RadiotherapyProtocols 2010V2 0

CCO, Radiotherapy Quality System 2010
Quality Procedure Radiotherapy Protocols
Radiotherapy
Protocols
This paper version of the Radiotherapy Protocols is only valid during 2010.
This will be progressively superceded by electronic dated individual sections
which will be complete for 2011.
Issue Date: 08-July-2010 Page 1 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Author: TSG Leads Authorised by: Copy No:
Introduction to Radiotherapy Protocol Book
This Protocol Book sets out to define standard protocol based treatments. The format
is designed to comply with the 2010 Department of Health Manual for Cancer
Services Radiotherapy Measures. Under these measures we are required to maintain a
list of acceptable treatment protocols, including palliative treatment, for all
radiotherapy modalities used which specifies for each protocol at least the following:
 The clinical indication
 The modality
 The tumour localisation and planning technique
 Dose/fractionation and overall treatment time relevant to the modality
 The treatment and immobilisation equipment and immobilisation
technique
 Any restrictions regarding which department in the network are
authorised to deliver the protocol or parts of the protocol, e.g. planning
 The conditions governing retreatment and the dose/fractionation and
overall treatment time which then applies
Where possible local standards are chosen to comply with national and internationally
defined standards and the Department of Health quality measures as follows:
Category status
This follows the Royal College of Radiologists Guidelines for defining categories of
patients.
(see The Timely Delivery of Radical Radiotherapy: standards and guidelines for the
management of unscheduled treatment interruptions; Third Edition 2008).
Definition of GTV and PTV
The measures also require that each department specifies the relationship between
PTV and CTV in a documented procedure. Where appropriate we have chosen to
incorporate this information into our standard protocols. This follows ICRU
definitions and is defined individually by each TSG for the techniques described
taking into account the tumour biology, local (CCO) generic immobilisation
techniques and planning tolerances.
(see appendix – immobilisation techniques and treatment setup variations).
Dose and fractionation
This is in accordance with Royal College of Radiologists Guidance on Radiotherapy
Dose-Fractionation June 2006. Each protocol should conform to the current RCR
Grade A recommendations. Lower grade recommendations may be included at local
discretion of the network.
Critical Structure Tolerance & Acute/Late effects
This is approved by the CCO tumour groups and as defined in peer reviewed clinical
trials
(see appendices – ‘Critical Structure Tolerances’ and ‘Acute/Late Effects definition’).

Author: TSG Leads Authorised by: Dr B J Haylock Copy No:
References
References are included where they are available. A comment is made on the level of
evidence for dose fractionation regimes as defined by RCR guidelines.
The document is also intended to better define those treatments that we at CCO
consider to be ‘standard protocol’ as opposed to ‘non-protocol’. Non-protocol
treatments include those cases where a technique is used to address a “one-off”
clinical need. In this situation a concession is required for treatment subject to its
clinical justification. They also include those techniques that are still under
development and are undergoing a planned assessment/implementation. These are
listed in the development project framework and referenced separately as appendices.
The final decision regarding the clinical use of a technique either under concession or
as part of a development project rests with the Clinical Director for Radiotherapy.
The protocol book will initially be available in paper form, dated ‘2010’. It can be
accessed electronically via the ISO9000 directory, CCOCOMMS or the Intranet. It is
intended to improve the electronic accessibility of individual protocols encouraging
their use as a valuable reference. The protocols are approved annually by the
appropriate Tumour Specific Group and when only available electronically, it will be
possible to update protocols more frequently in response to changes in our knowledge
base. It is intended that the electronic version of the protocols will replace the paper
version by 2011. The format and lay out of the index has been chosen to facilitate this
transition.

Contents
Breast
Breast + SCF/Chest Wall + SCF (+/- Axilla)............................................... 6
Breast Boost................................................................................................. 8
Breast/Chest Wall Only................................................................................ 9
Breast/Chest Wall and Axilla (modified monobloc).................................... 10
CNS
Acoustic Neuroma........................................................................................ 11
Brain Metastases (Isolated).......................................................................... 12
Brain Metastases (Multiple)......................................................................... 13
Ependymoma................................................................................................ 14
Glioma (High Grade)................................................................................... 15
Glioma (Low Grade)................................................................................... 16
Malignant Spinal Cord Compression........................................................... 17
Meningioma.................................................................................................. 18
Optic Nerve Glioma – Under Development – Requires Concession .......... 19
Orbital Tumours........................................................................................... 20
Pituitary........................................................................................................ 21
Primary CNS Lymphoma............................................................................. 22
Gastrointestinal
Anal Canal/Anal Margin............................................................................... 23
Oesophagus - Palliative................................................................................. 25
Oesophagus – Radical................................................................................... 26
Pancreas – Under Development – Requires Concession.............................. 28
Rectum.......................................................................................................... 29
Stomach......................................................................................................... 31
Gastrourinary
Bladder.......................................................................................................... 32
Penis............................................................................................................. 33
Prostate......................................................................................................... 34
Testicular...................................................................................................... 38
Gynaecological
Cervix............................................................................................................ 39
Endometrium................................................................................................ 40
Ovary............................................................................................................ 41
Vagina........................................................................................................... 42
Vulva............................................................................................................. 43
Head and Neck

Cervical Oesophagus.................................................................................... 45
Head and Neck Cancer General................................................................... 46
Larynx Glottic Larynx.................................................................................. 47
Sub-Glottic Larynx............................................................... 49
Supragottic............................................................................ 51
Lower Alveolus............................................................................................ 53
Maxillary Sinus/Nasal Cavity...................................................................... 55

Nasopharynx................................................................................................ 56
Oropharynx Base of Tongue.................................................................... 58
Buccal Mucosa..................................................................... 59
Floor of Mouth.................................................................... 61
Oral Tongue......................................................................... 62
Parotid Gland............................................................................................... 63
Pyriform Fossa............................................................................................ 64
Retromolar Trigone..................................................................................... 65
Soft Palate................................................................................................... 66
Thyroid....................................................................................................... 68
Tonsil.......................................................................................................... 69
Lung
Mesothelioma............................................................................................. 71
Non-Small Cell Lung.................................................................................. 72
Small Cell Lung.......................................................................................... 74
Lymphoma
Hodgkins..................................................................................................... 75
Non-Hodgkins............................................................................................. 76
Spleen.......................................................................................................... 78
Paediatric............................................................................................................... 79
Skin
Melanoma.................................................................................................... 80
Merkell Cell................................................................................................. 81
Non-Melanoma............................................................................................ 82
Other
Bone Metastases......................................................................................... 83
Soft Tissue Sarcoma.................................................................................... 84
Total Body Irradiation................................................................................ 85
Appendices – Available on CCO intranet
Appendix A – Treatments using IMRT ................................................................. 86

Tumour Group : Breast

Site: Breast + SCF or Chest Wall + SCF (+/- axilla)
Tumour: Invasive primary breast cancer
Intent: Radical RCR Category status: 2
1. Localisation method CT Sim (Brilliance/AcQSim) 5mm slices
Simulator using surface anatomy, position of scar, clips, operation notes
and mammographic findings to localise tumour bed - simple single plane,
with external contour of the central slice of the PTV taken using Osiris.
Wire to scar. Radio-opaque markers placed on lateral and medial ref points
2. Planning technique Simulator - isocentric, coplanar tangentials matched to a single anterior
field at fixed FSD to cover the SCF and axilla as appropriate.
CTSim – single isocentre backedge aligned tangentials matched to an
anterior nodal field using asymmetric jaws. PAB as needed.
3. Immobilisation QUEST board with patient position as per TWR3FISO. Chinstrap.
method
4. Volume definition and CTV = whole of breast tissue (or skin flaps from 5mm below skin surface
if post mastectomy) and including soft tissues down to deep fascia (but not
including underlying muscle and ribcage), and SCF +/- axilla
PTV=CTV+1cm
The field borders for the tangential fields are as follows:
Medial – the midline.
Lateral – 1cm below the breast plate or to the mid-axillary line.
Superiorly – the second intercostal space at the level of the Angle of Louis.
Inferiorly – to 1-2cm below the inferior extent of breast tissue – estimated
extent if post mastectomy.
The field borders for the anterior axilla and SCF field are as follows:
Medial – ipsilateral edge of the vertebral bodies
Lateral – lateral extent of the second rib
Lateral if axilla included – insertion of the Teres major into the humerus
Superior – at least 3cm above the head of the clavicle (ie to cover the SCF).
Inferior – matched to the tangential fields.
A posterior axillary field may occasionally be required for larger axillary
separations. This must be planned on an individual patient basis.
Critical structures Heart-distance of post edge of field to ant border of heart to be < 1.5cm.
Lungs- central lung distance for tangential fields not normally >2cm.
Hot spots > than 105% should be avoided in the skin and ribcage.

5. Dose and 40Gy in 15 daily fractions (Grade B)

Fractionation 50Gy in 25 daily fractions (Grade B)
45Gy in 20 daily fractions
6. Special instructions Attendance at Breast Care Class as per CCO Breast Care Class Standard
Referral to Breast Clinical Nurse Specialist Service at CCO in accordance
with CReST referral criteria
Provide patient with ‘Radiotherapy to the Breast’ information leaflet
7. Clinical Trials and None at present.
References
Date of approval by Lead Clinician/TSG: 13/04/2010

Site: Tumour bed boost

Tumour: Primary invasive breast cancer
1. Localisation method CT planned if Oncoplastic surgery. Clipping of tumour bed is encouraged.
The relation of scar to tumour bed should be ascertained from operation
notes, discussion with the operating surgeon and clinical examination.
CT scan - for incisions where scar does not overlie tumour bed. 5mm slices
and wire to scar. The (clipped) tumour bed including seroma if present, is
identified and outlined.
Mark up on set, if confirmed that scar overlies the tumour bed.
2. Planning technique For incisions where the scar does not overlie the tumour bed, planned
photon boost. Normally 3 field requiring 3D dataset. If depth is satisfactory
for an electron boost, moves from origin to tumour bed may be ascertained
from the scan on Prosoma, and an electron field can be marked directly,
using this information in the simulator. Note CT planning should be
employed for ph1 and ph2 for patients who have oncoplastic incisions who
will require identification of the tumour bed for a boost.
Direct single electron field, centred on scar where scar overlies tumour bed.
3. Immobilisation For patients receiving photon boost, position is as ph1 (see TWR2FISO)
method For electron boost, supine position on couch with abduction of ipsilateral
arm. Lateral tumours are best treated with patient rolled slightly to the side.
4. Volume definition and For photon boosts: CTV=the volume enclosed by surgical clips+ changes in
surrounding tissue architecture. The PTV=CTV+ 10mm (this margin may
be increased if close surgical margins or extensive DCIS)
For electron boosts, the treatment field normally consists of the tissue
defect from the surgery and the scar with an adequate margin. The whole
length of the scar does not always require inclusion in the boost field.
Critical structures Lungs, heart, skin.

