112年高醫放射線腫瘤科治療準則 - 公告第14版

放射線治療政策與程序之指引
Department of Radiation Oncology
Kaohsiung Medical University Chung-Ho Memorial Hospital
高雄醫學大學附設中和紀念醫院
放射腫瘤部編印
第十四版
2023 年 5 月 10 日修訂
Contents
I.Head and Neck Cancer……………………………….................. 1
1. Nasopharyngeal Cancer……………………………................ 1
2. Oropharyngeal Cancer………………………………………. 10
3. Hypopharyngeal Cancer…………………………………….. 16
4. Laryngeal Cancer……………………………………………. 25
5.Cancers Of Oral Cavity……………………………………….. 36
(1)Buccal Mucosa……………………………………………… 38
(2)Oral Tongue………………………………………………… 42
(3)Floor of Mouth……………………………………………… 47
(4)Gingiva……………………………………………………… 50
6. Thyroid Cancer……………………………………………….. 54
II. Cancers Of Gastro-Intestinal Tract……………………………. 60
1. Esophageal Cancer…………………………………………… 60
2. Gastric Cancer………………………………………………… 68
3. Pancreatic Cancer…………………………………………….. 73
4. Hepatocellular Carcinoma……………………………………. 81
5. Bile Duct Cancer……………………………………………… 86
6. Colorectal Cancer…………………………………………….. 93
III.Breast Cancer…………………………………………………. 103
1. Ductal Carcinoma In Situ (DCIS)……………………………. 106
2. Invasive Carcinoma………………………………………….. 109
IV.Lung Cancer………………………………………………….. 118
1. Non-Small Cell Lung Carcinoma……………………………. 124
2. Small Cell Lung Carcinoma…………………………………. 129
V. Gynecological Cancers……………………………………….. 137
1. Endometrial Cancer………………………………………….. 137
2. Cervical Cancer……………………………………………… 146
VI.Prostate Cancer……………………………………………….. 156
VII. Lymphomas…………………………………………………. 167
1. Hodgkin’s Lymphoma……………………………………….. 167
2.Non-Hodgkin’sLymphoma…………………………………… 174
VIII.Palliative Radiotherapy……………………………………... 180
1. Brain Metastases……………………………………………… 180
2. Bone Metastases……………………………………………… 184
IX.Central nervous system cancers………………………………. 186
Nasopharyngeal cancer (NPC)
Treatment recommendations for radiotherapy:
一、放射治療前準備：
於放射治療前，應回顧該病人的病理報告、影像檢查…等結果，已確定癌
症分期；必要時於多專科團隊會議時提出討論。
二、定位：以病人舒適性及耐受性為原則
1. 體位設定：病患模擬定位姿勢為仰臥(supine)，雙手放身體兩側。
2. 固定方法：
將雙手置放於兩側，並以臉部模具等輔具固定。治療中心標記在塑型面
膜上。口咬器與膝關節固定器必要時置放。
3. 模擬攝影之要求：
應採取電腦斷層輔助之模擬攝影，在電腦斷層掃瞄定位室，請病人依原
姿勢，在已製作好的固定模具上，根據定位雷射對到病患模具標記點。
影像擷取時電腦斷層之上下緣視腫瘤部位而定，上緣需至少包含眼眶上
緣，下緣至鎖骨與胸骨交接處往下 2 公分。掃描範圍及切片厚度條件，
可由主治醫師自行訂定。
三、電腦治療計畫部分：
1. 巨觀腫瘤體積(Gross Tumor Volume)：指肉眼或影像診斷可見之腫瘤。(以
下簡稱為 GTV) 應包含由 CT 影像、臨床資訊、MRI 影像或 PET 影像可
判讀之原發腫瘤(primary tumor)及臨床上呈陽性之淋巴腺(直徑大於 1 公
分之腫瘤、含有壞死區之腫瘤)。如果治療前做過化學治療，需考慮原來
部位之腫瘤或範圍皆應考慮治療。
2. 臨床靶體積(Clinical Target Volume)：指腫瘤及其可能侵犯之範圍，通常
由影像輔助圈選。(以下簡稱為 CTV)為包含 GTV 可能侵犯之範圍，可
分為 CTV-H、CTV-M 及 CTV-L。CTV-H 為 GTV 之高危險度可能侵犯
之範圍、CTV-M 為中高度風險侵犯風險之淋巴結及 CTV-L 為低侵犯風
險之淋巴結。
3. 計劃靶體積(Planning Target Volume)：考慮擺位誤差，內部器官移動及其
他可能產生誤差在 CTV 加上範圍之體積。(以下簡稱為 PTV)
4. 格雷(Gray)：為放射線吸收劑量之單位。(以下簡稱為 Gy)
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According to 8th AJCC cancer staging
◎ Stage I
➔ Definitive radiotherapy (RT) to nasopharynx and elective RT to

neck
◎ Stage II-IVB
➔
◎T2,N0,M0:
➔ Definitive RT ± concurrent systemic therapy if high risk features

(High risk features include bulky tumor volume, high serum EBV
DNA copy number)
◎T1–2,N1,M0 or T3,N0:
➔ Concurrent systemic therapy/RT

➔ Consider induction or adjuvant chemotherapy if high-risk features
◎T3-4,N1-3,M0 or any T,N2-3,M0:
➔ Induction chemotherapy followed by systemic therapy/RT

(preferred) (category 1).
➔ Concurrent systemic therapy/RT followed by adjuvant
chemotherapy
➔ Concurrent systemic therapy/RT (category 3)
◎ Stage IVC (M1)
◎Oligometastatic disease:
➔ Systemic therapy (if PS 0–1) followed by RT or cisplatin/RT

➔ Systemic therapy (if PS 0–2)
➔ Concurrent cisplatin + RT (if PS 0–1)
◎Widely metastatic and good PS (0-2):
➔ Systemic therapy → Consider RT if CR or near CR after systemic

therapy
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◎Widely metastatic and poor PS (3-4):
➔ Best supportive care
RT techniques:
Simulation:
■ Patient in supine position with head hyperextension.
■ Immobilized with a thermoplastic head and neck mask.
■ A mouth bite and knee rest may be used if indicated.
Field design:
■ Conventional radiotherapy: 3 fields (lateral opposed portal for
primary & upper neck, matched to a low neck field). Use a central
larynx block on low neck field.
Conventional border:
Superior: cover sphenoid sinus & base of skull.
Inferior: match plane above true vocal cord (to block larynx in
low neck field).
Posterior: spinous processes.
Anterior: 2-3 cm anterior to the gross tumor (includes pterygoid
plates and posterior 1/3 of maxillary sinus).
■ Target volumes for intensity-modulated radiotherapy (IMRT):
GTV: primary nasopharyngeal tumor & gross adenopathy,
(prechemotherapy extent)
CTV: covers GTV, microscopic infiltration & anatomic sites at risk
CTV-H: GTV + 5-10 mm margin (2 mm if abut neurological
structures)
CTV-M: CTV-H + 5 mm margin (2 mm if abut neurological
structures)
*Boundaries: posterior third of nasal cavity, posterior third of
maxillary sinuses, pterygoid fossa, parapharyngeal spaces,
lower half of sphenoid sinus, base of skull, bilateral
retropharyngeal region, level II, III, Va, If node-positive:
add level Ib into CTV-M.
CTV-L: elective nodal levels (ex. bilateral level IV and Vb)
3
PTV: CTV + 3-5 mm margin for systemic and random setup
variations
Dose prescriptions:
1. Simultaneous integral boost technique:
PTV-H: 70 Gy/35 fractions
(for T4 lesion, consider boost up to 10Gy if necessary)
For T1-T2 RT alone: 69.96 Gy/33 fractions (2.12Gy/fraction)
PTV-M: 63 Gy/35 fractions or 59.4 Gy/33 fractions
(range: 56-63Gy)
PTV-L: 56 Gy/35 fractions or 50.4 Gy/33 fractions
(range: 44-56Gy)
2. Sequential IMRT:
PTV-H: 1.8-2Gy per fraction to total dose 70-70.2Gy, with 2-3 separate
dose plans, PTV-M to PTV-low: 44-50Gy in 2Gy/fractions
(Care should be taken to avoid critical neural structures, therefore,
1.8Gy/fraction can be used, for doses >70Gy, fractionations can be
slightly modified (eg. <2Gy/fx in at least some of the treatment; an
additional 2-3 fractions can be added depending on clinical
circumstances) ■consider boost to 10Gy if residual tumor persisted.
Normal Organ Constraints:
Organ Constraints
Spinal cord Dmax < 45Gy
Brain stem Dmax < 54Gy
R't lens Dmax < 10Gy
L't lens Dmax < 10Gy
R't eye retina Dmax < 45Gy
L't eye retina Dmax < 45Gy
R't optic nerve Dmax < 54Gy
L't optic nerve Dmax < 54Gy
Chiasma Dmax < 54Gy
R't cochlea Dmax < 45Gy ; Dmean < 37Gy
L't cochlea Dmax < 45Gy ; Dmean < 37Gy
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R't parotid gland Dmean < 26Gy ; V20Gy< 50%
L't parotid gland Dmean < 26Gy ; V20Gy< 50%
Oral cavity Dmax < 65Gy ; Dmean< 55Gy
Larynx Dmean < 40Gy
Mandible Dmax < 70Gy
■ Priority 1: Critical organ at risk
Brainstem: max < 54Gy
Spinal cord: max < 45Gy
Optic chiasma: max < 54Gy
Optic nerve: max < 54Gy
Temporal lobes: max < 65Gy
■ Priority 2: Tumor targets
GTV:≧98% dose to 100%GTV, <1%GTV receive <95% dose
PTV:≧95% dose to 100% PTV, <10% PTV-h receive≧107%

dose
■ Priority 3: Intermediate-risk organ at risk
Mandible/TMJ: max < 60Gy
Lens: max < 10Gy
Eyeball (retina): max < 50Gy
■ Priority 4: Low-risk organ at risk
Parotid glands: mean<26-30Gy (at least 1 gland)
Cochlea: mean< 45Gy
Oral cavity: mean< 55Gy
Larynx: mean< 30-45Gy
Basic Principle for Primary Radiotherapy

1. Patient immobilization
2. Computerized tomography-assisted treatment planning
3. Tumor mapping from CT simulation, MRI, and PET scan if data is
available.
4. Daily radiation dose should be > 180cGy
5. Intensity modulation radiotherapy is preferred over 3D conformal
RT.
Supportive Care during Radiotherapy

1. Maintenance of oral hygiene and adequate use of analgesics is
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recommended.
2. Gastrostomy or naso-gastric tube feeding is indicated for patient
having 5-10% body weight loss or grade III mucositis and
pharyngitis.
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Isodose curve of Volumetric modulated arc therapy for NPC
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References:
1. NCCN 2022 version3.1. clinical practice guidelines in oncology: Head and
Neck Cancers
2. Salama JK, Haddad Rl, kies MS, et al. Clinical Practice Recommendations for
Radiotherapy Planning following Induction Chemotherapy in locoregionally
Advanced Head and Neck Cancer. Int J Radiat Oncol Biol Phys. 75(3):725-
733, 2009.
3. Hartford AC, Palisca MG, Eichler TJ, et al. American Society for Theraoeutic
Radiology and Oncology (ASTRO) and American College of Radiology
(ACR) practice guidelines for intensity-modulated radiation therapy (IMRT).
Int J Radiat Oncol Biol Phys. 2009;73(1):9-14.
4. IMRT Documentation Working Group, Holmes T, Das R, Low D, et al.
American Society of Radiation Oncology recommendations for documenting
intensity-modulated radiation therapy treatments. Int J Radiat Oncol Biol Phys.
2009;74(5):1311-1318.
5. Machtay M, Moughan J, Trotti A, et al. Factors associated with severe late
toxicity after concurrent chemoradiation for locally advanced head and neck
cancer: an RTOG analysis. J Clin Oncol 2008;26:3582-3589.
6. Chan SC, Chang JT, Wang HM, et al. Prediction for distant failure in patients
with stage M0 nasopharyngeal carcinoma: the role of standardized uptake
value. Oral Oncol 2009;45:52-58.
7. O'Sullivan B. Nasopharynx cancer: therapeutic value of chemoradiotherapy.
Int J Radiat Oncol Biol Phys 2007;69:S118-S121.
8. Lin JC, Jan JS, Hsu CY, et al. Phase III study of concurrent chemoradiotherapy
versus radiotherapy alone for advanced nasopharyngeal carcinoma: positive
effect on overall and progression-free survival. J Clin Oncol 2003;21:631-637.
9. Chen L et al.: Concurrent chemoradiotherapy plus adjuvant chemotherapy
versus concurrent chemoradiotherapy alone in patients with locoregionally
advanced nasopharyngeal carcinoma: a phase 3 multicenter randomised
controlled trial. Lancet Oncol 2012; 13: 163-171
10. Ng WT et al.: Clinical outcomes and patterns of failure after intensity-
modulated radiotherapy for nasopharyngeal carcinoma 2011;79:420-428
11. Lee N et al. Addition of bevacizumab to standard chemoradiation for
locoregionally advanced nasopharyngeal carcinoma (RTOG 0615): a phase 2
multi-institutional trial. Lancet Oncol 2012; 13: 172-80
8
12. Hui EP et al. Randomized phase II trial of concurrent cisplatin-radiotherapy
with or without neoadjuvant docetaxel and cisplatin in advanced
nasopharyngeal carcinoma. J Clin Oncol. 2009 Jan 10;27(2):242-9
13. Induction chemotherapy plus concurrent chemoradiotherapy versus concurrent
chemoradiotherapy alone in locoregionally advanced nasopharyngeal
carcinoma: a phase 3, multicentre, randomised controlled trial. Lancet Oncol.
2016 Nov;17(11):1509-1520
9
Oropharyngeal cancer
於放射治療前，應回顧該病人的病理報告、影像檢查…等期別判定；於多
專科團隊會議時提出討論。
二、定位：
1. 體位設定：
仰躺姿勢。所有病人模擬定位姿勢皆為仰臥(supine)，雙手放身體兩側。
2. 固定方法：
將雙手置放於兩側，並以臉部模具等輔具固定。治療中心標記在臉部模
具上。口咬器與膝關節固定器視情況而放。
姿勢，標記點對到定位雷射。金屬標記在影像上呈現中心點之位置。影
像擷取時電腦斷層之上下緣視腫瘤部位而定，電腦斷層之掃描範圍及條
件為由腦部前葉(frontal lobe)至主動脈弓(aortic arch)，應包含眼眶、鼻咽、
頸部，一般切片厚度約 3 毫米。掃描範圍及切片厚度條件，可由主治醫
師自行訂定。
三、靶體積定義 (Target Volume Definition) 及放射治療計畫規劃 (Radiation

Therapy Planning)：
3.1 根治性、未開刀之靶體積定義：
(1)腫瘤體積(Gross Tumor Volume)：指肉眼或影像診斷可見之腫瘤。(以下簡
稱為 GTV) 應包含由 CT 影像、臨床訊息、PET 或 MRI 影像可判讀之
主要腫瘤(primary tumor)及臨床上呈陽性之淋巴結(直徑大於 1 公分之腫
瘤、含有壞死區)。如果治療前做過化學治療，需考慮原來部位之腫瘤或範
圍皆應治療。
(2)臨床靶體積(Clinical Target Volume)：指腫瘤及其可能侵犯之範圍，通常由
影像輔助圈選。(以下簡稱為 CTV) 為包含 GTV 可能侵犯之範圍，可分
為 CTV-H、CTV-M 及 CTV-L。CTV-H 為 GTV+0.3–2 cm margin on
primary GTV and 3–5mm margin on nodal GTV、CTV-M 為高侵犯風險之
10
淋巴結及 CTV-L 為低侵犯風險之淋巴結。
(3)計劃靶體積(Planning Target Volume)：考慮擺位誤差及內部器官移動，在
CTV 加上範圍之體積。(以下簡稱為 PTV) 治療計畫標靶體積（PTV）之
定義：CTV+3~5mm margin。
(4)格雷(Gray)：為放射線吸收劑量之單位。(以下簡稱為 Gy)
3.2 根治性、手術切除後之靶體積定義：
(1)CTV (Clinical tumor volume)：
a. CTV-H：
原則如下：整個開刀範圍加上範圍(視原發部位解剖位置而定)及整個淋
巴結為陽性之部位。如果開刀範圍不明顯，可考慮找出手術前腫瘤之部
位並加上範圍。
b. CTV-M：
頸部淋巴結轉移中高危險區(視原發部位解剖位置而定)
c. CTV-L：
頸部淋巴結轉移低危險區(視原發部位解剖位置而定)
(2) 計劃靶體積(Planning Target Volume)：考慮擺位誤差或其他因素，在 CTV
加上範圍之體積 (以下簡稱為 PTV) 。治療計畫標靶體積（PTV）之定
義：CTV+3~5mm margin。
(3)放射治療計畫規劃靶體積：在 CTV 周圍視原發部位解剖位置而加上擺位
誤差及內部器官移動之隨機誤差，並需留意頭腳方向(cranio-caudal
directions)之範圍。
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◎ Definitive RT
■ Indication:
(1) RT alone: T1-2, N0-1 for p16(-), N0 for p16(+)
(2) Consider CCRT: (I) T3-4, N0-1, (II) any T, N2-3 (III) T1-2, N1
(3) Consider induction chemotherapy+ RT/CRT: (I) T3-4a, N0-1, (II)
any T, N2-3 (category 3)
◎ Post-operative RT for p16(HPV)-positive or negative
■ Indication:
(1) pT3 or pT4 primary
(2) N1, N2 or N3 nodal disease
(3) Nodal disease in levels IV or V
(4) Perineural invasion
(5) Lymphatic invasion
(6) Vascular invasion
(7) 1 positive node > 3cm or multiple positive nodes for p16(+)
◎ Post-operative CCRT for p16(HPV)-positive or negative
■ Indication:
(1) Extranodal extension (ENE)
(2) Positive margin
(3) Other risk factors (Example: Multiple minor risk factors)
◎ Distant metastasis
➔ RT for symptomatic relief as palliative intent
RT techniques:
Simulation:
■ Patient in supine position with head hyperextension
■ Immobilized with a thermoplastic head and neck mask
■ A mouth bite may be used if indicated
12
Field design:
■ Conventional radiotherapy: 3 fields (lateral opposed portal for
primary & upper neck, matched to a low neck field). Beam-split
above larynx at thyroid notch if possible.
Conventional border:
Superior: cover base of skull & mastoid
Inferior: match plane above true vocal cord (to block larynx in
low neck field)
Posterior: spinous processes
Anterior: 2 cm margin anterior to the gross tumor
■ Target volumes for IMRT
GTV: all gross disease on physical examination and imaging & all
nodes≧1cm in short axis; grossly abnormal as well as
suspicious lymph nodes should be included

