We evaluated global radiotherapy practices in the management of early-stage (AJCC/UICC 8th edition stages I-II) glottic cancer (ESGC). A cross-sectional online survey was conducted in March 2025 across centers worldwide. Data was collected on clinical practices, including staging, CT simulation, target volumes delineation, organs-at-risk contouring, radiotherapy techniques, dose and fractionation schedules, treatment delivery techniques, and image guidance practices. A total of 181 responses were received, primarily from Asia (41.4%) and Europe (24.3%). Most respondents were from non-academic public centers (44.2%), with multidisciplinary team involvement reported by 84.5%. Head and neck CT scan was the most used staging modality (80.1%). Intensity-Modulated Radiation Therapy was the most common planning technique (82.9%). Hypofractionated radiotherapy schedules predominated for T1 (84%) and T2 (72.4%) disease. T1a was typically treated with whole-larynx target volume (72.4%). Use of ipsilateral involved vocal cord irradiation varied by geographical region (p = 0.015), being most common in North America (44.8%) and Europe (38.6%). Accelerated fractionation for T2 also differed significantly (p < 0.001), with the highest use reported in North America (41.4%). Daily Cone-Beam Computed Tomography was acquired by (58.2%). In total, 70% of respondents expressed interest in the results of a future phase III randomized trial comparing stereotactic body radiation therapy to conventional radiotherapy. Significant global variations in radiotherapy practices for ESGC were observed, likely reflecting disparities in access and differences in institutional protocols. The development and implementation of standardized, evidence-based global guidelines are essential to harmonize care, minimize toxicity, and improve outcomes for patients with ESGC.

Introduction Clear cell carcinoma (CCC) of the uterus is a rare subtype of endometrial cancer, accounting for about 5% of cases and associated with poor prognosis. Limited data on CCC makes treatment challenging, with most guidelines based on retrospective studies. This case illustrates the use of radiation therapy for durable local control in a patient with oligometastatic uterine CCC. Case Presentation A 68-year-old woman was diagnosed with stage IA uterine CCC in March 2020. Following surgery, adjuvant chemotherapy, and brachytherapy, she developed an abdominal wall oligometastasis. Despite initial systemic treatment, her disease progressed with the appearance of a new lung nodule. She received definitive radiation therapy for the lung and abdominal wall oligometastases with complete resolution of both lesions on PET-CT scan. However, the patient developed systemic disease progression at distant sites 18 months later, for which she received further systemic therapy. Despite further disease progression, both irradiated sites (abdominal lesion and lung nodule) remained in complete remission with durable local control maintained for 25 months of follow-up. Conclusion Radiation therapy provided effective and durable local control in this case of oligometastatic uterine CCC. This suggests that definitive radiotherapy may be beneficial for managing oligometastatic CCC, though more research is needed to optimize treatment strategies. To our knowledge, there are no published reports describing the use of definitive radiotherapy for treating abdominal wall oligometastases from uterine CCC. This case is unique in demonstrating a durable complete response of this oligometastatic lesion following definitive external beam radiation (EBRT).

Background Brain metastasis represents the most prevalent form of brain tumors in adults, with a rising incidence resulting from significant advancements in cancer detection and therapeutic interventions. Current treatment protocols advocate for whole brain radiotherapy (WBRT) for patients who are not candidates for either surgical resection or stereotactic irradiation. However, cognitive decline remains a major side effect of this treatment modality. Hippocampal-sparing WBRT (HA-WBRT) has been shown to decrease brain toxicity, with the main concern being the probability of developing new brain metastasis in the hippocampal avoidance region.Case We report a case of a 73-year-old male presenting with multiple brain metastases and treated with HA-WBRT, who then developed a new single pontine lesion shortly after that was found to be located in an under-dosed peri-hippocampal area. We dosimetrically compared the patient's original IMRT plan to three new plans: a standard VMAT plan, an optimized IMRT plan, and an optimized VMAT plan, where optimization incorporated brainstem coverage as a planning objective, resulting in a notable improvement in brainstem dose distribution.Conclusion HA-WBRT poses a risk of peri-hippocampal metastasis due to underdosing of the upper brainstem that is inherent in HA-WBRT plans. Planning techniques should focus on optimizing coverage of the brainstem in an attempt to decrease this uncommon occurrence.

