2026-11-11

Myeloma / Plasma Cell

Prior RT is not a contraindication to cement augmentation; RT treats soft-tissue mass, not VCF instability.

IMWG consensus: cement augmentation for myeloma VCFs

TL;DR4-8 wk window: IMWG advises offering BKP or PV for painful myeloma VCFs, with VAS ≥6 triaging to immediate augmentation and up to 3 levels per session.

Trials discussed

CAFE

Why it mattersRadiation oncology

The RT boundary is explicit: RT shrinks a soft-tissue myelomatous mass but neither stabilises a VCF nor relieves bony neural compression, and prior RT or its dose does not contraindicate later cement. That narrows RT for painful myeloma VCFs to unresolved plasmacytoma, no systemic option, or posterior-element disease precluding BKP/PV, with marrow sparing as a stated aim.

Monday clinic

In a myeloma pt with a painful, MRI-confirmed unhealed VCF and no soft-tissue canal mass, this supports cement augmentation over RT for fracture pain; it does not apply to soft-tissue cord compression, where steroids, systemic therapy and RT come first. The longer read

11 details

Design

International Myeloma Working Group consensus statement updating the 2008 recommendations on vertebral cement augmentation in light of newer published data. No new patient data.

Radiotherapy

RT to be used judiciously and sparingly to spare marrow. Effective for a soft-tissue mass, not for bony compression, and does not stabilise the VCF. Prior RT and its dose are not contraindications to later PV or BKP.

vs leading data

CAFE is the one randomised trial cited for cancer VCFs, with only 49 MM pts. The osteoporotic sham-controlled trials (Kallmes, Buchbinder) were null for pain, which the panel attributes to excluding the sickest pts and enrolling facet-pain cases.

Discussion

Systemic therapy is framed as the most important modality, with bracing to bridge the first 1-2 cycles and augmentation if fracture pain persists. Metalwork is to be avoided where possible given failure and infection risk.

Applies to

myeloma pts with painful VCFs, with or without neurological deficit

Does not represent osteoporotic VCFs or solid-tumour spinal metastases, where the panel notes the myeloma spine may behave differently.

Limitations

VAS tiers are pragmatic triage, not validated cut points. BKP vs PV, timing relative to induction, and impending-fracture prediction are all deferred to future randomised trials.

Results

Tier	Panel position
Acute VCF, VAS ≥ 6	Immediate augmentation; TLSO brace can bridge while systemic therapy starts
Subacute, VAS 4-6	Chemo, bisphosphonate, analgesia first; augment if these fail or collapse risk rises
VAS 1-3	Watchful surveillance with periodic imaging

Open questions

BKP vs PV vs NSM head to head in myeloma VCFs
Optimal timing of augmentation relative to induction therapy
How to predict impending fracture in the myeloma spine

Sourced from Kyriakou, Charalampia et al.

📚 Sources · 📄 1 paper

📄 PAPER Kyriakou, Charalampia; Molloy, Sean; Vrionis, Frank et al. · Blood Cancer Journal (2019-02)

The role of cement augmentation with percutaneous vertebroplasty and balloon kyphoplasty for the treatment of vertebral compression fractures in multiple myeloma: a consensus statement from the International Myeloma Working Group (IMWG)

doi

Abstract

Abstract Multiple myeloma (MM) represents approximately 15% of haematological malignancies and most of the patients present with bone involvement. Focal or diffuse spinal osteolysis may result in significant morbidity by causing painful progressive vertebral compression fractures (VCFs) and deformities. Advances in the systemic treatment of myeloma have achieved high response rates and prolonged the survival significantly. Early diagnosis and management of skeletal events contribute to improving the prognosis and quality of life of MM patients. The management of patients with significant pain due to VCFs in the acute phase is not standardised. While some patients are successfully treated conservatively, and pain relief is achieved within a few weeks, a large percentage has disabling pain and morbidity and hence they are considered for surgical intervention. Balloon kyphoplasty and percutaneous vertebroplasty are minimally invasive procedures which have been shown to relieve pain and restore function. Despite increasing positive evidence for the use of these procedures, the indications, timing, efficacy, safety and their role in the treatment algorithm of myeloma spinal disease are yet to be elucidated. This paper reports an update of the consensus statement from the International Myeloma Working Group on the role of cement augmentation in myeloma patients with VCFs.