CTV-H: GTV+0.5–2 cm margin on primary GTV and 3–5mm
margin on nodal GTV
CTV-M: soft tissue and nodal regions adjacent to CTV-H and high
risk nodal area
CTV-L: elective low risk nodal area
PTV: CTV+3-5 mm margin
Dose prescriptions:
■ Definitive RT/CRT:
CTV-H: 66Gy (2.2Gy/fraction) -72Gy(1.8 to 2.0Gy/fraction)
CTV-M: 54Gy-63Gy(1.8-2Gy/fraction)
CTV-L: 44-50Gy (2.0Gy/fraction) or 50Gy-56Gy (1.6-1.8
Gy/fraction)
■ Post-operative RT/CRT:
CTV-H: 60Gy-66Gy(1.8 to 2.0Gy/fraction) can boost 4-6Gy for
positive margins or ECE
CTV-L: 50Gy-56Gy(1.6 to 2Gy/fraction)
■consider boost to10Gy if residual tumor persisted.
13
Dose constraints:
Organ Constraints
Chiasma Dmax < 54Gy
R't parotid gland Dmean < 26Gy ; V20Gy < 50%
L't parotid gland Dmean < 26Gy ; V20Gy < 50%
Oral cavity Dmax < 65Gy ; Dmean < 55Gy
Larynx Dmean < 40Gy

GTV: ≧98% dose to 100%GTV, <1%GTV receive <95% dose
PTV: ≧95% dose to 100% PTV, <10% PTV-h receive ≧107%
dose
Parotid glands: mean < 26-30Gy (at least 1 gland)
Larynx: mean < 30-45Gy
14
References:
1. NCCN guideline for Head and Neck cancer: 2023 version 1.
2. Overgaard J. Hansen HS, Specht L, et al. Five compared with six fractions per
week of conventional radiotherapy of squamous-cell carcinoma of head and neck:
DAHANCA 6 and 7 randomised controlled trial. Lancet 2003;362(9388):933-940
Advanced Head and Neck Cancer. Int J Radiat Oncol Biol Phys. 75(3):725-733,
2009.
Radiology and Oncology (ASTRO) and American College of Radiology (ACR)
practice guidelines for intensity-modulated radiation therapy (IMRT). Int J Radiat
Oncol Biol Phys. 2009;73(1):9-14.
5. IMRT Documentation Working Group, Holmes T, Das R, Low D, et al. American
Society of Radiation Oncology recommendations for documenting intensity-
modulated radiation therapy treatments. Int J Radiat Oncol Biol Phys.
2009;74(5):1311-1318.
6. Bourhis J, Calais G, Lapeyre M, et al. Concomitant radiochemotherapy or
accelerated radiotherapy: analysis of two randomized trials of the French Head and
Neck Cancer Group (GORTEC). Semin Oncol 2004;31:822-826. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/15599861.
7. Machtay M, Moughan J, Trotti A, et al. Factors associated with severe late toxicity
after concurrent chemoradiation for locally advanced head and neck cancer: an
RTOG analysis. J Clin Oncol 2008;26:3582-3589.
8. Schoenfeld GO, Arruda RJ, Morris CG, et al. Patterns of failure and toxicity after
intensity-modulated radiotherapy for head and neck cancer. Int J Radiat Oncol Biol
Phys. 2008;71:377-385.
9. Cooper JS, Zhang Q, Pajak TK et al. Long term follow up of the RTOG
9501/intergroup phase III trial: postoperative concurrent radiation therapy and
chemotherapy in high-risk squamous cell carcinoma of the head and neck. Int J
Radiat Oncol Biol Phys. 2012;84 1198-1205
10. Eric K. Hansen, et al. Handbook of Evidence-based Radiation Oncology.
Springer; 3rd ed. 2018 Edition
15
Hypopharyngeal cancer
於放射治療前，應回顧該病人的病理報告、影像檢查…等；於多專科團隊
會議時提出討論。
二、定位：
1. 體位設定：
2. 固定方法：
件為由腦部額葉(frontal lobe)至主動脈弓(aortic arch)，應包含眼眶、鼻咽、
頸部，切片厚度約 2.5-5 毫米。掃描範圍及切片厚度條件，可由主治醫
師自行訂定。
三、靶體積定義(Target Volume Definition)及放射治療計畫規劃(Radiation Therapy

Planning)：
(1)腫瘤體積(Gross Tumor Volume)：指肉眼或影像診斷可見之腫瘤。(以下簡稱
為 GTV) 應包含由 CT 影像、臨床理學檢查、PET 或 MRI 影像可判讀之主
要腫瘤(primary tumor)及臨床上轉移之淋巴結(直徑 1 公分以上、含有壞死
區)。如果治療前做過化學治療，需考慮原來部位之腫瘤或範圍皆應治療。
(2)臨床靶體積(Clinical Target Volume)：包括腫瘤及其可能侵犯之範圍，通常由
影像輔助 (以下簡稱為 CTV)。CTV 為包含 GTV 可能侵犯之範圍，可分為
CTV-H、CTV-M 及 CTV-L。CTV-H 為 GTV+ 0.3–2 cm margin on primary GTV
and 3–5mm margin on nodal GTV、CTV-M 為高侵犯風險之淋巴結或腫瘤及
CTV-L 為低侵犯風險之淋巴結或腫瘤。
(3)計劃靶體積(Planning Target Volume)：考慮擺位誤差或其他因素，在 CTV 加
16
上範圍之體積 (以下簡稱為 PTV) 。治療計畫標靶體積 (PTV)之定義：
CTV+3~5mm margin。
(4)格雷(Gray)：為放射線吸收劑量之單位。(以下簡稱為 Gy, 1 Gy = 100cGy)
(1) CTV (Clinical tumor volume)：
a. CTV-H：原則如下
原發腫瘤部位加上適當範圍(視原發部位解剖位置及術後狀況而定)及整個
淋巴結為陽性之部位。如果開刀範圍不明顯，可考慮找出手術前腫瘤之部
位並加上適當範圍。
c. CTV-L：頸部淋巴結轉移危險區(視原發部位解剖位置而定)
(2) 計劃靶體積(Planning Target Volume)：考慮擺位誤差或其他因素，在 CTV 加
上範圍之體積(以下簡稱為 PTV) 。治療計畫標靶體積（PTV）之定義：
CTV+3~5mm margin。
(3) 放射治療計畫規劃：在 CTV 周圍視原發部位解剖位置而加上擺位誤差之隨
機誤差，並需留意頭腳方向(cranio-caudal directions)之範圍。
17
◎ Definitive RT
■ Indication:
(1) RT alone: (I) most cT1N0
(II) selected cT2N0 [not requiring total laryngectomy]
(2) Induction chemotherapy + RT/CCRT: (I) cT1N+
(II) cT2-3 any N
(III) cT4a any N[category 3]
✓ RT: primary site CR and neck stable or improved
✓ CCRT: primary site PR and neck stable or improved
(3) Consider CCRT: (I) cT1N+
(II) cT2-3 any N
(III) cT4a any N [category 3]
◎ Post-operative RT
■ Indication:
(2) pN2 or pN3 nodal disease
(3) Close margins
(5) Lymphovascular invasion
(6) pT1N0 with positive margin
(7) pN1 without other adverse pathologic features
(8) after induction chemotherapy + surgery
◎ Post-operative CCRT
■ Indication:
(1) Extracapsular nodal spread
(2) Positive margin (except for pT1N0)
(3) multiple other risk factors
➔ Palliative RT for symptomatic relief
18
RT techniques:
Simulation:
Field design:
■ Definitive RT: treat primary, gross adenopathy & level II-V,
retropharyngeal nodal space in all cases
■ Conventional 3 field technique (bilateral opposed-lateral fields
matched to the lower-neck field):
Superior border: skull base and mastoid
Inferior border: 1 cm below the inferior extent of disease (or 1 cm
below cricoid)
Anterior border: 1 cm skin flash
Posterior border: behind the spinal processes
nodes≥1cm in short axis; grossly abnormal as well as
margin on nodal GTV
risk nodal area
■ For post-operative RT: Use 3-fields technique with stoma in low-
neck field. Lateral field cover neopharynx, adenopathy, and 1.5-2
cm margin on pre-operative extent of disease
19
Dose prescriptions:
■ Definitive RT/CRT:
CTV-H: 66Gy (2.2Gy/fx) to 70Gy (2Gy/fx), or 69.96Gy (2.12Gy/fx)
CTV-M to L:
✓ 44–50 Gy (2Gy/fx) in 3D-CRT and sequentially planned IMRT
✓ 54–63 Gy (1.6-1.8Gy/fx) in IMRT dose painting technique
■ Post-operative RT/CRT:
CTV-H: 60 Gy-66 Gy (2Gy/fx), can boost 4–6 Gy for margin+
CTV-M to L:
✓ 44–50 Gy (2Gy/fx) in 3D-CRT and sequentially planned IMRT
⚫ Consider boost 10 Gy if residual tumor persisted
⚫ Interval between resection to post-op RT ≤ 6weeks
◼ Reirradiation
⚫ The dose regimen depends on individual situation, common
recommended doses are as follows
✓ Conventional fractionation
◆ Definitive: 66–70 Gy (1.8-2Gy/fx)
◆ Postoperative: 56–60 Gy (1.8-2Gy/fx)
✓ Current SBRT schedules being used or investigated are in the
range of 35–44 Gy using 5 fractions.
◼ Palliative RT
✓ 50 Gy/20fx or 37.5 Gy/15fx
✓ 30 Gy/10fx
✓ 30 Gy/5fx, 2 frs/wk with ≥3 days between the 2 treatments
✓ 52–56 Gy/13–14 fx, 2 frs/wk
20
Dose constraints:
Organ Constraints
R't lens Dmax < 5Gy
L't lens Dmax < 5Gy
R't eye retina Dmax < 45Gy; Dmean < 35Gy
L't eye retina Dmax < 45Gy; Dmean < 35Gy
Chiasma Dmax < 54Gy
R't submandibular gland Dmean < 39Gy
L't submandibular gland Dmean < 39Gy
Larynx Dmean < 40Gy

GTV: ≥98% dose to 100%GTV, <1%GTV receive <95% dose
PTV: ≥95% dose to 100% PTV, <10% PTV-h receive ≥107% dose
Parotid glands: mean < 26~30Gy
Oral cavity: mean < 40Gy
21
22
References:
1. NCCN guideline for Head and Neck cancer: 2023 version 1.
week of conventional radiotherapy of squamous-cell carcinoma of head and
neck: DAHANCA 6 and 7 randomised controlled trial. Lancet
2003;362(9388):933-940
3. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or
without concomitant chemotherapy for locally advanced head and neck cancer.
N Engl J Med 2004;350:1945-1952.
4. Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent
radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the
head and neck. N Engl J Med 2004;350:1937-1944.
5. Bernier J, Cooper JS, Pajak TF, et al. Defining risk levels in locally advanced
head and neck cancers: A comparative analysis of concurrent postoperative
radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (#9501).
Head Neck 2005;27:843-850.
2009.
7. Hartford AC, Palisca MG, Eichler TJ, et al. American Society for Therapeutic
practice guidelines for intensity-modulated radiation therapy (IMRT). Int J
Radiat Oncol Biol Phys. 2009;73(1):9-14.
8. IMRT Documentation Working Group, Holmes T, Das R, Low D, et al.
American Society of Radiation Oncology recommendations for documenting
intensity-modulated radiation therapy treatments. Int J Radiat Oncol Biol Phys.
2009;74(5):1311-1318.
accelerated radiotherapy: analysis of two randomized trials of the French Head
and Neck Cancer Group (GORTEC). Semin Oncol 2004;31:822-826.
23
11. Schoenfeld GO, Arruda RJ, Morris CG, et al. Patterns of failure and toxicity
after intensity-modulated radiotherapy for head and neck cancer. Int J Radiat
Oncol Biol Phys. 2008;71:377-385.
Radiat Oncol Biol Phys. 2012;84:1198-1205
14. Laursen M, Specht L, Kristensen CA, Gothelf A, Bernsdorf M, Vogelius I,
Friborg J. An Extended Hypofractionated Palliative Radiotherapy Regimen for
Head and Neck Carcinomas. Front Oncol. 2018 Jun 11;8:206.
24
Laryngeal cancer
一、放射治療前準備：於放射治療前，應回顧該病人的病理報告、影像檢查…等；
於多專科團隊會議時提出討論。
二、定位：
1. 體位設定：
2. 固定方法：
將雙手置放於兩側，並以臉部模具等輔具固定。治療中心標記在臉部模具
上。口咬器與膝關節固定器視情況而放。
應採取電腦斷層輔助之模擬攝影，在電腦斷層掃瞄定位室，請病人依原姿
勢，標記點對到定位雷射。金屬標記在影像上呈現中心點之位置。影像擷取
時電腦斷層之上下緣視腫瘤部位而定，電腦斷層之掃描範圍及條件為由腦
部前葉(frontal lobe)至主動脈弓(aortic arch)，應包含眼眶、鼻咽、頸部，切
片厚度約 2.5-5 毫米。掃描範圍及切片厚度條件，可由主治醫師自行訂定。

Planning)：
為 GTV) 應包含由 CT 影像、臨床訊息、PET 或 MRI 影像可判讀之主要腫
瘤(primary tumor)及臨床上呈陽性之淋巴結(直徑 1 公分以上或含有壞死
區)。如果治療前做過化學治療，需考慮原來部位之腫瘤或範圍皆應治療。
(2)臨床靶體積(Clinical Target Volume)：指腫瘤及其可能侵犯之範圍，通常由
影像輔助判定。(以下簡稱為 CTV) 為包含 GTV 可能侵犯之範圍，可分為
CTV-H、CTV-M 及 CTV-L。CTV-H 為 GTV+0.3–2cm margin on primary
GTV and 3–5mm margin on nodal GTV、CTV-M 為高侵犯風險之淋巴結及
CTV-L 為低侵犯風險之淋巴結。
(3)計劃靶體積(Planning Target Volume)：考慮擺位誤差，在 CTV 加上範圍之
體積(以下簡稱為 PTV)。治療計畫標靶體積（PTV）之定義：CTV+3~5mm
margin。
25
(4)格雷(Gray)：為放射線吸收劑量之單位。(以下簡稱為 Gy, 1 Gy = 100cGy)
(1) CTV (Clinical tumor volume)：
a. CTV-H：原則如下
整個開刀範圍加上範圍(視原發部位解剖位置而定)及整個淋巴結為陽性之
部位。如果開刀範圍不明顯，可考慮找出手術前腫瘤之部位並加上範圍。
加上範圍之體積 (以下簡稱為 PTV)。治療計畫標靶體積（PTV）之定義：
CTV+3~5mm margin。
(3) 放射治療計畫規劃：在 CTV 周圍視原發部位解剖位置而加上擺位誤差及
內部器官移動之隨機誤差，並需留意頭腳方向(cranio-caudal directions)之範
圍。
26
◎Glottic larynx
◼ Definitive
(1) RT alone: cTis, cT1-2N0 or selected cT3N0
(2) CRT: cT3anyN, N+, selected T4a but decline surgery
(3) Induction chemotherapy + RT/CRT : cT3anyN, N+, selected T4a
but decline surgery
✓ RT: primary site CR/PR
✓ CRT: primary site PR
◼ Post-operative
(1) Post-op RT:
✓ pT4, pN2-3, PNI, LVI, close margin, subglottic extension
✓ pN1 without other risk features
✓ after induction chemotherapy + surgery
(2) Post-op CRT:
✓ ENE+
✓ Positive margin [except for cT1-2N0 or selective cT3N0]
✓ consider for other risk features, ex: multiple risk features
(pT4, pN2-3, PNI, LVI, close margin, subglottic extension)
[except for cT1-2N0 or selective cT3N0]
◎ Supraglottic larynx
◼ Definitive
(1) RT alone: cT1-2N0 or selected cT3N0
(2) CRT: cT3anyN, N+, selected T4a but decline surgery
(3) Induction chemotherapy + RT/CRT : cT3anyN, N+, selected T4a
but decline surgery
✓ RT: primary site CR/PR
✓ CRT: primary site PR
◼ Post-operative
(1) Post-op RT:
27
✓ pT3-4, pN2-3, PNI, LVI, close margin
✓ pN1 without other risk features
✓ after induction chemotherapy + surgery
(2) Post-op CRT:
✓ ENE+
✓ Positive margin [except for cT1-2N0 or selective cT3N0]
✓ consider for other risk features, ex: multiple risk features
(pT3-4, pN2-3, PNI, LVI, close margin)
RT techniques:
Simulation:
Field design:
■ For T1-2N0 glottic cancer: 5x5 cm for T1 or 6x6 cm for T2 field
with the superior border at the top of the thyroid cartilage, the
inferior border at the bottom of the cricoid for T1 and one tracheal
ring below cricoid for T2, a 1 cm skin flash anteriorly, and 1-2 cm
margin posteriorly (or the anterior edge of the vertebral body)
■ For T3-4N0 glottic cancer: Superior border: 2 cm above the angle of
the mandible, posterior border: behind the spinal processes, inferior
border: include 1.5-2 cm margin on the subglottic extent of the
tumor. Match the lateral fields to the low-neck field.
■ For T1N0 supraglottic cancer: primary tumor + level II-III neck node
regions
■ For T2-4, node positive supraglottic cancer: primary tumor + level
II-III neck node regions with a matched low-neck field (to cover
level II, III, IV, and V neck regions).
nodes≥1cm in short axis; grossly abnormal as well as
28
margin on nodal GTV
risk nodal area
■ For post-operative RT: Use 3-fields technique with stoma in low-
neck field. Lateral field cover neopharynx, adenopathy, and 1.5-2 cm
margin on pre-operative extent of disease.
Dose prescriptions:
■ Definitive RT
◆ Glottic cancer:
TisN0: 60.75 Gy (2.25Gy/fx) to 66 Gy (2Gy/fx)
T1N0: 63 Gy (2.25Gy/fx) to 66 Gy (2Gy/fx)
or 50 Gy (3.12Gy/fx) to 52 Gy (3.28Gy/fx)
T2N0: 65.25 Gy (2.25Gy/fx) to 70 Gy (2Gy/fx)
≥T2, N1:
CTV-H: 66 Gy (2.2Gy/fx) to 70 Gy (2Gy/fx)
CTV-M to L:
✓ 44–50 Gy (2Gy/fx) in 3D-CRT and sequentially IMRT
◆ Other sites:
CTV-H: 66 Gy (2.2Gy/fx) to 70 Gy (2Gy/fx)
CTV-M to L:
■ Definitive CRT
CTV-H: 70 Gy
CTV-M to L:
29
◼ Post-operative RT/CRT:
CTV-H: 60–66Gy (2Gy/fx), may boost 4–6 Gy for margin+
CTV-M to L:
⚫ Consider boost 10Gy if residual tumor persisted
⚫ Interval between resection to post-op RT ≤ 6weeks
◼ Reirradiation
✓ Conventional fractionation
◆ Definitive: 66–70 Gy (1.8-2Gy/fx)
◆ Postoperative: 56–60 Gy (1.8-2Gy/fx)
✓ Current SBRT schedules being used or investigated are in the
range of 35–44 Gy using 5 fractions.
◼ Palliative RT
✓ 50 Gy/20fx or 37.5 Gy/15fx
✓ 30 Gy/10fx
✓ 30 Gy/5fx, 2 frs/wk with ≥3 days between the 2 treatments
✓ 52–56 Gy/13–14 fx, 2 frs/wk
30
Dose constraints:
Organ Constraints
R't lens Dmax < 5Gy
L't lens Dmax < 5Gy
R't eye retina Dmax < 45Gy; Dmean < 35Gy
L't eye retina Dmax < 45Gy; Dmean < 35Gy
Chiasma Dmax < 54Gy
R't submandibular gland Dmean < 39Gy
L't submandibular gland Dmean < 39Gy
GTV: ≥98% dose to 100%GTV, <1%GTV receive <95% dose
PTV: ≥95% dose to 100% PTV, <10% PTV-h receive ≥107% dose
Parotid glands: mean < 26~30Gy (at least 1 gland)
Cochlea: mean < 45Gy
Oral cavity: mean < 40Gy
31
Bilateral opposed field for a case of glottic cancer (left vocal cord cancer)
Three fields (lateral opposed portal for primary & upper neck, matched to
a low neck field) for a case of laryngeal cancer receiving post-operative
RT.
32
33
References:
1. NCCN guideline for Head and Neck cancer: 2023 version 1
week of conventional radiotherapy of squamous-cell carcinoma of head and
neck: DAHANCA 6 and 7 randomised controlled trial. Lancet
2003;362(9388):933-940
3. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or
without concomitant chemotherapy for locally advanced head and neck cancer. N
Engl J Med 2004;350:1945-1952.
4. Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy
and chemotherapy for high-risk squamous-cell carcinoma of the head and neck.
N Engl J Med 2004;350:1937-1944.
5. Bernier J, Cooper JS, Pajak TF, et al. Defining risk levels in locally advanced
head and neck cancers: A comparative analysis of concurrent postoperative
radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (#9501).
Head Neck 2005;27:843-850.
2009.
practice guidelines for intensity-modulated radiation therapy (IMRT). Int J
Radiat Oncol Biol Phys. 2009;73(1):9-14.
8. IMRT Documentation Working Group, Holmes T, Das R, Low D, et al. American
Society of Radiation Oncology recommendations for documenting intensity-
modulated radiation therapy treatments. Int J Radiat Oncol Biol Phys.
2009;74(5):1311-1318.
accelerated radiotherapy: analysis of two randomized trials of the French Head
and Neck Cancer Group (GORTEC). Semin Oncol 2004;31:822-826.
34
11. Schoenfeld GO, Arruda RJ, Morris CG, et al. Patterns of failure and toxicity after
intensity-modulated radiotherapy for head and neck cancer. Int J Radiat Oncol
Biol Phys. 2008;71:377-385.
Radiat Oncol Biol Phys. 2012;84:1198-1205
14. Laursen M, Specht L, Kristensen CA, Gothelf A, Bernsdorf M, Vogelius I,
Friborg J. An Extended Hypofractionated Palliative Radiotherapy Regimen for
Head and Neck Carcinomas. Front Oncol. 2018 Jun 11;8:206.
35
Oral cavity
於放射治療前，應回顧該病人的病理報告、影像檢查…等；於多專科團隊會
議時提出討論。
二、定位：
1. 體位設定：
2. 固定方法：
將雙手置放於兩側，並以臉部模具及頭枕等輔具固定。治療中心標記在塑型
模具上。口咬器與膝關節固定器視情況而放。
應採取電腦斷層輔助之模擬攝影，在電腦斷層掃瞄定位室，請病人依原姿勢，
標記點對到定位雷射。金屬標記在影像上呈現中心點之位置。影像擷取時電
腦斷層之上下緣視腫瘤部位而定，電腦斷層之掃描範圍及條件為由腦部前葉
(frontal lobe)至主動脈弓(aortic arch)，應包含眼眶、鼻咽、頸部，切片厚度
約 3 毫米。掃描範圍及切片厚度條件，可由主治醫師自行訂定。