5. Dose and 15Gy in 5 daily fractions, 16Gy in 8 daily fractions
Fractionation 10Gy in 5 daily fractions
9Gy in 3 daily fractions
6. Special instructions Digital photograph to record field for electron mark up.
7. Clinical Trials and None at present
References

Tumour Group: Breast

Site: Breast or Chest Wall only Tumour: DCIS, invasive primary breast cancer
Simulator using surface anatomy, position of scar, clips, operation notes
and mammographic findings to localise tumour bed - simple single plane,
with external contour of the central slice of the PTV taken using Osiris.
Wire to scar. Radio-opaque markers on lateral and medial reference points
2. Planning technique Isocentric, coplanar backedge aligned tangentials.
3. Immobilisation QUEST board with patient position as per TWR2FISO.
method
4. Volume definition and CTV = the whole of the breast tissue (or the skin flaps from 5mm below the
skin surface if post mastectomy) and including the soft tissues down to the
deep fascia but not including the underlying muscle and ribcage.
PTV=CTV+1cm
The field borders are as follows:
Medial – the midline.
Lateral – 1cm below the breast plate or to the mid-axillary line.
Superiorly – the second intercostal space at the level of the Angle of Louis.
Inferiorly – to 1-2cm below inferior extent of breast tissue – estimated
extent if post mastectomy.
Critical structures Heart-distance of post edge of field to ant border of heart to be < 1.5cm.
Lungs-central lung distance for tangential fields not normally >2cm.
Hot spots of >105% should be avoided in the skin and ribcage
5. Dose and 40Gy in 15 daily fractions (Grade B) 50Gy in 25 daily fractions (Grade B)
Fractionation 45Gy in 20 daily fractions
7. Clinical Trials and Breast Only: IMPORT LOW/ IMPORT HIGH/ PRIME
References Chest Wall Only: SUPREMO

Tumour Group: Breast

Site: Breast/chest wall and axilla (modified monobloc) Tumour: Invasive primary breast cancer
Wire to scar. Radio-opaque markers placed on medial and lateral ref points
2. Planning technique Isocentric, coplanar modified, extended tangentials.
3. Immobilisation Stable, supine position on QUEST board. Head straight, ipsilateral
method shoulder/arm extended superiorly to exclude all or as much as possible of
the humeral head from the field elbow flexed a little and rotated backwards.
Chinstrap.
4. Volume definition and CTV = whole of breast tissue (or skin flaps from 5mm below skin surface if
post mastectomy) and including soft tissues down to deep fascia (but not
including underlying muscle and ribcage), and the contents of the axilla.
PTV=CTV+1cm
The field borders are as follows:
Medial – the midline (or a little beyond) allowing coverage of breast tissue
inferiorly, after appropriate THR to ensure optimum axillary coverage.
Lateral – mid-axillary line (or slightly post to mid-axillary line) to ensure
all breast tissue encompassed and field border is behind clavicle or
covering axillary contents.
Superiorly – ~ ⅔ of clavicle included, covering level 3 axillary nodes.
Inferiorly – to 1-2cm below the inferior extent of breast tissue.
Heart-distance of post edge of field to ant border of heart to be < 1.5cm.

Critical structures Lungs- central lung distance for tangential fields should not normally
exceed 2.5cm, maximum acceptable in exceptional cases, 3cm.
Hot spots of greater than 105% should be avoided in the skin and ribcage
5. Dose and 45Gy in 20 daily fractions (Grade C)
Fractionation
References

Tumour Group: CNS

Tumour: ACOUSTIC NEUROMA
Intent: Radical RCR Category Status: 2
1. Localisation method CT/MRI and image registration
2. Planning technique Single plane

Scan using 2mm SRS protocol – co registered with MRI
3. Immobilisation Stereotactic Radiosurgery
method Leibinger frame (fixed)
Stereotactic Conformal Radiotherapy
Radionics frame (tumour ≤ 3cm)
Headfix frame (tumour > 3cm)
Shell if relocatable frame not possible
4. Volume definition and Stereotactic Radiosurgery
CTV = GTV – visible tumour
PTV – visible tumour + 1mm (but not extending into brain stem)
GTV – gross tumour
CTV = GTV
Critical structures Brain stem

5. Dose and Stereotactic Radiosurgery
Fractionation 12.5 Gy / 1# (at 80%)
54Gy / 30# / 6weeks
6. Special instructions

References

Tumour Group: CNS

Tumour: BRAIN METASTASES – Isolated 1-3 (consider Stereotactic Radiosurgery or boost post
whole brain radiotherapy)
Intent: Palliative RCR Category status: 3
1. Localisation Method Stereotactic Radiosurgery (SRS) is suitable for single or limited number
of metastases each ≤3cm max diameter when surgery is not appropriate and
systemic disease controlled or potentially controlled.
2. Planning Technique Planning MRI with image registration

SRS – MRI – co-registration or CT plans
3. Immobilisation Radionics frame (relocatable) and treat on Varian linac
Method
4. Volume Definition and SRS – GTV = enhancing lesion

CTV = GTV
PTV = CTV + 2mm
Critical Structures Brain stem, optic chiasm and nerves, cochlear
5. Dose and SRS – 15/17.5Gy / 1#
Fractionation
6. Special Instructions Steroid – Dex cover, overnight stay post.

Follow up 4/52 post radiotherapy then 3/12 and 6/12.

References

Tumour Group: CNS

Tumour: BRAIN METASTASES – Multiple – Whole Brain Radiotherapy (WBRT)
1. Localisation Method WBRT – Orfit cast – simulator planning same technique for
NB. Prophylactic Cranial Irradiation (PCI) – see small cell lung cancer
2. Planning Technique Simulator planning. Parallel opposed pair (Reids line avoiding eyes)
3. Immobilisation WBRT – Orfit shell – treat on Cobalt or low energy Linac

Method
4. Volume Definition and GTV = Whole cranium, inferior border Reids line = 50% of iso dose
Critical Structures Eyes
5. Dose and WBRT
Fractionation 1. Uncontrolled peripheral disease and multiple mets – 20Gy / 5# / 5days
(Grade A)
1a. Major co-morbidities – 12Gy / 2# / 1week (Grade B)
2. Controlled peripheral disease (prognosis >6/12 – 30Gy / 10# / 2weeks)
or if considering SRS and post excision of sol met.
6. Special Instructions Consider Dexamethasane
TLD eyes
In very palliative cases avoid eyebrows
References Royal College of Radiologists (RCR) – Dose-Fractionation 2006

Tumour Group: CNS

Tumour: EPENDYMOMA
Ependymomas in childhood are treated as per UKCCCR protocols.
Ependymomas in adults are treated as follows:
1. Localisation method AcQSIM + MR fusion.
Whole CNS is incorporated for disseminated and stage III and infratentorial
disease.
2. Planning technique Planned non-coplanar fields, Spinal fields, Supine – please refer to whole
CNS protocol (TWJSPCNS)
3. Immobilisation Treatment shell
method
4. Volume definition and For stages I-IV supratentorial

critical structures GTV = tumour
PTV = GTV + 2cm margin
For disseminated and stage III and infratentorial
Whole CNS
5. Dose and Local RT: 54-60Gy / 30# / 6weeks
Fractionation Whole CNS: Phase 1 – 35Gy / 21# / 3.5weeks
Phase 2 – Posterior fossa boost – 20Gy / 12# / 2.5weeks
6. Special Instructions

References

Tumour Group: CNS

Tumour: GLIOMA (ASTROCYTOMA & OLIGODENDROGLIOMA)
HIGH GRADE III OR IV AS PER CENTRIC
Intent: Radical or Palliative RCR Category status: 1 / 2 / 3
1. Localisation Method Radical: CT Plan (+ MR co-reg if not well seen on prior CT scan).
Planned fields.
Palliative: Poor prognosis + RPA status. Suitable for Cobalt + orfit
fixation. CT planned as per brain metastasis.
2. Planning Technique Planned fields
Poor prognosis – lateral opposed fields
3. Immobilisation Perspex shell or Orfit cast
Method
4. Volume Definition High grade – Radical (Pre-op Bx only)
Single phase - GTV = enhancing lesion post resection. Surgical tumour bed
plus any residual enhancing tumour on planning scan.
CTV = Margin 2-3cms can be reduced in anatomical boundaries where
spread unlikely eg bone. Post-op image important to take into account any
shift of tumour bed post-op.
PTV = CTV + 0.5cm
Eyes/lens/lac glands, optic nerves and chiasm, pituitary, brain stem and
Critical Structures
cochlear.
5. Dose and 60Gy / 30#
Fractionation Retreat (limited volume after extended duration of survival) 50Gy / 30#
Over 70yrs – 45Gy / 20# / 4weeks
In older patients with poor prognosis – 40Gy / 15# / 3weeks or 30Gy / 10# /
2weeks
6. Special Instructions Concurrent Temodol for Grade IV, PS 0 + 1.
Provide ‘Radiotherapy to the Brain’ information leaflet.
Follow up – Post RT with MRI and repeat 6/12 with scan.
7. Clinical Trials and Centric (Stupp 2004)
References Avaglio

Tumour Group: CNS

Tumour: GLIOMA (ASTROCYTOMA & OLIGODENDROGLIOMA)
LOW GRADE I OR II – ASTRO (A), OLIGO (O) AND MIXED (OA)
1. Localisation Method CT + MRI fusion
(T2) + series
2. Planning Technique Planned non-coplanar fields
3. Immobilisation Perspex shell or Orfit cast

Method
4. Volume Definition Low Grade as per BR13 study
GTV = High signal intensity on T2 sequence or FLAIR corresponding to
hypodense area on CT image including any enhancement on CT.
In post-op essential to use post-op images.
CTV = GTV – 1.5-2cm – across midline only when midline structure eg
corpus collosum is invaded. 5mm sufficient in anatomical boundaries eg
tentoria and meningies.
PTV = 0.5-0.7mm – for treatment uncertainties
Critical Structures
Brain stem – contralateral >50-60% of total dose
Eyes/ lens - >5Gy, retina <40Gy, pituitary gland, ear,
optic chasm/nerves/brain stem – No >107% of 55gy
5. Dose and 50.4Gy / 28# / 5½ weeks
Fractionation 54Gy / 30# - poor prognosis eg enhancement imaging - indicates “high”
grade
6. Special Instructions Provide ‘Radiotherapy to the Brain’ information leaflet.
7. Clinical Trials and BR13 - closed

References

Tumour Group: CNS

Tumour: MALIGNANT SPINAL CORD COMPRESSION
1. Localisation method Simulator planning based on recent MRI (or CT if contraindicated)
2. Planning technique Single posterior field (under couch) or lateral fields possible for cervical
cord
Occasionally ant/post if bulky anterior disease
Including one vertebra either side of MRI (or good quality CT) abnormality
8 to 9cm wide (cervical-lumbar) with extension to cover lateral disease
Prescribe at 5-8cm depending on particular level of cord (cervical-lumbar)
– measured on MRI/CT.
3. Immobilisation Simple immobilisation
method Mattress used for comfort
4. Volume definition and
critical structures
5. Dose and Good prognosis, i.e. patients presenting with good performance status:
Fractionation either ambulant or with only a short history (< 24 hours) of immobility
20Gy / 5# / 5days (RCR Grade C )
30Gy / 10# / 2weeks (RCR Grade C)
Poor Prognosis, i.e. patients expected to live < 6 months and who have a
poor chance of neurological recovery. In practice this group includes those
with established paraplegia for more than 24 hours. Main aim of treatment
is relief of pain
8Gy / 1# (RCR Grade C)
6. Special Instructions Nurse flat until after ½ of treatment
Dexamethasone 16mg daily initially, reduce over 5-7 days then stop (NICE
clinical guidance 75, Nov 2008)
7. Available trials SCORAD