OBJECTIVES:To evaluate factors affecting the delay in head and neck cancer (HNC) diagnosis in Lebanon. METHODS:Patients with HNC presenting between August 1, 2023, and August 1, 2024, to the American University of Beirut Medical Center (AUBMC) were recruited. A questionnaire was administered to characterize the demographic, socioeconomic, and clinical factors affecting their cancer diagnosis, and their charts were reviewed retrospectively for their cancer demographics and to account for any discrepancies. RESULTS:A total of 78 participants were analyzed: 34 with early-stage (Stages 1 and 2) and 44 with late-stage (Stages 3 and 4) HNC. Late-stage participants had a significantly lower rate of university education (43.2% vs. 70.6%; p = 0.016), private insurance (27.3% vs. 64.7%; p = 0.001), and regular dental check-ups (29.5% vs. 52.9%; p = 0.036). They also reported more financial issues (52.3% vs. 26.5%; p = 0.022) and lack of awareness (65.9% vs. 29.4%; p = 0.001). Late-stage patients traveled longer distances for care (p = 0.043) and had issues with transport (38.6% vs. 8.8%; p = 0.003). Presentation (Type 1 delay) and referral (Type 2 delay) delays were significantly longer for late-stage HNC patients (median: 45 vs. 14 days, p < 0.001; 14 vs. 8.5 days, p < 0.001, respectively). Diagnosis delays were similar between groups (median: 7.00 days), but with a statistically significant mean difference (6.21 vs. 7.74 days). CONCLUSIONS:This study highlights the need to address patient awareness and healthcare barriers to improve timely HNC diagnosis. Enhancing symptom awareness and referral efficiency can significantly reduce diagnostic delays and associated morbidity in Lebanon. LEVEL OF EVIDENCE: 4:

Treatment of locally advanced rectal cancer (LARC), clinical stages II–III, typically involves multimodal treatment options. Over the past decade, the role of radiation therapy as a neoadjuvant treatment for LARC has evolved and is currently a part of total neoadjuvant therapy (TNT). Some recently published studies advocate for the omission of radiation therapy entirely, while others report on a non-operative approach that emphasizes the use of higher radiation therapy doses. This review aims to evaluate the latest literature on the current role of radiation therapy in the management of LARC, with a discussion of how to best select the most appropriate treatment protocol based on individual patient and tumor characteristics, comorbidities, and personal needs and preferences.

Background:Prostate cancer is the most common solid tumor in males, with a significant incidence worldwide. PSA screening and digital rectal examination are standard screening methods, yet some patients present with advanced disease because of delayed detection. We present the case of locally advanced prostate cancer presenting with large pelvic lymphadenopathy as a unique presentation. Case Presentation:A 65-year-old man presented with lower urinary tract symptoms and a significantly elevated PSA of 226 ng/mL. Physical examination revealed a large, non-tender pelvic mass. Multiparametric MRI revealed a large PIRADS 5 lesion in the prostate (5.6 × 3.6 cm) with extensive invasion, including seminal vesicles and the right posterior bladder wall. PET PSMA scan showed extensive regional lymph node involvement but no distant metastasis. Prostate biopsy showed Gleason 8 (4 + 4) adenocarcinoma. The patient was classified as having Stage IVa (T3bN1M0) prostate cancer and underwent treatment with androgen deprivation therapy (ADT), androgen receptor pathway inhibitors, and intensity-modulated radiotherapy (IMRT), targeting the prostate and pelvic lymph nodes. The patient achieved a PSA at 6 months 1.5 ng/mL, and <0.006 ng/mL at 15 months with significant regression of the pelvic mass and lymphadenopathy. Discussion:De novo metastatic prostate cancer is more prevalent in developing countries, likely due to delayed detection and under-screening. Our case is unique in presenting a pelvic mass as the initial manifestation of locally advanced prostate cancer. While existing guidelines do not subclassify stage IVa prostate cancer patients based on size of the lymph node, our case highlights the importance of personalized treatment strategies based on lymph node involvement. Conclusion:This case presents a unique manifestation of prostate cancer as a large pelvic mass. It emphasizes the importance of early screening and advanced treatment strategies to enhance patient outcomes.