Planning)：
為 GTV) 應包含由 CT 影像、臨床訊息、PET 或 MRI 影像可判讀之主要
腫瘤(primary tumor)及臨床上呈陽性之淋巴結(直徑大於 1 公分含有壞死
區)。如果治療前做過化學治療，需考慮原來部位之腫瘤範圍皆應治療。
(2)臨床靶體積(Clinical Target Volume)：指腫瘤及其可能侵犯之範圍，通常由影
像輔助規劃。(以下簡稱為 CTV) 為包含 GTV 可能侵犯之範圍，可分為
CTV-H、CTV-M 及 CTV-L。CTV-H 為 GTV 之可能侵犯之範圍、CTV-M
為高侵犯風險之淋巴結及 CTV-L 為低侵犯風險之淋巴結。
(3)計劃靶體積(Planning Target Volume)：考慮擺位誤差及內部器官移動，在
CTV 加上範圍之體積。(以下簡稱為 PTV) 治療計畫標靶體積（PTV）之定
36
義：CTV 加上 daily setup error。
(1)CTV (Clinical target volume)：
a. CTV-H：
原則如下：整個開刀範圍 (視原發部位解剖位置而定)及整個淋巴結為陽
性之部位。如果開刀範圍不明顯，可考慮找出手術前腫瘤之部位並加上
範圍。
b. CTV-M：頸部淋巴結轉移高危險區(視原發部位解剖位置而定)
c. CTV-L：頸部淋巴結轉移低危險區(視原發部位解剖位置而定)
(2)放射治療計畫規劃靶體積 (PTV)：在 CTV 周圍視原發部位解剖位置而加
上擺位誤差及內部器官移動之隨機誤差，並需留意頭腳方向(cranio-caudal
directions)之範圍。一般建議 CTV-PTV margin 為 0.3-0.5 cm。
37
Buccal cancer
◎ Definitive RT
■ Indication:
(1) RT alone: T1- T2N0
(2) Consider CCRT: (I) T3-4N0 (II) T1-4N+
■ Indication:
(5) Vascular/lymphatic invasion
(6) One positive node without other adverse features
(7) Close margin
■ Indication:
(1) Extranodal extension
(2) Positive margin
(3) Multiple other risk factors*
*Risk factor: pT3 or pT4 primary, N2 or N3 nodal disease, Nodal
disease in levels IV or V, Perineural invasion, Vascular/lymphatic
invasion.
➔ RT for symptomatic relief
RT techniques:
Simulation:
38
■ A mouth bite should be used if indicated
Field design:
■ Treatment is usually with an ipsilateral wedged photon pair
■ Field borders are 2 cm anterior and superior to the lesion; the
posterior aspect of the spinous processes if nodes are irradiated;
inferiorly at the thyroid notch
■ The oral commissures and lips are shielded if possible
■ Post-operative volume included the tumor bed, scars, and ipsilateral
lymph node level
■ Patients with positive nodes received neck RT to upper and lower
neck
Dose prescriptions:
◼ RT alone:
Primary and involved LNs: 70Gy (1.8-2Gy/fraction) or
66Gy(2.2Gy/fraction)
Low to intermediate risk: 44-50Gy (2Gy/fraction) to 54-63Gy (1.6-
1.8Gy/fraction)
■ Post-operative RT:
Primary: 50-66Gy (1.8-2Gy/fraction)
Neck: involved neck: 60-66Gy (2Gy/fraction) (high-risk nodal
stations)
uninvolved neck: 44-50Gy (2Gy/fraction) to 54-63Gy (1.5-
1.8Gy/fraction) (low-risk nodal stations)
⚫ Interval between resection to post-op RT ≦6weeks if wound or flap
is suitable for RT
■ CCRT
Primary and gross adenopathy: 70Gy (range: 63~77Gy)
Neck: 50Gy (low-risk nodal stations) (range: 45~55Gy)
39
Organ Constraints
Chiasma Dmax < 54Gy
Larynx Dmean < 40Gy

dose
Parotid glands: mean < 26-30Gy (at least 1 gland)
Larynx: mean < 30~45Gy
40
41
Tongue cancer (Oral tongue)
◎ Definitive RT
■ Indication:
(1) RT alone: T1-T2N0
■ Indication:
(7) Close margin
■ Indication:
(2) Positive margin
invasion.
42
RT techniques:
Simulation:
Field design:
■ With opposed lateral fields, the superior border is 1-1.5 cm above the
dorsum of the tongue or 2 cm above tumor. The inferior border is at
the thyroid notch. The posterior border is placed at the posterior
aspect of the spinous processes. The anterior border is 2 cm anterior
to the tumor.
■ When node positive, a low-neck field is matched to the inferior
border of the opposed lateral fields
■ T1N0 & T2N0→suggestion of RT field: tumor bed + bilateral level I,
II, and III neck regions
■ T3-4N0 & T1-4N+→ suggestion of RT field: tumor bed + bilateral
level I, II, III, and V neck regions; level IV should be included for
N+ disease
Dose prescriptions:
◼ RT alone:
1.8Gy/fraction)
Primary: 50-66Gy (2Gy/fraction)
stations)
43
is suitable for RT

Organ Constraints
Chiasma Dmax < 54Gy
R't parotid gland Dmean < 26Gy; V20Gy < 50%
Larynx Dmean < 40Gy


dose
44
45
46
Floor of mouth
◎ Definitive RT
■ Indication:
(2) Consider CCRT: (I)T3-4N0 (II) T1-4N+
■ Indication:
(7) Close margin
■ Indication:
(2) Positive margin
invasion.
47
RT techniques:
Simulation:
Field design:
■ With opposed laterals, the superior border is 1-1.5 cm above the
dorsum of the tongue or 2 cm above tumor. Level I nodes are always
treated, and level II is included for depth of invasion > 1.5 mm (with
posterior border at the posterior aspect of the spinous processed).
The inferior border is at the thyroid notch. The lower lip is excluded
when possible.
■ When node positive, a low neck field is matched to the inferior
border of the opposed lateral fields.
Dose prescriptions:
◼ RT alone:
1.8Gy/fraction)
stations)
is suitable for RT
48
Organ Constraints
Chiasma Dmax < 54Gy
Larynx Dmean < 40Gy

dose
49
Gingiva
◎ Definitive RT
■ Indication:
■ Indication:
(7) Close margin
■ Indication:
(2) Positive margin
invasion.
50
RT techniques:
Simulation:
Field design:
■ For gingival lesions, if perineural invasion is present, the entire
hemi-mandible from mental foramen to the temporomandibular joint
is treated
■ Fields cover the primary with 2 cm margins and upper neck nodes
■ The low-neck may be treated for T3/4 or N+ disease
Dose prescriptions:
◼ RT alone:
1.8Gy/fraction)
stations)
is suitable for RT
51
Organ Constraints
Chiasma Dmax < 54Gy
Larynx Dmean < 40Gy


dose
Larynx: mean< 30~45Gy
52
References:
1. Adelstein DJ, Li Y, Adams GL, et al. An intergroup phase III comparison of
standard radiation therapy and two schedules of concurrent chemoradiotherapy in
patients with unresectable squamous cell head and neck cancer. J Clin Oncol. 21:
92-8, 2003. PMID: 12506176
2. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without
concomitant chemotherapy for locally advanced head and neck cancer. NEJM.
350(19): 1945-52, 2004.
3. Bernier J, Cooper JS, Pajak TF. Defining risk levels in locally advanced head and
neck cancers: A comparative analysis of concurrent postoperative radiation plus
chemotherapy trials of the EORTC (#22931) and RTOG (# 9501). Head & Neck.
27(10): 843-50, 2005.
4. Bourhis J, Amand C, Pignon JP, et al. Update of MACH-NC (Meta-analysis of
chemotherapy in head and neck cancer) database focused on concomitant
chemoradiotherapy. Proc Am Soc Clin Oncol (ASCO). 488, 2004. Abstract 5505.
5. Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiation
therapy and chemotherapy in high-risk SCCA of the head and neck: The RTOG
9501/Intergroup phase III trial. NEJM. 350(19):1937-44, 2004.
6. Radiation Therapy Oncology Group, Protocol 0619, website: www.rtog.org.
8. NCCN 2023 version 1. clinical practice guidelines in oncology: Head and Neck
Cancers
53
Thyroid cancer
於放射治療前，應回顧該病人的病理報告、影像檢查…等；於多專科團
隊會議時提出討論。
二、定位：
1. 體位設定：
2. 固定方法：
應採取電腦斷層輔助之模擬攝影，在電腦斷層掃描定位室，請病人依原
件為由腦部前葉(frontal lobe)至主動脈弓(aortic arch)，應包含眼眶、鼻咽、
頸部，切片厚度約 3-5 毫米。掃描範圍及切片厚度條件，可由主治醫師
自行訂定。
Planning)：
3.1 靶體積定義：
為 GTV) 應包含由 CT 影像、臨床訊息、PET 或 MRI 影像可判讀之主要
腫瘤(primary tumor)及臨床上轉移之淋巴結(短軸直徑大於 1 公分、含有壞死
區)。
(2)臨床靶體積(Clinical Target Volume)：包括腫瘤及其可能侵犯之範圍，通常由
影像輔助 (以下簡稱為 CTV)。CTV 為包含 GTV 可能侵犯之範圍，可分為
CTV-H、CTV-M 及 CTV-L。CTV-H 為 GTV+0.5–2 cm margin on primary
GTV and 3–5mm margin on nodal GTV、CTV-M 為高侵犯風險之淋巴結或腫
瘤及 CTV-L 為低侵犯風險之淋巴結或腫瘤。
(3)計劃靶體積(Planning Target Volume)：考慮擺位誤差或其他因素，在 CTV 加
上範圍之體積 (以下簡稱為 PTV) 。治療計畫標靶體積（PTV）之定義：
54
CTV+3~5mm margin。
3.2 手術切除後之靶體積定義：
(1)CTV (Clinical tumor volume)：
a. CTV-H：
原則如下：
原發腫瘤部位加上適當範圍(視原發部位解剖位置及術後狀況而定)及整個
淋巴結為陽性之部位。如果開刀範圍不明顯，可考慮找出手術前腫瘤之部
位並加上適當範圍。
加上範圍之體積 (以下簡稱為 PTV) 。治療計畫標靶體積（PTV）之定義：
CTV+3~5mm margin。
(3)放射治療計畫規劃：在 CTV 周圍視原發部位解剖位置而加上擺位誤差之隨
機誤差，並需留意頭腳方向(cranio-caudal directions)之範圍。

◎ Indication:
(1) Inoperable or recurrent disease

(2) Failure after 131I treatment
(3) Residual tumor in the neck after surgery, and unresectable with
inadequate 131I uptake for differentiated tumors.
(4) Distant metastasis
(5) Anaplastic carcinoma→ post-op adjuvant RT, or RT for
unresectable disease. For R0 or R1 resection of ATC, adjuvant
radiotherapy or chemoradiation should start as soon as the patient
is sufficiently recovered from surgery, ideally 2–3 weeks
postoperatively.
(6) Consider EBRT for patients >45 years old with gross extrathyroid
extension with high risk of having microscopic residual disease.
Also consider for patients with gross ECE or non-iodine-avid
disease
55
(7) For viscerally invasive disease or rapid progression, upfront
EBRT/IMRT, neoadjuvant therapy may be most appropriate.
RT techniques:
◎ Simulation:
■ Simulate patient supine with neck extended using a thermoplastic

mask to immobilize head and shoulders
◎ Field design:
(1) Advanced differentiated or medullary thyroid cancer:

CTV may include the thyroid bed (as identified on preoperative
imaging, delineated by surgical clips, any residual
disease/thyroid tissue). Regional lymph node levels II–VI can
be included if involved or as elective volumes if not evaluated.
For example: thyroid bed from hyoid bone to aortic arch,
tracheoesophageal groove, bilateral nodal levels II to VI, and
upper mediastinal nodes to the aortic arch. Consider extending
mediastinal coverage inferiorly to the carina if +LN in low neck
or upper mediastinum. May include retropharyngeal nodes
and/or level I if adjacent level II nodes involved.
(2) If primary indication for RT is ETE or +margins, may consider
treating thyroid bed alone. This extends from the bottom of the
hyoid to just below the suprasternal notch.
(3) Anaplastic thyroid cancer:
GTV includes gross primary disease and involved lymph nodes
(determined on contrast-enhanced CT, MRI, and/or FDG-PET,
assuming obtaining these studies does not delay start of
treatment).
High-risk CTV may include involved lymph node regions and
postoperative bed in the case of partial or complete debulking
surgery.
Elective nodal regions may be included in low-dose CTV if
extended-field RT is used.
56
For example: gross disease and post-surgical bed, trachea-
esophageal groove, bilateral nodal levels II to VI, upper
mediastinum, tracheostomy site if present. May include level I
and/or retropharyngeal nodes if at risk.
◎ Target volumes for IMRT
nodes≧1cm in short axis; grossly abnormal as well as suspicious lymph
nodes should be included

CTV include:
margin on nodal GTV
CTV-M: soft tissue and nodal regions adjacent to CTV-H and
high risk nodal area
CTV-L: Lower risk elective coverage, such as uninvolved
levels II–V and VII, tracheostomy site if present.
PTV: CTV+0.3-0.5 cm margin
◎ Dose prescriptions:
CTV-H: 66Gy-73Gy
CTV-M: 58Gy-66Gy
CTV-L: 45Gy-56Gy
◎Adjuvant RT for high-risk disease (after R1 resection and R0 for
ATC):
Microscopic disease (thyroid bed, involved resected lymph node
regions): 60–66 Gy in 1.8–2 Gy per fraction
Elective nodal regions: 50–56 Gy in 1.6–2 Gy per fraction
◎Salvage RT after R2 resection or inoperable patients:
Gross disease: 66–70 Gy in 1.8–2 Gy per fraction

Microscopic disease (thyroid bed, involved resected lymph node
regions): 60–66 Gy in 1.8–2 Gy per fraction
57
Elective nodal regions: 45–56 Gy in 1.6–2 Gy per fraction
◎ Dose constraints:
■ Spinal cord < 45Gy

