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xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article reviews the American Society for Radiation Oncology (ASTRO) evidence-based guidelines on the role of postoperative radiation therapy in patients with endometrial cancer. Also discussed are recommendations to serve as guidelines for definitive and adjuvant radiotherapy treatment in patients with locally advanced non-small cell lung cancer.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOncology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EReproductive Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERespiratory Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERadiology Radiography\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOncology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EReproductive Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERespiratory Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERadiology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EOncology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERadiography\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EGUIDELINE FOR POSTOPERATIVE RADIATION THERAPY IN ENDOMETRIAL CANCER\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EThe American Society for Radiation Oncology (ASTRO) evidence-based guideline addressing the role of postoperative radiation therapy in patients with endometrial cancer found that external beam radiation and brachytherapy were relevant treatment options for patients with intermediate- and high-risk disease. Anne H. Klopp, MD, PhD, University of Texas MD Anderson Cancer Center, Houston, Texas, USA, presented guidelines on behalf of the ASTRO endometrial cancer guideline task force [Klopp A et al. \u003Cem\u003EPract Radiat Oncol\u003C\/em\u003E. 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EIn clinical practice, appropriate protocol for the use of radiation as adjuvant treatment in patients with endometrial cancer is unclear. Even though prospective studies have been conducted, many have weaknesses that make deciphering optimal treatment regimens difficult. This guideline aims to offer recommendations for the use of adjuvant radiation in treatment of patients with postoperative endometrial cancer.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EAn expert panel reviewed 330 articles to develop recommendations, and it categorized evidence quality using the American College of Physicians Strength of Evidence Rating. The panel focused on survival, local and distant recurrence rate, toxicity, and quality-of-life outcomes. Patient population of interest was determined as adult women with stage I to IVA endometrial cancer of any histology who underwent hysterectomy. Treatments investigated included no adjuvant therapy and pelvic radiation and\/or vaginal brachytherapy with or without chemotherapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EThe guideline addressed 5 key questions:\u003C\/p\u003E\n         \u003Col class=\u0022list-ord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-6\u0022\u003EWhich patients with endometrioid endometrial cancer require no additional therapy after hysterectomy?\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-7\u0022\u003EWhich patients with endometrioid endometrial cancer should receive vaginal cuff radiation?\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-8\u0022\u003EWhich women with early-stage endometrial cancer should receive postoperative external beam radiation? Which women with stage III to IVA endometrial cancer should receive postoperative external beam radiation?\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-9\u0022\u003EWhen should brachytherapy be used in addition to external beam radiation?\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n               \u003Cp id=\u0022p-10\u0022\u003EHow should radiation therapy and chemotherapy be integrated in the management of endometrial cancer?\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ol\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EAfter hysterectomy in patients with endometrioid endometrial cancer, researchers found that adjuvant radiation is not indicated for all patients. Patients with grade 1 to 2 disease and \u0026lt; 50% myometrial invasion and patients with no residual disease in hysterectomy specimen, despite positive biopsy, may avoid additional radiation treatment. Evidence for patients with grade 1 to 2 disease was high, and strength of recommendation was considered strong, with 100% of reviewers agreeing. Evidence for patients with no residual disease was low due to lack of randomized evidence, but experts considered recommendation strength strong with 94% agreement. Patients with low-risk findings should still be monitored after hysterectomy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ERecurrence of early-stage endometrial cancer often occurs at the vaginal cuff; therefore, vaginal cuff brachytherapy has an important role in postoperative treatment. Vaginal cuff brachytherapy is considered an appropriate treatment option in patients with grade 1 to 2 disease with \u0026lt; 50% myometrial invasion and increase of risk factors, such as older age and high lymphovascular space involvement. In these patients, vaginal cuff brachytherapy is considered a treatment option but not an absolute necessity. This was considered a strong recommendation, with moderate evidence and 94% agreement. Patients with grade 3 disease and no myometrial invasion may also be candidates for vaginal cuff brachytherapy. Although evidence was low, consensus was high at 94%.