The treatment of locally advanced head and neck squamous cell carcinoma (LA-HNSCC) has traditionally relied on a multimodal approach, combining surgery, radiation therapy (RT), and chemotherapy. While chemotherapy plays a critical role in improving cure rates and functional outcomes, its substantial toxicity remains a major concern, particularly in older patients. These challenges are especially relevant for those who are unfit for chemotherapy or decline conventional concurrent chemoradiotherapy (CCRT), highlighting the need for alternative therapeutic options. Many patients are at high risk for severe side effects, often preventing them from completing the full chemotherapy regimen. This review explores alternative strategies to definitive CCRT of carcinomas of the larynx, hypopharynx and oropharynx, aiming to optimize treatment outcomes while minimizing toxicity. We discuss altered fractionation strategies as a promising alternative to conventional RT, offering a balance between treatment efficacy and quality of life. Additionally, we examine emerging approaches, including the combining of targeted therapies, immunotherapy, hyperthermia, photodynamic therapy and nanoparticle-based treatments with RT, which provide alternative or complementary options to traditional therapies in the management of LA-HNSCC.

BACKGROUND/AIMS:Muscle-invasive bladder cancer (MIBC) has a 5-year survival rate of 40-60% following traditional treatment with neoadjuvant chemotherapy (NAC) and radical cystectomy (RC), which significantly impacts quality of life. Bladder preservation strategies, including maximal transurethral resection of the bladder tumor (TURBT), NAC, and radiation therapy, offer similar survival rates with better quality of life. Immune checkpoint inhibitors like avelumab show potential benefits when combined with bladder preservation modalities. This phase II randomized, non-comparative, double-arm, open-label, multicenter trial evaluates the efficacy and safety of two tetra-modality bladder preservation strategies in MIBC patients (T2-T4N0M0). The primary endpoint is the 2-year proportion of bladder-preserved participants. Secondary endpoints include response rates post-induction, quality of life, and safety evaluations. METHODS:Eighty participants will be randomized 1:1 into Arm A or Arm B. All participants will first receive induction chemotherapy (DDMVAC or GC) combined with avelumab, followed by disease evaluation using imaging and TURBT. Those achieving a complete or near-complete response will proceed to hypofractionated radiation therapy (55 Grays in 20 fractions). After radiation, Arm A will receive maintenance avelumab for 1 year, while Arm B will follow a watch-and-wait approach. Non-responders in both arms will be referred for salvage RC. CLINICAL TRIAL REGISTRATION:NCT06686381 (ClinicalTrials.gov).

ABSTRACT Objectives Moderate hypofractionation for localized prostate cancer has become a standard of care in many radiation therapy centers worldwide. Several fractionation and planning protocols exist, with CHHiP and PROFIT (60 Gy in 20 fractions) being 2 of the most commonly used. We retrospectively compared the doses received by organs at risk (OARs) using these 2 protocols. Materials and Methods We retrospectively reviewed the charts of 25 randomly selected de-identified patients treated with intensity-modulated radiation therapy (IMRT) for prostate cancer in a single tertiary care center. For each patient, we generated 2 sets of contours for target volumes and OARs in accordance with both CHHiP and PROFIT protocols. A total of 50 IMRT plans, using Prowess Panther software version 5.10, were generated and achieved the respective planning targets and normal tissue constraints. The related-samples Wilcoxon signed-rank test was used to compare the mean dose, V60, V50, and V40 of each of the bladder, rectum, and penile bulb. Results Patients had a mean age of 73 years, average prostate-specific antigen level of 9.8 ng/mL, mostly a Gleason score of 7, and a clinical stage that ranged from T1c to T2c. In the CHHiP plans, the rectum averaged a significantly lower V60 (0.5% vs 4.5%, P < .001) and V50 (13.1% vs 15.7%, P = .026) than with PROFIT. Similarly, the bladder in CHHiP averaged a significantly lower V60 (1.9% vs 7.7%, P < .001) and V50 (13.2% vs 15.5%, P = .035). The penile bulb received a lower mean dose (21.9 Gy vs 30.5 Gy, P < .001), V50 (5.6% vs 14.4%, P = .037), and V40 (11.4% vs 35.2%, P < .001) on average in the CHHiP plans as well. Conclusion In our dosimetric comparison, CHHiP spared the OARs to a greater degree than PROFIT. While contouring and planning using the CHHiP protocol are usually more demanding, we expect that greater sparing of OARs will minimize clinical toxicity in patients with prostate cancer receiving moderately hypofractionated radiation therapy.

