onc brain

SFRO consensus update, part of the RecoRad 4th edition, covering adult external beam radiotherapy and brachytherapy practice. Constraints were compiled from international consensus guidelines and clinical trial data, then validated by national reference experts rather than derived from a new dataset.

Tables are indexed by tumour site and by fractionation: normofractionation, moderate hypofractionation, accelerated hyperfractionation (lung), and ablative regimens split by fraction number (1, 3, 4, 5, 8). Dmax is approximated by D2 % in normofractionation and D0.035 cm3 in stereotactic plans; several hypofractionated entries are given as EQD2.

No clinical endpoint. The deliverable is a set of dose-volume objectives intended for direct implementation into treatment planning systems as standardized clinical objectives.

Constraints are tiered as optimal versus mandatory, with ALARA used where no numeric threshold is offered (parotid in the brain table, lacrymal gland under moderate hypofractionation). The authors require that pts be informed of the risk when a constraint is exceeded.

Breast constraints are anchored to the schedules of START B (40 Gy in 15) and FAST-FORWARD (26 Gy in 5); liver constraints are built on the ASTRO clinical practice guideline across 3, 5 and ≥ 20 fractions. This is a national harmonization layer over those sources, not a competing evidence synthesis.

The authors state most constraints still rest on 3D conformal-era data, which sits awkwardly with IMRT's larger low-dose bath and with ablative dose gradients. Biological modifiers of risk (individual radiosensitivity, genomic profile, concurrent immunotherapy) are not accounted for, and dose to immune organs at risk is named as unresolved.

The value here is harmonization, not novelty: the stated problem is the multiplicity of circulating constraint sets and the absence of a single reference. The optimal/mandatory tiering is the part that changes daily behaviour, because it tells a planner which values are negotiable against target coverage and which are not.

ESTRO task force literature review, then two Delphi survey rounds with a purposively selected expert panel, refined at ESTRO 2025 in Vienna. Ten multiple-choice questions covered areas of controversy. Consensus was predefined at ≥75% agreement, strong consensus at ≥90%, thresholds borrowed from APCCC.

Panel: eleven radiation oncologists, three medical physicists, one RTT from nine European countries. Voting counts per question ran 12 to 14. Target patient population is localised prostate cancer, with ISUP 2-3, cT1c-cT2c, PSA <20 ng/mL carrying strong consensus for SBRT as standard treatment outside a trial.

Standard is 36.25 Gy in five fractions of 7.25 Gy to 95% of the PTV, with 40 Gy to 95% of the prostate CTV (PACE-B), or 42.7 Gy in seven fractions of 6.1 Gy (HYPO-RT-PC). Prostate is contoured on T2-weighted planning MRI registered to CT; seminal vesicles omitted in low risk, proximal 1 cm included for all in PACE, proximal 2 cm to 30 Gy/5 fx in Gleason 4+3 or NCCN high risk. Rectal, bladder, femoral head, bowel and optional urethra PRV / penile bulb / crura constraints are given for five-fraction schedules only.

ADT per existing international guidelines, independent of the radiation schedule (100%, 13 votes). Intermediate risk: short-term ADT with conventional fractionation improves overall and cancer-specific survival by 7%, with no added benefit beyond roughly four months. High risk: long-term ADT plus RT improves overall and disease-specific survival irrespective of dose escalation.

No efficacy endpoint. The output is a set of recommendations plus per-question panel agreement percentages, so every "result" here is opinion measured against opinion.

The dose recommendation tracks PACE-B rather than splitting the difference with HYPO-RT-PC, whose lower biologically effective dose was still non-inferior, which the authors read as evidence 40 Gy in five fractions may not be needed for everyone. The unresolved counterweight is NRG-GU005, presented in preliminary form at ASTRO 2025: 36.25 Gy in five fractions gave lower side effects but a slightly higher three-year biochemical relapse rate, cause not yet determined. On protons, PARTIQoL found no difference in outcomes or QoL versus IMRT, with pencil beam scanning in only 48% of cases.

High-risk practice is running ahead of its evidence: HYPO-RT-PC is the only phase III reporting oncologic outcomes in high-risk pts and they were 11% of participants, while PACE-C has published toxicity but not oncological outcomes. Urethral sparing is recommended on mechanistic and single-study grounds while a post hoc PACE-B analysis found no significant association between urinary substructure dose and late urinary toxicity, and the panel itself flags the PACE-B urethra V42 <50% constraint as possibly too permissive.

