surgery and post-op radiotherapy
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy

Techniques
Isocentric lateral opposed pair – depending upon disease extent an anterior
split field may be added
Isocentric right-angled wedge pair – depending upon nodal status a half
anterior split field may be added

Treatment Volume
Lateral fields Phase 1 treatment volume:
Superior – zygomatic arch
Inferior – hyoid
Anteriorly – 2cm anterior to tumour
Posteriorly – spinous process of C2.

Phase 2 treatment volume if nodes present
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Wedge Pair Phase 1 treatment volume:
Superior – zygomatic arch
Inferior – hyoid
Anteriorly – 2cm anterior to tumour
Posteriorly – centre of vertebral bodies
Medially – midline to 2cm beyond midline

Phase 2 treatment volume:
Primary disease only

If nodes present add anterior split field
Superior – to match lower border of upper fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles
Medial – lateral edge of vertebral bodies




Issue Date: 13-Aug-10    Page 44 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

Treatment Schedule
 • 50 – 55Gy / 20# / 4 weeks
 • Total – 63 Gy / 30# / 6 weeks.
         o Phase 1 – 42 Gy / 20#.
         o Phase 2 – 21 Gy / 10#.
 • Total – 66 Gy / 33# / 6.5 weeks.
         o Phase 1 – 44 Gy / 22#.
         o Phase 2 – 22 Gy / 11#.
 • Anterior split field – 50 Gy / 25# / 5 weeks
                          40.5 Gy / 15# / 3 weeks.
 • Post Electron Boost – 10 Gy / 5#.
                          16 Gy / 8#.




Issue Date: 13-Aug-10    Page 45 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                      2007
Quality Procedure                                                    Radiotherapy Protocols

                                    TONSIL
T1 and T2 N0/N1
 • Lateralised (1cm clear of midline if soft palate involved), node –ve
     tumours without evidence of base of tongue involvement
 • Use Ipsilateral wedge pair
 • 2 phases may be used to include prophylactic irradiation of 1st station
     nodes (levels I &II)

T1 and T2 N2/N3
  • There is a significant risk of bilateral nodal spread and base of tongue
involvement when ipsilateral nodes are involved.
  • Use lateral opposed fields
  • 2 phases maybe used to include prophylactic irradiation of 1st station
      nodes (levels I &II)

T3 and T4 N0, N+ve
 • When operable, combined surgery and post-op radiotherapy (consider
     chemoradiation in suitable cases)
 • When inoperable, consider chemo-radiation, radical radiotherapy or
     palliative radiotherapy

Techniques
Isocentric lateral opposed pair – depending upon disease extent an anterior
split field may be added
Isocentric anterior and posterior oblique wedge pair – depending upon
nodal status a half anterior split field may be added

Treatment Volume
Wedge pair Phase I treatment volume
Superior – top of the hard palate
Inferior – bottom of the hyoid bone
Anteriorly – middle 1/3rd of the tongue
Posteriorly – just in front of the spinal cord.
Medially – midline of palate

Phase 2 treatment volume:
Primary disease only

Lateral opposed fields Phase I treatment volume
Superior – top of the hard palate
Inferior – bottom of the hyoid bone
Anteriorly – middle 1/3rd of the tongue
Posteriorly – to include spinous process of C2.

Phase 2 treatment volume if nodes present
Reduced off cord.
Electron adjacent fields may be used depending upon nodal disease status.

Issue Date: 13-Aug-10      Page 46 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                  Protocol.doc
Author:    A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols

If nodes present add anterior split field
Superior – to match lower border of upper fields
Inferior – to include heads of the clavicles
Lateral – to include medial 2/3rds of clavicles
Medial – lateral edge of vertebral bodies

Treatment Schedule

Large volume
 • Total – 63 Gy / 30# / 6 weeks.
         o Phase 1 – 42 Gy / 20#.
         o Phase 2 – 21 Gy / 10#.
 • Total – 66 Gy / 33# / 6.5 weeks.
         o Phase 1 – 44 Gy / 22#.
         o Phase 2 – 22 Gy / 11#.
 • Anterior split field – 50 Gy / 25# / 5 weeks
                          40.5 Gy / 15# / 3 weeks.
 • Post Electron Boost – 10 Gy / 5#.
                          16 Gy / 8#.