Tumour Group: CNS

Tumour: MENINGIOMA
1. Localisation method Stereotactic frame or shell
MRI and image registration
2. Planning technique Single phase avoiding critical structures if possible
3. Immobilisation Stereotactic frame (Radionics or Headfix) or shell depending on intended

method treatment volume and patient’s dental condition.
4. Volume definition and GTV = tumour

PTV = GTV + clinical and setup margin
Please refer to volume definitions appendix
Critical structures Eyes, optic nerves and chiasm, pituitary, brain stem
5. Dose and Benign - 54Gy / 30# / 6weeks
Fractionation Atypical/Malignant (Grade II or III) - 60Gy / 30# / 6weeks (if optic
nerve/chiasm not involved)
6. Special instructions TLD eyes if beam is near eyes

References

Tumour Group: CNS

Tumour: OPTIC NERVE GLIOMA – UNDER DEVELOPMENT – REQUIRES CONCESSION
1. Localisation method
2. Planning technique
3. Immobilisation
method

critical Structures
5. Dose and
Fractionation
7. Clinical Trials and

References
Date of approval by Lead Clinician/TSG: XX/XX/XXXX

Tumour Group: CNS

Tumour: ORBITAL TUMOURS – Exopthalmosis (bilateral treatment)
Intent: Radical / Palliative RCR Category status: 1 / 2 / 3
1. Localisation Method CT simulator scan
2. Planning Technique CT Planning

Parallel opposed field with central blocking to avoid lens
3. Immobilisation Perspex shell
Method
4. Volume Definition and Field size 4 – 4.5cm x 8 or 9cm

Critical Structures Central axis is clearly defined line posterior to lens.
5. Dose and 20Gy / 10# / 2weeks
Fractionation
6. Special Instructions TLD eyes
7. Clinical Trials and NB. Other orbital tumours eg uveal melanoma – consider protons
References

Tumour Group: CNS

Tumour: PITUITARY
1. Localisation method MRI + CT plan image registration
2. Planning technique Conformal

3 field isocentric technique – 2 laterals and a superior field
3. Immobilisation Headfix stereotactic frame (or shell if not dentate)
method
4. Volume definition and GTV = tumour

PTV = GTV + clinical and setup margin
Please refer to volume definitions appendix
Critical structures Optic nerve, optic chiasm

5. Dose and 45Gy / 25# / 5weeks (Grade C)
Fractionation
6. Special instructions Provide ‘Radiotherapy to Brain’ information leaflet

References

Tumour Group: CNS

Tumour: PRIMARY CNS LYMPHOMA
1. Localisation method Simulate and scan according to TWJSPCNS
2. Planning technique Lateral opposed fields to ‘Helmet’ only

Whole CNS if positive cytology or spinal disease
3. Immobilisation Perspex shell, supine as per TWJSPCNS
method
4. Volume definition and Helmet – whole head down to C2 (optional phase II boost if primary seen
Critical Structures to be localised)
Whole CNS standard technique as per TWJSPCNS
5. Dose and Phase I (helmet) – 45Gy / 25# / 5weeks
Fractionation Phase II (primary lesion + 20mm margin) – 9Gy / 5# / 1week
Whole CNS – 35Gy / 21#
Posterior fossa boost – 20Gy / 12# / 2.5weeks
6. Special Instructions See also specialist planning technique instructions

References

Tumour Group: Gastrointestinal

Tumour: ANAL CANAL/ANAL MARGIN
Intent: Radical RCR Category status: 2 or 3
1. Localisation method CT SIM or SIM and Virtually simulated
Palpable nodal masses and margin tumours marked with wire
2. Planning technique All prone if possible with full bladder
1) Small tumours grade I or 2/T1N0M0/T2 <3cm N0M0
3 Field (post + 2 laterals)
2) Standard treatment all grades (T2 >3cm / T3-T4N0M0/ grade 3 T1)
2 phases – I – ant and post – large parallel opposed fields
II – 3 fields – post + 2 laterals or ant post to cover nodes
3. Immobilisation Usually prone unless unstable or unable to lie prone. Allows position of
method bolus (wax)
Supine if nodal boost required.
4. Volume definition and 1. Small tumours (grade I – 2/ T1N0M0 / T2 <3cm N0M0)
critical structures GTV = All macroscopic disease
CTV = GTV + 2.5cm margin
PTV = CTV + 5mm margin
2. Standard treatment
Here field borders are indicated as defined in ACT II protocol, this
incoporates GTV, CTV + PTV Phase I and II.
For Phase II PTV represents 3cms expansion on GTV.

5. Dose and 1. Small tumours : 45 / 20# / 2weeks – as ACT I

Fractionation plus iridium boost (15-20Gy in patients with persistent
disease at EUA – 4 - 6 weeks)
or 50Gy / 20# if no boost appropriate
2. Standard : I – 30.6Gy / 17# / 23days
II – 19.8Gy / 11# / 15days
NB. If large fields need to be avoided for phase II – consider electron
boost to nodes and 3 field plan to primary.
1. Palliative patients :
In frail patients who cannot tolerate chemotherapy a single phase I planned
treatment (see above) is possible either parallel opposed pair or 3 field plan
depending on bulk of disease.
2. SPLIT course
Some frail patients benefit from an unfashionable SPLIT course.
Vancouver Technique (Ref). Planning as ACT II for Phase I and II.
Dose fractionation: Phase I – POP – 26Gy / 13# / 17days, 5FU/mito week 1
If tolerates well can proceed to Phase II and convert no radical after 3½
weeks: Phase II – 3 field 24Gy / 12# / 16days, 5FU/mito week 1.

References ACT I, ACT II, Vancouver Technique – B. Cummings


Tumour: OESOPHAGEAL CARCINOMA
1. Localisation method Combination of:
Barium swallow (caution if risk of aspiration)
Position of stent
Diagnostic CT + OGD report (PET if available)
2. Planning technique Simple palliation – conventional simulator planning – POP AP pair
Complex palliation may be planned as per radical treatment*
3. Immobilisation Stable supine, arms by side
method
4. Volume definition GTV = gross primary disease / area of bulk disease causing symptoms
CTV = GTV + 1cm in all directions at discretion of clinician to take
account of total volume + condition of patient
PTV = CTV + 1cm
Critical structures Lungs, Spinal cord, Kidneys

5. Dose and 40Gy / 15# / 3weeks if small tumour and minimal metastases*
Fractionation 30Gy / 10# / 2weeks (Grade D)
20Gy / 5# / 1weeks (Grade D)
Brachytherapy alone – 10Gy to 1cm (Grade B) – good for haemostasis
6. Special Instructions 2x weekly weight
Dietician referral

References


Tumour: OESOPHAGEAL CARCINOMA
Intent: Radical (FIT PATIENTS) RCR Category status: 1
1. Localisation method Combination of:
Barium swallow (caution if risk of aspiration)
Stent position
Diagnostic CT
OGD report and PET images or MRI
2. Planning technique CT/Sim – 3D CT Planning
Consider IV contrast to delineate pulmonary artery
3. Immobilisation Stable supine position. Usually on QUEST board with arms up. Indexed
method knee and foot supports
4. Volume definition and GTV = gross primary + nodal disease – defined on planning CT
incorporating information from CT, PET, MRI, OGD, EUS and Barium
CTV = GTV + margin of up to 1cm radially (modified posteriorly where
closer than 1.3cm) and 2cm sup/inf – along the line of the oesophagus.
For tumours within 2cm of OGJ the CTV extends 2cm but includes mucosa
of stomach in direction of nodal stations on the lesser curve.
PTV = Radical PTV = CTV + 5mm
Critical Structures = Sup/inf PTV = CTV + 10mm
Lungs – V20, Spinal cord <80% (40Gy) , Kidneys, heart v80% (v40Gy)
<30% - see SCOPE I trial
5. Dose and Primary chemoradiotherapy – As per SCOPE I trial
Fractionation 50Gy / 25# / 5weeks – with neoadjuvant and concurrent Cisplatin +
Capecitabine or 5FU (Grade B)
MODIFIED RADICAL – For small localised tumours in elderly or frail
patients unfit for true radical treatment or chemotherapy – 40Gy / 15# /
3weeks – boost to compensate for lack of chemo with HDR brachy boost
(10Gy to 1cm from central axis) within 7 days of XRT.
Some poor performance status patients but with good cardiac and renal
function may be considered for 40Gy / 15# / 3weeks + 1 cycle concurrent
Cisplatin/5FU in week 1. Ref: Walsh.
6. Special Instructions 2x weekly weight
and Dietician referral
Provide ‘Radiotherapy to the Oesophagus’ information leaflet
Follow-up 4/52; 3/12 for 1year then 6/12 for 5years.

7. Clinical Trials and SCOPE 1

References


Tumour: PANCREAS – UNDER DEVELOPMENT – REQUIRES CONCESSION
Intent: Radical or Palliative RCR Category status: 2 or 3
1. Localisation method
2. Planning technique
3. Immobilisation
method

Critical structures
5. Dose and Radical: 50Gy/25#

Fractionation Palliative: 30Gy/10#
7. Clinical Trials and See ESPAC5

References
Date of approval by Lead Clinician/TSG: XX/XX/XXXX


Tumour: RECTUM
1. Localisation method CT, use of oral contrast for post-op or risk of adhesions unless specific
contraindications, comfortably full bladder
2. Planning technique 3 field technique
3. Immobilisation Prone position if possible. Belly board in selected patients to minimize
method small bowel toxicity, ankle stocks (if appropriate shape)
4. Volume definition Preoperative
All radical patients should be CT planned or virtually simulated. The
Clinical target volume should include the gross tumour, the mesorectum,
presacral space and internal iliac lymph nodes. A 1cm margin is added to
the CTV to obtain the PTV. ¹
Post Operative: The Clinical target volume should include tumour bed,
presacral, internal iliac lymph nodes and inferior pelvic space for low rectal
cancers. NB. Pre-op oral barium required to delineate small bowel. Wire
on perineal scar.
Critical Structures Small bowel (v15< 120cc if small bowel outlined)²

5. Dose and Short course preoperative radiotherapy:

Fractionation 25Gy/ 5# / 1week (Grade A) - Surgery should take place within 7 days of
short course pre-op radiotherapy, should be treated Mon-Fri.
Long course preoperative radiotherapy:
45Gy/25#/5 weeks (Grade A) with concurrent chemotherapy +/- boost
For late T3 and T4 tumours and for patients with pelvic side wall lymph
nodes, a smaller volume external beam boost or brachytherapy boost
should be considered. Patients with circumferential tumours are not suitable
for brachytherapy boost.³
 5.4-9Gy/3-5#/3-5 days (RCR Grade A) – boost must exclude small
bowel or
 HDR brachytherapy 10Gy @ 10mm from surface
Postoperative radiotherapy:
45Gy/25#/5wks (RCR Grade B) +/- boost 5.4-9 Gy/3-5#/3-5 days – boost
must exclude small bowel
 10-15Gy to gross macroscopic disease or HDR as above
If unfit for chemotherapy, e.g. ischaemic heart disease, older patients
45Gy/20#/4wks
39Gy/13#/3wks +/- boost
Papillon 30-60Gy/1-2#/14days or HDR as above
Palliative Treatment
‘Radical’ Palliation: 45Gy/20#/4wks or 45Gy/25#/5weeks +/- chemo +/-
boost as above
Simple palliation 10Gy / 1#, 20Gy / 5# / 1week, 30Gy / 10 / 2weeks
6. Special Instructions Concurrent chemotherapy = 5Fu days 1-4 and 29-33 or oral Capecitabine
on the days of radiotherapy only
Comfortably full bladder for radical treatments
Provide ‘Radiotherapy to the Bowel’ information leaflet
References 1. Myerson et al. A radiation therapy oncology group consensus panel
contouring atlas IJROBP Vol. 74 (3) 824-830; Roels et al. Definition and
delineation of the clinical target volume for rectal cancer IJROBP Vol. 65
(4) 1129-1142
2. QUANTEC. Kavanagh et al. Radiation dose–volume effects in the
stomach and small bowel. IJROBP Vol. 76 (3) S101-107
3. German study- pre op vs. post op, 50.4Gy/28# vs. 50.4Gy/28# plus
5.4Gy/3# respectively; Sauer et al. Preoperative versus Postoperative
Chemoradiotherapy for Rectal Cancer. NEJM 2004 Vol. 351: 1731-40
Date of approval by Lead Clinician/TSG: Awaiting final TSG approval


