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Ocular, Orbital, and Optic Nerve Tumors

Key Points Incidence An estimated 3540 cases of primary ocular tumors occur annually. Uveal melanoma is the most frequently occurring intraocular primary tumor; retinoblastoma, seen primarily in children, is the second most frequently occurring primary tumor. Biologic Characteristics Specific histopathology and genetic subtype influence clinical behavior. Staging Evaluation The Collaborative Ocular Melanoma Study (COMS) size criteria are used for uveal melanoma; for orbital lymphoma, the Ann…

Spinal Cord Tumors

Key Points Incidence Spinal cord tumors (excluding bony metastases) are rare tumors representing only 3% of all central nervous system malignancies. They are anatomically classified into three main categories based on their relationship with the cord: extradural, intradural extramedullary, and intradural intramedullary. Intramedullary tumors are more common in children, while extramedullary tumors occur more frequently in adults. Biological Characteristics The histological type is an important prognostic…

Pituitary Tumors and Craniopharyngiomas

Key Points Incidence Pituitary tumors represent approximately 10% to 15% of primary intracranial tumors. Biologic Characteristics The vast majority of pituitary tumors are benign and may be functional (i.e., secrete excess hormones) or nonfunctional. The pathogenesis of pituitary tumors is largely unknown. Genetic predisposition for the development of pituitary adenomas has been described in several syndromes. Pituitary carcinomas are extremely rare. Staging Evaluation Evaluation for patients…

Benign Brain Tumors: Meningiomas and Vestibular Schwannomas

Meningiomas Incidence Meningiomas comprise approximately 35% of all primary intracranial neoplasms, rendering them the single most frequently reported primary intracranial tumor. Because of the significant longevity associated with this diagnosis, the estimated prevalence of 97.5 per 100,000 is significantly higher than the annual incidence of approximately 7.6 per 100,000. Grading Most meningiomas are benign (WHO grade I) and progress slowly, but despite this, can produce considerable…

High-Grade Gliomas

Key Points Incidence There are approximately 75,000 new cases of brain tumors diagnosed in the United States each year. Gliomas now account for nearly 75% of malignant brain tumors. Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor. Biological Characteristics The World Health Organization (WHO) classification of brain tumors was revised and published in 2016, introducing a new classification incorporating molecular parameters such as…

Low-Grade Gliomas

Key Points Epidemiology The estimated incidence of low-grade gliomas (LGG) is approximately 2,000 cases per year, comprising 5-10% of newly diagnosed primary brain tumors. Biological Characteristics Molecular characterization has emerged as a critical element in the diagnosis, prognosis, and management of LGG. WHO grade II tumors are subdivided into three classes: (1) oligodendroglioma (1p/19q codeleted, IDH-mutated tumors), (2) IDH-mutated non-1p/19q codeleted astrocytoma, and (3) IDH wild-type…

Metastatic Disease : Bone, Spinal Cord, Brain, Liver, and Lung

Local tumor control is now achieved with modern combined-modality therapy. Metastatic disease, therefore, dominates the survival outcomes of patients with cancer. Metastases to the bone, lung, liver, and brain cause organ dysfunction and pain, with substantial changes in quality of life. Metastases to any of these organs can lead to a shorter life. Although palliative care comprises a large part of the clinical practice of oncology,…

Stereotactic Body Irradiation: Extracranial Tumors

The success of stereotactic radiosurgery (SRS) for intracranial lesions spawned interest in applying the same principles of narrowly focused high-dose per-fraction irradiation in the management of selected extracranial tumors. The transition included an initial effort to design and implement a surgically placed rigid frame for spine immobilization, but soon thereafter noninvasive means to target lung, liver, and other nonbrain lesions were developed. Stereotactic body radiotherapy (SBRT)…

Stereotactic Irradiation: CNS Tumors

The term radio-surgery was possibly first used in a medical context more than 90 years ago, when Dr. Francis Hernaman-Johnson described in a lecture to the Royal Society of Medicine an assortment of indications where x-ray therapy might be combined with surgery for benign and malignant indications. From the modern perspective, Dr. Hernaman-Johnson's oration is quaint but wonderfully lyrical, at times invoking Biblical metaphors and Greek…