■ Lung: V20 < 30%
■ Esophagus: mean dose < 34Gy
■ Brachial plexus: max < 66Gy
■ Parotid gland mean ≤ 26 Gy
58
References:
1. NCCN guideline for Thyroid carcinoma: 2022 version 3
2. Perez and Brady’s Principles and Practice of Radiation Oncology 7th ed.
3. Target volume delineation and field setup: A practical guide for comformal and
intensity-modulated radiation therapy; Chap 8 Thyroid cancer
4. Handbook of evidence-based radiation oncology 3rd ed. III Head and neck,
thyroid cancer
5. Farahati J, Reiners C, Stuschke M,et al. Cancer. 1996 Jan ;77(1):172-80.
Differentiated thyroid cancer. Impact of adjuvant external radiotherapy in
patients with perithyroidal tumor infiltration (stage pT4).
6. Simpson WJ, Panzarella T, Carruthers JS et al. Int J Radiat Oncol Biol Phys.
1988 Jun;14(6):1063-75.Papillary and follicular thyroid cancer: impact of
treatment in 1578 patients.
59
Esophageal cancer
於放射治療前，應回顧該病人的病理報告、影像檢查…等；於多科團隊會議
時提出討論。
二、定位：
1. 體位設定：
仰躺姿勢。所有病患模擬定位姿勢皆為仰臥(supine) ；如果病患能配合，
雙手高舉頭上。
2. 固定方法：
為求擺位再現性高，可盡量選擇使用真空墊(vacuum bag)或 cast 作為固定

模具。如果有治療鎖骨上窩區域之病患，可考慮製作頭頸部之固定模具。
若位置為食道及胃交接處或有胃侵犯之腫瘤，請病患空腹
應採取電腦斷層輔助之模擬攝影，在電腦斷層掃瞄定位室，請病患依原姿
勢躺在已製作好的固定模具上。
電腦斷層之掃描範圍及條件應可包含整個肺部，切片厚度 5 毫米。掃描範
圍及切片厚度條件，可由主治醫師自行訂定。
4. 特殊注意事項：
為考慮肺部呼吸造成之腫瘤移動，可考慮安排四度空間電腦斷層掃描影像
(4D CT)，但應考慮實際執行狀況，為非必要需求。
三、電腦規劃部分：
靶體積定義(Target Volume Definition)及放射治療計畫規劃(Radiation Therapy
Planning)：
(1)GTV：
應包含由 CT 影像或治療前 PET 影像可判讀之主要腫瘤(primary tumor)及
臨床上轉移之淋巴結。如果治療前做過化學治療，所有在影像看到之腫瘤皆
應治療。
60
(2)CTV：
為包含 GTV 及可能侵犯之範圍。原發腫瘤之上下緣延伸 3-4 公分，而周
圍往外擴 1 公分；若是淋巴結則加上 0.5-1.5 公分的範圍。預防之選擇性淋
巴結照射則以腫瘤之部位來決定。參考如下:
(i)頸部食道癌:考慮須包含鎖骨上窩淋巴結；若有臨床淋巴結陽性應考慮
更高位之頸部淋巴結
(ii) 近端上 1/3 食道癌: 鎖骨上窩淋巴結，食道旁淋巴結
(iii)中段 1/3 食道癌:食道旁淋巴結
(iv) 遠端下 1/3 食道癌:食道旁淋巴結，胃小彎處淋巴結，腹腔淋巴結。
(3)PTV：
CTV 加上適當範圍(約 0.5-1 公分)；呼吸造成之不確定性也應考慮。
61
◎ Pre-operative CCRT
■ Indication:
(1) T1b -T4aN0-+
◎ Definitive CCRT
■ Indication:
(1) T1b -4aN0-+ who decline surgery
(2) T4b
(3) Medically unfit for surgery
(4) Cervical esophageal cancer
■ Indication:
(1) Close margin or R1 resection (microscopic residual cancer)
(2) R2 resection (macroscopic residual cancer)
(3) High risk pT2N0 lower esophagus or G-E junction
adenocarcinoma (: poorly differentiated histology or higher
grade, lymphovascular invasion, perineural invasion, young
patients age <50 y/o (category 2B)
(4) pT3-4aN0 adenocarcinoma
(5) Node positive for adenocarcinoma.
(6) pT3-4N2-3 for Squamous cell carcinoma (optional)
◎ Palliative RT
➔Symptomatic relief, ie. Bone metastasis, dysphagia, obstruction,

pain, chronic bleeding, etc.
➔Unresectable, unable to tolerate chemoradiation
➔Esophageal obstruction causing malignant dysphagia: EBRT and /or
brachytherapy
◎In some circumstances such as residual tumor after standard treatment,
EBRT alone due to certain causes, or TIA case who cannot receive ESD
62
or surgery…: may consider adding brachytherapy
RT techniques:
Simulation:
■ Simulate patient supine with arms up
■ Use of an immobilization device for reproducibility of daily set-up
■ When clinically appropriate, use of IV and/or oral contrast for
simulation may be used to add in target localization
Field design:
GTV: Primary tumor and involved regional lymph nodes
CTV: Superiorly and inferiorly plus 3-4cm expansion, and 1cm
radial expansion, Nodal CTV: 0.5-1.5cm expansion from
GTVn
# Elective nodal region: depend on location of the primary tumor
(1) Cervical esophagus: supraclavicular fossa (SCF) and higher
echelon cervical nodes (esp. >N1)
(2) Proximal third of the esophagus: SCF, paraesophageal nodes
(3) Middle third of the esophagus: paraesophageal nodes
(4) Distal third of the esophagus: paraesophageal nodes, lesser
curvature, celiac axis nodal regions
PTV: 0.5-1cm. The uncertainties arising from respiratory motion
should be taken in consideration.
# Respiratory motion may be significant for distal esophageal and

EGJ lesions. When 4D-CT planning or other motion
management techniques are used, margins may be modified to
account for observed motion and may also be reduced if
justified. The4D-CT data may also be used to create an internal
target volume (ITV) from which subsequent CTV and PTV
expansions can be made.
Dose prescriptions:
■ For pre-operative RT: 41.4~50.4Gy (1.8-2.0Gy/d) (according to NCCN
guidelines)
■ For post-operative RT:
63
patients have not received pre-operative RT: 45-50.4Gy,
patients have received pre-operative RT: consider boost 20Gy if
clinically indicated
■ For definite RT: 50-66Gy
■ Higher dose may be appropriate for tumors of the cervical esophagus:
up to 60-66Gy (1.8-2Gy/Fr)
■ RT dose up to 65Gy using IMRT has been reported in the literatures.
Not routinely recommended here and should be used with precaution.
■Brachytherapy:
■Boost after EBRT: 10-16Gy in 2 fractions, reference isodose is
usually placed at 5 mm tissue depth
■Palliation for obstruction: 7-28Gy in 1-4 fractions, depend on
clinicians.
Dose constraints:
Organ Constraints
Spinal cord Max ≦ 45Gy
Heart V30Gy≦30% (closer to 20% preferred), Mean dose < 30Gy
V40Gy≦10%
V30Gy≦15%
V20Gy ≦ 20%
Total lung
V10Gy ≦ 40%
V5Gy≦50%.
Mean dose<20Gy
Liver V30Gy ≦20%, Mean dose <25Gy
V20Gy ≦ 33%
Kidney
Mean dose <18Gy
Mean dose<45Gy (if not within PTV)
Stomach
Max dose <54Gy
Max bowel dose < 54Gy
Bowel
V45Gy<195cc
64
Example field for mid-esophageal cancer
Examples of IMRT-based planning for upper esophageal tumor
65
References:
1. NCCN 2022 version 5. clinical practice guidelines in oncology: Esophageal and
Esophagogastric Junction Cancers
2. Chen J, Zhu J, Pan J et al. Postoperative radiotherapy improved survival of poor
prognostic squamous cell carcinoma esophagus. Ann Thorac Surg
2010;90(2):435-42.
3. Gebski V, Burmeister B, Smithers BM, et al. Survival benefits from neoadjuvant
chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis .
Lancet Oncol 2007;8(3):226-34.
4. Kranzfelder M, Buchler P, , Friess H et al. Surgery within multimodal therapy
concepts for esophageal squamous cell carcinoma. Adv Med Sci 2009; 54(2): 158-
69.
5. Welsh J, Gomez D, Palmer MB, et al. Intensity-Modulated Proton Therapy
Further Reduces Normal Tissue Exposure During. Int J Radiat Oncol Biol Phys
2011.
6. Suh, Y. G., et al. "High-dose Versus Standard-dose Radiotherapy with Concurrent
Chemotherapy in Stages II-III Esophageal Cancer." Jpn J Clin Oncol. 2014
7. "Surgically treated oesophageal cancer developed in a radiated field: Impact on
peri-operative and long-term outcomes. " Eur J Cancer. 2017 Feb 22;75:179-189
8. Minsky BD et al. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III
trial of combined-modality therapy for esophageal cancer: high-dose versus
standard-dose radiation therapy. J Clin Oncol. 2002 Mar 1;20(5):1167-74.
9. Ruppert BN et al. Cisplatin/Irinotecan versus carboplatin/paclitaxel as definitive
chemoradiotherapy for locoregionally advanced esophageal cancer. Am J Clin
Oncol. 2010 Aug;33(4):346-52
10. Li QQ et al. Definitive concomitant chemoradiotherapy with docetaxel and
cisplatin in squamous esophageal carcinoma. Dis Esophagus. 2010 Apr;23(3):253-
9
11. Iyer et al. Controversies in the multimodality management of locally advanced
esophageal cancer: evidence-based review of surgery alone and combined-
modality therapy. Ann Surg Oncol. 2004 Jul;11(7):665-73
12. Sjoquist KM et al. Survival after neoadjuvant chemotherapy or
chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-
66
analysis. Lancet Oncol. 2011 Jul;12(7):681-92.
13. Spaander MC et al. Esophageal stenting for benign and malignant disease:
European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline
Endoscopy. 2016 Oct;48(10):939-48
14. Lettmaier S, et al. Intraluminal brachytherapy in oesophageal cancer: defining its

role and introducing the technique. J Contemp Brachytherapy. 2014; 6(2): 236–
241.
15. Fuccio L et al. Brachytherapy for the palliation of dysphagia owing to esophageal
cancer: A systematic review and meta-analysis of prospective studies. Radiother
Oncol. 2017;122(3):332-339.
16. Taggar AS et al. Endoluminal high-dose-rate brachytherapy for locally recurrent
or persistent esophageal cancer. Brachytherapy.2018; 17(3): 621–627
17. Ronan J Kelly et al. Adjuvant Nivolumab in resected esophageal or
gastroesophageal junction cancer. NEJM. 2021 Apr 1;384(13):1191-1203
67
Gastric cancer
◎ Consider perioperative chemotherapy or neoadjuvant CCRT
■ Indication:
(1) Medically potentially resectable disease
(2) Unresectable disease
■ Indication:
(1) R1 resection (microscopic residual cancer)
(2) R2 resection (macroscopic residual cancer)
(3) R0 resection: T3, T4, any N or any T, N+ (for patients who have
NOT undergone primary extended lymph node (D2) dissection)
➔ C/T (palliative RT for symptomatic relief)
RT techniques:
Simulation:
■ CT simulation and patient should be instructed to avoid intake of a
heavy meal for 3 hours before simulation and treatment.
■ Patient in supine position with arm up.
■ Immobilize with cushion or cast.
Field design:
■ Use pre-operative CT image, post-operative CT image and surgical
clips to guide target definition.
■ 3D conformal radiotherapy plans include 3-4 fields to reduce dose to
normal tissue such as small bowel, spinal cord, liver and kidneys.
■ General target volume: initial tumor bed, remaining stomach
(especially for margins less than 5 mm), adjacent structures,
anatomic site, and regional nodes for node positive patient.
68
(1) Proximal one-third / Cardia / Esophagogastric junction primaries:
• A 3-5 cm of distal esophagus, medial left hemidiaphragm and
adjacent pancreatic body should be included.
• Nodal areas at risk include: adjacent paraesophageal,
perigastric, suprapancreatic, and celiac lymph nodes.
(2) Middle one-third/Body primaries:
• Body of pancreas should be included.
• Nodal areas at risk include: perigastric, suprapancreatic,
celiac, splenic hilar, porta hepatic, and pancreaticoduedenal
lymph nodes.
(3) Distal one-third/Antrum/Pylorus primaries:
• Head of pancreas, a 3-5 cm margin of duodenal stump should
be included if the gross lesion extended to the gastroduodenal
junction.
• Nodal areas at risk include: perigastric, suprapancreatic,
celiac, splenic hilar, porta hepatic, and pancreaticoduedenal
lymph nodes.
Dose prescriptions:
■ Daily fraction size of 1.8-2 Gy.
■ 45-50.4 Gy/25-28fx to gross tumor and regional lymphatic area
■ Higher dose (50-60Gy/25-30fx) may be used for positive surgical
margin or huge tumor or huge lymph nodes in selected case.
Dose constraints:
■ Spinal cord < 45Gy
■ Kidney: Dmean < 15Gy; V20Gy<30%
■ Liver:V30Gy<30%
■ Small bowel: Dmax < 45 Gy
69
A case of gastric cancer s/p subtotal gastrectomy (R2 resection) + LN
dissection received adjuvant CCRT.
70
Tomotherapy (IMRT+IGRT) for gastric cancer.
71
References:
1. AJCC Cancer Staging Manual Eighth Edition.
2. NCCN clinical practice guidelines in oncology: gastric cancer, version
2:2022
3. Willett CG, Gunderson LL, Stomach, in: Perez and Brady's principals and
practice of radiation oncology, 5th ed. Lippincott Williams & Wilkins, 2007;
1318-1335.
4. Tepper JE, Gunderson LE, Radiation treatment parameters in the adjuvant
post-operative therapy to gastric cancer. Semin Radiat Oncol 2002; 12(2):
187-195.
5. Macdonald JS, Smalley S, Benedetti J, et al. Chemoradiotherapy after surgery
compared with surgery alone for adenocarcinoma of the stomach or
gastroesophageal junction (intergroup 0116). N Engl J Med 345: 725-730, 2001.
6. Smalley SR, Gunderson L, Tepper J, et al. Gastric surgical adjuvant
radiotherapy consensus report: rationale and treatment implementation. Int J
Radiat Oncol Biol Phys 2002; 52:283-293.
7. Liu GF, Bair RJ, Bair E, Liauw SL, Koshy M. Clinical outcomes for gastric
cancer following adjuvant chemoradiation utilizing intensity modulated
versus three-dimensional conformal radiotherapy. PLoS One. 2014 Jan
9;9(1):e82642. doi: 10.1371/journal.pone.0082642. eCollection 2014.
72
胰臟癌放射治療指引
一、放射治療之適應症 (indication) :
1) Resectable/Borderline resectable (neoadjuvant)

2) Locally advanced
3) Resected (adjuvant)
4) Palliative (non-metastatic and metastatic)
5) Recurrent
• In all scenarios, the goal of delivering radiotherapy (RT) is to sterilize
vessel margins, and enhance the likelihood of a margin-negative
resection, and provide adequate local control to prevent or delay
progression of local disease while minimizing the risk of RT exposure to
surrounding organs at risk (OARs).
Radiation can also be used to palliate pain and bleeding or relieve
obstructive symptoms in patients who have progressed or recurred
locally.
◎ Definitive CCRT
■ Indication:
Locally advanced tumor without distant metastasis
■Indication: After resection, patients may receive adjuvant RT for
features that pose them at a high risk for local recurrence (if, positive
resection margins and/or lymph nodes).
5-FU-based chemoradiotherapy as part of adjuvant therapy remains
an acceptable choice
73
二、放射治療前準備：
於放射治療前，應回顧該病人的病理報告、影像檢查等。
If patients present with biliary obstruction (jaundice/elevated direct

bilirubin), plastic or metal stents should be placed by endoscopic
retrograde cholangiopancreatography (ERCP) prior to initiation of RT. A
percutaneous drain can also be used if ERCP stent placement is unsuccessfl.
三、定位：
1.體位設定：
仰躺姿勢。所有病患模擬定位姿勢皆為仰臥(supine)，雙手上舉。
2.固定方法：
可選擇真空墊(vacuum bag)和 wing board 作為固定模具，提高擺
位重複性，建議 NPO 三小時。
3.模擬攝影之要求：
採取電腦斷層模擬攝影，於電腦斷層掃描定位室，請病患依原姿
勢躺於製作完成固定模具上，定位雷射線對映到病患標記點。影
像擷取時電腦斷層之上下緣視腫瘤部位而定，切片厚度約為 1.0 -
5.0 毫米。掃描範圍及切片厚度條件，可由主治醫師自行訂定。
四、靶體積定義 (Target Volume Definition) 及放射治療計畫規劃
(Radiation Therapy Planning)：
(1) GTV 應包含由 CT 影像(在最短軸直徑大於 1 公分之腫瘤)

74
及治療前 PET 影像可判讀之主要腫瘤(primary tumor)及臨床上呈
陽性之淋巴腺。如果治療前做過化學治療，所有在影像看到之腫瘤
皆應治療。應包含原來部位之腫瘤之範圍。
(2) CTV 為包含 GTV 可能侵犯之範圍，為包含 GTV 可能侵
犯之範圍，可由 GTV 加 0.5~1.5 公分之範圍形成。
(3) PTV：包含 CTV，於周圍加上 0.5-2.0 公分範圍，形成
PTV。
◼ 胰臟癌頭部包含：腫瘤加上 2-3 公分，胰十二指腸、上胰腺、腹
腔淋巴結、肝門及十二指腸（pancreaticoduodenal,
suprapancreatic, celiac nodes, porta hepatis, entire duodenal loop）
◼ 胰臟癌體部或尾部包含：腫瘤加上 2-3 公分，胰十二指腸、橫向
上胰腺淋巴結、脾臟淋巴結（pancreaticoduodenal, lateral
suprapancreatic nodes, nodes of splenic hilum）
五、治療劑量 RT Dosing:
■ Resectable/Borderline Resectable (Neoadjuvant):

For chemoradiation, the following RT doses have been reported:
36 Gy in 2.4 Gy fractions to 45–54 Gy in 1.8–2.0 Gy fractions (doses
higher than 54 Gy may be considered on a clinical trial).
■ Resected (Adjuvant)
For chemoradiation, RT dose generally consists of 45–50.4 Gy in 1.8–2.0
Gy fractions to the tumor bed, surgical anastomoses
(hepaticojejunostomy and gastrojejunostomy may be omitted if clinically
appropriate), and adjacent lymph node basins, potentially followed by an
75
additional 5–9 Gy to the tumor bed and anastomoses, if clinically
appropriate. Careful attention to the bowel and stomach dose is
warranted. Escalation above 54 Gy should ideally be avoided or used
only in a clinical trial.
◎ For resectable cases, it may be reasonable to resect within a few weeks
of RT. However, with borderline resectable cases, it may be optimal to
resect 4–8 weeks after RT to allow for downstaging and sterilization of
the margin. Surgical resection can be performed >8 weeks following RT;
however, radiation-induced fibrosis may potentially increase the
difficulty of the resection.
◎ Elective nodal irradiation (ENI) is controversial for resectable/
borderline resectable/locally advanced disease. If ENI is performed,
patients should receive concurrent fluoropyrimidinebased chemotherapy
or dose-reduced gemcitabine when using conventional fractionation
regimens.
■ Locally Advanced (Definitive):
For chemoradiation, RT dose generally consists of 45–54 Gy in 1.8–2.0
Gy fractions. Doses higher than 54 Gy may be considered on a clinical
trial. hypofractionated approach. (67.5 Gy in 15 fractions or 75Gy in 25
fractions) are also acceptable.
■ SBRT (limited data)
It should preferably be utilized as part of a clinical trial or at an
experienced, high-volume center. SBRT doses of 3 fractions (total dose
30–45 Gy) or 5 fractions (total dose 25–50 Gy) have been reported.
However, caution is warranted utilizing higher doses and normal tissue
contstraints must be respected
◎Stereotactic body radiotherapy (SBRT) should be avoided if direct
invasion of the bowel or stomach is observed on CT, MRI, or endoscopy.
■ Stent should be placed before RT in obstructive jaundice patients
76
六、危急器官定義之劑量限制
■ Stomach: max < 45Gy