Tumour: STOMACH – REQUIRES CONCESSION FOR RADICAL
Adjuvant postoperative radiotherapy or chemo-radiotherapy is only recommended for high risk
patients with a clear margin of resection. The treatment can be very toxic and requires a patient
with good performance status and intensive support during and after treatment
Palliative treatment can be useful in selected cases
1. Localisation method Empty stomach
2. Planning technique Palliative - Parallel opposed pair

Radical - Conformal
3. Immobilisation Knee support and ankle stocks
method

Critical structures
5. Dose and Palliative: 30Gy / 10# / 2weeks or 20Gy / 5# / 1week

Fractionation
6. Special instructions Post-op: please refer to MacDonald et al technique, NEJM
7. Clinical Trials and MacDonald et al, N Engl J Med. 2002 Jan 17;346(3):210-1.
References

Tumour Group: Genitourinary

Tumour: BLADDER
Intent: Radical and Palliative RCR Category status: TCC 1, other radical 2, palliative 3
1. Localisation method CT scan, image fusion for patients with hip replacement
Empty bladder
2. Planning technique Conformal
3. Immobilisation Supine position, knee and foot supports
method
4. Volume definition and GTV=whole bladder. Margin to PTV=1.5cm. 2 cm margin for a sup tumour
 include prostatic urethra in men, particularly for inferior tumours
 treat with a phase I (whole bladder) and phase II (10-14 Gy, partial
bladder volume) in small localized tumours, in patients with a large
residual volume or diverticulum
 for patients with large residual volume consider indwelling catheter or
treatment of small volume throughout
 pelvic lymph nodes are not routinely treated (for exception see
protocol)
Critical structures Small bowel and rectum. Use dose volume constraints as for prostate if
problematic
5. Dose and Radical: 64Gy / 32#s / 6wks or 55Gy/20#/4wks (Grade B)

Fractionation Palliative: 21Gy / 3# /1 wk (Grade A)
30-36 Gy / 6# / 6 wks, 30-35Gy/10-15#, 10 Gy single #
6. Special instructions Empty bladder, weekly FBC, U+E
Concurrent chemo Cisplatin
Provide ‘Radiotherapy to the Bladder’ leaflet
Cystoscopy 2-4 months after completion of radical radiotherapy
7. Clinical Trials and NCRN SPARE (closed)
References


Tumour: PENIS
1. Localisation Method Clinical examination of patient by consultant.
2. Planning Technique Laterally opposed fields, 100SSD with wax block and wax plug.
3. Immobilisation Wax block and wax plug encasing penis fastened to immobilise.
Method Supine.
4. Volume Definition and Clinically assessed dependent on tumour and patient anatomy.
Critical Structures Ensure penis is held away from the abdomen by wax collar in wax block.
5. Dose and 50-55Gy /20#/ 28days - midplane
Fractionation
6. Special Instructions Needs floor clinic review weeks 3 and 4.

References


Tumour: PROSTATE
Intent: Radical or palliative RCR Category status: 2 or 3
Referral Criteria: low risk group (PSA<10ng/ml and Gleason score≤6 and T1-T2a),
intermediate risk group (PSA10-20ng/ml or Gleason score 7 or T2b-c),
high risk group (PSA > 20ng/ml or Gleason ≥8ng/ml or T3-T4)
1. Localisation method CT, use MRI/CT image fusion for patients with unilateral or bilateral total
hip replacement
Use Relaxit and drinking protocol. If distended rectum at planning and no
gold seed markers give instructions for low residual diet and laxatives,
rescan after 1 week. No contrast.
2. Planning technique Standard/palliative dose: Conformal CT planned
Dose escalated: Forward or inverse planned IMRT if dose constraints not
reached
Prostate and Pelvic lymph nodes: Rapid Arc IMRT
Postoperative: conformal CT planned
3. Immobilisation Ankle stocks and knee support – supine position
method

4. Volume definition and Dose escalation:

Low risk:
GTV1 = CTV1 = prostate
GTV2 = CTV2 = prostate and base of seminal vesicles
No Fiducial Markers Fiducial markers and daily IGRT
PTV1 CTV1 + 5mm CTV1 + 3mm
Moderate risk:
GTV1 = CTV1 = Prostate and base of Seminal Vesicles
GTV2 = CTV2 = Prostate and Seminal Vesicles
No Fiducial Markers Fiducial Markers and daily IGRT
High risk:
Consider Pelvic Lymph Node RT in fit patients; otherwise treat as per
moderate risk group.
GTV1 = CTV1 = Prostate and base of Seminal Vesicles
GTV2 = CTV2 = Prostate and Seminal Vesicles
GTV3 = CTV3 = Pelvic Lymph Nodes
PTV1 CTV1 +5mm
PTV2 CTV2 +10mm
PTV3 CTV3 +5mm
Low dose protocol:

GTV = CTV = Prostate and (base of) Seminal Vesicles
PTV CTV + 10mm
Postoperative:
GTV = CTV = Prostatic bed including ureteric resection, base of Bladder
and Seminal Vesicles
PTV CTV + 10mm
Critical structures Rectum: Outlined 10mm above and below PTV (Prostate and Seminal
Vesicles)
Small Bowel (if within 1cm of PTV): Outlined 10mm beyond any PTV
Bladder
Femoral Heads

The Dose Constraints to Critical Structures are based on the CHHIP trial.
Rectum
Dose For % of total dose Relative max Volume (%)
74/37 72/32
50.3 47.6 68% 60%
60.0 56.7 81% 50%
65.1 61.6 88% 30%
70.3 66.5 95% 15%
74.0 72.0 100% 3%
Bladder
74/37 72/32
50.3 47.6 68% 60%
60.0 56.7 81% 25%
74.0 72.0 100% 5%
Small bowel
74/37 72/32
45.1 42.1 61% 78cc
50.3 47.6 68% 17cc
54.7 51.8 74% 14cc
60.0 56.7 81% 1cc
65.1 61.6 88% none
Femoral head
74/37 72/32
50.3 47.6 68% 50%
5. Dose and Dose escalation: All treatments are prescribed in 32 fractions.

Fractionation The PTV doses are as follows:
PTV1 = 72 Gy (min 68.4Gy, max 75.6Gy, median 72Gy)
PTV2 = 64 Gy (min 60.8 Gy, median 64Gy)
Where pelvic lymph nodes are included:
PTV3 = 50Gy (min 48Gy, median 50Gy)
Low dose protocol: 30-36 Gy in 6 fractions in 6 weeks or

64 Gy in 32 fractions in 6 weeks
Postoperative: 66 Gy in 33 fractions
6. Special instructions Provide patient with ‘Radiotherapy to the Prostate’ and ‘Patients receiving
radiotherapy to the prostate – preparation for planning and treatment’
information leaflets
Tamsulosin for obstructive bladder symptoms,

7. Clinical Trials and NCRN CHHIP, RADICALS

References


Tumour: TESTICULAR (seminoma)
Intent: Radical RCR Category status: 1 / 2 / 3
1. Localisation method CT scan and virtual simulation
2. Planning technique Parallel opposed pair
3. Immobilisation Supine, knee supports, ankle stocks

method
4. Volume definition and Stage I with no risk factors: para-aortic node from D10/11 to L5/S1
Critical structures Stage I with risk factors para-aortic and ipsilateral pelvic nodes : D10/11 to
ipsilateral groin
Stage II A/B or residual disease post chemo: define nodes on CT scan
5. Dose and Stage I with no risk factors for pelvic node disease
Fractionation POP 20Gy / 10# / 2weeks
Stage I and Stage IIA or IIB seminoma with risk of pelvic node disease
30Gy / 15# / 3weeks
6. Special instructions Radiotherapy as adjuvant treatment for stage I seminoma is only used if
there is a contraindication for adjuvant single agent carboplatin

References
Comments Radiotherapy is an effective treatment modality for relapsed, chemo

resistant disease either with non seminomatous and seminoma histology.
Planning method, volume and dose needs to be individualised.

Tumour Group: Gynaecological

Tumour: CERVIX
1. Localisation method CT with contrast as appropriate. Full bladder
2. Planning technique Radical Planning

Conformal
Palliative Planning
Conformal or virtual simulation or simulator
3. Immobilisation Supine position, knee and foot supports, arms on chest
method
4. Volume definition and Outline gross tumour and enlarged nodes (GTV). Field should be at least to
Critical Structures L5 superiorly, in case of vaginal involvement 2-3cm below the lower extent
of disease. Lateral border 1cm beyond pelvic brim. Posterior border at
junction of S2 and S3 vertebrae or 2cm anterior to the most concave part of
anterior sacrum. Take into account MRI images to cover the sacrum if
necessary.
Upper border top of sacrum, lower border at bottom of Obturator foramen.
In case of vaginal involvement, 2cm-3cm below the lower extent of
disease.
5. Dose and 45Gy / 25# / 35days (Grade B)
Fractionation + Brachytherapy: HDR – 21Gy / 2# to point “A”
If bulky lymph nodes
Consider 50.4Gy / 28# / 38days (Grade B)
+ Brachytherapy: HDR – 21Gy / 3# to point “A”
+/- parametrial boost if disease extends to parametrium – 5.4Gy/ 3# / 3days
If brachytherapy not appropriate consider a small volume EBRT boost as
phase 2, dose 14.4-16Gy / 8#
For patients with locally advanced disease concomitant platinum based
chemotherapy is recommended (Grade A).
Palliative
20Gy / 5# / 7days or 30Gy / 10# / 14days
8-10Gy / 1# - this can be repeated if necessary
6. Special Instructions Provide ‘Radiotherapy to the female pelvis’ information leaflet
Gynae CNS support and use of vaginal dilators
References


Tumour: ENDOMETRIUM
Intent: Adjuvant or Palliative RCR Category status: 2 or 3
1. Localisation method Adjuvant: CT for field definition for virtual simulation
Palliative: simulator for AP POP
2. Planning technique Virtual simulation – 3 or 4 fields to pelvis. Or AP POP
3. Immobilisation Supine with knee and foot supports. Arms on chest, comfortably full
method bladder.
4. Volume definition and Adjuvant radiotherapy to pelvis: PTV includes upper half of vagina,
lower common iliac, external iliac and internal iliac nodes. Laterally PTV
bisects S2/S3 and anteriorly to the anterior aspect of symphisis pubis.
Shielding to normal tissues as appropriate
Superiorly – include top of sacrum
Inferiorly – include upper half of vagina
Laterally – 1cm clear of pelvic side walls
Palliative radiotherapy: PTV – encompassing gross disease using smaller
field sizes to minimise acute toxicity
Critical structures Small bowel
5. Dose and Adjuvant radiotherapy: 45Gy/25# (Grade C)