Consensus / guideline

Skin / Melanoma

Two RT guidance documents, both built on retrospective or single-institution series with no randomised surgery vs RT data.

GEC-ESTRO ACROP skin brachytherapy recommendations

TL;DRDepth sets the technique: contact BT for skin tumours <5 mm deep, interstitial for ≥5 mm or curved surfaces; no standard dose schedule endorsed.

Why it mattersRadiation oncology

The dosimetric fine print gates safety: with the Valencia applicator prescribed at 3 mm, skin surface dose runs around 135%, and omitting the plastic cap raises skin dose 2.5× (Valencia) or 10× (Leipzig). Recording surface dose, not only prescription-depth dose, is what lets late toxicity be compared across schedules.

Monday clinic

In a NMSC under 5 mm deep on a flat or small surface, this supports contact BT (mould, flap or shielded applicator) as the technique; it does not extend to lesions 5 mm or thicker or on curved facial surfaces, where interstitial implant is the stated option. The longer read

10 details

Design

GEC-ESTRO ACROP recommendation document (Radiother Oncol 2018) drawing on published series and an ABS report; no new outcome data and no formal grading of evidence stated in source.

Radiotherapy

Contact techniques prescribe to 3–5 mm (moulds/flaps) or 3–4 mm (shielded applicators); interstitial catheters sit 8–12 mm apart and at least 3 mm under the skin. Shielded applicators need at least 5 mm GTV→CTV plus 1–2 mm PTV, and a CT with surface markers is the standard for moulds and implants.

Applies to

BCC, SCC, Merkel cell and post-excision keloids treated with surface or interstitial BT, including elderly and frail pts

Does not represent eyelid lesions where function can be preserved surgically, for which surgery is the stated gold standard.

vs leading data

The anchor cited is the ABS report summarizing 19 published protocols, with local control in the 90–100% range. Head-to-head data vs surgery are limited to a nasal vestibule HDR comparison (no difference in locoregional control or survival, better function and cosmesis) and an electronic BT vs Mohs matched-pair cohort.

Limitations

Schedule grid mixes LDR, HDR and electronic sources with different gradients (8% vs 12% per mm), so totals are not interchangeable. BED is set aside for surface work because overall treatment time varies, leaving no common dose currency.

Discussion

The firm content is geometric and dosimetric; the dose content is a menu, not a ranking. Hypofractionation in frail pts is accepted at the cost of reduced cosmesis, which is the trade a reader is actually making when choosing once-weekly schedules.

Results

Technique	Indication	Prescription depth	Geometry
Surface moulds / flaps	Regular surfaces; flaps for larger volumes; custom moulds for nose, pinna, hand, fingers	3–5 mm	Source-to-skin distance 5 mm
Shielded applicators (radionuclide or electronic)	Small lesions on regular surfaces	3–4 mm	GTV→CTV at least 5 mm, plus 1–2 mm PTV
Interstitial	Thickness 5 mm or more, irregular surfaces	PTV equals CTV	Catheters 8–12 mm apart, at least 3 mm under skin

Histology	CTV margin
BCC, well defined	5 mm
BCC, poorly defined, large, infiltrative, morphoeic or sclerotic	7–10 mm
SCC <20 mm	10–15 mm
SCC >20 mm	15–20 mm
Merkel cell	20–30 mm peripheral; deep 5–10 mm below visible extension
Post-operative	Whole surgical site; margins per histopathology