Issue Date: 13-Aug-10    Page 47 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                      2007
Quality Procedure                                                    Radiotherapy Protocols

                                   THYROID
N.B Eye disease see ‘Orbital tumours’
Techniques
 • Isocentric anterior oblique wedge pair
 • Isocentric anterior and posterior opposed fields
 • Consider use of 2:1 weighting ant/post

Treatment Volume
Anterior Oblique Fields
Superior – mastoid tip
Inferior – Carina
Posterior – anterior to spinal cord

Anterior and Posterior Opposed Fields
Phase 1
Superior – mastoid tip
Inferior – carina
Lateral – medial 2/3rds of clavicle

Phase 2
A more localised volume to bulk disease

Treatment Schedule
 • 50Gy / 20# / 4 weeks
 • Total – 60–64Gy / 30-32# / 6.5 weeks in one or two phases


                         CERVICAL OESOPHAGUS
NB – Patients are CT planned.
Usually chemo-radiation unless post –op.
Techniques
 • Isocentric anterior oblique fields
 • Isocentric anterior and posterior fields (phase 1) with isocentric anterior
    oblique fields (phase 2)
 • Compensators or a double wedge would be used with the anterior
    oblique fields

Treatment volume
 • Is dependant upon EUA findings and MRI scans with an adequate
     margin.

Treatment Schedule
 • 44Gy / 22# / 4.5 weeks
 • 22Gy / 11# / 2.2 weeks
 • Total – 60-64Gy / 30-32# / 6 weeks
   o Phase 1 – 40-46 Gy / 20 – 23#

Issue Date: 13-Aug-10      Page 48 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                  Protocol.doc
Author:    A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                      2007
Quality Procedure                                                    Radiotherapy Protocols

    o Phase 2 – 18-20 Gy / 9-10#
                         SKIN (NON-MELANOMA)
Wherever possible, patients should be treated with orthovoltage equipment. It
is accepted that some tumours may be more appropriately treated with
electrons or a combination of electrons and x-rays.
Most tumours can be treated with 80kv employing filter 5 on MVX. Higher
energies may be necessary for the thicker tumours. Large tumours or those
with an irregular shape may require a purpose-built lead cut-out. An internal
eye shield is necessary for treatment of eyelid tumours. Suitable lead
shielding is available for nostrils, ears and previously irradiated areas, if
needed.

Treatment Volume
 • To include lesion with a 1cm margin
 • NB – volume increased when treating with electrons due to penumbra
 • NB – lesions below the knee should be treated with electrons

Treatment Schedule
 • 35Gy / 5# / 5 days
 • 45Gy / 10# / 12 days
 • 50Gy / 15#I / 19 days
 • 30Gy / 3# / 15 days (0-7-14)
 • 28Gy / 2# / 42 days
                           SKIN (MELANOMA)

Lentigo Maligna
Radiotherapy may be used for this, when surgery is not possible :

Schedule :
55Gy / 15 # using MVX
This requires prior mould room prep.

Malignant Melanoma metastatic to nodes
Use RT only if there is EXTRA capsular extension
Treatment Volume
PTV: to include the next eschelon of nodesto a radical dose
   o 45-50 Gy / 20-25 # Daily on Megavoltage

Melanoma Metastases
Use standard skin technique and dose appropriate for site

                         MERKEL CELL TUMOUR
Protocol under development




Issue Date: 13-Aug-10      Page 49 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                  Protocol.doc
Author:    A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                      2007
Quality Procedure                                                    Radiotherapy Protocols

GLIOMA (ASTROCYTOMA & OLIGODENDROGLIOMA)
Low Grade: (Grade I and II)

Techniques – CT plan + MR fusion. Planned non-coplanar fields.

Treatment Volumes
GTV = Tumour
PTV = 2cm Margin on GTV
Single phase avoiding critical structures if possible
If not possible consider minimising dose by using 2 phases

Critical Stuctures
Eyes; Optic Nerves and chiasm; Pituitary; Brain stem

Treatment Schedule Options
 • 54 / 30# /6 weeks - depending on prognostic factors e.g. Bulk; Age

High Grade: (Grade III and IV)
GOOD PROGNOSIS (based on age and performance status)
If age < 70 and PS 0-2 and GBM for concurrent temozolomide

Techniques – Perspex shell. CT plan (+MR fusion if not well visualised on
CT) Planned fields.