Fractionation HDR to vault - 6Gy at 5mm from applicator surface treating top 2-4cm
Radical radiotherapy: external beam as per adjuvant followed by HDR –
6Gy x 2 fractions at the uterine serosa
Pelvic recurrences in untreated patients: external beam as per adjuvant
radiotherapy followed by HDR to vault – 6Gy x 2 fractions at 5mm
Palliative radiotherapy: 20Gy/5#, 30Gy/10#, 40Gy/15#, 8-10Gy/1#,
single HDR insertion for vaginal bleeding
6. Special instructions Provide ‘Radiotherapy to the female pelvis’ information leaflet
7. Clinical Trials and PORTEC-3 (see trial protocol for planning and dose specifications)
References


Tumour: OVARY
Intent: Palliative RCR Category status: 2 or 3
1. Localisation method CT scan for field definition using virtual simulation
2. Planning technique AP POP or 4 field
3. Immobilisation Supine, knee and foot supports

method
4. Volume definition and Gross tumour with 2cm margin

Critical structures
5. Dose and 30Gy / 10# over 14 days

Fractionation 8Gy / 1#
6. Special Instructions Small volume if treating pelvis to reduce morbidity

References


Tumour: VAGINA
1. Localisation method CT scan for field definition using virtual simulation
2. Planning technique Dependent on anatomical site of primary:

AP POP if inguinal lymph nodes included in field
4 fields for mid/upper vaginal disease
3. Immobilisation Supine, arms by side, radio-opaque marker at introitus
method
4. Volume definition and GTV primary disease identified using clinical examination/EUA/imaging
CTV depends upon position of tumour, as differing lymphatic drainage
lower 1/3 vagina to include whole vagina and inguinal nodes
middle and upper vagina to include whole vagina, internal, external and
common iliac nodes
Critical structures Small bowel

5. Dose and Phase 1 45Gy/25#
Fractionation Phase 2 14-16Gy/7-8#
6. Special instructions Provide "Radiotherapy to female pelvis" information leaflet

Gynae CNS support and use of vaginal dilators
References


Tumour: VULVA
1. Localisation method CT can for field definition using virtual simulation
2. Planning technique Radio-opaque marker is used to define extent of palpable disease and
lymph nodes.
AP POP or direct field in case of primary disease when no need to treat
nodes.
3. Immobilisation Supine, arms across chest with comfortably full bladder
method
4. Volume definition and Radical Treatment
Critical structures Initial volume – gross tumour and sites of potential microscopic disease
Usually parallel opposed fields
Superior border – 2cm above inferior border of SI joint
Inferior border – 2cm below inferior extend of disease
Lateral border – include all of femoral neck
Fields can be weighted anteriorly to improve dose distribution
Electrons can be used to treat groin nodes
Adjuvant Treatment – Positive Groin Nodes
Fields as for radical treatment but shield vulva if possible ie clear margins
Inguinal nodes – inferior border 2cm inferior to lesser trochanter
Close or +ve margins with –ve groin nodes
Treat tumour bed with 2cm margin
Nodal areas not treated
Un-dissected Groin
When using electrons CT/MRI images are helpful in choosing appropriate
energy.
Palliative Volume
Small fields to cover gross tumour and margin

5. Dose and Radical schedules

Fractionation 45Gy / 25# / 5weeks followed by boost: 16Gy / 8# (Grade B)
50.4Gy / 28# / 5.5weeks with chemotherapy (Grade B)
Adjuvant
45Gy / 25# / 5weeks
Concurrrent Chemoradiation
50.4Gy / 20# / 5.5weeks with concurrent 5 Fluorouracil infustion plus
cisplatin 60mg/m2 week 1 and 5 Fluorouracil infusion on week 5. A small
volume boost taking the dose to 60Gy can be considered (photons,
electrons or brachytherapy) (Grade B)
Palliative schedules
30Gy / 10# / 2weeks
6Gy weekly over 3-6weeks
10-20Gy / 5# / 1week
8-10Gy single fraction
6. Special instructions Provide ‘Radiotherapy to female pelvis – use of vaginal dilators’

References

Tumour Group: Head and Neck

Tumour: CERVICAL OESOPHAGUS
1. Localisation method CT scan
2. Planning technique Conformal field arrangements:

 Isocentric anterior oblique fields
 Isocentric anterior and posterior fields (phase 1) with IMRT
fields(phase 2)
 Compensators or a double wedge would be used with the anterior
oblique fields
3. Immobilisation Patient supine in treatment shell on 5 point IMRT board
method
4. Volume definition and Dependent upon EUA findings and MRI scans with an adequate margin
Critical Structures
5. Dose and Phase 1: 40-46Gy / 20-23#
Fractionation Phase 2: 18-20Gy / 9-10#
Total – 60-64Gy / 30-32# / 6weeks
6. Special Instructions Usually chemo radiation unless post op

References


Tumour: HEAD AND NECK CANCER GENERAL
Intent: Radical or Palliative RCR Category status: 1 , 2 or 3
1. Localisation method CT Scan +/- MRI for specialised
2. Planning technique As per protocol
3. Immobilisation Perspex shell or orfit cast

method
4. Volume definition and CTV = only macroscopic disease with 2cm margin
Critical Structures
5. Dose and Good performance (WHO 0-2/young patients/prognosis <3months)

Fractionation 40.5Gy / 15# / 21days
30Gy / 6# / 2weeks (max cord dose = 27Gy / 6#)
30Gy / 10# / 2weeks
Stage III or IV (fit patients offered definitive radiotherapy)
Moderately accelerated radiotherapy eg
66-68Gy in 2Gy fractions / x6 a week / over 5.5weeks (Grade A)
72Gy / in 6weeks using concomitant boost (Grade A)
66-70Gy / in 6.5-7weeks plus synchronous chemotherapy (Grade A)
Poor performance (WHO 3-4/elderly/frail patients/prognosis
>3months)
Consider carefully whether radiotherapy is indicated
Anterior neck fields only
An applied dose using 5/6 MV photons with midline shielding to cord. If
significant lymphadenopathy in the lower neck use AP opposing fields
Non-Computed Opposing Fields
Palliative treatment – mid plane dose
6. Special Instructions Consider all appropriate shielding requirements
References


Tumour: LARYNX – GLOTTIC LARYNX (tumour limited to true vocal cords and 5mm below)
1. Localisation method T1 or T2
Simulator (CT scan for those patients with very short neck – PTV + virtual
simulation)
T3 or T4
Simulator – examine patients neck for nodes (CT scan to produce data set
in some circumstances)
2. Planning technique T1 or T2
Simple isocentric lateral fields, single central axis contour (short neck
patients = ant oblique fields, CT scanned + virtually simulated)
T3 or T4
Isocentric lateral fields – large fields may require a CT scan to produce a
data set in order to achieve a uniform homogeneous distribution
3. Immobilisation Supine, clear shell
method Head in neutral position to achieve straight spinal cord. Shoulders
extended towards feet.
4. Volume definition T1 and T2 N0
Superior – Hyoid bone
Inferior – 10mm below cricoid
Anteriorly – clear front of cast
Posteriorly – front of vertebral bodies or to include the anterior ⅓ of
vertebral bodies
T3 or T4
Superior – arch of atlas
Inferior – root of neck
Anteriorly – clear front of cast
Posteriorly – posterior to vertebral bodies or spinous process
Critical Structures Spinal cord

5. Dose and T1 or T2
Fractionation 55Gy/20# /28days (Grade C)
66Gy / 33# / 47days (Grade B)
T3 or T4
Total: 65Gy / 30# / 6weeks - Phase 1: 43Gy / 20# - Phase 2: 22Gy / 10#
(Grade A)
Total: 66-70Gy / 33-35# = 6.5-7weeks - Phase 1: 44Gy / 22# - Phase 2:
22Gy / 11# (Grade A)
Post electron boost: 10Gy / 5#
16Gy / 8# (involved ipsilateral neck +ve)
6. Special Instructions To be weighed weekly
Referral to CNS and/or dietician as appropriate
Provide ‘Radiotherapy to the Head or Neck’ information leaflet
References


Tumour: LARYNX – SUB-GLOTTIC LARYNX
1. Localisation method T1 and T2 N0
Examine patient’s neck for neck nodes.
In simulator determine plane of treatment and produce localisation film.
Simulation with access to previous CT/MRI scans
CT scan – PTV – Virtual Simulated - verified
T3 and T4 node +ve
Examine patients neck (if no neck resection)
CT scan for data set
2. Planning technique T1 and T2 N0
Isocentric lateral opposed fields
More commonly ant oblique fields and 0.5cm of wax on front of cast
T3 and T4 node +ve
Isocentric sup oblique fields (compensators or segmental field technique)
3. Immobilisation Supine – neck extended and shoulders extended towards feet, clear shell
method

Incorporate prophylactic irradiation of 1st station nodes (levels III + IV)
Superior – hyoid bone
Inferior – 2cm below tumour on scan
Anteriorly – to clear front of cast
Posteriorly – back edge of vertebral body
T3 and T4 node +ve
Phase 1: Superior – 2cm above C1/C2 junction
Inferior – to include stoma or 1cm below sSN or below clavicles
to include level IV nodes
Anteriorly – to clear front of cast
Posteriorly – include spinous process of C2
Phase 2: Reduce off cord – add post neck electrons

5. Dose and T1 and T2 N0

Fractionation Total: 63Gy / 30# / 6weeks - Phase 1: 42Gy / 20# - Phase 2: 21Gy / 10#
(Grade B)
Total: 66-70Gy / 33-35# / 6.5-7weeks - Phase 1: 44Gy / 22# - Phase 2:
22Gy / 11# (Grade A)
Anterior split field: 50Gy / 25# / 5weeks
40.5Gy / 15# / 3weeks
Adjacent field dose (post neck off spinal cord): 10Gy / 5#
16Gy / 8#
References


Tumour: LARYNX – SUPRAGLOTTIC LARYNX
1. Localisation method T1 and T2 Node –ve + Node +ve
Examine patients neck (if no neck resection)
CT scan for data set if necessary to produce a homogenous dose
distribution.
T3 and T4
Simulation with access to previous CT/MRI scans. CT scan for data set
2. Planning technique T1 and T2 Node –ve + Node +ve
Isocentric lateral opposed fields – ant split field added if node +ve.
T3 and T4
Isocentric superior oblique fields – compensator technique or segmental
field technique
3. Immobilisation Supine – head in neutral position and shoulders extended towards feet,
method clear shell. NB. Thermoplastic mask for palliative patients

Incorporate prophylactic irradiation of 1st station nodes (levels II & III)
Phase 1:
Superior – 2cm above C1/C2 junction
Inferior – lower border of cricoid or root neck along clavicle
Anteriorly – to clear the front of the cast
Posteriorly – if nodes are present include spinous process of C2. If node -
ve post border lies in front of the vertebral bodies.
Volume of anterior split field
Superior – to match lower border or upper fields
Inferior – to include heads of the clavicles
Lateral – to include medial ⅔ of clavicles
Phase 2 treatment volume if nodes present
Reduced off cord – electron adjacent fields may be used depending upon
nodal disease status.