Applicator	Dose/fx	Fractions	Frequency	Total
Moulds / flaps	3 Gy	17–18	3×/wk	51–54 Gy
Moulds / flaps	4 Gy	10–12	3×/wk	40–48 Gy
Moulds / flaps	5 Gy	10–12	2×/wk	50–60 Gy
Moulds / flaps	5 Gy	8	Twice a day, daily	40 Gy
Leipzig	3 Gy	17–18	3×/wk	51–54 Gy
Leipzig	5 Gy	8	2×/wk	40 Gy
Leipzig	10 Gy	3	1×/wk	30 Gy
Valencia / Esteya / Xoft	7 Gy	6	2×/wk	42 Gy
Valencia / Esteya / Xoft	5 Gy	8–10	2×/wk	40–50 Gy

Modality	Mean total dose	Mean recurrence
External	13.5 ± 3.3 Gy	22.2 ± 16%
HDR BT	13.7 ± 2.6 Gy	10.5 ± 15%
LDR BT	19.3 ± 1.2 Gy	21.3 ± 2.1%

Open questions

Optimal dose per fraction for skin surface brachytherapy
Randomized comparison of skin brachytherapy vs surgery
Long-term cosmesis of large-fraction schedules in frail pts

Sourced from Guinot, Jose L. et al.

📚 Sources · 📄 1 paper

📄 PAPER Guinot, Jose L.; Rembielak, Agata; Perez-Calatayud, Jose et al. · Radiotherapy and Oncology (2018-03)

GEC-ESTRO ACROP recommendations in skin brachytherapy

doi

Radiation Consensus / guideline

ASTRO guideline: definitive and postoperative RT for BCC and cSCC

TL;DRThe guideline gives explicit strength and evidence grades for definitive RT, PORT, nodal RT, BED10 dose ranges and concurrent systemic therapy in non-metastatic BCC and cSCC. Most rest on low-to-moderate evidence.

Why it mattersRadiation oncology

The nodal dose ceiling is the practical read. The adjuvant dose is 6000-6600 cGy after lymphadenectomy, and the panel says no data support 6600 cGy even for positive margins or ECE. It also exempts a single <3 cm cervical node without ECE from adjuvant RT, so de-escalation in both directions has explicit cover.

Monday clinic

In resected cSCC with close or positive margins that cannot be re-excised, this supports PORT as a Strong recommendation. The same margin scenario in BCC gets only a conditional recommendation, which leaves room for shared decision-making. The longer read

10 details 3 trials watching

Design

ASTRO task force guideline: systematic MEDLINE review (May 1988 through June 2018) graded by strength × QoE. Consensus came from a modified Delphi process with a ≥75% agreement threshold (≥90% for expert opinion). Endorsed by AAPM, ABS, ACR, AHNS and SSO.

Population & inclusion

Adults with non-metastatic invasive BCC or cSCC treated with curative-intent RT. Re-irradiation, palliation and dosimetric studies were excluded. Minimum cohort size was ≥100 pts for KQ1, ≥50 for KQ2 to 4 and ≥15 for KQ5.

Radiotherapy

Primary-site dosing is given as BED10 ranges, not fixed schedules. Definitive: conventional 70-93.5, hypofractionated 56-88. Postoperative: conventional 59.5-79.2, hypofractionated 56-70.2. Gross perineural spread on imaging gets definitive-equivalent dose, preferably conventionally fractionated.

vs leading data

Cisplatin with adjuvant RT has randomized support in mucosal head and neck SCC. The one randomized trial in high-risk resected cSCC found no benefit from weekly carboplatin added to PORT, which is why the guideline recommends against it. Nodal dosing and the 6-week start window are extrapolated from mucosal H&N practice.

Applies to

adults with non-metastatic invasive BCC or cSCC of the head and neck, trunk or limbs receiving definitive or postoperative curative-intent RT

Does not represent metastatic disease, re-irradiation, palliation, or mucosal H&N, vulvar, penile or perianal skin carcinoma.