The document's real contribution is the negative recommendations: no elective pelvic nodal RT with prostate SBRT outside a trial (100%, 12 votes) and no routine rectal spacer (85%, 11 votes), both areas where practice has drifted ahead of randomised data. It does not settle prostate volume cut-off, prophylactic medication, or whether intra-fraction tracking is required below a 5 mm margin, all of which returned no consensus.

Expert-driven clinical practice statement. A core group of six radiation oncologists, three physicists, and one research fellow drafted statements from the literature, then an international panel of 17 radiation oncologists voted once on 31 statements (agree / disagree / no opinion, no-opinion retained in the denominator). No second round.

Recurrent or second-primary HNSCC within a previously irradiated region, definitive or postoperative reirradiation. Nasopharyngeal cancers and rare histologies are excluded, the former covered by separate 2021 international recommendations.

Definitive: CTV = GTV + 5 mm (94%), IMRT to ~66 Gy for GTV >25 cc, IMRT or SBRT below 25 cc, SBRT at an equivalent ~40 Gy in five fractions. Postoperative: normofractionated IMRT ~60 Gy (94%), SBRT discouraged for lack of data. Elective nodal irradiation is not recommended in either setting (100%).

The output is agreement, not an outcome. Each statement carries an observed agreement percentage against predefined thresholds (high ≥85%, moderate 70-84%, low <70%) plus an Oxford-adapted evidence level 1 to 4.

24 of 31 (77%) statements reached high consensus. The seven moderate statements cluster on R0-unlikely postoperative indications (82%), RPA class III exclusion (76%), postoperative CTV rules (82%), the 66 Gy reference dose (82%), hyperfractionation (76%), SBRT dose (76%), and cord/brainstem cumulative limits (70%, the lowest).

The supporting literature reports pooled grade 3 or higher acute toxicity of 32% and late toxicity of 29% across 39 studies (3766 pts). Carotid blowout occurred in 41 (2.6%) of 1554 reirradiated pts with carotid involvement, with mortality in 29 (76%) of 38 with data. Mandibular osteoradionecrosis rates ranged 2% to 18%.

The technique statements track Vargo's multi-institutional comparison: in RPA class II, IMRT gave 2-yr OS 35.4% vs 18.6% for SBRT (p<0.001), but the difference vanished for ≥35 Gy in five fractions to ≤25 cc or T1-T2 targets. The 66 Gy threshold comes from Caudell's 505-pt cohort (2-yr OS 49.3% with ≥66 Gy vs 34.2% at 60.0-65.9 Gy vs 30.4% below 60 Gy), the same cohort that found no locoregional-control or OS gain from elective nodal irradiation.

Agreement was computed with no-opinion votes left in the denominator, so a statement can read as moderate because panellists abstained rather than objected, and the text does not report how often that happened. Evidence levels are also assigned to the highest available direct evidence, so a level 3 label does not mean the specific dose corridor or margin was tested at that level.

The moderate-agreement statements are the informative ones: they mark where the field genuinely splits (cord and brainstem cumulative limits, hyperfractionation, SBRT dose), and the authors read that split as clinical uncertainty rather than process failure. Sequencing against first-line immune checkpoint inhibitors is explicitly left open, with no randomised data on whether to treat locally first or defer.

Literature-based systematic review plus RAND/UCLA modified Delphi appropriateness rating, run under the standing ARS AUC methodology with PICOTS framing and PRISMA 2020 assessment. Two rounds of voting; ratings collapse to usually not appropriate, may be appropriate, usually appropriate.

Locoregionally recurrent rectal cancer. Eligible evidence was prospective observational, phase 2/3, and retrospective series of at least 25 patients, published January 1, 2013 to July 16, 2025, English language, animal studies excluded.

There is no efficacy endpoint. The output is an appropriateness rating per treatment option across five PICO questions: surgery, preoperative/perioperative therapy, nonoperative management, RT/reirradiation, and systemic therapy.

116 references carried the evidence: 10 well-designed randomized phase 2/3, 29 moderately well designed, 76 retrospective, 1 meta-analysis. The committee's stated conclusion is that margin-negative resection is the ultimate determinant of survival and local control, with preoperative systemic therapy, RT, or both used to facilitate it.

Two thirds of the evidence base (76 of 116) is retrospective, so a modified Delphi vote is doing work the trials cannot. The document is an executive summary: the per-scenario appropriateness grid, which is the part a reader would carry to tumor board, is not in the source excerpt available here.