5. Dose and Total: 63Gy / 30# / 6weeks - Phase 1: 42Gy / 20# - Phase 2: 21Gy / 10#
Fractionation Total: 64Gy / 32# / 6.5weeks - Phase 1: 56Gy / 28# - Phase 2: 8Gy / 4#
(Grade B)
(Grade B)
Total: 70Gy / 35# / 7weeks- Phase 1: 44-46Gy / 22-23# - Phase 2: 20-22Gy
/ 10-11# (Grade A)
Anterior spilt field: 50Gy / 25# / 5weeks
Post electron boost: 10Gy / 5#
16Gy / 8#
References


Tumour: LOWER ALVEOLUS
Intent: Radical RCR Category status: 1 / 2 / 3
1. Localisation method Simulator + CT scan
2. Planning technique Wedged pair or similar
3. Immobilisation Perspex Shell

method
4. Volume definition and Isocentric right-angled wedge pair – depending on nodal status a half
Critical Structures anterior split field may be added
Isocentric lateral/anterior oblique wedge pair – depending upon nodal
status a half anterior split field may be added
Phase 1 treatment volume
Superior – 1.5cm above tumour, for larger lesions, the pterygoids should be
covered
Inferior – hyoid
Anteriorly – symphysis
Posteriorly – to include spinous process of C2
If nodes present add half anterior split field
Superior – to match lower border of lateral fields
Medial – lateral edge of vertebral bodies
If nodes present phase 2 treatment volume
Reduced off cord – electron adjacent fields may be used depending upon
nodal disease status
Fractionation Total: 60-70Gy / 30-35# / 6-7weeks - Phase 1: 44-46Gy / 22-23# - Phase 2:
16-24Gy / 8-12# (Grade A)
40.5Gy / 15# / 3weeks
Adjacent field dose (post neck off spinal cord): 10Gy / 5#
16Gy / 8#


References


Tumour: MAXILLARY SINUS/NASAL CAVITY
1. Localisation method CT planned with contrast (PTV only)
2. Planning technique CT – Isocentric anterior and 2 lateral fields

Segmental field arrangement or IMRT may be required to produce
homogenous plan
3. Immobilisation Supine, Clear shell, Mouth bite – is desirable to spare dose to tongue if
method patient can tolerate it. Head in neutral and comfortable position
4. Volume definition and Governed by PTV. 5mm margin around PTV.

Anterior field
Superior – 1cm above cribiform plate or supraorbital ridge
Inferior – upper alveolus through mouth bite
Medial - contralateral inner canthus
Lateral – to cover gingivo-buccal sulcus
Lateral fields
Anterior – 2cm anterior to tumour
Posterior – to include the pterygoid fossa and lateral retrophayngeal node
Critical Structures Optic nerves, chiasm, brain stem, retina and lens.
5. Dose and Total: 64-70Gy / 32-35Gy / 6.5weeks - Phase 1: 44-46Gy / 22-23# - Phase
Fractionation 2: 20-22Gy / 10-11#
NB – dose may need to be reduced to respect tolerance of critical normal
tissues
6. Special Instructions The dose is biased from the anterior field with a weighting of 2 or 3:1.
References


Tumour: NASOPHARYNX
2. Planning technique Chemo-radiation: Used for stage III/IV patients (1987 UICC) using the
intergroup regime
CT planning is required with MR fusion for image registration.
Delineate targets and organs at risk (OAR)
method
4. Volume definition and GTV= gross tumour and involved nodes

Critical structures CTV1= GTV+5mm (may be reduced to 1mm adjacent to critical OAR)
CTV2= adjacent involved structures and high risk nodes
CTV3= lower risk nodes
PTV1= CTV1+5mm(reduced to 1mm adjacent to spinal cord and/or
brainstem)
PTV2= CTV2+5mm (reduce as above)
PTV3= lower neck fields (conventional)
If nodes present add anterior split field
Superior – to match upper fields
NB – if positive nodes in the lower neck use anterior/posterior fields
5. Dose and Total: 66-70Gy / 33-35# / 6.5-7weeks (Grade A)

Fractionation Anterior split field: 50Gy / 25# / 5weeks
40.5Gy / 15# / 3weeks
If positive nodes in lower neck:
Ant/post fields 50Gy /25#/ 5 weeks Phase I
20Gy/ 10#/ 2weeks Phase II


References


Tumour: OROPHARYNX – BASE OF TONGUE
2. Planning technique Isocentric lateral opposed pair – depending upon disease extent an anterior
split field may be added

method
4. Volume definition and Phase 1 treatment volume
Critical structures Superior – 1cm above base of tongue
Inferior – level of glottis
Anteriorly – to include faucial pillar and portion or oral tongue
Lateral – to include medial ⅔ of clavical
If nodes present phase 2 treatment volume: Reduced off cord
Electron adjacent fields may be used depending upon nodal disease status
5. Dose and 50-55Gy / 20# / 4weeks
Fractionation Total – 63Gy / 30# / 6weeks - Phase 1: 42Gy / 20# - Phase 2: 21Gy / 10#
Total – 66-70Gy / 33-35# / 6-7weeks - Phase 1: 44-46Gy / 22-23# - Phase
2: 20-26Gy / 10-13# (Grade A)
Anterior split field – 50Gy / 25# / 5weeks or 40.5Gy / 15# / 3weeks
Post Electron Boost – 10Gy / 5# (if neck –ve)
References


Tumour: OROPHARYNX – BUCCAL MUCOSA
2. Planning technique Isocentric wedge pair – depending upon nodal status a half anterior split
field may be added
Isocentric lateral opposed pair – depending upon nodal status an anterior
method
4. Volume definition and Isocentric wedge pair fields phase 1 treatment volume
Critical Structures Superior – 2cm above tumour or 1cm beyond graft
Inferior – hyoid
Medially – depends on extend of tumour
Anteriorly – 2cm above tumour or 1cm beyond graft
Isocentric parallel opposed fields phase 1 treatment volume
Superior – 2cm above tumour or 1cm beyond graft
Inferior – hyoid
Anteriorly – 2cm above tumour or 1cm beyond graft
If nodes present add anterior split
Lateral – to include medial ⅔ of clavicle
If nodes present – phase 2 treatment volume: Reduced off cord
Add electron adjacent fields to boost area overlying cord


Fractionation Total – 63Gy / 30# / 6weeks - Phase 1: 42Gy / 20# - Phase 2: 21Gy / 10#
Total – 66-70Gy / 33=35# / 6-7weeks - Phase 1: 44-46Gy / 22-23# -Phase
2: 16-24Gy / 8-12# (Grade A)
Post RT to a total dose of 60-64Gy / 30-32# / 6weeks in one or two phases
Anterior split field – 50Gy / 25# / 5weeks
40.5Gy / 15# / 3weeks
Post boost off spinal cord - 10Gy/5# (non-involved contralateral neck +ve)
16Gy/8# (involved ipsilateral neck +ve)
16Gy electrons / 8# (bilateral neck +ve)
References


Tumour: OROPHARYNX - FLOOR OF MOUTH
2. Planning technique Isocentric lateral opposed pair – for lesions at or crossing midline.
Depending upon disease extent an anterior split field may be added.
3. Immobilisation Mouth bite, Perspex shell
method
4. Volume definition and Phase 1:
Critical structures Superior – through mouth bite
Inferior – Hyoid
Anteriorly – to include palpable disease with a 2cm margin
Posteriorly – to include anterior ⅔ of vertebral goodies or to include
spinous process of C2
Inferior – to include heads of the clavicals
If nodes present phase 2 treatment volume: Reduced off cord – electron
adjacent fields may be used depending upon nodal disease status
5. Dose and Total: 50-55Gy / 20# / 4weeks
20-24Gy / 10-13# (Grade A)
Post RT to a total dose of 60-64Gy / 30-32# / 6weeks in one or two phases
40.5Gy / 15# / 3weeks
Post Electron Boost: 10Gy / 5# (non-involved contralateral neck +ve)
References


Tumour: OROPHARYNX – ORAL TONGUE
2. Planning technique Isocentric lateral opposed pair – depending upon nodal status an anterior
Isocentric right-angled wedge pair – depending upon nodal status a half
anterior split field may be added
method
4. Volume definition and Phase 1 treatment volume
Critical structures Superior – 1.5cm above dorsum of tongue, sparing hard palate if possible
Inferior – vallecula
Anteriorly – to include palpable disease with a 2cm margin
Posteriorly – to mid vertebral unless node +ve when it should include
spinous process of C2
If nodes present phase 2 treatment volume: Reduced off cord – electron
adjacent fields may be used depending upon nodal disease status.
16-24Gy / 8-12# (Grade A)
40.5Gy / 15# / 3weeks
Post Electron Boost: 10Gy / 5# or 16Gy / 8#
References


Tumour: PAROTID GLAND
2. Planning technique Isocentric right-angled wedge pair – depending upon nodal status a half
Isocentric anterior and posterior oblique wedge pair – depending upon
nodal status a half anterior split field may be added
NB –take care to avoid exit of post oblique field through contralateral eye
method
4. Volume definition and Superior – Zygomatic arch or 2cm above most superior extent of disease
Critical Structures (must be inferior to the eyes)
Inferior – hyoid or 1cm inferior to the mandible
Anteriorly – anterior border of the masseter muscle
Posteriorly – through the mastoid process
Medially – the lateral pharyngeal wall or 2cm beyond the medial extent of
the tumour
If nodes present phase 2 treatment volume: Reduced off cord
5. Dose and Total: 66-70Gy / 33-35# / 6-7weeks - Phase 1: 44-46Gy / 22-23# - Phase 2:
Fractionation 20-26Gy / 10-13# (Grade A)
40.5Gy / 15# / 3weeks
References


Tumour: PYRIFORM FOSSA
Intent: Radical RCR Category status: 1 or 2
2. Planning technique Isocentric lateral opposed fields
Isocentric superior oblique fields (compensators would be used)
NB – technique is dependent upon the position of the lower border. If the
supraclaviular fossa needs treating, superior oblique fields should be used
method
4. Volume definition and Small treatment volume
Critical Structures Superior – angle of jaw
Inferior – 1cm below cricoid cartilage
Anteriorly – to clear neck
Posteriorly – to lie in front of the spinal cord
Large treatment volume – Phase 1
Superior – 2cm above C1/C2 junction
Inferior – to include stoma or 1cm below SSN or root of neck – must be at
least 2cm below cricoid cartilage
Anteriorly – to clear the front of the cast
Posteriorly – if nodes are present include spinous process of C2. If no
nodes, post. Border is to lie in front of the vertebral bodies
Phase 2 volume if nodes present: Reduced off cord – electron adjacent
fields may be used depending upon nodal disease status
5. Dose and Total: 65Gy / 30# / 6weeks -Phase 1: 43Gy / 20# - Phase 2: 22Gy / 120#
20-26Gy / 10-13# (Grade A)
Post Electron Boost: 10Gy / 5#
16Gy / 8#
Post RT: 60-64Gy / 30-32# / 6.5weeks in one or two phases
References