■ Small intestine: V45 < 195c.c.
■ Kidney (at least one): mean dose < 15~18Gy
■ Liver: mean < 28~32Gy
No clear dose constraints for SBRT currently exist but are emerging.
77
Adapted from RTOG 1102 (IMRT, 2.2–54 Gy); RTOG 0848 (3-D or
IMRT)
78
References:
1. Eric KH, Mack R, Pancreatic cancer in: Handbook of Evidence-Based Radiation
Oncology, 3nd ed.
2. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ® )
3. Pancreatic Adenocarcinoma Version 2.2022
4. Moletta L, Serafini S, Valmasoni M, et al. Surgery for recurrent pancreatic cancer:
Is it effective? Cancers (Basel) 2019;11(7):991.
5. Pawlik TM, Laheru D, Hruban RH, et al; Johns Hopkins Multidisciplinary
Pancreas Clinic Team. Evaluating the impact of a single-day multidisciplinary
clinic on the management of pancreatic cancer. Ann Surg Oncol 2008
Aug;15(8):2081-2088.
6. Yovino S, Poppe M, Jabbour S, et al. Intensity-modulated radiation therapy
significantly improves acute gastrointestinal toxicity in pancreatic and ampullary
cancers. Int J Radiat Oncol Biol Phys 2011 Jan 1;79(1):158-162.
7. Katz MH, Crane CH, Varadhachary G. Management of borderline resectable
pancreatic cancer. Semin Radiat Oncol 2014;24(2):105-112.
8. Marabelle A, Le DT, Ascierto PA, et al. Efficacy of pembrolizumab in patients with
noncolorectal high microsatellite instability/mismatch repair-deficient cancer:
results from the phase 2 KEYNOTE-158 study. J Clin Oncol 2020;38:1-10.
9. Marabelle A, Le DT, Ascierto PA, et al. Efficacy of pembrolizumab in patients with
noncolorectal high microsatellite instability/mismatch repair-deficient cancer:
results from the phase 2 KEYNOTE-158 study. J Clin Oncol 2020;38:1-10.
10. Herman JM, Chang DT, Goodman KA, et al. Phase 2 multi-institutional trial
evaluating gemcitabine and stereotactic body radiotherapy for patients with locally
advanced unresectable pancreatic adenocarcinoma. Cancer 2015;121(7):1128-
1137.
11. Mellon EA, Hoffe SE, Springett GM, et al. Long-term outcomes of induction
chemotherapy and neoadjuvant stereotactic body radiotherapy for borderline
resectable and locally advanced pancreatic adenocarcinoma. Acta Oncol
2015;54(7):979-985.
12. Yang W, Reznik R, Fraass BA, et al. Dosimetric evaluation of simultaneous
integrated boost during stereotactic body radiation therapy for pancreatic cancer.
Med Dosim 2015;40(1):47-52.
13. Adv Radiat Oncol. 2020 Jun 25;6(1):100506. doi: 10.1016/j.adro.2020.06.010.
eCollection Jan-Feb 2021.Ablative Five-Fraction Stereotactic Body Radiation
Therapy for Inoperable Pancreatic Cancer Using Online MR-Guided Adaptation.
Comron Hassanzadeh 1, Soumon Rudra 1, Ani Bommireddy 2, William G
Hawkins 3, Andrea Wang-Gillam 4, Ryan C Fields 3, Bin Cai 1, Justin Park 1,
79
Olga Green 1, Michael Roach 5, Lauren Henke 1, Hyun Kim 1
14. Reyngold M, O'Reilly EM, Varghese AM, et al. Association of ablative radiation
therapy with survival among patients with inoperable pancreatic cancer. JAMA
Oncol 2021;7:735-738.
80
肝臟放射治療指引
◎ Adjuvant RT
■ Indication:
(1) Hepatocelluar carcinoma (HCC) with portal vein tumor
thrombosis (PVTT)
(2) Unresectable, medically inoperable or recurrent liver tumor
(3) 其餘任何可定位之病灶均可施行，通常為治癒之治療及栓
塞之輔助治療或在上述治療不適合時，做為主要治療
例如:無法手術切除或經導管動脈栓塞術的原發部位，肝癌
轉移性病灶，肝門靜脈侵犯，總膽管侵犯導致黃疸，腹腔
淋巴結轉移，右心房或下腔靜脈血栓阻塞。
◎ Selection criteria for Stereotactic body radiotherapy (SBRT):
(1) Primary HCC unsuitable to other loco-regional therapies
(2) Child–Pugh A or B liver disease
(3) Barcelona Clinic Liver Cancer (BCLC) stage A, B or C
(4) ECOG performance status 0–2 (Karnofsky Performance Status >70%)
(5) Minimum life expectancy of 3 months
(6) 1–3 inoperable HCC lesions with diameter ≤6 cm
(7) No evidence of extrahepatic progressive or untreated disease
(8) Disease-free liver volume >700 cm3
(9) No prior radiation therapy to the targeted area.
RT techniques:
Simulation:
■ CT simulationand 3D treatment planning is encouraged.
◼ CT simulation and MR simulation for MR linac.
■ Patient in supine position with both arms up.
■ Immobilize with cushion or cast.(MR linac is not applicable)
81
■ When clinically appropriate, use of IV (especially for visualization of
HCC with portal vein invasion) and/or oral contrast for CT
simulation to aid in target localization.
■ 4D CT is useful at time of simulation to evaluate organ motion
during respiration. Respiratory gating might be used to decrease field
size.
■ For SBRT:
Patients were immobilized with a thermoplastic body cast or
cushion (MR linac is not applicable). Respiratory motion should be
managed, including abdominal compression to minimize respiratory
organ motion, beam gating with the respiratory cycle, dynamic
tumor tracking, or active breathing control (ABC) or others. Motion-
encompassing targeting is appropriate when motion is minimal.
Field design:
(1) For conventional/IMRT:
■ Radiotherapy field for liver tumor: CTV = GTV + 1cm, PTV = CTV
+ (1~2cm in superior/inferior direction, 0.5~1cm anterior/posterior
direction, 0.5cm laterally).
(2) For SBRT:
■ RT planning was designed to treat the CT-defined (arterial-phase)
gross tumor volume. Planning CT images were co-registered with
magnetic resonance imaging (MRI) if available to better identify the
gross tumor volume (GTV). The clinical target volume (CTV) was
defined as equal to the GTV. In patients who underwent 4D-CT
scan, an internal target volume (ITV) was defined as the envelope of
all GTVs in the different respiratory phases. The planning target
volume (PTV) was generated from either the GTV or the ITV by
adding an overall isotropic margin of 5 mm (from ITV) or of 7 to 10
mm in the cranial-caudal axis and 4 to 6 mm in the anterior-
posterior and lateral axes.
Dose prescriptions: depending on the ability to meet normal organ
constraints and underlying liver function.
82
■(1) Conventional R/T dose:
30~66Gy in 10~33 fractions.
■(2)Stereotactic body radiation therapy (SBRT) or

hypofractionated R/T dose:
SBRT: generally 30~50 Gy in 3~5 fractions (健保給付條件: 原發
性肝膽單一病灶，肝功能為 Child-Pugh A 至 B 級，ECOG status
≦2(或 Karnofsky Performance Scale/KPS≧70)，病灶最大徑≦5
公分且無法接受手術切除、血管栓塞治療及電燒灼治療。)
Hypofractionated schedules : 37.5-72Gy in 10-15 fractions
Dose limitations for conventional RT

■ Small bowel: V45Gy < 195c.c.
■ Spinal cord: < 45~50Gy
■ Kidney: mean < 15~18Gy
■ Liver: mean < 28~32Gy
Dose limitations for SBRT
◼ Mean Liver Dose (Liver-GTV)
➢ 50 Gy/5fx: 13 Gy
➢ 45 Gy/5 fx: 15 Gy
➢ 40 Gy/5 fx: 15 Gy
➢ 35 Gy/5 fx: 15.5 Gy
➢ 30 Gy/5 fx: 16 Gy
➢ 27.5 Gy/5 fx: 17 Gy
83
84
References:
1. External beam radiation therapy for inoperable hepatocellular carcinoma with
portal vein thrombosis (2001). Kaohsiung Journal of Medical Science 17:610-
614. Chih-Jen Huang, Shi-Long Lian, Shin-Cherng Chen, Ding-Kwo Wu , Shu-
Yi Wei, Ming-Yii Huang and Yu-Hui Ho.
2. NCCN Guidelines Version 3.2022 Hepatobiliary Carcinoma
3. Tao R, Krishnan S, Bhosale PR, et al. Ablative radiotherapy doses lead to a
substantial prolongation of survival in patients with inoperable intrahepatic
cholangiocarcinoma: a retrospective dose response analysis. J Clin Oncol
2016;34:219-226.
4. Bush DA, Smith JC, Slater JD, et al. Randomized clinical trial comparing proton
beam radiation therapy with transarterial chemoembolization for hepatocellular
carcinoma: results of an interim analysis. Int J Radiat Oncol Biol Phys.
2016;95:477-482.
5. Hong TS, Wo JY, Yeap BY, et al. Multi-institutional phase II study of high-dose
hypofractionated proton beam therapy in patients with localized, unresectable
hepatocellular carcinoma and intrahepatic cholangiocarcinoma. J Clin Oncol
2016;34:460-468.
6. Hoffe SE, Finkelstein SE, Russell MS, Shridhar R. Nonsurgical options for
hepatocellular carcinoma: evolving role of external beam radiotherapy. Cancer
Control 2010;17:100-110.
7. Wahl DR, Stenmark MH, Tao Y, et al. Outcomes after stereotactic body
radiotherapy or radiofrequency ablation for hepatocellular carcinoma. J Clin
Oncol 2016;34:452-459.
8. Cardenes HR, Price TR, Perkins SM, et al. Phase I feasibility trial of stereotactic
body radiation therapy for primary hepatocellular carcinoma. Clin Transl Oncol
2010;12:218-225.
9. Andolino DL, Johnson CS, Maluccio M, et al.Stereotactic body radiotherapy for
primary hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2011;81:e447-
453.
10. Finn RS, Qin S, Ikeda M, et al. Atezolizumab plus bevacizumab in unresectable
hepatocellular carcinoma. N Engl J Med 2020;382:1894-1905..
11. Qi W, Fu S, Zhang Q, et al. Charged particle therapy versus photon therapy for
patients with hepatocellular carcinoma: A systematic review and meta-
analysis.Radiother Oncol 2015;114:289-295.
12. AAPM TG 76 & 101
85
Bile Duct Cancer
◎ Resectable
(R1-2 or N1 for intrahepatic cholangiocarcinoma;

R0-2 or N0 or N1 or Carcinoma in situ at margin for extrahepatic
cholangiocarcinoma)
post-op: Fluoropyrimidine chemoradiation
◎ Unresectable
Fluoropyrimidine chemoradiation
◎ Distant metastatic disease
RT for symptomatic relief
RT techniques
Simulation:
■ Patient in supine position with both arms up.
■ Immobilize with cushion or cast.
■ CT simulation with IV and oral contrast if needed.
■ 4D CT is useful at time of simulation to evaluate organ motion
during respiration. Respiratory gating might be used to decrease field
size.
Field design:
■ Cover tumor bed, porta hepatis, celiac axis + 1.5 cm margins.
■ Consider extending field 3–5 cm into liver to cover additional
intrahepatic bile duct length for margin.
■ Add additional margins as needed to account for organ motion
secondary to breathing, determined using fluoroscopy or perform 4D CT
to define ITV.
86
Dose prescriptions:
1. Adjuvant EBRT
Postoperative EBRT using conventional 3D conformal RT or IMRT is
an option for resected extrahepatic cholangiocarcinoma and
gallbladder cancer.
Target volumes should cover the draining regional lymph nodes to 45 Gy
at 1.8 Gy/fraction and 50 – 60 Gy at 1.8 -2Gy/fraction to the tumor
bed depending on margin positivity
• SBRT (1–5 fractions) is an acceptable option for intrahepatic tumors.
2. Unresectable
All tumors irrespective of the location may be amenable to radiation
therapy (3D conformal radiation therapy, intensity-modulated radiation
therapy [IMRT], or stereotactic body radiation therapy [SBRT]).
Conventionally fractionated radiotherapy with concurrent
fluoropyrimidine-based chemotherapy to standard or high dose is
acceptable for intrahepatic and extrahepatic tumors.
Hypofractionation with photons or protons is an acceptable option for
intrahepatic tumors.
Palliative EBRT is appropriate for symptom control and/or prevention of
complications from metastatic lesions, such as bone or brain.
## RT dosing, depending on the ability to meet normal organ
constraints and underlying liver function:
Conventional fractionation (postoperative or unresectable):
◊ Initial volumes to 45 Gy in 1.8 Gy per fraction
◊ Boost to 50 to 60 Gy in 1.8–2 Gy per fraction
Hypofractionation (unresectable): 58–67.5 Gy in 15 fractions for a
median biologic equivalent dose of 80.5 Gy.5,6
SBRT (unresectable):
◊ 30–50 Gy (typically in 3–5 fractions)
Dosing for SBRT for biliary tract tumors:
◊ Dosing is generally 30–50 Gy in 3–5 fractions, depending on the ability
to meet normal organ constraints and underlying liver function.
87
◊ Other hypofractionated schedules >5 fractions may also be used if
clinically indicated.
◊ For intrahepatic tumors, SBRT in 1–5 fractions is an acceptable option.
If patients present with biliary obstruction (jaundice/elevated direct
bilirubin), plastic or metal stents may be placed prior to initiation of
radiotherapy.
Dose constraints:
■ Small bowel <45–50.4 Gy/25–28 fx
■ Spinal cord <45 Gy/25 fx
■ Liver (see previous sections, use NTCP model)
■ Kidney 1/3 < 20 Gy
Dose constraints for SABR
88
89
90
91
References:
1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ® )
Hepatobiliary Cancer Version 5.2022 (Jan. 13 2023).
2. Ben-Josef E, Guthrie KA, El-Khoueiry AB, et al. SWOG S0809: A phase II
intergroup trial of adjuvant capecitabine and gemcitabine followed by
radiotherapy and concurrent capecitabine in extrahepatic cholangiocarcinoma
and gallbladder carcinoma. J Clin Oncol. 2015 Aug 20;33(24):2617-22.
3. Tao R, Krishnan S, Bhosale PR, et al. Ablative radiotherapy doses lead to a
substantial prolongation of survival in patients with inoperable intrahepatic
cholangiocarcinoma: a retrospective dose response analysis. J Clin Oncol
2016;34:219-226.
4. Hong TS, Wo JY, Yeap BY, et al. Multi-institutional phase II study of high-
dose hypofractionated proton beam therapy in patients with localized,
unresectable hepatocellular carcinoma and intrahepatic cholangiocarcinoma. J
Clin Oncol 2016;34(5):460-8.
5. Abou-Alfa GK, Sahai V, Hollebecque A, et al. Pemigatinib for previously
treated, locally advanced or metastatic cholangiocarcinoma: a multicentre,
open-label, phase 2 study. Lancet Oncol 2020. [Epub ahead of print]
6. Horgan AM, Amir E, Walter T, Knox JJ. Adjuvant therapy in the treatment of
biliary tract cancer: a systemic review and meta-analysis. J Clin Oncol
2012;30:1934-1940
7. Mallick S, Benson R, Haresh KP, et al. Adjuvant radiotherapy in the treatment
of gallbladder carcinoma: What is the current evidence? J Egypt Natl Canc
Inst 2016;28:1-6.
8. Kim Y, Amini N, Wilson A, et al. Impact of chemotherapy and external-beam
radiation therapy on outcomes among patients with resected gallbladder
cancer: A multiinstitutional analysis. Ann Surg Oncol 2016;23:2998-3008
9. Apisarnthanarax S, Barry A, Cao M, et al. External beam radiation therapy for
primary liver cancers: An ASTRO Clinical Practice Guideline. Pract Radiat
Oncol 2022;12:28-51.
92
Colorectal cancer
Colon cancer
◎ Consider pre-operative CCRT
■ Indication:
(1) T3-4 and/or N+, and surgeons assess the tumor may not be
completely resected by the imaging evaluation.
T3N0M0 At high risk for systemic recurrence
T4N0M0 (MSS/pMMR)
T4, N1-2
T any, N2
Initially unresectable Non-metastatic T4
(2) Locally unresectable or medically inoperable
◎ Adjuvant post-operative RT
■ Indication:
(1) RT may be considered for close or positive margin
(2) Consider RT for T4 with penetration to a fixed structure
◎ Consider IORT
■ Indication: for patients with T4 or recurrent cancers as an additional

boost
(1)C/T (palliative RT for symptomatic relief)

(2)In patients with a limited number of liver or lung metastases, RT to
metastatic site can be considered in highly selected cases or in clinical
trial
(3) Consider SBRT for patients with oligometastatic disease
93
RT techniques (IMRT is preferred):
Simulation:
■ Patient in supine position
Field design:
◆ For pre-operative RT:
■ Gross tumor volume (GTV) was the macroscopic tumor visible on CT
or MRI. The GTV included a 1-cm margin at any site of adherence or
organ involvement.
■ Clinical target volume (CTV) was defined as the GTV with a margin
of 2 cm while respecting anatomic boundaries.
■ The planning target volume (PTV) was defined as the CTV with a 1-
cm expansion.
◆ For post-operative RT:
■ RT field should include margin around tumor bed based on pre-
operative imaging and/or surgical clips.
■ Generally, the primary tumor site should be covered with a 4- to 5-cm
margin proximally and distally and with a 3- to 4-cm margin medially
and laterally to cover areas of potential residual disease.
■The nodal basins in the mesentery beyond surgical margins are usually
not treated.
Dose prescriptions:
■ Pre-op RT: 45Gy~54Gy/25fx~30fx to PTV.
■ Post-op RT: 45~50.4Gy in 25-28 fractions, consider boost for close or
positive margins up to 54~60Gy.
94
Organ Constraints
Small intestine Dmax < 50Gy
Liver V30Gy < 30%
R't Kidney V20Gy < 30% ; Dmean < 15Gy
L't Kidney V20Gy < 30% ; Dmean < 15Gy
Femoral head Dmax < 45Gy
U- bladder Dmax < 65Gy ; V40Gy < 50%
95
Rectal cancer
◎Consider pre-operative regimen
(A) Total neoadjuvant therapy