The committee explicitly declines to move practice, framing the update as reassurance about combined-modality therapy rather than a new position. For a radiation oncologist the operative question is where RT sits relative to surgical resectability, and the summary answers it in one direction only: RT is a means to R0, not an alternative to it.

Evidence-based recommendation update from the GEC-ESTRO Breast Cancer Working Group. Systematic search 2010 to 2024 across PubMed, Medline, Scopus and Cochrane returned 618 articles, supplemented by reference lists, conference abstracts and book chapters. Ten prospective randomized trials and seven retrospective comparative studies with ≥ 5 yr median follow-up formed the evidence base.

Applies to pts after breast-conserving surgery being considered for partial breast irradiation. The low-risk group is age > 40 yr, unifocal or multifocal within 2 cm, pTis or T1-2 (≤ 30 mm), pN0 or pN1mi, all histology types, no EIC, no extensive LVI, negative invasive margins (≥ 2 mm for DCIS).

The document addresses who gets APBI, not how. No dose, fractionation, technique (brachytherapy vs external beam) or target-volume recommendation is given in the source text.

Two categories replace the prior scheme: low-risk good candidates and high-risk contraindicated. Contraindications are BRCA 1-2 mutation, age < 40 yr, positive invasive margins (< 2 mm for DCIS), multicentric or > 30 mm disease, triple negative, EIC positive, extensive LVI, and ≥ pN1a or pNx.

Recommendation strength per criterion is not reported in the source text, so a reader cannot tell which thresholds rest on randomized data and which on panel opinion. The evidence base mixes ten randomized trials with seven retrospective comparative series without stated weighting.

The direction of travel is eligibility expansion: the authors state the 2010 criteria can be significantly expanded so more pts may receive APBI in routine practice. What the document does not settle is whether the widened boundary holds at the margins it moved most, node-micrometastatic and multifocal disease, where the randomized APBI trials enrolled few pts.

Expert opinion from the EORTC cutaneous lymphoma tumour group, tabulating published retrospective and small prospective series (Tables 1 and 2) into a dose algorithm (Figs 2A/2B). No pooled estimate, no protocol-registered synthesis.

Covers MF, Sézary syndrome, pcALCL, CD4+ small/medium T-LPD, pcMZL, pcFCL, and DLBCL leg type. Explicitly excludes the aggressive CTCL variants (subcutaneous panniculitis-like, gamma/delta, CD8+ epidermotropic, NK/T), where the authors say low-dose RT has a limited role.

MF plaques/tumours 8-12 Gy in two or three fractions; low-dose TSEBT 8-12 Gy for palliation and up to 24 Gy pre-autologous transplant; pcALCL few relapses at 20 Gy, palliative 2×4 Gy; CD4+ T-LPD 4 Gy in two fractions; DLBCL leg type consolidation reduced to 30 Gy, with 20 Gy reported post-systemic. Modalities named: electrons, photons, kilovoltage X-ray, brachytherapy.

The efficacy signal is uniformly high ORR across the tabulated series, but the discriminating result is dose-dependent local control: ≥92% 1-yr local control after low-dose MF RT versus an inferior rate at 4 Gy, and 28% vs 5% local relapse for 4 Gy vs 8-50 Gy in the ILROG registry series (p < 0.001).

Grade 3/4 toxicity is absent across most tabulated low-dose series. The one clear dose-toxicity signal in MF local RT is 27% grade 3/4 following 12 Gy versus 0% after 4-8 Gy; a prospective DLBCL leg-type cohort reported 14%.

The reference frame is the 30-40 Gy conventional standard that governed cutaneous lymphoma until roughly two decades ago. This document formalises the retreat from it, but does so on a base the authors concede is retrospective, so it codifies practice already in motion rather than establishing it.

The dose tables mix single-lesion and per-patient denominators and span decades of technique, so a 4 Gy series and a 40 Gy series are not comparing like populations. Several tabulated rows report dose comparisons as n.s. in cohorts far too small to exclude a real difference, which is not the same as equivalence.

The unresolved question is not whether reduced dose works but where its floor sits, and the answer looks subtype-specific rather than universal. The authors' own response-adapted proposal (escalate to a cumulative 24 Gy for residual disease or failure after 4 Gy) concedes that 4 Gy alone is a starting position, not a definitive prescription.