BackgroundAnti-PD1 antibodies have gained popularity in the treatment of skin cancers. These drugs have been FDA approved for treatment of cutaneous melanoma and unresectable/metastatic squamous cell carcinoma of the skin. However, the use of anti-PD1 antibodies is not established for resectable cutaneous squamous cell carcinoma, as the mainstay treatment is surgical excision.CaseA 49-year-old female with Xeroderma Pigmentosum presented with an ulcerating lateral nasal mass causing obstruction. Biopsy confirmed cutaneous squamous cell carcinoma and was staged as IVA (T2N2cM0) based on PET-CT findings, which showed a 2.7 × 2.3 cm left nasal mass and radiotracer-avid cervical lymph nodes. Despite surgical recommendations, the patient declined surgery due the expected morbidity and disfigurement. Instead, she received neoadjuvant Pembrolizumab (200 mg IV every 3 weeks). After two cycles, PET-CT and MRI showed significant reduction in the nasal mass and decreased cervical lymph node involvement. On physical exam, the nasal lesion had resolved. Multidisciplinary tumor board discussion recommended radiation therapy instead of neck dissection, considering the patient's clinical response and potential surgical morbidity. After a third Pembrolizumab cycle, she received 66 Gy in 33 fractions, followed by continued adjuvant immunotherapy.

PURPOSEThis study aims to assess the status of radiation oncology peer review procedures across the Middle East, North Africa, and Türkiye (MENAT) region.METHODSA cross-sectional electronic survey was conducted among radiotherapy centers in the MENAT region in March 2024. It assessed peer review practices, departmental demographics, perceived importance of peer review, and potential barriers.RESULTSData from 177 radiation oncology centers revealed varying peer review implementation across the MENAT region. Egypt had the highest participation (16.4%) among all responders. Most centers (31%) treated 500-1,000 cases annually. The majority (77.4%) implemented peer review, with varying levels between countries and across different centers. Advanced radiotherapy techniques significantly correlated with implementation of peer review (P < .05). Peer review meetings were mostly scheduled on a weekly basis (46%) and organized by radiation oncologists (84.7%). Target volume contouring (89%) and radiotherapy prescription (82%) were frequently peer-reviewed. Respondents with peer review at their institutions significantly valued peer review for education, adherence to guidelines, improving planning protocols, and reducing variation in practice institutions without peer review (P < .05). The most frequently reported barriers to peer review were having a high number of patients (56%) and shortage of time (54%).CONCLUSIONPeer review is essential for improving the quality of practice in radiation oncology. Despite some discrepancies, numerous obstacles, and challenges in implementation, it is instrumental in the improvement of patient care in most centers throughout the region. Raising awareness among radiation oncologists about the importance of peer review is paramount to lead to better outcomes.

Background Primary brain rhabdomyosarcoma is a rare primary brain malignancy with few case reports. The vast majority of cases of primary brain rhabdomyosarcoma occur in pediatric patients, and immunohistochemistry can distinguish it from embryonal subtypes; however, few cases of primary brain rhabdomyosarcoma in adults have been reported in the literature. Case presentation We report the case of a 26-year-old White male patient who was found to have primary brain alveolar rhabdomyosarcoma after developing headaches for several months. A brain MRI revealed a mixed cystic and solid tumor along the vermis of the cerebellum. The patient underwent a gross total surgical resection, which confirmed the diagnosis of alveolar rhabdomyosarcoma. Further staging workup for another primary focus or disseminated disease yielded negative results, confirming the diagnosis of primary alveolar rhabdomyosarcoma of the brain. Conclusion The standard of care for managing this rare type of brain tumor involves surgery with adjuvant chemoradiotherapy. Further studies should be conducted for a better diagnostic and therapeutic understanding.

Children with cancer previously treated with radiotherapy face the likelihood of side effects that can be debilitating or fatal. This study aimed to assess the long-term effect of medulloblastoma radiotherapy on the DNA double-strand break (DSB) repair capability of primary fibroblasts derived from lung biopsies of previously irradiated young sheep. This study included biopsies from three control and five irradiated sheep. The treated sheep had previously received spinal radiotherapy at a total dose of 28 Gy, which is equivalent to pediatric medulloblastoma treatment. Lung biopsies were taken 4 years post-irradiation from high-dose (HD, >18 Gy) and low-dose (LD, <2 Gy) regions. Fifteen cell lines were extracted (six control, four LD and five HD). The cells were irradiated, and DNA DSB repair was analyzed by immunofluorescence. Clonogenic, trypan blue and micronuclei assays were performed. Both the HD and LD cell lines had a significantly higher number of residual γH2AX foci 24 h and a significant decrease in pATM activity post-irradiation compared to the control. There was no statistically significant difference in the clonogenic assay, trypan blue and micronuclei results. Our study showed that a previous irradiation can impair the DNA DSB repair mechanism of ovine lung fibroblasts.