Immunotherapy With Radiotherapy

Emergence of Immunotherapy Immunotherapy encompasses a class of biologic substrates including peptides, recombinant antibodies, and cells that are administered to target the immune system and treat disease. In the field of oncology, immunotherapy has old origins (like the use of bacilli Calmette-Guérin [BCG] in bladder cancer), and it has recently re-emerged as a promising treatment paradigm to expand the repertoire of therapeutic options beyond traditional approaches…

Targeted Radionuclide Therapy

Abbreviations ADCC = antibody-dependent cellular cytotoxicity AML = acute myeloid leukemia APL = acute promyelocytic leukemia ASCT = autologous stem cell transplant BED = biological equivalent dose BMT = bone marrow transplantation BU = busulfan CLL = chronic lymphocytic leukemia CR = complete response with no evidence of disease for ≤ 1 month CTCL = cutaneous T-cell lymphoma CY = cytoxan or cyclophosphamide DLCL = diffuse large-cell…

Charged Particle Radiotherapy

Over recent years, the interest and technologic advances in charged particle therapy have resulted in the opening of numerous charged particle radiation oncology centers across the globe. Interest in the use of charged particle radiotherapy derives from the superior dose distributions that can be achieved with these particles compared with those produced by standard photon therapy techniques, as well as the potential for higher biological effect…

Total Body Irradiation

Total body irradiation (TBI) is a radiotherapy technique that has been applied to treat various benign and malignant diseases over the past century. The technique has evolved in parallel with an increase in the knowledge of the biologic response to ionizing radiation and improvements in radiation dosimetry and treatment delivery. TBI remains an important component of hematopoietic stem cell transplant (HSCT), with the goal of eradicating…

Intraoperative Irradiation

Intraoperative radiotherapy (IORT) is the delivery of radiation during surgery ( Video 22.1 ). The rationale is straightforward: escalating radiation dose may enhance local tumor control. In many clinical situations, the dose delivered by external-beam radiation techniques is limited by tolerance of surrounding normal tissues. To overcome this, intraoperative irradiation has been employed as a technique facilitating tumor dose escalation. In the era of precision medicine,…

Intensity-Modulated and Image-Guided Radiotherapy

In this chapter, we will describe both theoretical and practical considerations for modern image-guided radiotherapy (IGRT) simulation, planning, and treatment delivery. Most of the concepts can be applied to all forms of highly conformal therapy, including 3D conformal radiotherapy (3D CRT), intensity-modulated radiotherapy (IMRT), and volumetric-modulated arc therapy (VMAT). We also describe practical steps and workflows that can be applied to specific treatment planning technique(s). Definitions…

Brachytherapy

General Principles Brachytherapy is arguably the most conformal of all the modes of radiotherapy. Accurate placement of sources directly in the target area allows for precise dose delivery to the target with unparalleled sparing of normal adjacent tissue. Although a conformal therapy, it is by nature inhomogenous in dose delivery, with the advantage that much of the central regions of the target get a greater dose…

Quality and Safety in Radiation Oncology

Introduction The Relationship Between Safety and Quality Health care is replete with examples of errors culminating in adverse events that compromise the quality and value of care. It comes as no surprise that optimum oncological outcomes depend on excellent execution and design of a radiotherapy plan. In the clinical trial setting, there are numerous reports of the association of protocol variations with inferior survival, or worse,…

Late Effects After Radiation

Introduction and General Considerations Statement of the Problem Incidental irradiation of normal tissues is unavoidable during radiotherapy. The primary determinants of injury are the radiation dose (total dose and dose per fraction) and the volume of normal tissue irradiated. Additional treatment factors that influence risk include dose rate, overall treatment time, treatment energy, the use of concurrent chemotherapy, radiation protectors or other biological modifiers, and the…

Palliative Radiation Medicine

It has been estimated that between 40% and 60% of referrals for radiation treatment fall under the rubric of palliative consults. Furthermore, as systemic therapies improve, patients with metastatic disease can live longer, which effectively increases the denominator of patients referred for palliative radiotherapy consultations. Consequently, expertise in radiation oncology necessarily includes expertise in palliative care. Thus, an understanding of palliative radiation as a discrete body…