Treatment Volume
Single phase – GTV = enhancing lesion
             PTV = GTV + 2 – 3cm margin

Treatment Schedule Options
   • 60Gy / 30# / 6 weeks
   • Retreat 50Gy / 30 # / 6 weeks

POOR PROGNOSIS
Techniques
Suitable for Cobalt and orfit fixation.
Sim planned. Lateral opposed fields

Treatment Volume
Partial brain or simple plan to cover tumour with 2-3 cms margin

Treatment Schedule Options
   • 45Gy / 20# / 4 weeks
   • 30Gy/ 10# / 2 weeks for poorer prognosis elderly patients




Issue Date: 13-Aug-10      Page 50 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                  Protocol.doc
Author:    A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols


                         OPTIC NERVE GLIOMA

Protocol under development




                              GERMINOMA

Technique
    o Localised – cranial irradiation
    o Leptomeningeal dissemination – primary chemo and whole CNS axis
      RT
    o Use planning MR scan

Localised
  o Phase I – PTV – ventricular system plus primary, with 3cm margin.
      30.6 Gy / 17# / 3.5 weeks
  o Phase II – GTV – primary tumour
                   PTV /GTV +2cm
                   19.8 Gy / 11# / 2.1 weeks

Leptomeningeal dissemination (see Buckner JCO 1999)
  o Initial chemo cisplatin/etoposide 4 cycles
  o RT depending on response
         o If complete response –      CSA RT 19.8 Gy / 11# / 2.1 weeks
                                       Local boost 10.8 Gy / 6# / 1.1 weeks
         o In less than CR – CSA RT 30.6 / 17# / 3.2 weeks
                                       Local boost 23.4 Gy / 13# / 2.5
                                       weeks (but consider spinal cord
                                       tolerance)




Issue Date: 13-Aug-10     Page 51 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                      2007
Quality Procedure                                                    Radiotherapy Protocols


                        PRIMARY CNS LYMPHOMA
4 weeks post 6 weeks MACOP-B Chemotherapy

Techniques
   • Lateral opposed fields to ‘Helmet’ only
   • Whole CNS if positive cytology or spinal disease

Treatment Volumes
   • Helmet – whole head down to C2 (optional phase II boost if primary
      seen to be localised)
   • Whole CNS standard technique

Treatment Schedule
   • Phase I (helmet) – 45Gy / 25# / 5 weeks
     Phase II (primary lesion + 2cm margin) – 9Gy / 5# / 1 week
   • Whole CNS - 35Gy / 21#
                   posterior fossa boost – 20Gy / 12# / 2.5 weeks




Issue Date: 13-Aug-10      Page 52 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                  Protocol.doc
Author:    A Melbourne     Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols


                             EPENDYMOMA

Techniques
   • Localised: AcQSIM + MR fusion. Planned non-coplanar fields.
   • Whole CNS

Treatment Volume
   • For stages I-IV supratentorial – PTV = tumour (GTV) + 2cm margin
   • For disseminated and stage III and infratentorial – whole CNS (see
      above)

Treatment Schedule
Local RT – 54 – 60Gy / 30# / 6 weeks
Whole CNS - Phase I – 35Gy / 21# / 3.5 weeks
              Phase II – Posterior fossa boost – 20Gy / 12# / 2.5 weeks.




                                PITUITARY

Techniques
Head fix stereotactic frame (or shell if not dentate)
Planning MRI + CT plan image registration

Treatment Volumes
GTV = Tumour
PTV = GTV + 7.5 mms (if stereotactic frame)
           +10 mm (if shell)

Treatment Schedule
      • 45Gy/ 25# / 5 weeks




Issue Date: 13-Aug-10     Page 53 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols


                         ACOUSTIC NEUROMA
Micro surgery, and stereotactic conformal radiotherapy may be considered for
all tumours which have been shown to progress.
For small tumours (< or = 30mm maximum extra canalicular diameter)
microsurgery and stereotactic radiosurgery are options.

Stereotactic Radiosurgery
• Leibinger frame
• MRI planning with image registration
• GTV – visible tumour
• PTV – visible tumour + 1mm ( but not extending into brain stem)
• Dose – 12.5 Gy / 1# (at 80%)

Stereotactic Conformal Radiotherapy

Fixation – Small tumour (< or = 30mm) Radionics Frame
large tumour (>30mm) – Headfix frame
Shell if relocatable frame not possible

Planning - MRI and image registration
GTV – gross tumour
PTV – Radionics frame GTV + 5mm
     - Headfix frame GTV + 7.5 mm
     - Shell GTV + 10mm
Dose – 54 Gy / 30# / 6 week


                              MENINGIOMA
Techniques – stereotactic frame or shell depending on intended treatment
volume and patients dental condition