1. C/T (12~16 wks) + long-course chemo/RT
2. C/T (12~16 wks) + short-course RT
3. Long-course chemo/RT + C/T (12~16 wks)
4. Short-course RT + C/T (12~16 wks)
(B) Neoadjuvant therapy
1. Long-course chemo/RT
2. Short-course RT
■ Indication of total neoadjuvant therapy:

(1) T1-2, N1-2
(2) T3-4, N any
(3) Locally unresectable tumor or medically inoperable
■ Indication of neoadjuvant therapy:
(1) T1-2, N1-2
(2) T3-4, N any
(3) T any, N any, M1 resectable or unresectable synchronous
liver only and/or lung only metastases
(4) Isolated pelvic/anastomotic recurrence
Surgery should be delayed 4-12 weeks.
Best tumor response 8 weeks after completion of RT
◎ Adjuvant post-operative CCRT
■ Indication:
(1) After transabdominal resection: pT3-4, N any or T1-4, N1-2
(2) After transanal excision:
pT1Nx with high risk features (positive margins,
lymphovascular invasion, poorly differentiated tumors, or
96
submucosal invasion to the lower third of the submucosal
level) or pT2Nx→ short course RT added as treatment option.
◎ Considered IORT
■ Indication: very close or positive margins after resection, as an

additional boost, especially for patients with T4 or recurrent
cancers
RT techniques
CT simulation:
→ Proper immobilization
→ Arms up position if supine position
→ Supine or prone position
→ Suggest half-full bladder (intake 300 c.c. of water 30 minutes before
simulation)
→ ≤5mm slices
Field design:
■ Tumor target volumes:
✓ The gross tumor volume (GTV) encompassed rectal tumors and
clustered lymph nodes or lymph nodes with a diameter greater than
1 cm on CT or magnetic resonance imaging.
✓ The clinical t
✓ Target volume (CTV) included the primary tumor, the
mesorectum, the sacral canal, and the perirectal, presacral,
hypogastric, obturator, and internal iliac lymphatic drainage.
✓ If tumor invaded to prostate gland, the bladder, or the vagina, the
CTV was extended to cover the involved organ and the external
iliac nodal regions.
✓ For lesions with anal invasion, the perineum and bilateral inguinal
lymph nodes were included in the CTV.
✓ A PTV was generated by adding a 5 to 7 mm margin uniformly
around the clinical target volume. In areas in which the tumor was
close to the small bowel and bladder, a 0.5-cm expansion was
97
used.
✓ The outlined organs at risk were the uninvolved rectum, bladder,
and small bowel.
✓ The small bowel was outlined 1 cm above and below the PTV.
■ Conventional border (by 3 field or 4 field technique)
Superior: L5-S1 junction
Inferior: 4-5 cm below the distal tumor margin
Lateral: 1-1.5 cm beyond the true pelvis
Posterior: 1 cm behind the sacrum
Dose prescriptions:
■ For VMAT/Rapid Arc, helical tomotherapy or MRlinac:
- for resectable diseases: 45~50.4 Gy to the gross tumor and pelvic
lymphatic area, then can consider boost:
1. pre-operative: gross tumor + 2-cm margin with 5.4Gy/3fr
2. post-operative: gross tumor bed + 2-cm margin with 5.4-
9.0Gy/3-5fr
■ For 3D conformal radiotherapy: 45Gy/25fx to PTV, followed by a
boost dose of 5.4 Gy administered in 3 fractions to the primary
tumor and involved nodes by two lateral fields if needed.
■ Definitive RT for unresectable cancers: 50~64Gy (1.8-2Gy/fx)
■ Short-course RT: 25 Gy in 5 fractions

Organ Constraints
Liver V30Gy < 30%
R't Kidney V20Gy < 30% ; Dmean < 15Gy
L't Kidney V20Gy < 30% ; Dmean < 15Gy
98
Three-field technique (PA + bilateral opposed fields) for a case of rectal
cancer s/p LAR receiving post-operative RT
99
IMRT technique
For reirradiation of previously treated patients with recurrenc disease
(IMRT preferred)
100
References:
2. NCCN clinical practice guidelines in oncology:
rectal cancer, version 3, 2022 colon cancer, version 2, 2022
3. ASTRO 2015 (colorectal and anal cancer, EDU session)
4. QUANTEC (Radiation constraint and related toxicities)
5. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative
chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731-40.
6. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic
irradiation. Int J Radiat Oncol Biol Phys 1991;21:109-122.
7. Mak AC, Rich TA, Schultheiss TE, et al. Late complications of postoperative
radiation therapy for cancer of the rectum and rectosigmoid. Int J Radiat Oncol
Biol Phys 1994;28:597-603.
8. Gallagher MJ, Brereton HD, Rostock RA, et al. A prospective study of treatment
techniques to minimize the volume of pelvic small bowel with reduction of acute
and late effects associated with pelvic irradiation. Int J Radiat Oncol Biol Phys
1986;12:1565-1573.
9. Nutting CM, Convery DJ, Cosgrove VP, et al. Reduction of small and large bowel
irradiation using an optimized intensity-modulated pelvic radiotherapy technique
in patients with prostate cancer. Int J Radiat Oncol Biol Phys 2000;48:649-656.
10. Portelance L, Chao KS, Grigsby PW, et al. Intensity-modulated radiation therapy
(IMRT) reduces small bowel, rectum, and bladder doses in patients with cervical
cancer receiving pelvic and paraaortic irradiation. Int J Radiat Oncol Biol Phys
2001;51:261-266.
11. Roeske JC, Lujan A, Rotmensch J, et al. Intensity-modulated whole pelvic
radiation therapy in patients with gynecologic malignancies. Int J Radiat Oncol
Biol Phys 2000;48;1613-1621.
12. Duthoy W, De Gersem W, Vergote K, et al. Clinical implementation of intensity-
modulated arc therapy (IMAT) for rectal cancer. Int J Radiat Oncol Biol Phys
2004;60:794-806.
13. Urbano MTG, Henrys AJ, Adams EJ, et al. Intensity-modulated radiotherapy in
patients with locally advanced rectal cancer reduces volume of bowel treated to
high dose levels. Int J Radiat Oncol Biol Phys 2006;65:907-916.
15. Hernando-Requejo O, López M, Cubillo A, et al. Complete pathological responses
in locally advanced rectal cancer after preoperative IMRT and integrated-boost
chemoradiation. Strahlenther Onkol. 2014 Jun;190(6):515-520. Epub 2014 Apr 9.
16. J. Hallet, F.S. Zih, M. Lemke et al. Neo-adjuvant chemoradiotherapy and
101
multivisceral resection to optimize R0 resection of locally recurrent adherent
colon cancer. Eur J Surg Oncol 40 (2014) 706-712.
17. Nascimbeni R, Burgart LJ, Nivatvongs S et al. Risk of lymph node metastasis in
T1 carcinoma of the colon and rectum. Dis Colon Rectum. 2002 Feb; 45(2): 200-
206.
18. Ngan SY, Burmeister B, Fisher RJ et al. Randomized trial of short-course
radiotherapy versus long-course chemoradiation comparing rates of local
recurrence in patients with T3 rectal cancer: Trans-Tasman Radiation Oncology
Group trial 01.04. J Clin Oncol. 2012 Nov 1;30(31):3827-33.
102
Breast cancer
一、放射治療前準備：於放射治療前，應回顧該病人的病理報告、影像檢查…等；
必要時於多科團隊會議時提出討論。
二、定位：
1. 體位設定：
仰躺姿勢。所有病人模擬定位姿勢基本為仰臥(supine) ；如果病人能配合，
雙手高舉頭上或患側之手臂上舉。較肥胖及巨大乳房且只照射乳房可考慮俯
臥姿勢(prone)
2. 固定方法：
為求擺位再現性，可選擇使用 Cast(thermoplastic cast)或胸板(chest board)或
真空墊(vacuum bag)作為固定模具。標記治療中心(isocenter)，另在真空墊的
側面也要貼上標記。
應採取電腦斷層輔助之模擬攝影，在電腦斷層掃瞄定位室，請病人依原姿勢
躺在固定模具上。金屬標記在影像上呈現中心點之位置。
如果有手術後之刀疤(surgical scar)，應在刀疤貼上標記；若接受 oncoplastic
surgery 另建議將乳房之乳暈(areola)貼上標記定位用。
電腦斷層之掃描範圍及條件為由下顎骨(Mandible)至乳房下緣，應可包含整
個肺部，切片厚度約 5 毫米。掃描範圍及切片厚度條件，必要時可由主治醫
師自行訂定。左側乳癌呼吸運動較大之可考慮使用呼吸調控(Active breathing
control) 。
⚫ 靶體積定義(Target Volume Definition)及放射治療計畫規劃(Radiation
Therapy Planning)
⚫ 3D CT-based treatment planning should be routinely used to delineate target
volumes and adjacent organs at risk.
⚫ 接受術前化學治療後才開刀的病人，術後放射線治療的規劃以
maximal disease stage (ie. Clinical stage, pathologic stage, tumor
characteristics) at diagnosis (before pre-op systemic therapy) and pathology
103
results after pre-op systemic therapy)
四、治療時機：
放射線治療通常在化學治療後實施。
全乳房照射(Whole Breast Irradiation)

(1)靶體積定義：經乳房保留手術(Breast-Conserving Surgery)之病人，CTV 包含
整個患側之乳房。
(2)放射治療計畫規劃：傳統兩階段
第一階段(Phase 1)
處方劑量：40-42.5 Gy in 15-16 fractions
45-50.4 Gy in 25-28 fractions
照射次數：每日 1 次，每周 5 次
第二階段(Phase 2)
處方劑量：10-16Gy/4-8frs
(Boost to 60-66Gy Hand book of EB)
照射次數：4~8 次，每日 1 次，每周 5 次。
註記：第二階段使用光子或電子射束治療腫瘤部位(tumor bed)。
Ultra-hypofractionated WBRT: 28.5Gy/5fx, once-a-week:

⚫ Age > 50y/o
⚫ Post-BCS with pTis/T1/T2/N0
同時整合加強治療全乳房照射(Whole Breast Irradiation)

(Intensity Modulated Radiotherapy-Simultaneous Integral Boost technique)
CTV-high:
(1)靶體積定義：
經乳房保留手術(Breast-Conserving Surgery)之病人，CTV-mid 包含整個患側
之乳房。CTV-high 包含腫瘤區域(tumor bed)等高危險區。
(2)放射治療計畫規劃：
處方劑量：55~66 Gy
照射次數：25~33，每日 1 次，每周 5 次。
CTV-mid:
104
處方劑量：45~60Gy (45-50Gy)
照射次數：25~30 次，每日 1 次，每周 5 次。
胸壁及局部淋巴線照射(Chest Wall and Regional Lymph Nodes Irradiation)

(1)靶體積定義：經改良型乳癌根除手術(Modified Radical Mastectomy, MRM；乳
房全切除+腋下淋巴腺廓清術)之病人，CTV 包含整個患側之胸壁、全乳房
手術後之傷疤、腋下淋巴腺(Axillary Lymph Nodes) 或加上上鎖骨窩淋巴腺
(Supraclavicular Lymph Nodes)或內乳淋巴結(Internal Mammary Lymph
Nodes)。如果需要可考慮覆蓋適當厚度之組織類似物(bolus)於皮膚上，確保
皮膚得到足夠之劑量。
(2)放射治療計畫規劃：
胸壁及局部淋巴線照射之放射治療療程規劃
處方劑量：45-50.4 Gy (25-28 fractions) ± scar boost (1.8-2 Gy per fraction)
照射範圍：整個患側之胸壁、手術後之傷疤、腋下淋巴腺或加上鎖骨窩淋巴
腺或內乳淋巴結(Internal Mammary Lymph Nodes)
照射次數：每日 1 次，每周 5 次。
加速分次部分乳房照射 Accelarated Partial Breast irradiation(APBI)：For low-

risk, early breast cancer pt’s.
Patients suitable for APBI to be one of the following:

(1) ≥50 years with invasive ductal carcinoma measuring ≦2cm (pT1), negative
margin≥2mm, no LVI, ER-positive, and BRCA negative
(2) Histology grade 1 or 2, screening-detected DCIS measuring≦2.5cm with negative
margin widths of ≥3mm
RT Dose:
105
Ductal carcinoma in situ:
◎ Adjuvant post-operative RT:
■ Indication:
All patients receiving breast conservative surgery should are
indicated for RT, (some may choose to omit RT: old women, small
tumor (<0.5 cm), unicentric tumor, low grade tumors excised with
wide(>1cm) negative margins).
Radiation techniques:
Simulation:
■ Patient in supine position with ipsilateral(/or bilateral) arm abducted
and externally rotated
■ Immobilized with breast board or cast
■ Wire all surgical scars and inferior border (2 cm from inframammary
fold)
Field design:
■ Conventional tangential fields:
Medial border: at mid-sternum
Lateral border: mid-axillary line
Inferior border: 2 cm from inframammary fold or depend on
individuals
Superior border: head of clavicle or second intercostal space
*Boost field is delivered to tumor bed(may consider no boost (for
widely negative margin in women over 60))
靶體積定義：
經乳房保留手術(Breast-Conserving Surgery)之病人患，CTV-mid 包含整
個患側之乳房。CTV-high 包含腫瘤區域(tumor bed)等高危險區。
PTV: CTV + 0.5-1.0cm generally
Dose prescriptions:
106
■whole breast:
■boost to tumor bed if indicated: 10-16Gy, generally 2-2.5 cm around

surgical scar
For IMRT or IGRT technique

■ Simultaneously integral boost technique
Whole breast: 40~55 Gy/25~35 fractions
Tumor beds: 55~66 Gy/25~35 fractions
Constraints:
Organ Constraints
Heart V25Gy < 10%
R't lung V20Gy < 20%
L't lung V20Gy < 20%
Esophagus Dmax < 75Gy ; V55Gy < 65% ; Dmean < 34Gy
Liver V30Gy < 30%
107
108
Invasive carcinoma
◎ Adjuvant post-operative RT:
■ Indication:
(1) All patients receiving breast conservative surgery (RT optional for
T1N0, ER+, age≧70 yrs, receive endocrine therapy)
(2) Post-mastectomy patients:
(I) lymph node positive
(II) tumor > 5 cm
(III) margin positive
(IV) close margins (< 1 mm)
(V) extracapsular nodal spread
(3) Patients receiving pre-operative chemotherapy: adjuvant RT should
be based on pre-chemotherapy tumor characteristics
◎Pre-operative RT:
■ Indication: Locally advance invasive breast cancer patients who had

no response to pre-operative chemotherapy
◎ Distant metastasis or recurrence:
◆ Supraclavicular fossa: SCF is indicated for those with LN >4 post

BCS or mastectomy patients, and is strongly recommended for those
with 1-3 LN post BCS or mastectomy patients, if negative LN,
Radiation to SCF is not recommended except for those with tumor
>5cm, margin positive post mastectomy patients (depend on
individuals)
109
Radiation techniques:
Simulation:
■ Patient in supine position with ipsilateral(or bilateral) arm abducted
and externally rotated
■ Immobilized with breast board
■ Wire all surgical scars and inferior border (2 cm from inframammary
fold)
Field design:
■ Conventional tangential fields:
Medial border: at mid-sternum
Lateral border: mid-axillary line
Inferior border: 2 cm from inframammary fold
Superior border: head of clavicle or second intercostal space
*Internal mammary RT performed with matched electron or with
wide tangential field
*Boost field is delivered to tumor bed
■ IMRT: For BCS, CTV1 = Tumor bed + 1~2 cm margin
CTV2 = whole breast ± Supraclavicular
fossa±Axillary nodal area ± Internal
mammary nodal area
■ IMRT: for MRM, CTV1 = chest wall ± Supraclavicular
fossa±Axillary nodal area ± Internal
mammary nodal area PTV: CTV +
0.5-1.0cm generally
Dose prescriptions:
Post- breast conservative surgery, RT dose:
■40-42.5 Gy in 15-16 fractions or
to whole breast, then 10~16 Gy boost to tumor bed
For IMRT or IGRT technique