Limitations

AJCC eighth edition skin staging covers head and neck only, so the T3/T4 PORT trigger has no staged equivalent on the trunk or limbs. Microscopic perineural invasion has no recommendation; only gross spread is addressed.

Discussion

Strength and evidence diverge on purpose: several Strong recommendations sit on Low QoE and reflect panel conviction, not measured benefit. The cSCC vs BCC split in PORT strength is the guideline's most usable distinction. The panel considered recommending against routine elective nodal RT but judged the data insufficient either way.

Results

Scenario	Strength	QoE
Cannot undergo or decline surgery	Strong	Moderate
Surgery would compromise function or cosmesis	Conditional	Moderate
Genetic radiosensitivity (ataxia telangiectasia, Gorlin, Li-Fraumeni)	Conditionally not recommended	Expert Opinion

Indication	Histology	Strength	QoE
Gross perineural spread, clinical or radiologic	BCC + cSCC	Strong	Moderate
Close/positive margins, not correctable surgically	cSCC	Strong	Low
Recurrence after margin-negative resection	cSCC	Strong	Moderate
T3/T4	cSCC	Strong	Moderate
Desmoplastic/infiltrative + chronic immunosuppression	cSCC	Strong	Moderate
Close/positive margins, not correctable surgically	BCC	Conditional	Low
Recurrence after margin-negative resection	BCC	Conditional	Low
Locally advanced/neglected, into bone or muscle	BCC	Conditional	Low

Scenario	Strength	QoE
Clinically apparent nodes → lymphadenectomy + adjuvant RT (except single <3 cm cervical node, no ECE)	Strong	Moderate
Definitive nodal RT only if inoperable or unresectable	Strong	Moderate
Imaging + SLNB to guide nodal RT, high-risk cSCC	Conditional	Expert Opinion
Elective nodal RT, cSCC thickness >6 mm, only if primary field overlaps basin	Conditional	Low
Adjuvant after lymphadenectomy: 6000-6600 cGy at 180-200 cGy/fx	Strong	Moderate
Elective, no lymphadenectomy: 5000-5400 cGy at 180-200 cGy/fx	Strong	Moderate

Setting	Conventional (180-200 cGy/fx)	Hypofractionation (210-500 cGy/fx)
Definitive	BED10 70-93.5	BED10 56-88
Postoperative	BED10 59.5-79.2	BED10 56-70.2

Open questions

Optimal management of microscopic perineural invasion

recruiting Study of a Strategy Integrating Adjuvant Radiation Therapy Versus Strategy Based on Monitoring in the Treatment of Carcinomas Spinocellular With High Risk of Recurrence Phase 3

n=266 · primary completion 2031-06 · phase 3 adjuvant RT vs surveillance, high-risk cSCC
Standardized fractionation schemes across skin RT modalities
Role of systemic therapy with RT: neoadjuvant, adjuvant, concurrent

recruiting Neoadjuvant Pembrolizumab in Cutaneous Squamous Cell Carcinoma Phase 2

n=27 · primary completion 2025-06 · neoadjuvant pembro before surgery + PORT, HN cSCC

active A Study of Radiation Therapy and Cemiplimab for People With Skin Cancer Phase 2

n=34 · primary completion 2027-10 · RT + cemiplimab, unresectable locally advanced cSCC

Sourced from Likhacheva, Anna et al.

📚 Sources · 📄 1 paper

📄 PAPER Likhacheva, Anna; Awan, Musaddiq; Barker, Christopher A. et al. · Practical Radiation Oncology (2020-01)

Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive Summary of an American Society for Radiation Oncology Clinical Practice Guideline

doi

Radiation Curative Consensus / guideline

Thoracic / Lung

Shortened curative schedules rest on radiobiological equivalence and retrospective series, not randomised comparison.