Treatment Volumes
GTV = Tumour
PTV = GTV Radionics Frame + 5mm Margin
             Headfix Frame +7.5mm margin
             Shell +10mm margin
Single phase avoiding critical structures if possible + 10mm

Critical Stuctures
Eyes; Optic Nerves and chiasm; Pituitary; Brain stem

Treatment Schedule Options
Benign: 54Gy / 30# / 6 weeks

Atypical/Malignant: 60Gy / 30# /6 weeks (if optic nerve / chiasm not
involved)
Issue Date: 13-Aug-10     Page 54 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

          MALIGNANT SPINAL CORD COMPRESSION
Treat extradural disease – visualise on MRI + 2 vertebral bodies

Dose
Poor prognosis – for pain relief – 8Gy / 1#
Other – 20 Gy / 5# / 5 days
     - 30 Gy / 10# / 2 weeks
Prescribe at 5-8cm depending on particular level in cord (cervical – lumbar)



                         BRAIN METASTASES
Whole Brain
  o Orofit and cobalt
Schedule
  o 20Gy / 5# / 5 days
  o 30 Gy / 10# / 2 weeks
  o 12Gy / 2 # / 1week


Prophylactiic Cranial Irradiation (PCI)
See: Small cell lung cancer



Stereotactic Radiosurgery
For single or limited number of metastases each </= 3cm max diameter, and
surgery not appropriate and systemic disease controlled or potentially
controllable.
   o Radionics frame
   o Planning MRI with image registration
   o Varian collimator
   o GTV – enhancing disease
   o PTV – GTV +2mm
Dose
   o 15-17.5 Gy / 1#




                         CRANIOPHARYNGIOMA
Protocol under development


Issue Date: 13-Aug-10     Page 55 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols


                         ORBITAL TUMOURS
THYROID EYE DISEASE

Techniques
   • CT Planning
   • Parallel opposed field with central blocking to avoid lens

Treatment Schedule
   • 20Gy / 10 # / 2 weeks

PROTON THERAPY
This specialised treatment not included within the scope of this protocol book




Issue Date: 13-Aug-10     Page 56 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                     2007
Quality Procedure                                                   Radiotherapy Protocols

          HODGKINS / NON-HODGKINS LYMPHOMA
Techniques
Involved field
Mantle technique
Inverted Y

Treatment Volume
Involved field
Treating the involved nodes with a 5cm margin.
Mantle
Superior border – lower ear junction
Lower border – T10-11 junction NB if mediastinal nodes present then include
L1
Lateral borders – to cover axillae
Inverted Y
Superior border – top of T10
Para-aortic width – 9cm wide
Pelvic field width – extended at the level of L4/5 to cover any nodes
Lower border – approx. at the bottom of the obturators


Treatment Schedule
General: 35Gy / 20# / 4 weeks
NHL Site specific:
   o Neck 36Gy / 20 #
   o Abdomen 26Gy / 10 #
   o Paraaortics 26Gy / 13 #
   o Stomach 20Gy / 10 #
   o Orbit 30Gy / 20 #
   o Neck/Sup mediastinum 45Gy / 25 #
A boost may be necessary
A shorter schedule may be used for palliation



                                   SPLEEN

                         Protocol under development




Issue Date: 13-Aug-10     Page 57 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                 Protocol.doc
Author:    A Melbourne    Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                       2007
Quality Procedure                                                     Radiotherapy Protocols

                        PAEDIATRIC MALIGNANCIES



All paediatric patients are enrolled into UKCCCR protocols.

Please refer to individual tumour site protocol




Issue Date: 13-Aug-10       Page 58 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                   Protocol.doc
Author:    A Melbourne      Authorised by:   Dr B J Haylock                        Copy No:
CCO, Radiotherapy Quality System                                                    2007
Quality Procedure                                                  Radiotherapy Protocols


                         BONE METASTASES

SIMPLE PALLIATION:

    o Rib metastases; Consider direct field HVX 8Gy single #
    o Deeper lesions ; Consider cobalt direct field
                          8 Gy single or 20Gy / 5 # / 1 week
    o Scattered lesions: Consider hemibody
                          Upper: 6Gy single
                          Lower: 8 Gy single




Issue Date: 13-Aug-10    Page 59 of 59          Filename:    CCO Radiotherapy   Issue No: 1.2
                                                Protocol.doc
Author:    A Melbourne   Authorised by:   Dr B J Haylock                        Copy No:

				
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