onc brain

Modified Delphi consensus, 20 North American multidisciplinary experts, iterative discussion and voting over two rounds. Followed by a 29-case pilot concordance exercise against external experts.

Framework spans the full HCC spectrum, from unifocal ≤3 cm (Class 1A) to distant metastases (Class 4B). Class assignment keys on tumor burden, Vp level of portal invasion, and poor prognostic features (>8 cm, AFP >1000 ng/mL, poor differentiation).

EBRT including SBRT is named a first-line locoregional option in Classes 1A through 3A, on par with TARE, RFA/MWA, and TACE. No dose or fractionation is specified anywhere in the framework: the stated rationale is ablative dose delivered selectively to limit radiation-induced liver injury. In Class 4A, EBRT is not routinely indicated outside palliation of symptomatic disease.

Expert decisions matched BEACON in 28 of 29 cases (96.6%) vs 72.4% for BCLC 2025. The single discordant case was combination systemic plus locoregional therapy for vascular invasion reaching the right atrium.

BCLC keeps radiation outside its core allocation algorithm; BEACON moves it in. The supporting evidence the panel cites is uneven: DOSISPHERE (ORR 71 vs 36%, OS 26.6 vs 10.7 mo) for personalized-dosimetry TARE is randomised, while the SBRT case in Class 3B rests on RTOG1112, which reached only p=0.06 for OS vs sorafenib.

The 72.4% BCLC comparator was scored by BEACON's own authors against cases the same group selected, and 29 cases cannot exercise nine classes evenly. Round-1 per-class agreement is unreadable from the source table because vote counts and class labels arrived unpaired.

The framework's real claim is that intrahepatic burden and Vp level, not BCLC's stage buckets, should drive allocation, and that radiation-based modalities are burden-appropriate rather than stage-restricted. Whether that improves outcomes is untested: validation against empiric clinical data is deferred to the HCC-Live Consortium.

Delphi consensus framework, not an efficacy study. Concordance figures measure opinion against opinion. Elevates EBRT/TARE to first-line locoregional status in a formal allocation system.

International contouring consensus under IROCK, convened at ASTRO 2023. 16 radiation oncologists contoured 4** RCC SABR scenarios on CT alone via EduCase; a STAPLE algorithm generated the 95% consensus contour, refined across 2 online meetings in May and June 2024. Statements were revised to uniform (100%) agreement**.

Panelists, not patients: inclusion required ≥10 prior RCC SABR cases, with 14 of 16 having treated ≥10 in the preceding 12 months. Cases were a >10 cm RCC with IVC tumor thrombus, a central tumor abutting the hilum, a local recurrence post-nephrectomy, and a post-RFA cavity recurrence.

Target is the iGTV (GTV incorporating internal motion); no participant added a microscopic-spread margin, so no separate ITV is recommended. The most common PTV expansion was a uniform 5 mm, predicated on supine vacuum-cushion setup, 4D-CT sim, IV contrast and daily CBCT. Dose objectives and OAR constraints for 1, 3, or 5 fractions are tabulated from FASTRACK-II and AQuOS-II.

Overall median DSC 0.85 (range 0.40-0.95), median MDA 2.17 mm (0.71-10.82), median HD 9.00 mm (4.00-89.31), with DSC above 0.70 in every case. Two-way ANOVA showed all three metrics differed by case (P < .05); only MDA differed by participant (P = .03).

IROCK previously supplied the outcome evidence (its pooled international analyses and the FASTRACK-II phase 2), and both showed heterogeneous dose, fractionation and planning conventions across contributing centers. This fills the delineation gap those datasets left open, and it borrows its constraint table from FASTRACK-II and the ongoing AQuOS-II rather than deriving new dose-response thresholds.

The renal substructure question is left deliberately unsettled: cortex is defined for use, hilum is explicitly not a dose-limiting OAR, on the reasoning that sparing an unvalidated structure would redistribute dose into parenchyma that does correlate with renal function. AQuOS-II is the trial that may resolve it.

CT-only images were supplied on purpose, for international accessibility, so measured variation likely overstates what an MRI-equipped center would see. Participants never recontoured post-consensus, so the guideline's own effect on agreement is unmeasured, and adoption assumes urology, radiology and nephrology collaboration plus advanced planning technology.

Expert consensus atlas, not an outcome study: 16-panel STAPLE contours with unanimous statements, no efficacy or toxicity endpoint, unvalidated prospectively.

Three-round Delphi. 57 statements drafted after literature review across epidemiology-pathophysiology (n=8), causes (n=10), imaging (n=10), histopathology (n=9), management (n=20), plus an exploratory research set of 8. Consensus prespecified at ≥80% agreement on a 5-point Likert scale.

The voting panel, not patients: 15 volunteers (2 radiation/clinical oncologists, 4 neuro-oncologists, 4 medical oncologists, 2 neurosurgeons, 1 neuropathologist, 1 neuroradiologist, 1 nuclear medicine physician), expanded by 5 more in round 1 (4 neuro-oncologists, 1 radiation/clinical oncologist) to 20 total. Clinically the scope is RN after RT for primary glial or metastatic brain tumors.

RN is called uncommon below EQD2 ~40 Gy (α/β 2 Gy), rising with dose per fraction, total dose and irradiated volume. V12Gy ~10 cm³ carries a 5-10% symptomatic necrosis risk after single-session SRS; for hypofractionated SRT, brain-plus-target V20Gy (3fx) or V24Gy (5fx) <20 cm³ associates with <10% any necrosis and <4% RN requiring resection. Re-irradiation risk stays under 10% at cumulative EQD2 100-110 Gy and reaches up to 25% above 130 Gy.

Consensus reached on 53 of 57 statements after three rounds. Diagnostic and management statements are tabulated separately in the details; the four that failed to reach 80% are not identified in the available text.

The document's practical contribution is a decision sequence rather than a new treatment: advanced MRI first, amino acid PET to add confidence, tissue when doubt persists, and treatment triggered only by symptoms of >7 days with increasing severity. Its most consequential position is moving bevacizumab from rescue to an expected next step at a defined steroid threshold (dependence >4 weeks or dexamethasone 8 mg/day), which is a lower bar than many centres apply.

Agreement percentages measure how a self-selected 20-person European panel voted, and the panel skews neuro-oncology (8 of 20) over radiation oncology (3 of 20) for a complication defined by dose and volume. FET and F-DOPA availability is largely European, so the imaging algorithm's top tier is not reproducible in most centres worldwide. The 4 non-consensus statements are not enumerated in the accessible text, so the reader cannot see where the panel actually split.

Delphi expert-opinion document, no efficacy endpoint. Agreement measured against opinion, not outcomes; authors state absence of Level 1 evidence and call for randomised trials.

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.