Few case reports describe metastatic prostate cancer to the thyroid cartilage. While earlier reports identified the metastatic lesions upon developing symptoms, more recent ones have detected them via prostate-specific membrane antigen positron emission tomography (PSMA PET). Herein, we report the case of a patient with metastatic castrate-resistant prostate cancer and a PSMA PET-detected lesion in the thyroid cartilage. Over the course of 2 years, he received multiple lines of chemotherapy and hormonal therapy, and his overall disease status fluctuated - some nodal and bony metastases resolved while others appeared anew. His thyroid cartilage lesion, however, slowly progressed in a consistent fashion with increasing uptake on successive PSMA PET images. Apart from mild dysphonia, the patient remained to be asymptomatic from this lesion, and no local therapies were used. To our knowledge, this is the first close follow-up of prostate cancer metastatic to the thyroid cartilage, shedding light on the course of such lesions and helping answer management-related questions, which are particularly relevant as more occult metastases are discovered in the PSMA PET era.

Purpose:This study of internal mammary lymph node chain (IMC) irradiation in patients with left breast cancer aimed at comparing the merits of using, on one hand, a dedicated direct IMC electron field versus a wide tangent photon field covering both breast and IMC on the other. The objective was to produce guidelines allowing clinicians to readily determine the preferred method for each patient.Methods and Materials:For 19 patients with cancer of the left breast/chest wall, we produced 2 treatment plans each using a different technique: the electron technique using 2 standard opposed photon tangents covering only the breast or chest wall along with a matching adjacent electron field targeting the IMC only or the wide tangent technique using 2 opposed wide tangents covering simultaneously IMC and breast or chest wall. All plans were then optimized for acceptable target coverage.Results:For patients where the left anterior descending coronary artery (LAD) was located outside of the wide tangent fields (13 patients), the wide tangent technique resulted in lower dose to the LAD, left lung, and heart. When the LAD was inside the wide tangents (6 patients), dose was lower with the electron technique for LAD and heart. In all cases, regardless of LAD location, the wide tangent technique returned strictly superior dose homogeneity but much higher right (contralateral) breast dose.Conclusions:A flowchart was produced based on LAD location that allows the clinician to readily determine the preferred technique for each patient without having to perform and compare 2 treatment plans, thus saving valuable planning time.

Objective. This study aims at quantifying the lifetime attributable risk of secondary fatal cancer (LARFAC) to patients receiving adjuvant radiotherapy treatment for thymoma, a neoplasm where cure rates and life expectancy are relatively high, patient age at presentation relatively low and indications for radiotherapy controversial depending on the disease stage. Approach. An anthropomorphic phantom was scanned, organs were contoured and a standard 6 MV 3DCRT treatment plan was produced for thymoma treatment. The phantom was loaded with thermoluminescent dosimeters (TLDs) and treated by linear accelerator per plan. The TLDs were subsequently read for out-of-field dose distribution while in-field dose distribution was obtained from the planning system. Sex and age-specific lifetime radiogenic cancer risk was calculated as the sum of in-field risk and out-of-field risk. The latter risk was estimated using hybrid ICRP 2007 103-BEIR VII tables of organ-specific risks based on the linear-no threshold (LNT) model and applicable at low doses, while the former using mathematical risk models applicable at high doses. Main results. The LARFAC associated with a prescribed dose of 50 Gy to target volume in 25 fractions was in the approximate range of 1%–3%. The risk was higher for young and female patients. The largest contributing organ to this risk were the lungs by far. Using the LNT model inappropriately to calculate risk at therapeutic doses (in-field) would overestimate the risk up to tenfold. Significance. The LARFAC to patient from thymoma radiotherapy was quantified taking into consideration the inapplicability of the LNT model at therapeutic doses. The risk is not negligible; the information may be relevant to patients and clinicians.