Tumour: RETROMOLAR TRIGONE
2. Planning technique Isocentric right-angled wedge pair – depending upon nodal status a half
anterior split field my be added
Isocentric ipsilateral oblique fields – depending upon nodal status a half
method
4. Volume definition and The CTV must extend superiorly to include the madibular ramus because
Critical Structures of the high risk of microscopic spread. The temporomandibular joint
should be avoided if possible to minimise the risk of trismus
Treatment Volume*
Superior – temporomandibular junction
Inferior – hyoid
Anteriorly – masseter muscle
Posteriorly – mid vertebral body
If nodes present add half anterior split field
Superior – to match lower border of upper fields
Fractionation Total: 66Gy / 33# / 6.5wks - Ph1: 44Gy / 22# - Ph 2: 22Gy / 11# (Grade A)
Half anterior split field: 50Gy / 25# / 5weeks or 40.5Gy / 15# / 3weeks
References


Tumour: SOFT PALATE
Isocentric right-angled wedge pair – depending upon nodal status a half
method
4. Volume definition and Lateral fields phase 1 treatment volume
Critical Structures Superior - Zygomatic arch
Inferior – hyoid
Anteriorly – 2cm anterior to tumour
Posteriorly – spinous process of C2
Phase 2 treatment volume if nodes present: Reduced off cord – electron
Wedge pair phase 1 treatment volume
Superior – Zygomatic arch
Inferior – hyoid
Anteriorly – 2cm anterior to tumour
Posteriorly – centre of vertebral bodies
Medially – midline to 2cm beyond midline
Primary disease only


Fractionation Total: 63Gy / 30# / 6weeks - Phase 1: 42Gy / 20# - Phase 2: 21Gy / 10#
Total: 66Gy / 33# / 6.5weeks - Phase 1: 44Gy / 22# - Phase 2: 22Gy / 11#
(Grade A)
Anterior split field: 50Gy / 25# / 5weeks or 40.5Gy / 15# / 3weeks
References


Tumour: THYROID
2. Planning technique Isocentric anterior oblique wedge pair
Isocentric anterior and posterior opposed fields
Consider use of 2:1 weighting ant/post
method
4. Volume definition and Anterior Oblique Fields
Critical Structures Superior – mastoid tip
Inferior – carina
Posterior – anterior to spinal cord
Anterior and Posterior Opposed Fields
Phase 1
Superior – mastoid tip
Inferior – carina
Lateral – medial ⅔ of clavicle
Phase 2
A more localised volume to bulk disease
Fractionation Total: 60-64Gy / 30-32# / 6.5weeks in one or two phases
References


Tumour: TONSIL
Isocentric anterior and posterior oblique wedge pair – depending upon
nodal status a half anterior split field may be added.
method
4. Volume definition and Wedge Pair Phase I treatment volume
Critical Structures Superior – top of the hard palate
Inferior – bottom of the hyoid bone
Anteriorly – middle ⅓ of the tongue
Posteriorly – just in front of the spinal cord
Medially – midline of palate
Primary disease only
Lateral opposed fields Phase I treatment volume
Superior – top of the hard palate
Inferior – bottom of the hyoid bone
Anteriorly – middle ⅓ of the tongue
Phase 2 treatment volume if nodes present: Reduced off cord – electron

5. Dose and Total: 63Gy / 30# / 6weeks - Phase 1: 42Gy / 20# - Phase 2: 21Gy / 10#
Fractionation Total: 66Gy / 33# / 6.5weeks - Phase 1: 44Gy / 22# - Phase 2: 22Gy / 11#
(Grade A)
40.5Gy / 15# / 3weeks
Post Electron Boost: 10Gy / 5#
16Gy / 8#
References

Tumour Group: Lung

Tumour: MESOTHELIOMA
1. Localisation method Simulator or planning scan no localisation required (drain site)
2. Planning technique Template to mark area for treatment
3. Immobilisation Radical : Lung board, knee and foot supports

method Palliative : As appropriate for comfort and stability
4. Volume definition and Symptomatic (eg pain, SVC, oesophageal obstruction)
Critical structures
5. Dose and Tumour masses – 20-25Gy / 5# / 1week or 30-32.5Gy / 10# / 2weeks

Fractionation Hemi-thorax – 12.5-20Gy / 5# / 1week (12.5Gy/5# may be given at same
time as chemotherapy is troublesome local symptoms and immediate
chemotherapy required)
To intrathoracic drains, biopsy sites etc (unless life expectancy
<3months)
10-12Gy / 1# (MV or HVX)
12.5Gy / 1# (Cobalt) with 0.5cm bolus
Thoracotomy scars – 25Gy / 5# / 1week, tangent pair or electrons with
bolus (eg post decortication)

References

Tumour Group: Lung

Tumour: NON-SMALL CELL LUNG
1. Localisation method CT scan or Simulator planning dependent on stage or 4D scan dependent
on site in lung – fluoroscopy to check tumour motion where significant
respiratory motion suspected prior to 4D scanning.
2. Planning technique Radical: Conformal
Palliative: Conformal or simple AP parallel pair (as appropriate for
comfort and stability)
3. Immobilisation Lung board - Additional immobilisation device if stereotactic body
method radiotherapy is used. Please see SBRT protocol
4. Volume definition and Lung – V20 preferably ≤ 30% maximum 35%
Cord – usually ≤ 45Gy but for paravertebral or pancoast tumours cord dose
of 52.5Gy / 20# justifiable
Oesophagus – for prescribed doses >52.5Gy, ≤12 cm oesophagus should be
included in PTV
Critical structures Normal lung tissue, Spinal cord, Myocardium, Oesophagus, Brachial
Plexus
5. Dose and Radical Treatment:
Fractionation SBRT: 18 Gy x 3#/1 week or 11 Gy x 5#/2 weeks (please see protocol)
64Gy / 32# / 6.5weeks (Grade B) when overlap with previous radiotherapy
treatment or concerns for normal tissue toxicity.
55 Gy/ 20#/ 4 weeks.
a) Dose to isocentre can be increased to 60 Gy if GTV cold
b) 50-52.5 Gy/ 20#/ 4 weeks if spinal cord in field or post operative
Palliative Treatment:
37.5 Gy / 15# / 3weeks (for field lengths ≥ 10 cm, cord max 37.5Gy)
If cord and oesophagus are not in field – 39Gy / 13# / 17days (Grade B)
36Gy / 12# / 16days
30-32.5Gy / 10# / 2weeks (cord max 32.5Gy / 10#)
27Gy / 6# / 2weeks - treatment on alternate days (Grade D)
20-25Gy / 4-5# / 1week (cord max in 5# 22.5Gy if concerns re: lung
function use V12 <30%)
Consider – 20Gy / 5# / 1week (Grade B)
16- 17Gy / 2# / over 8days (Grade A) – for moderate to poor performance
status patients (spinal cord shielding may be necessary)
8-10Gy / 1# (Not preferred if left ventricle is in irradiated volume)
Chemo-Radiotherapy: 55Gy / 20# / 26days

6. Special instructions Standard chemotherapy regime = Cisplatin 20mg/m² concurrent with

fractions 1-4 and 16-20 plus Vinorelbine 15mg/m² days 1-8 and 16-20. Or
cisplatin single agent 20 mg/m2 depending on comorbidity, PS and field
size.
If there is evidence of response and the patient’s performance status is
maintained, this is followed by:
Cisplatin 80mg/m² day 1 and Vinorelbine 30mg/m² days 1, 8 and 21 day
intervals commencing 4weeks after completion of concurrent treatment
Provide ‘Radical Radiotherapy to the Chest’ or ‘Palliative Radiotherapy to
the Chest’ information leaflet as appropriate
7. Clinical Trials and IDEAL-CRT is process of being opened. Isotoxic radiotherapy dose
References escalation over seven weeks with standard chemotherapy. See protocol for
full details

Tumour Group: Lung

Tumour: SMALL CELL LUNG
1. Localisation method Simulator/CT dependent on stage
Verify if required
2. Planning technique Radical : Conformal
Palliative : Simple parallel pair or Conformal
3. Immobilisation Radical : Lung board, knee and foot supports
method Palliative : As appropriate for comfort and stability
4. Volume definition and For concurrent: gross disease as seen on scan, No Elective nodal irradiation
Critical structures For sequential: Nodal sup/inf length as seen on pre-chemotherapy scan but
primary volume as seen on post-chemotherapy scan
5. Dose and Radical:
Fractionation 40Gy / 15# / 3weeks
Palliative: 30Gy / 10# / 2weeks
20Gy / 5# / 5-7days
27 Gy/ 6#/ 2 weeks6-10Gy / 1#
For selected patients with SCLC, prophylactic cranial radiotherapy:
25 Gy/ 10#/ 2 weeks
6. Special instructions Provide ‘Radical Radiotherapy to the Chest’ or ‘Palliative Radiotherapy to
the Chest’ information leaflet as appropriate
7. Clinical Trials and None at present. CONVERT in the process of being opened for LD SCLC.
References Cisplatin/etoposide with concurrent radiotherapy starting with second
cycle. Randomising between 45 Gy/30#/3 weeks bd vs. 66 Gy/33#. Please
see protocol for details

Tumour Group: Lymphoma

Tumour: HODGKINS DISEASE
Intent: Radical / Palliative RCR Category status: 2 / 3
1. Localisation method CT planned
2. Planning technique Dependent on site. May use virtual sim. Parallel Opposed Pair may be
useful but for more difficult sites in the abdomen 3 fields may cover
volume better. Consider half beam blocking off cord if one side of neck.
3. Immobilisation Supine, orfit cast if appropriate.
method
4. Volume definition and Outline enlarged lymph node areas based on CT scan at presentation and
after chemotherapy. Areas positive on PET scan should be included in the
GTV even if not enlarged. Negative enlarged nodes may still contain
lymphoma and should be included. Treat the clinically involved lymph
node region with/without the adjacent lymph node regions.
Margin to PTV: 1-2cm lateral and 2-5cm superior/inferior.
If initial disease displaced adjacent extranodal tissues without infiltration
then the initial tumour bulk does not need to be covered, e.g. mediastinal
nodes
Always treat unilateral SCF with axilla, the bilateral SCF with upper
mediastinum and the whole neck from mastoid to below clavicle
Critical structures Commonly mouth and cord
5. Dose and Bulky residual disease or bony involvement: 40Gy/20#
Fractionation Small volume residual disease: 30Gy/15# (Grade B)
Large field sizes in mediastinum or abdomen: 35Gy/20# (Grade C)
Palliative radiotherapy: 30Gy/10#, 20Gy/5#, 8Gy/1# (all Grade D)
References


Tumour: Non-Hodgkins Lymphoma (NHL)
1. Localisation method CT, Simulator or mark up on set dependent on site/stage Use
pre-chemotherapy CT and PET to define GTV extent
2. Planning technique CT – Conformal or virtually simulated
Simulator – Direct field/parallel pair
Mark up on set – define lesion clinically, (skin and conjunctiva)
3. Immobilisation CNS, eye, conjunctiva and neck and extra-nodal sites neck:
method oroplast
All other: supine leg and ankle support
4. Volume definition CNS: Whole brain including both orbits if ocular involvement
and critical structures Cranio-spinal axis radiotherapy may be used if chemo-resistant –
see CNS protocol and involve Consultant authorised to prescribe
in this area
Eyes and conjunctiva (high grade): Fit patients with CNS
directed chemotherapy followed by radiotherapy to the eye
Orbital NHL: CTV=orbit
Conjunctiva NHL : CTV=anterior orbit
Neck nodes: CTV= affected nodes and 1 cm margin AP, RL, 2.5
cm SI
Extra-nodal sites, e.g. Waldeyer’s ring, thyroid, salivary
gland, nose and sinus: GTV dependent on extent, planning
principles as per relevant head and neck protocol. Avoid bilateral
parotid irradiation if possible.
Mediastinum: : CTV= affected nodes and 1.5 cm margin AP,
RL, 2.5 cm SI
Abdomen and pelvis : CTV= affected nodes and 1.5 cm margin
AP, RL, 2.5 cm SI
Stomach: CT planning to limit kidney/liver dose. CTV stomach
and any lymphadeopathy
Spleen: CT planning to limit kidney/liver dose. DIBH gating if
possible (see spleen protocol)
Testis: Treat contra-lateral testis, direct anterior field with lead
shielding; post chemotherapy may not include inguinal lymph
nodes