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EThe expert panel recommends that patients with grade 1 to 2 disease and \u2265 50% myometrial invasion and patients with grade 3 and \u0026lt; 50% invasion receive vaginal cuff radiation. This was supported by moderate evidence and 100% consensus. In these patients with intermediate-risk cancer, guidelines strongly recommend that vaginal cuff brachytherapy be considered the preferred treatment choice versus pelvic radiation, especially in patients who underwent comprehensive nodal assessment, even though evidence strength was low.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe advantage of pelvic external beam radiation is that it treats a wide area. It can treat the vagina as well as regional lymphatic; therefore, the consideration for pelvic radiation as a treatment option is associated with pelvic node involvement. In patients with grade 3 disease and \u2265 50% myometrial invasion or cervical stroma and in patients with grade 1 to 2 disease and \u2265 50% invasion with increase of risk factors, pelvic radiation is an appropriate treatment postoperative therapy. Evidence strength supporting this recommendation was high for both patient groups.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EPelvic radiation is also associated with a low rate of vaginal recurrence; therefore, vaginal brachytherapy following pelvic radiation has limited potential for added benefit. Guidelines do not recommend brachytherapy after pelvic radiation as a treatment option. Evidence for this combination therapy is limited to retrospective studies with small patient numbers, and it received only a 77% agreement. Dr Klopp noted that vaginal brachytherapy after pelvic radiation may be considered when appropriate external beam radiation doses cannot be achieved and need to be supplemented with vaginal brachytherapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EIn high-risk patients with positive nodes or involved uterine serosa, ovaries\/fallopian tubes, vagina, bladder, or rectum, pelvic radiation with chemotherapy is the preferred treatment regimen, with moderate strength of evidence and 100% consensus. Guidelines do not support chemotherapy without radiation, nor do they support radiation without chemotherapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EWhen chemotherapy and radiation are used to treat patients with high-risk endometrioid cancer, the strongest recommendation supports the use of concurrent chemotherapy and radiation, followed by adjuvant chemotherapy. This recommendation had moderate strength of evidence and a 77% agreement rate. A total of 82% of experts also found alternative sequencing strategies of external beam radiation with chemotherapy acceptable, but the recommendation was given a weak rating because of low strength of evidence.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EIn the studies reviewed, toxicity was usually local with vaginal cuff brachytherapy, and it involved vaginal complications and mild urinary side effects. Pelvic radiation, in contrast, had higher rates of gastrointestinal toxicity, mainly diarrhea.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EResearchers noted that external beam radiation and vaginal brachytherapy have a significant role in adjuvant treatment for endometrial cancer, and the high-quality evidence used to develop these guidelines supports that pelvic recurrence is reduced by radiation therapy. Patient risk factors should be considered when therapy is chosen, and further knowledge of preferred therapy regimens should be gained from current studies.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EGUIDELINE FOR DEFINITIVE AND ADJUVANT RADIOTHERAPY IN LOCALLY ADVANCED NON-SMALL CELL LUNG CANCER\u003C\/h2\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EASTRO is currently assembling recommendations to serve as guidelines for definitive and adjuvant radiotherapy treatment in patients with locally advanced non-small cell lung cancer (LA-NSCLC). George Rodrigues MD, PhD, University of Western Ontario, London, Ontario, Canada, presented current guideline progress on behalf of the ASTRO locally advanced lung cancer practice guideline task force.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003ERadiotherapy in patients with LA-NSCLC is indicated as palliative treatment in patients with poor performance status and prognosis, as definitive treatment with chemotherapy or alone, and as adjuvant treatment in preoperative and postoperative settings. Guidelines for the use of palliative radiotherapy in patients with lung cancer are available, but despite over 40 years of evidence, guidelines for definitive and adjuvant radiotherapy have not been determined. This guideline aims to provide guidance for definitive and adjuvant radiotherapy in the treatment of patients with LA-NSCLC, and it addresses 5 key questions:\u003C\/p\u003E\n         \u003Col class=\u0022list-ord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n               \u003Cp id=\u0022p-22\u0022\u003EWhat is the ideal external beam dose fractionation for the curative-intent treatment of LA-NSCLC with radiation therapy alone?\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n               \u003Cp id=\u0022p-23\u0022\u003EWhat is the ideal external beam dose fractionation for the curative-intent treatment of LA-NSCLC with chemotherapy?\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n               \u003Cp id=\u0022p-24\u0022\u003EWhat is the ideal timing of external beam radiation therapy in relation to systemic chemotherapy for the curative-intent treatment of LA-NSCLC?\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n               \u003Cp id=\u0022p-25\u0022\u003EWhat are the indications for adjuvant postoperative radiotherapy for the curative-intent treatment of LA-NSCLC?\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\n               \u003Cp id=\u0022p-26\u0022\u003EWhen is neoadjuvant radiotherapy prior to surgery indicated for the curative-intent treatment of LA-NSCLC?