Reduced fractionation in lung RT during COVID-19

TL;DRCOVID-era consensus on shorter curative lung RT: 30Gy to 34Gy single-fraction SABR, 50Gy in 5 fractions, and 15-fraction schedules modelled against 55Gy/20.

Why it mattersRadiation oncology

The transferable part is the radiobiology: at α/β of 10, 52Gy/15 is quoted as isoeffective with 55Gy/20 for tumour control, and at α/β of 3, 50Gy/15 is isotoxic for late effects. That is a modelled bridge from 20 to 15 fractions, not outcome data, and OAR constraints still gate it.

Monday clinic

In a small peripheral lung tumour clear of the chest wall, this supports single-fraction SABR as a reduced-visit option; it does not extend to lesions abutting the chest wall, where cited chest wall toxicity was 30.6%. The longer read

8 details 2 trials watching

Design

Consensus guidance from lung clinical oncologists, built from a literature search plus published and unpublished centre audits. No new patient data.

Radiotherapy

Options span 30Gy to 34Gy single-fraction SABR for small peripheral tumours, 50Gy in 5 fractions (Glasgow, RTOG 0813 constraints), 15-fraction radical schedules modelled against 55Gy/20, and 40Gy in 15 fractions with concurrent or sequential chemotherapy.

Safety

Cited single-fraction data put chest wall toxicity at 30.6% for lesions abutting the chest wall vs 8.2% for tumours ≤1cm from it. One concurrent chemoRT cohort reported 25% ≥grade 3 oesophagitis and 10% ≥grade 3 pneumonitis.

vs leading data

The 5-fraction SABR recommendation leans on RTOG 0813 dose constraints rather than new dose-finding. Hypofractionated radical schedules are justified by isoeffect calculation and retrospective series reporting outcomes comparable to ≥60Gy conventional RT.

Applies to

lung cancer pts planned for curative-intent RT when departments need fewer visits

Does not represent a tested replacement for standard fractionation outside resource-constrained settings.

Limitations

Toxicity numbers come from mixed cited cohorts with different regimens and selection, so they are not directly comparable across rows. The isotoxicity claims depend on assumed α/β values.

Discussion

The document reframes fractionation as a risk-benefit trade under infection risk, not a new standard. It does not settle whether 15-fraction concurrent chemoRT matches standard schedules for late toxicity.

Open questions

Late toxicity of 15-fraction concurrent chemoRT vs standard schedules

recruiting Hypofractionated Versus Conventional Chemoradiotherapy Followed by Consolidative Immunotherapy in Locally Advanced NSCLC Phase 3

n=311 · primary completion 2029-06 · phase 3 RCT hypofx vs conventional CCRT, safety endpoint
Outcomes of single-fraction SABR adopted during the pandemic

recruiting Single-Fraction Pulmonary Ablative Radiotherapy Outcomes and Quality-of-life Workup

n=190 · primary completion 2028-11 · prospective 1-fx lung SBRT cohort, outcomes + QoL
Validity of assumed α/β values for hypofractionated lung RT

Sourced from Faivre-Finn, C. et al.

📚 Sources · 📄 1 paper

📄 PAPER Faivre-Finn, C.; Fenwick, J.D.; Franks, K.N. et al. · Clinical Oncology (2020-08)

Reduced Fractionation in Lung Cancer Patients Treated with Curative-intent Radiotherapy during the COVID-19 Pandemic

doi

Radiation Curative Consensus / guideline

🩹 Myeloma / Plasma Cell

IMWG consensus: cement augmentation for myeloma VCFs

🌞 Skin / Melanoma

GEC-ESTRO ACROP skin brachytherapy recommendations

ASTRO guideline: definitive and postoperative RT for BCC and cSCC

🫁 Thoracic / Lung

Reduced fractionation in lung RT during COVID-19

Myeloma / Plasma Cell

Skin / Melanoma

Thoracic / Lung