■ Simultaneously integral boost technique
110
Whole breast: 40~55 Gy/25~35 fractions(45-50Gy/23-25frs)
Tumor beds: 55~62 Gy/25~35 fractions
Fon pN0:
• APBI in selective low-risk patients
• Consider omitting breast irradiation in patients over 70 y/o with
ER(+), cN0, pT1 with adjuvant endocrine therapy
Post-mastectomy, RT dose:
■45-50.4 Gy in 25-28 fractions
to chest wall
■ 45-50.4 Gy in 25-28 fractions
to supraclavicular fossa
■ 5-10 mm bolus typically used every other day until moist
desquamation occurs (for patient underwent total mastectomy)
■ For inflammatory or locally advanced breast cancer, boost to total
dose 60~66 Gy
Tangential fields for left breast and axillary area, matched to an ipsilateral
AP supraclavicular field. A case of left breast cancer s/p BCS and
chemotherapy received adjuvant RT.
111
Constraints:
Organ Constraints
Heart V25Gy < 10%
R't lung V20Gy < 20%
L't lung V20Gy < 20%
Liver V30Gy < 30%
112
113
References:
1. NCCN 2.2023: breast cancer
2. Whelan T, MacKenzie R, Julian J, et al. Randomized trial of breast irradiation
schedules after lumpectomy for women with lymph node-negative breast cancer.
J Natl Cancer Inst 2002;94: 1143-1150.
3. Antonini N, Jones H, Horiot JC, et al. Effect of age and radiation dose on local
control after breast conserving treatment: EORTC trial 22881-10882. Radiother
Oncol 2007;82:265-271.
4. Bartelink H, Horiot JC, Poortmans P, et al. Recurrence rates after treatment of
breast cancer with standard radiotherapy with or without additional radiation. N
Engl J Med 2001;345:1378-1387.
5. International Commission on Radiation Units and Measurements. ICRU Report No
50: Prescribing, Recording and Reporting Photon Beam Therapy. Bethesda, MD:
ICRU Publications 1993.
6. International Commission on Radiation Units and Measurements. ICRU Report No
62: Prescribing, Recording and Reporting Photon Beam Therapy (Supplement to
ICRU Report 50). Bethesda, MD: ICRU Publications 1999.
9. RTOG 9804: A Prospective Randomized Trial for Good-Risk Ductal Carcinoma In
Situ Comparing Radiotherapy With Observation. J Clin Oncol 33:709-715. © 2015
by American Society of Clinical Oncology
10. Long-Term Outcomes of Invasive Ipsilateral Breast Tumor Recurrences After
Lumpectomy in NSABP B-17 and B-24 Randomized Clinical Trials for DCIS. J
Natl Cancer Inst 2011;103:478–488
11. The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy
hypofractionation for treatment of early breast cancer: a randomised trial. Lancet
2008; 371: 1098–107
12. Long-Term Results of Hypofractionated Radiation Therapy for Breast Cancer. N
Engl J Med 2010; 362:513-52
13. Murray Brunt A et al. Hypofractionated breast radiotherapy for 1 week versus 3
weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a
multicentre, non-inferiority, randomized, phase 3 trial. Lancet 2020;395:1613-1626.
114
Breast cancer IORT Guidelines
I. Tumor Type:
DCIS, Invasive ductal carcinoma, Lobular carcinoma,
Mucinous carcinoma, Medullary carcinoma
Primary or recurrent (single or previous whole breast
irradiation) tumor
Protocol
Primary tumor
1. TARGIT A: 20Gy to tumour bed (IORT)
• Tumour size < 3.5cm
• Sentinel LNs: (-)
• Luminal Type A/B
2. TARGIT B: 20Gy to tuomur bed (IORT) +
4005cGy/15fx EBRT to ipsilateral whole breast +
axillary LNs + Supraclavicular LNs
• Tumour size: any T
• Sentinel LN s: any N
• Luminal Type A/B, Her2, Triple Negative,
Ki67>30%
• LVI (+)
3. TARGIT E
• > 70 y/o
• Have trouble come to the hospital for post-op
irradiation
Recurrent/metastatic tumour
⚫ NCCN Guidelines: Patients suitable for APBI to be one of the
following:
(3) ≥50 years with invasive ductal carcinoma measuring ≦2cm (pT1),
negative margin≥2mm, no LVI, ER-positive, and BRCA negative
(4) Histology grade 1 or 2, screening-detected DCIS measuring≦2.5cm
with negative margin widths of ≥3mm
115
References:
1. Fastner G, Gaisberger C, Kaiser J, Scherer P, Ciabattoni A, Petoukhova A, Sperk
E, Poortmans P, Calvo FA, Sedlmayer F, Leonardi MC. ESTRO IORT Task
Force/ACROP recommendations for intraoperative radiation therapy with
electrons (IOERT) in breast cancer. Radiother Oncol. 2020 Aug;149:150-157. doi:
10.1016/j.radonc.2020.04.059. Epub 2020 May 13. PMID: 32413529
2. Strnad V, Major T, Polgar C, Lotter M, Guinot JL, Gutierrez-Miguelez C, Galalae
R, Van Limbergen E, Guix B, Niehoff P, Lössl K, Hannoun-Levi JM. ESTRO-
ACROP guideline: Interstitial multi-catheter breast brachytherapy as Accelerated
Partial Breast Irradiation alone or as boost - GEC-ESTRO Breast Cancer Working
Group practical recommendations. Radiother Oncol. 2018 Sep;128(3):411-420.
doi: 10.1016/j.radonc.2018.04.009. Epub 2018 Apr 21. PMID: 29691075
3. Konsultationsfassung der S3-Leitliniefür die Früherkennung, Diagnostik, Therapie
und Nachsorge des Mammakarzinoms. Langversion 4.04 – _September 2020
AWMF-Registernummer: 032-045OL (German 2020 breast cancer treatment
guideline)
4. Wenz F, Budach W. Personalized radiotherapy for invasive breast cancer in 2017 :
National S3 guidelines and DEGRO and AGO recommendations. Strahlenther
Onkol. 2017 Aug;193(8):601-603.
5. NCCN 2.2023: breast cancer
6. Whelan T, MacKenzie R, Julian J, et al. Randomized trial of breast irradiation
schedules after lumpectomy for women with lymph node-negative breast cancer.
J Natl Cancer Inst 2002;94: 1143-1150.
7. Antonini N, Jones H, Horiot JC, et al. Effect of age and radiation dose on local
control after breast conserving treatment: EORTC trial 22881-10882. Radiother
Oncol 2007;82:265-271.
8. Bartelink H, Horiot JC, Poortmans P, et al. Recurrence rates after treatment of
breast cancer with standard radiotherapy with or without additional radiation. N
Engl J Med 2001;345:1378-1387.
9. International Commission on Radiation Units and Measurements. ICRU Report
No 50: Prescribing, Recording and Reporting Photon Beam Therapy. Bethesda,
MD: ICRU Publications 1993.
10. International Commission on Radiation Units and Measurements. ICRU Report
No 62: Prescribing, Recording and Reporting Photon Beam Therapy (Supplement
to ICRU Report 50). Bethesda, MD: ICRU Publications 1999.
116
13. Vaidya JS, Bulsara M, Wenz F, Sperk E, Massarut S, Alvarado M, Williams NR,
Brew-Graves C, Bernstein M, Holmes D, Vinante L, Pigorsch S, Lundgren S, Uhl
V, Joseph D, Tobias JS; TARGIT-A authors. The TARGIT-A Randomized Trial:
TARGIT-IORT Versus Whole Breast Radiation Therapy: Long-Term Local
Control and Survival. Int J Radiat Oncol Biol Phys. 2023 Jan 1;115(1):77-82
14. Vaidya JS, Bulsara M, Baum M, Wenz F, Massarut S, Pigorsch S, Alvarado M,
Douek M, Saunders C, Flyger HL, Eiermann W, Brew-Graves C, Williams NR,
Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Corica
T, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Le Blanc-Onfroy M,
Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McCready D, Hoefer
R, Kelemen P, Petralia G, Falzon M, Joseph DJ, Tobias JS. Long term survival
and local control outcomes from single dose targeted intraoperative radiotherapy
during lumpectomy (TARGIT-IORT) for early breast cancer: TARGIT-A
randomised clinical trial. BMJ. 2020 Aug 19;370
117
肺癌放射治療指引
Non-small-cell lung cancer:
staging Treatment
Early-Stage NSCLC Op or SABR 健保事前申請規範:
(Stage I, selected node- Stereotactic body 本項醫療服務項目，健保以包
negative Stage IIA) radiation 裹給付方式支付，全療程為 2
therapy(SBRT) 週、分 6 次(含)治療為限，故
/Stereotactic ablative
在符合專家訂定的給付規定
radiotherapy(SABR)
身體立體定位放射下，須同時符合下列之適應
治療健保支付經專症：原發性早期肺部惡性腫瘤
家討論及醫學實證 (依據 2009AJCC 分期定義為
報告，目前僅對於 N0 之≦stageⅡ)患者，病灶最
原發性早期肺部及大徑≦5 公分，ECOG status≦
肝膽單一病灶之惡 2(或 Karnofsky Performance
性腫瘤治療效果 Scale/KPS≧70)，且須符合以
佳，可替代原本健下(high surgical risk)ABC 條件
保給付之直線加速之一：
器遠隔照射治療 A.poor pulmonary function，不
In patients treated 適合接受 lobectomy 手術者
with surgery, (依外科醫師檢視或會診紀
postoperative 錄)。
radiotherapy B.年齡≧75 歲，致開胸受術可
(PORT) is not 能造成嚴重損傷或危險性
recommended 大，不適手術者(依外科醫師檢
unless there are
視或會診紀錄)。
positive margins.
C.有嚴重心肺疾病或其它內科
疾病，經麻醉科評估不適全
身麻醉者。
SABR for Node-Negative For centrally located Particular attention should be
Early-Stage NSCLC
tumors (defined paid to tumors abutting the
variably as within 2 bronchial tree and esophagus to
cm of the proximal avoid severe toxicity. RTOG
bronchial tree 0813 evaluated the toxicity of 5-
and/or abutting fraction regimens and found no
mediastinal pleura) high-grade toxicities at 50 Gy
and even ultra-central in 5 fractions
tumors (defined as
abutting the
proximal bronchial
tree), 4 to 10 fraction
118
risk adapted
SABR regimens
appear to be effective
and safe, while 54 to
60 Gy in 3 fractions
is unsafe and should
be avoided.
Locally Advanced NSCLC CCRT Preoperative systemic therapy
(Stage II–III) is recommended for
and postoperative RT is an
patients with
inoperable stage II option for patients with
(node-positive) and resectable stage IIIA NSCLC
stage III NSCLC (minimal N2 and treatable
with lobectomy).
Preoperative CCRT is an
alternative option for patients
with resectable stage IIIA
NSCLC and is recommended for
resectable superior sulcus
tumors.
Advanced/Metastatic RT is recommended Definitive RT to oligometastases
NSCLC (Stage IV)
for local palliation or (limited number is not
prevention of universally defined but clinical
symptoms (such as trials have included 3–5
pain, bleeding, or metastases)
obstruction). In two randomized phase II
Definitive/consolidati trials, significantly improved
ve local therapy to PFS and OS•
isolated or limited • When treating
oligometastatic/oligoprogressive
metastatic sites
lesions, if SABR is not feasible,
(oligometastases) other dose-intensive
(including but not accelerated/hypofractionated
limited to brain, lung, CRT regimens may be used.
and adrenal gland)
achieves prolonged
survival in a small
proportion of well-
selected patients with
good performance
119
status who have also
received radical
therapy to the
intrathoracic disease.
Palliative RT for For palliation of
Advanced/Metastatic thoracic symptoms,
NSCLC higher dose / longer-
course thoracic RT
(eg, ≥30 Gy in 10
fractions) is
associated with
modestly improved
survival and
symptoms,
particularly in
patients with good
performance status
Abbreviation
120
Small-cell lung cancer:
(1) Limited stage →
consider operation, adjuvant radiotherapy and chemotherapy
clinical stage I–IIA (T1–2, N0, M0) who have undergone lobectomy and
are found to have regional nodal involvement on final pathology,
postoperative RT is recommended in pathologic N2 and may be
considered in pathologic N1 stage, either sequentially or concurrently
with chemotherapy.
*Principles of postoperative RT for NSCLC, including target volumes
and doses, are recommended.
Selected patients with stage I–IIA (T1–2, N0, M0) SCLC who are
medically inoperable or in whom a decision is made not to pursue surgery
may be candidates for stereotactic ablative RT (SABR) to the primary
tumor followed by adjuvant systemic therapy.
*Principles of SABR for SCLC are similar to those for NSCLC
Commonly Used Doses for SABR (also known as SBRT)
121
• Timing: RT concurrent with systemic therapy is standard and
preferred to sequential chemo/RT.
RT should start early, with cycle 1 or 2 of systemic therapy (category
1).
A shorter time from the start of any therapy to the end of RT (slow early
responders [SER]) is significantly associated with improved survival.
Dose and schedule:

If using once-daily conventionally fractionated RT, 66–70 Gy are
preferred.
(2) Extensive stage:

• Consolidative thoracic RT is beneficial for selected patients with ES-
SCLC with complete response or good response to systemic therapy,
especially with residual thoracic disease and low-bulk extrathoracic
metastatic disease. Studies have demonstrated that consolidative
thoracic RT up to definitive doses is well-tolerated, results in fewer
symptomatic chest recurrences, and improves long term survival.
Dosing and fractionation of consolidative thoracic RT should be

individualized within the range of 30 Gy in 10 daily fractions up to
definitive dosing regimens in patients with a longer life expectancy.
122
二、放射治療前準備：
於放射治療前，應詳細檢視該病人的相關組織病理報告、影像檢查等；可於
多科團隊會議時提出討論。
三、定位：
1. 體位設定：
仰躺姿勢。病人模擬定位姿勢以仰臥(supine)為主；如果病人能配合，雙手高
舉頭上。
2. 固定方法：
可選擇 cast 或真空墊(vacuum bag)作為固定模具，提高重複擺位之準確性。
採取電腦斷層模擬攝影，於電腦斷層掃描定位室，請病患依原姿勢戴上製作
完成的固定模具上，定位雷射線對應到病患標記點。
電腦斷層模擬攝影之掃描範圍及條件為環狀軟骨(cricoid cartilage)至第二腰
椎(L2 spine)上緣，應可包含整個肺部，切片厚度 1-5 mm。電腦斷層模擬攝
影掃描範圍及斷層攝影厚度條件，可由主治醫師自行訂定。
4. 其他: 考慮肺部呼吸所造成胸腔內腫瘤移動，可考慮安排四度空間電腦斷層
掃描影像(4D CT)，應考慮實際執行狀況。
靶體積定義(Target Volume Definition)及放射治療計畫規劃(Radiation
Target definition: RT target volumes should be defined based on the pretreatment
PET scan and CT scan obtained at the time of RT planning, as well as any positive
biopsies. PET/CT should be obtained, preferably within 4 weeks and no more than 8
weeks, before treatment.
Ideally, PET/CT should be obtained in the treatment position.
(1)GTV：包含 CT 或 MRI 影像或治療前 PET 影像檢查結果中之主要腫
瘤(primary tumor)及影像上有意義之淋巴結(最短軸直徑大於 1 公分)。
(2)CTV：為包含 GTV 周邊可能侵犯之範圍加上 0.5-1 公分，或可藉由 4D
CT 求得 ITV (internal target volume)。
(3)PTV：CTV 在頭端-腳端方向(cranio-caudal directions)與橫向(axial plane)
各加上 0.5-1 公分範圍。
123
Non-small cell lung cancer
◎ Definitive radiotherapy
◎ Adjuvant radiotherapy
■Indication:
(1) Margin positive
(2) Extracapsular nodal spread
(3) Stage IIIA (T1–2, N2; T3, N1); Stage IIIB (T3, N2)
◎ Distant metastases
➔ C/T (radiotherapy for symptomatic relief and/or thoracic regional

therapy)
Radiotherapy techniques:
Simulation:
■ Patient in supine position with arms up and proper immobilization
Field design:
■ Target volume:
Three randomized trials found improved survival for IFI versus ENI,
possibly because it enabled dose escalation.
■ GTV: gross primary tumor and lymph nodes ≧ 1 cm on CT scan
■ CTV: GTV + 0.5-1 cm margin

■ PTV: add 0.5-1 cm margin on CTV to account for setup variations
and respiratory motion
* Parenchymal lesions are better defined in the lung window of a CT
image
* In cases in which atelestasis is present, PET helps to delineate the
GTV better than CT scan does alone
* Treat the supraclavicular fossa if an upper lobe primary or gross
124
upper mediastinal lymphadenopathy
Dose prescriptions:
Commonly Used Doses for Conventionally Fractionated and
Palliative RT
■ Pre-operative radiotherapy: 45 to 54 Gy in 1.8 to 2 Gy per fraction

■ Post-operative radiotherapy: Dose based on margin status. The CTV
includes the bronchial stump and high-risk draining lymph node stations.
Lung dose constraints should be more conservative as tolerance appears
to be reduced after surgery.
In patients with clinical stage I/II upstaged surgically to N2 with
completely resected disease, two randomized studies did not show an
OS benefit of PORT, although locoregional control was significantly
improved.
PORT (generally following postoperative chemotherapy) may be
125
considered for selected patients with high-risk N2 disease, such as
ECE, multi-station involvement, inadequate lymph node
dissection/sampling, and/or refusal or intolerance of adjuvant
systemic therapy.
■ Definite radiotherapy: 60~70Gy
Palliative RT for Advanced/Metastatic NSCLC;
Single-fraction stereotactic RT of 12–16 Gy produced better control of

pain response and local control of non-spine bone metastases compared to
standard 30 Gy in 10 fractions in a randomized phase II trial, and may be
promising for patients with longer expected survival.
Normal Tissue Dose-Volume Constraints for Conventionally

Fractionated RT with Concurrent Chemotherapy
Commonly Used Doses for SABR (also known as SBRT)
126
➢ For centrally located tumors (defined as within 2 cm of the
proximal bronchial tree), 4 to 10 fraction risk-adapted SABR
regimens appear to be effective and safe, while 54 to 60 Gy in 3
fractions is unsafe and should be avoided.
➢ SABR is most commonly used for tumors up to 5 cm in size,
though selected larger isolated tumors can be treated safely if
normal tissue constraints are respected.
➢ Suggest fractionation: 48 Gy in 4 fractions or 54-60 Gy in 3-5
fractions
Exception: Dose may be modified with previous radiotherapy.
NOTE: The interaction of strong VEGF inhibitors with prior or
subsequent dose-intensive RT (SABR or definitive dose accelerated
fractionation) involving the proximal bronchial tree, hilar vessels, or
esophagus can lead to serious toxicity. Careful coordination of medical
and radiation oncology on the therapeutic strategy is important, including
the choice and sequencing of systemic agents with strong VEGF
inhibitors and the dose and fractionation of radiation, especially for
patients with metastatic disease. Bevacizumab and ramucirumab are
recombinant monoclonal antibodies that target the vascular endothelial
growth factor (VEGF) or VEGF receptor, respectively.
Maximum Dose Constraints for SABR (also known as SBRT)
127
128
Small cell lung cancer
• RT has a potential role in all stages of SCLC, as part of either
definitive or palliative therapy.
◎ Definitive radiotherapy
■ Indication:
(1) Limited stage
adjuvant postoperative RT: pathologic N2 and may be
considered in pathologic N1 stage, either sequentially
or concurrently with chemotherapy.
Definitive RT: Selected patients with stage I–IIA (T1–2,N0,M0) SCLC
who are medically inoperable or in whom a decision is made not to
pursue surgery may be candidates for stereotactic ablative RT (SABR)
Timing:
##RT concurrent with systemic therapy is standard and preferred to
sequential chemo/RT.
##RT should start early, with cycle 1 or 2 of systemic therapy (category
1). A shorter time from the start of any therapy to the end of RT (SER) is
significantly associated with improved survival.
(2) If complete or partial response to therapy →
consider prophylactic cranial irradiation (PCI)
Prophylactic Cranial Irradiation:
i) In patients with LS-SCLC who have a good response to initial therapy,

PCI decreases brain metastases and increased overall survival in meta-
analyses.
• The benefit of PCI is unclear in patients who have undergone definitive
therapy for very early LS-SCLC, ie, pathologic stage I–IIA (T1–
2,N0,M0).
However, PCI may have a benefit in patients who are found to have
pathologic stage
129
IIB or III SCLC after complete resection.
ii) In patients with ES-SCLC that has responded to systemic therapy, PCI
decreases brain metastases.
• The preferred dose for PCI to the whole brain is 25 Gy in 10 daily
fractions. A shorter course (eg, 20 Gy in 5 fractions) may be appropriate
in selected patients with extensive-stage disease.
• Neurocognitive function: Increasing age and higher doses are the most
predictive factors for development of chronic neurotoxicity.
PCI is not recommended in patients with poor performance status or
impaired neurocognitive function.
• Hippocampal-avoidance (HA) PCI using IMRT may be considered as a

potential strategy to improve cognitive preservation.
In patients who develop brain metastases after PCI, repeat WBRT may be
considered in carefully selected patients; SRS is preferred, if feasible.
However, patients with metastases within 5 mm of the hippocampi,
leptomeningeal metastases, and other high risk features were not eligible
for hippocampal-sparing WBRT on NRG CC001.43
(3) Poor response to C/T
(4) Extensive stage:
Consolidative thoracic RT is beneficial for selected patients with ES-
SCLC with complete response or good response to systemic therapy,
especially with residual thoracic disease and low-bulk extrathoracic
metastatic disease. Studies have demonstrated that consolidative
thoracic RT up to definitive doses is well-tolerated, results in fewer
symptomatic chest recurrences, and improves long-term survival
in some patients.
130
Radiotherapy techniques:
Simulation:
■ Patient in supine position with both arms up and proper
immobilization
Field design:
■ The radiotherapy target volumes should be defined on the CT
simulator scan image obtained at the time of RT planning.
■ PTV expand 1.5 cm margin to GTV, including ipsilateral hilum, and
bilateral mediastinum from thoracic inlet to subcarinal region (5 cm
below carina or adequate margin on subcarinal area).
Limited stage: Historically, clinically uninvolved mediastinal nodes have
been included in the radiotherapy target volume, whereas uninvolved
supraclavicular nodes generally have not been included.
ENI has been omitted in current prospective clinical trials (including