\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ol\u003E\n         \u003Cp id=\u0022p-27\u0022\u003EThe expert panel found that radiotherapy alone demonstrated superiority when compared with observation strategies or chemotherapy alone and may serve as definitive treatment in patients who cannot receive combined modality therapy. Radiotherapy alone was associated with toxicity\u2014specifically, esophagitis and pneumonitis.\u003C\/p\u003E\n         \u003Cp id=\u0022p-28\u0022\u003EWhen radiotherapy is used alone, a conventionally fractionated minimum dose of 60 Gy is suggested to improve local control and other clinical outcomes. This recommended dose was based on high-quality evidence and 100% consensus.\u003C\/p\u003E\n         \u003Cp id=\u0022p-29\u0022\u003EWhen chemotherapy is given concurrently with radiotherapy, a dose of 60 Gy should be administered in 2-Gy once-daily fractions for 6 weeks for patients receiving standard thoracic radiotherapy. Investigators found that increasing the dose higher than 60 Gy had no association with clinical benefit. Moderate-quality evidence supported both recommendations. Other findings also supported the use of conventional fractionated therapy when no benefit was seen with hyperfractionated radiotherapy that did not accelerate treatment course.\u003C\/p\u003E\n         \u003Cp id=\u0022p-30\u0022\u003EIn sequential chemotherapy, ideal radiotherapy dose and schedule have not been determined. Phase 3 trials have found that using accelerated hyperfractionated therapy to increase the biologically equivalent dose may offer better outcomes when following chemotherapy. Accelerated radiotherapy needs additional evaluation to determine optimal therapeutic ratio of treatment in advanced imaging radiotherapy planning and delivery of treatment.\u003C\/p\u003E\n         \u003Cp id=\u0022p-31\u0022\u003EConcurrent chemoradiation had better response rate, overall survival, and local control than chemotherapy followed by radiation, according to phase 3 data, and the most common chemotherapy regimens were cisplatin with etoposide and carboplatin with paclitaxel, although optimal chemotherapy in concurrent regimen has not been decided. Sequential chemotherapy followed by radical radiation in patients who could not tolerate concurrent therapy was associated with improved overall survival when compared with radiotherapy alone.\u003C\/p\u003E\n         \u003Cp id=\u0022p-32\u0022\u003EInvestigators also noted that evidence does not support the use of routine induction chemotherapy before chemoradiotherapy nor consolidation chemotherapy after chemoradiotherapy, but both may be used to manage specific cases. Induction chemotherapy may be an appropriate treatment option when bulky tumors are present, and consolidation chemotherapy may be an appropriate treatment option when full chemotherapy doses were not administered during radiotherapy in the presence of suspected micrometastatic disease.\u003C\/p\u003E\n         \u003Cp id=\u0022p-33\u0022\u003EPhase 3 trials and meta-analyses found that postoperative radiotherapy in patients with resected LA-NSCLC and N2 disease improved local control as compared with observation, but a benefit in overall survival was not found. In patients with resected LA-NSCLC and N0-1 disease, postoperative radiotherapy had worse survival outcomes when compared with observation and is not suggested for treatment in this patient population.\u003C\/p\u003E\n         \u003Cp id=\u0022p-34\u0022\u003ECurrently, chemotherapy is the standard of care in patients with resected disease because it has demonstrated a benefit in overall survival; therefore, postoperative radiotherapy should follow chemotherapy to avoid any possible interference. Conventionally fractionated doses administered for adjuvant postoperative radiotherapy range from 50 to 54 Gy. Quality of evidence for this dose range was considered low but received 100% consensus.\u003C\/p\u003E\n         \u003Cp id=\u0022p-35\u0022\u003EInvestigators recognize that appropriate doses for postoperative radiotherapy may be different for patient subsets. A conventionally fractionated dose of 54 to 60 Gy may be considered with chemotherapy to improve local control in patients with microscopic residual primary disease and\/or microscopic nodal disease, and patients with gross residual primary and\/or macroscopic nodal disease may receive a conventionally fractionated dose \u2265 60 Gy with chemotherapy to improve local control.\u003C\/p\u003E\n         \u003Cp id=\u0022p-36\u0022\u003EIn patients with resectable stage III NSCLC, level I evidence supporting induction radiotherapy or chemoradiotherapy before resection surgery is nonexistent. When radiotherapy is used preoperatively, doses \u2265 45 Gy should be administered to match previous trials, although no optimal dose has been determined. Acceptable mediastinal clearance rates appeared to be correlated with preoperative conventionally fractionated doses up to 60 Gy, but no evidence of association with overall survival was found.\u003C\/p\u003E\n         \u003Cp id=\u0022p-37\u0022\u003EInvestigators found that an increase in treatment benefit was associated with no weight loss, female sex, and only 1 involved nodal station in patients receiving trimodality therapy, but evidence was not sufficient enough to develop patient selection criteria for trimodality treatment. Trimodality therapy was also associated with improved survival when preoperatively planned lobectomy was performed, as compared with pneumonectomy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-38\u0022\u003EBy addressing 5 key questions, recommendations offer guidance for definitive and adjuvant radiotherapy in patients with LA-NSCLC. Full guidelines will be published in \u003Cem\u003EPractical Radiation Oncology\u003C\/em\u003E.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/31\/26.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm1o1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}