onc brain

ESTRO-convened multi-disciplinary expert group developing delineation guidelines through discussion and review of current evidence and international practice. Drafts were reviewed by HNSCC experts from countries outside the authorship (Japan, Hong Kong, Australia, Brazil, Mexico, Canada, Denmark, France, Spain, Poland, Ireland, UK) and modified on their feedback. No efficacy endpoint, no patient cohort.

Patients with oral cavity squamous cell carcinoma requiring post-operative radiotherapy, regardless of margin status and other histological risk factors. R2 resection (macroscopic residual disease) is explicitly out of scope. Companion background manuscript from the same group covers indications for PORT.

Planning CT 2.0 mm slices (range 1-3 mm), skull base to below sterno-clavicular joint, IV contrast mandatory, rigid co-registration with pre-op contrast-enhanced CT and/or MRI matched to C1-C3 vertebral bodies or nearby bone, not to soft tissue. CTV-P is the composite of GTV-P pre-op + 10 mm and surgical defect/flap + 5 mm, edited for bone, fascia, air, teeth and any intra-oral prosthesis. Nodal margin is 5 mm on GTV-N pre-op without pENE, 10 mm with pENE.

None. The stated aim is consistency of delineation to enable multi-institutional audit, clinical trials and RTQA. Authors position prospective audits of practice and outcomes as the route to establishing these volumes as standard of care.

Extends the 2018 international CTV-P consensus for definitive HNSCC RT, whose 5+5 mm geometric expansion supplies the 10 mm used here around GTV-P pre-op. Cites the DAHANCA finding that geometric expansion is more conformal than anatomical margins, a post-hoc De-ESCALaTE analysis correlating the anatomical-to-geometric protocol change with lower late dysphagia, and non-randomised Dutch series where reducing the high-risk margin 10 mm to 6 mm cut salivary and constrictor dose. GORTEC's 2020 flap delineation guidance is named as an adjunct.

The 5 mm and 10 mm margins are imported from definitive-setting geometry and one surgical pathology series (>95 % of microscopic infiltration within 5 mm of GTV-P edge), not from post-operative recurrence mapping. The dose to dissected but uninvolved levels rests on a 1993 MD Anderson observation never tested prospectively, and is left to clinician discretion (EQD2 50-60 Gy). The whole method assumes accurate pre-op to planning CT co-registration, and the fallback where it fails is to treat the entire involved level, a larger volume.

The novel move is refusing to pick between the two available surrogates for a resected tumour: re-created pre-op GTV and operative bed are contoured independently and unioned, because each fails in a different direction. Fig 3.1 shows a GTV-P pre-op extending superiorly past the defect toward the infratemporal fossa, and Fig 8.1 a pectoralis major pedicled flap whose composite volume extends outside the oral cavity and is trimmed back. What is left unsettled is dose de-escalation to central flap tissue, where the guideline offers a flap avoidance structure for standardisation while stating there is a lack of data and consequently a lack of consensus.

ESTRO expert guideline, no efficacy endpoint. Fills a documented gap (no prior post-op HNSCC CTV consensus); authors themselves position prospective audit as the validation step.

PRISMA systematic review of PubMed and Embase (searched 28 June 2022) across four topics, excluding conference abstracts, non-English publications and series of fewer than five patients. A 12-member multidisciplinary panel of radiation oncologists, urologists and medical oncologists voted in two rounds by modified Delphi, with RAND methodology defining disagreement.

Scope is tier A disease, local-only intraprostatic radiorecurrence after definitive RT, with BCR defined as PSA 2.0 ng/ml above nadir. Evidence was restricted to men whose primary treatment was conventionally fractionated EBRT, and prior brachytherapy patients were excluded from the synthesis. Every variant presumes the patient wants curative-intent local salvage.

All accepted salvage schemas fit in six or fewer fractions. For focal salvage, GETUG-AFU 31 defines GTV by mpMRI plus choline PET with a 5-7 mm margin bound by the prostatic capsule; whole-gland salvage SBRT has prospective support from the Fuller series. Dose constraints and IGRT method are out of scope.

Long hormone courses are recommended against across all salvage scenarios. A short 4-6 mo LHRH agonist carries moderate consensus as a radiosensitizer with salvage SBRT in patients without cardiac history, weaker consensus with cardiac comorbidity, and classic ADT is preferred over novel hormonal agents.

The toxicity read that drives the reirradiation preference comes from pooled retrospective data that could not evaluate sexual toxicity and included no PSMA PET selection. Approaches that combine biopsy and ablation in one procedure are discouraged, since histologic confirmation must precede salvage.

No prior consensus guideline addressed intraprostatic radiorecurrence exclusively. The hormone-only comparators being displaced (Crook intermittent vs continuous ADT, TOAD immediate vs delayed, EMBARK enzalutamide MFS benefit) all enrolled before PET-based selection and none isolated a biopsy-confirmed, local-only cohort. RTOG 0526 reported after MASTER closed, adding prospective LDR support.

The search closed 28 June 2022 with an acknowledged lag to publication. MASTER carries between-study heterogeneity and follow-up asymmetry favoring older modalities, so its flat efficacy comparison is not a randomised one. The hormone recommendation rests on no qualifying study and is extrapolated from de novo intermediate-risk data.

Settled: image, biopsy with both systematic and targeted cores, then prefer reirradiation over hormones alone. Not settled: the modality for a second salvage, for castrate-resistant local recurrence, for short PSA doubling time, or after prior grade 3 toxicity, all of which drew panel disagreement.

Appropriate use criteria from a 12-member Delphi panel; the output is a recommendation grid, not an efficacy result. No trial endpoint, so efficacy verdicts do not apply.