5. Dose and Radical intent:

Fractionation CNS: Whole brain: 45Gy/25#. If ocular involvement : 30Gy/20#
Intraocular NHL: 30Gy/15#
High grade DLBCL NHL: 30Gy/15# post chemotherapy,
consider 40Gy /20# for primary treatment
Low grade NHL: 24Gy/12#
Bone: 40Gy/20# to whole bone
Skin: 8Gy single fraction (T or Bcell) consider fractionated
course for large lesion
Palliative intent: depends on histology, bulk and fitness15Gy/5
fraction or equivalent for high grade NHL, 4Gy/2# for low grade
6. Special instructions Refer to lymphoma protocol and CNS protocols for more details
7. Clinical Trials and FORT for low grade NHL
References


Tumour: SPLEEN
1. Localisation method Indication for treatment :
radical low grade non Hodgkins lymphoma / maltoma of the spleen, high
grade NHL or Hodgkin’s post chemotherapy
Palliative: Hypersplenism (CML, CLL, MGUS)
Localisation:
Radical: CT planning consider gating or breath hold
Palliative: Simulate and check palpate spleen prior to each treatment.
2. Planning technique Radical: CT plan
Palliative: Parallel opposed pair
3. Immobilisation Radical: ankle stocks and knee support – supine position
method Palliative: mattress
4. Volume definition and CTV: spleen no margin
PTV: according to respiratory motion 1.5-2.5 cm less with gating
Critical structures Kidney
5. Dose and Radical low grade non Hodgkins lymphoma / maltoma of the spleen
Fractionation 24Gy/12~#; high grade NHL or Hodgkin’s post chemotherapy 30Gy/15#
Palliative 5Gy/5# weekly
6. Special instructions Regular FBC check, may drop quickly; consider antibiotic prophylaxis and
vaccination for radical patients
7. Clinical Trials and FORT for low grade non Hodgkins lymphoma / maltoma
References

Paediatric
Paediatric radiotherapy should only be carried out by (or in occasional circumstances,

under the supervision of), a clinician experienced in the provision of radiotherapy to
children and who is a member of the CCLG Radiotherapy group.
Children should be treated according to nationally agreed guidelines or within

national and international clinical trials and the clinician should be familiar with and
have access to the latest version of these protocols.
A significant proportion of paediatric diagnoses are eligible for Department of Health

funding to travel abroad for high energy proton therapy. The up to date list and
guidance may be found at https://www.rcr.ac.uk/content.aspx?PageID=1527 (RCR
website).

Tumour Group: Skin

Tumour: MELANOMA
1. Localisation method Dependent on site
2. Planning technique Dependent on site
3. Immobilisation Dependent on site
method
4. Volume definition and Malignant Melanoma metastatic to nodes
Critical structures PTV: to include the next station of nodes to a radical dose
5. Dose and Lentigo Maligna
Fractionation Field size1-2.9cm 35Gy/5#; 3-4.9cm 45 Gy/10#, >5cm50Gy/16# or
55Gy/20# using MVX or electrons (prescription dose to 95%, requires
mould room prep)
Malignant Melanoma metastatic to nodes
Inguinal nodes only 45 gy/20 fractions (option to prescribe with a 3:2
weighting)
Inguinal nodes in elderly/frail patients, 30Gy/6 fractions 3 times weekly.
Large volume postoperative radiotherapy after axillary dissection and
inguinal dissection including the iliac nodes 60Gy/30 fractions
For the axilla, use a shell, virtual simulation with mantle type lung
shielding and CT planning with segments to ensure dose homogeneity. For
the pelvis I have hitherto used 3D conformal radiotherapy.
Melanoma Metastases
Use standard skin technique and dose appropriate for site
6. Special instructions Provide ‘Radiotherapy to Skin Cancers’ information leaflet
References

Tumour Group: Skin

Tumour: MERKEL CELL
1. Localisation method Dependent on site
2. Planning technique Dependent on site
method
4. Volume definition and Treatment of primary tumour bed + regional lymphnodes should be
Critical Structures considered in high risk cases of good performance status.
5. Dose and Treat axillary + nodes as per melanoma protocol.
Fractionation Treating primary site with close/involved margins = 60-66Gy/30-33# or
45Gy / 15# / 21days in elderly patients or small volume tumours.
6. Special Instructions Provide ‘Radiotherapy to Skin Cancers’ information leaflet
References

Tumour Group: Skin

Tumour: NON MELANOMA
1. Localisation method Clinical set up
2. Planning technique Planned on set; complex shapes and HDR selectron need mould room input
orthovoltage (most sites) or electrons (scalp, lower leg or hand) or perspex
mask for HDR selectron (scalp, lower leg or hand)
Large lesion with invasion of underlying structures are best CT planned in
Perspex mask with bolus
method
4. Volume definition and MVX BCC 5-7mm margin 10mm for morphoeic lesion)
Critical structures SCC 10-15 mm depending on size
Electrons use wax build up (normally 5mm) to increase skin dose to 100%
BCC 10mm margin, 15mm for morphoeic lesion)
SCC 15mm
HDR selectron 10-15mm
5. Dose and 35Gy / 5# / 5days (30 Gy for microscopic residual disease post surgery)
Fractionation 45Gy / 10# / 12days (40 Gy for microscopic residual disease post surgery)
50Gy / 15# / 19days (45 Gy for microscopic residual disease post surgery)
22Gy / 1# / 1days
6. Special instructions Provide ‘Radiotherapy to Skin Cancers’ information leaflet

References

Tumour Group: Other

Tumour: BONE METASTASES
1. Localisation method Simulator or HVX dependent on site
2. Planning technique Dependent on site. Simple field arrangement - usually single field or
parallel opposed pair. Linac or Cobalt is appropriate. HVX may be used in
some cases.
Examples:
Rib metastases: Direct field on HVX
Deeper lesions: Direct field or parallel pair on Cobalt
Scattered lesions: Upper or lower hemibody
3. Immobilisation Simple immobilisation aimed at improving comfort as well as stability.
method Exact immobilisation dependent on site, e.g. knee support, mattress
4. Volume definition and Dependent on site
Critical structures
5. Dose and Examples:
Fractionation Rib Metastases: 8Gy / 1# (Grade A)
Deeper Lesions: 8Gy / 1# *Grade A) or 20Gy / 5# / 1week (Grade C)
Scattered Lesions: Upper hemibody: 6Gy / 1# - Lower hemibody: 8Gy /
1# (Grade C)
Initial Therapy of Pain: 8Gy / 1# (Grade A)
6. Special instructions Dependent on site
References

Tumour Group: Other

Tumour: SOFT TISSUE SARCOMA
1. Localisation method CT/Simulator – dependent on site and intent
2. Planning technique Conformal or simple parallel pair
3. Immobilisation Dependent on site – may need vacubag
method
4. Volume definition and Dependent on site
Critical Structures
5. Dose and Pre-op: 50Gy/25# (Grade C) (rare – age, disease dependent)
Fractionation Post-op: 60-66Gy/30-33#
Unresectable tumours: 66Gy/33# (Grade C) (phased where possible –
patient status dependent)
Palliation: 6-8Gy/1# up to 40Gy/15# depending on clinical circumstances
and field size (Grade D)
7. Clinical Trials and VORTEX

References

Tumour Group: Other

Tumour: TOTAL BODY IRRADIATION
1. Localisation method Clinical measurements and CT
2. Planning technique CT to define lung compensator and hip separation, clinical measurements
to define head compensator and bolus; refer to TPJBITR and TWJTBIDE
for details
3. Immobilisation Pillow to support arms over chest
method Bolus for neck, waist and legs
Critical structures Lung
5. Dose and 14.4 Gy / 8# / 4days on M10-5
Fractionation
6. Special instructions Need test dose to check compensator and bolus

References

Treatments using IMRT
Mesothelioma
Prostate


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CCO, Radiotherapy Quality System 2010

Quality Procedure Radiotherapy Protocols

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Introduction to Radiotherapy Protocol Book

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Head and Neck

Maxillary Sinus/Nasal Cavity...................................................................... 55

Appendices – Available on CCO intranet

Appendix A – Treatments using IMRT ................................................................. 86

Issue Date: 08-July-2010 Page 5 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group : Breast

Issue Date: 08-July-2010 Page 6 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

5. Dose and 40Gy in 15 daily fractions (Grade B)

Date of approval by Lead Clinician/TSG: 13/04/2010

Issue Date: 08-July-2010 Page 7 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Site: Tumour bed boost

Critical structures Lungs, heart, skin.

Date of approval by Lead Clinician/TSG: 13/04/2010

Issue Date: 08-July-2010 Page 8 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: Breast

Date of approval by Lead Clinician/TSG: 13/04/2010

Issue Date: 08-July-2010 Page 9 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: Breast

Heart-distance of post edge of field to ant border of heart to be < 1.5cm.

Date of approval by Lead Clinician/TSG: 13/04/2010

Issue Date: 08-July-2010 Page 10 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: CNS

2. Planning technique Single plane

Critical structures Brain stem

7. Clinical Trials and None at present.

Date of approval by Lead Clinician/TSG: 07/07/2010

Issue Date: 08-July-2010 Page 11 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: CNS

2. Planning Technique Planning MRI with image registration

4. Volume Definition and SRS – GTV = enhancing lesion

6. Special Instructions Steroid – Dex cover, overnight stay post.

7. Clinical Trials and None at present.

Date of approval by Lead Clinician/TSG: 09/06/2010

Issue Date: 08-July-2010 Page 12 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: CNS

3. Immobilisation WBRT – Orfit shell – treat on Cobalt or low energy Linac

Date of approval by Lead Clinician/TSG: 09/06/2010

Issue Date: 08-July-2010 Page 13 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: CNS

4. Volume definition and For stages I-IV supratentorial

7. Clinical Trials and None at present.

Date of approval by Lead Clinician/TSG: 07/07/2010

Issue Date: 08-July-2010 Page 14 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: CNS

Date of approval by Lead Clinician/TSG: 09/06/2010

Issue Date: 08-July-2010 Page 15 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: CNS

3. Immobilisation Perspex shell or Orfit cast

7. Clinical Trials and BR13 - closed

Date of approval by Lead Clinician/TSG: 09/06/2010

Issue Date: 08-July-2010 Page 16 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: CNS

7. Available trials SCORAD

Date of approval by Lead Clinician/TSG: 23/04/2010

Issue Date: 08-July-2010 Page 17 of 86 Filename: TPCPROTS.d20 Issue No: 2.0

Tumour Group: CNS

3. Immobilisation Stereotactic frame (Radionics or Headfix) or shell depending on intended

4. Volume definition and GTV = tumour