CALGB 30610/RTOG 0538 and the EORTC 08072 [CONVERT] trial).
Inclusion of the ipsilateral hilum in the target volume, even if not grossly
involved, differs between these trials but may be reasonable.
Dose prescriptions:
■ radiotherapy for limited-stage SCLC: 66-70Gy
■ radiotherapy for extensive-stage SCLC: consolidative thoracic RT
should be individualized within the range of 30 Gy in 10 daily fractions
to 66-70 Gy ..
■ Prophylactic cranial radiotherapy: 25Gy/10 fractions
or 20Gy/5 fractions (recommended for selected patients with extensive-
stage disease.)
In patients with LS-SCLC who have a good response to initial therapy,

PCI decreases brain metastases and increases overall survival.
In patients with ES-SCLC that has responded to systemic therapy, PCI
decreases brain metastases.
Concurrent systemic therapy and high total RT dose (>30 Gy) should be
avoided in patients receiving PCI.
131
Normal tissue constraints:
Organ Constraints
Heart V40Gy < 50% ; Dmean < 20Gy
normal lung V20Gy < 40% ; Dmean < 20Gy
Liver V30Gy < 30%
Constraints for CCRT

Organ Constraints
Heart V40Gy < 50% ; Dmean < 20Gy
normal lung V20Gy < 35% ; Dmean < 16.5Gy ; V5Gy < 42%
Esophagus V55Gy < 50%
132
IMRT technique for lung cancer
133
References:
1. NCCN Clinical Practice Guidelines in Oncology: lung cancer NSCLC and SCLC.
version 2023.version 1 and 2023.version 3, respectively.
2. Le Pechoux C, et al. Postoperative radiotherapy versus no postoperative radiotherapy in
patients with completely resected non-small-cell lung cancerand proven mediastinal N2
involvement (Lung ART): an open-label, randomised, phase 3 trial. Lancet Oncol
2022;23:104-114.
3. Hui Z, et al. Effect of postoperative radiotherapy for patients with pIIIA-N2 non-small
cell lung cancer after complete resection and adjuvantchemotherapy: the phase 3 PORT-
C randomized clinical trial. JAMA Oncol 2021;7:1178-1185
4. Chung HC, Piha-Paul SA, Lopez-Martin J, et al. Pembrolizumab after two or more lines
of prior therapy in patients with advanced small-cell lung cancer (SCLC): Results from
the KEYNOTE-028 and KEYNOTE-158 studies. 2019 AACR Annual Meeting.
Abstract CT073. Presented April 1, 2019.
5. Ott PA, Elez E, Hiret S, et al. Pembrolizumab in patients with extensive-stage small-cell
lung cancer: results from the phase Ib KEYNOTE-028 study. J Clin Oncol
2017;35:3823-3829.
6. International Commission on Radiation Units and Measurements. ICRU Report No 50:
Prescribing, Recording and Reporting Photon Beam Therapy. Bethesda, MD: ICRU
Publications 1993.
7. International Commission on Radiation Units and Measurements. ICRU Report No 62:
Prescribing, Recording and Reporting Photon Beam Therapy (Supplement to ICRU
Report 50). Bethesda, MD: ICRU Publications 1999.
8. Kong F-M S, et al. NRG-RTOG 1106/ACRIN 6697: A phase IIR trial of standard versus
adaptive (mid-treatment PETbased) chemoradiotherapy for stage III NSCLC—Results
and comparison to NRG-RTOG 0617 (non-personalized RT dose escalation). J Clin
Oncol 2021;39:8548-8548..
9. Rosen LR, Fischer-Valuck BW, Katz SR, et al. Helical image-guided stereotactic body
radiotherapy (SBRT) for the treatment of early-stage lung cancer: a single-institution
experience at the Willis-Knighton Cancer Center. Tumori. 2014 Jan-Feb;100(1):42-8.
doi: 10.1700/1430.15814.
10. Gjyshi O, et al. Toxicity and survival after intensity-modulated proton therapy versus
passive scattering proton therapy for NSCLC. J Thorac Oncol 2021;16:269-277..
11. Chang JY, et al. Stereotactic ablative radiotherapy for operable stage I non-small-cell
lung cancer (revised STARS): long-term results of a single-arm, prospective trial with
prespecified comparison to surgery. Lancet Oncol 2021;22:1448-1457.
12. Rusthoven CG, Kavanagh BD, Karam SD. Improved survival with stereotactic ablative
radiotherapy (SABR) over lobectomy for early stage non-small cell lung cancer
134
(NSCLC): addressing the fallout of disruptive randomized data. Ann Transl Med
2015;3:149
13. Rusch VW, Giroux DJ, Kraut MJ, et al. Induction chemoradiation and surgical
resection for superior sulcus non-small-cell lung carcinomas:long-term results of
Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Clin Oncol
2007;25:313-318.
14. Four-year survival with durvalumab after chemoradiotherapy in stage III NSCLCancer
update from the PACIFIC trial. J Thorac Oncol 2021;16:860-867..
15. Slotman BJ, van Tinteren H, Praag JO, et al. Use of thoracic radiotherapy for extensive
stage small-cell lung cancer: a phase 3 randomised controlled trial. Lancet. 2015 Jan
3;385:36-42.
16. De Ruysscher D, Pijls-Johannesma M, Bentzen SM, et al. Time between the first day of
chemotherapy and the last day of chest radiation is the most important predictor of
survival in limited-disease small-cell lung cancer. J Clin Oncol 2006;24:1057-1063.
17. Wolfson AH, Bae K, Komaki R, et al. Primary analysis of a phase II randomized trial
Radiation Therapy Oncology Group (RTOG) 0212: Impact of different total doses and
schedules of prophylactic cranial irradiation on chronic neurotoxicity and quality of life
for patients with limited-disease small-cell lung cancer. Int J Radiat Oncol Biol Phys
2011;81:77-84.
18. Brown PD, Pugh S, Laack NN, et al. Memantine for the prevention of cognitive
dysfunction in patients receiving whole-brain radiotherapy: a randomized, doubleblind,
placebo-controlled trial. Neuro Oncol 2013;10:1429-1437.
19. van Meerbeeck J, De Ruysscher D, Belderbos J, et al. Neuro-cognitive (HVLT-R total
recall) functioning in localized vs. metastatic small-cell lung cancer with or without
hippocampus sparing PCI: Results from a phase III trial [abstract]. Eur Respir J
2019;54: DOI: 10.1183/13993003.congress-2019.OA5103
20. De Dios NR, Murcia M, Counago F, et al. Phase III trial of prophylactic cranial
irradiation with or without hippocampal avoidance for small cell lung cancer [abstract].
Int J Radiat Oncol Biol Phys 2019;105:s35-s36.
21. Gondi V, Pugh S, Mehta M, et al. NRG Oncology CC003: A randomized phase II/ III
trial of prophylactic cranial irradiation with or without hippocampal avoidance for small
cell lung cancer [abstract]. J Clin Oncol 2019;37:TPS8578-TPS8578.
22. Brown P, Gondi V, Pugh S, et al. Hippocampal avoidance during whole-brain
radiotherapy plus memantine for patients with brain metastases: Phase III trial NRG
Oncology CC001. J Clin Oncol 2020;38:1019-1029.
23. Rusthoven CG, Yamamoto M, Bernhardt D, et al. Evaluation of first-line radiosurgery
vs whole-brain radiotherapy for small cell lung cancer brain metastases: the FIRE-
SCLC cohort study. JAMA Oncol 2020;e201271
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24. Moreno AC, Fellman B, Hobbs BP, et al. Biologically effective dose in stereotactic
body radiotherapy and survival for patients with early-stage NSCLC. J Thorac Oncol
2020;15:101-109.
25. Nestle U, Schimek-Jasch T, Kremp S, et al. Imaging-based target volume reduction in
chemoradiotherapy for locally advanced non-small-cell lung cancer (PET-Plan): a
multicentre, open-label, randomised, controlled trial. Lancet Oncol 2020;21:581-592.
26. Bogart JA, Wang XF, Masters GA, et al. Phase 3 comparison of high-dose once daily
(QD)thoracic radiotherapy (TRT) with standard twice-daily (BID) TRT in limited stage
small cell lung cancer (LSCLC): CALGB 30610 (Alliance)/RTOG 0538. J Clin Oncol
2021;39:8505-8505.
27. Grønberg BH, Killingberg KT, Fløtten Ø , et al. High-dose versus standard-dose twice-
daily thoracic radiotherapy for patients with limited stage small-cell lung cancer: an
open-label, randomised, phase 2 trial. Lancet Oncol 2021;22:321-331.
28. Qiu B, Li QW, Liu JL, et al. Moderately hypofractionated once-daily compared with
twicedaily thoracic radiation therapy concurrently with etoposide and cisplatin in
limited-stage small-cell Lung Cancer: a multi-center, Phase II, randomized trial. Int J
Radiat Oncol Biol Phys 2021;S0360-3016.
29. Belderbos JSA, De Ruysscher DKM, De Jaeger K, et al. Phase 3 randomized trial of
prophylactic cranial irradiation with or without hippocampus avoidance in SCLC
(NCT01780675). J Thorac Oncol 2021;16:840-849
136
Endometrial cancer
Indications of RT:
◼ Disease limited to the uterus (endometrioid histology) and not
suitable for primary surgery: EBRT and/or brachytherapy
◼ Suspected or gross cervical involvement and not suitable for
primary surgery: EBRT + brachytherapy ± systemic therapy
◼ Suspected extrauterine disease and Locoregional disease not

suitable for primary surgery: EBRT ± brachytherapy ± systemic
therapy
 Surgically stage I
Stage IA (<50% myometrial invasion)
◼ G1, G2: observation (preferred) or vaginal brachytherapy (if
LVSI(+) and/or age ≥60y); Vaginal brachytherapy strongly
suggested if two risk factors present.
◼ G3: vaginal brachytherapy (preferred) or observation (if no
myoinvasion) or EBRT (if age ≥70y or LVSI(+)(category 2B))
Stage IB (≥50% myometrial invasion)
◼ G1: vaginal brachytherapy (preferred) or observation (if age
<60y and LVSI(-))
◼ G2: vaginal brachytherapy (preferred) or EBRT (if age ≥60y
and/or LVSI(+)) or observation (if age< 60y and LVSI(-)); No
sexual behavior history, vaginal brachytherapy replaced by
EBRT.
◼ G3: RT (EBRT ± vaginal brachytherapy) ± systemic
therapy
137
 Surgically stage II
◼ EBRT(preferred) and/or vaginal brachytherapy ± systemic therapy
(category 2B for systemic therapy)
 Surgically stage III-IV: systemic therapy ± EBRT ± vaginal

brachytherapy
 Serous or clear cell carcinoma or Carcinosarcoma of the

endometrium:
138
◼ Primary treatment: surgical staging
◼ Adjuvant Treatment:
➢ Non-invasive Stage IA:
1. Washing (-): Vaginal Brachytherapy (preferred)
2. Washing (+): Vaginal Brachytherapy + Systemic
therapy
➢ Invasive Stage IA, Stage IB, II: Chemotherapy ±
EBRT ± vaginal brachytherapy, or EBRT ± vaginal
brachytherapy
➢ StageIII, IV: Chemotherapy ± EBRT ± vaginal brachytherapy
◼ Not suitable for primary surgery: EBRT ± brachytherapy ±
systemic therapy
 Local/regional recurrence
◼ Previous EBRT: surgical exploration ± resection ± IORT
(category 3 for IORT)
◼ No prior RT or previous brachytherapy only: EBRT ±
brachytherapy ± systemic therapy
RT techniques:
Simulation:
■ Patient in supine position with cast or cushion immobilization
■ Suggest half-full bladder (intake 300 cc of water 30 minutes before
simulation)
Field design:
■ Treat with four box field or AP/PA technique
■ Conventional RT field:
➢ Superior: L4/5 junction
➢ Inferior: 3 cm below most inferior vaginal involvement (often at
inferior portion of obturator foramen) or include lower 1/2 vagina
➢ Lateral: 1.5-2 cm lateral to pelvic rim
➢ Posterior: commonly situated 0.5 cm posterior to the anterior
border of the S2-3 vertebral junction, but this is varied according to
139
surgical and histological findings
➢ Anterior: pubic symphysis
■ Delineation of target volume for IMRT in post-operative treatment of
endometrial cancer (Consensus guideline---RTOG and GOG group):
Small et al. Int J Radiat Oncol Biol Phys, 2008; 71:428-434.

Dose prescriptions:
◼ Post-operative:
➢ EBRT (45-50Gy) + HDR brachytherapy boost to submucosal 0.5
cm, doses of 3 to 5 Gy x 2 fractions; target limited to the upper
two-thirds of the vagina.
1. If gross residual disease:EBRT boost to 60-70Gy.
2. If gross nodal disease: EBRT boost to 60-65 Gy.
3. HDR brachytherapy: preferably 6–8 weeks after surgery but
should not exceed 12 weeks.
➢ Vaginal brachytherapy alone: HDR brachytherapy to vaginal
mucosa with 7 Gy x 3 fractions or 6 Gy x 5 fractions or 4-5Gy x 6
fractions; target limited to the upper two-thirds of the vagina. (in
cases of extensive LVSI or positive margins, a longer segment of
the vagina may be treated).
◼ Medical operable
➢ Radical hysterectomy and bilateral salpingooophorectomy
(RH/BSO) and surgical staging
➢ Pre-op RT for gross stage IIB: 75-80Gy to point A/paracervical
dose (category 2B); then (TH/BSO) and surgical staging
140
◼ Not suitable for primary surgery
➢ Tumor-directed RT (EBRT 45~54Gy + HDR brachytherapy to
point A with 17.5~27Gy) ± chemotherapy
➢ Chemotherapy (category 2B)
HDR brachytherapy (Treatment should be modified based on normal

tissue tolerance or on biologic equivalence calculations):
*Limit urinary-bladder and rectal points to < 80% of point A dose
Dose constraints:
Organ Constraints
Small intestine Dmax < 54Gy ; V30Gy < 120c.c. ; V15Gy < 200c.c.
Rectum Dmax < 60Gy ; V50Gy < 50%
Functional kidney V20Gy < 30% ; Dmean < 15Gy
141
Four box fields for a case of endometrial cancer.
142
Tomotherapy (IMRT+IGRT) for an endometrial cancer.
143
References:
2. NCCN guidelines version 1.2022 clinical practice guidelines in oncology: Uterine
Neoplasms
3. Fishman DA, Roberts KB, Chambers JT, et al. Radiation therapy as exclusive
treatment for medically inoperable patients with stage I and II endometrioid
carcinoma of the endometrium. Gynecol Oncol 1996; 61:189-196.
4. Creutzberg CL, van Putten WL, Koper PC, et al. Surgery and postoperative
radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma:
multicentre randomised trial. PORTEC Study Group. Post Operative Radiation
Therapy in Endometrial Carcinoma. Lancet 2000; 355:1404-1411.
5. Scholten AN, van Putten WL, Beerman H, et al; PORTEC Study Group.
Postoperative radiotherapy for Stage 1 endometrial carcinoma: long-term outcome
of the randomized PORTEC trial with central pathology review. Int J Radiat Oncol
Biol Phys 2005; 63(3):834-838.
6. Alektiar KM, Venkatraman E, Chi DS, Barakat RR. Intravaginal brachytherapy
alone for intermediate-risk endometrial cancer. Int J Radiat Oncol Biol Phys 2005;
62(1):111-117.
7. Nout RA, Putter H, Jürgenliemk-Schulz IM, et al. Vaginal brachytherapy versus
external beam pelvic radiotherapy for high-intermediate risk endometrial cancer:
Results of the randomized PORTEC-2 trial [abstract]. J Clin Oncol 2008;
26:LBA5503.
8. ASTEC/EN.5 Study Group, Blake P, Swart AM, et al. Adjuvant external beam
radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG
EN.5 randomised trials): pooled trial results, systematic review, and meta-analysis.
Lancet 2009; 373(9658):137-146.
9. Kong A, Johnson N, Cornes P, et al. Adjuvant radiotherapy for stage I endometrial
cancer. Cochrane Database Syst Rev 2007; (2):CD003916.
10. Koh WJ, Tran AB, Douglas JG, et al. Radiation therapy in endometrial cancer. Best
Pract Res Clin Obstet Gynaecol. 2001; 15:417-432.
11. Hogberg T, Rosenberg P, Kristensen G, et al. A randomized phase-III study on
adjuvant treatment with radiation (RT) ± chemotherapy (CT) in early-stage high-
risk endometrial cancer (NSGO-EC-9501/EORTC 55991) [abstract]. J Clin Oncol
144
2007; 25:5503.
12. Wolfson AH, Brady MF, Rocereto T, et al. A gynecologic oncology group
randomized phase III trial of whole abdominal irradiation (WAI) vs. cisplatin-
ifosfamide and mesna (CIM) as post-surgical therapy in stage I-IV carcinosarcoma
(CS) of the uterus. Gynecol Oncol 2007; 107(2):177-185.
13. Herrera FG, Cruz OS, Achtari C, Bourhis J, Ozsahin M. Long-term Outcome and
Late Side Effects in Endometrial Cancer Patients Treated with Surgery and
Postoperative Radiation Therapy. Ann Surg Oncol. 2014 Mar 7
14. Boothe D, Patel SH, Stessin A, Parashar B, Nori D, Wernicke AG. Comparing the
rates of urinary tract infections among patients receiving adjuvant pelvic intensity
modulated radiation therapy, 3-dimensional conformal radiation therapy, and
brachytherapy for newly diagnosed endometrial cancer. Pract Radiat Oncol. 2013
Oct-Dec;3(4):269-74. doi: 10.1016/j.prro.2012.12.002. Epub 2013 Jan 28.
15. Pros and cons of vaginal brachytherapy after external beam radiation therapy in
endometrial cancer. Gynecol Oncol. 2016 Jan;140(1):167-75.
16. Vogel TJ, et al. An analysis of current treatment practice in uterine papillary serous
and clear cell carcinoma at two high volume cancer centers. J Gynecol Oncol
2015;26:25-31.
145
Cervical cancer
◎ Definitive RT
■ Indication:
(1) Stage IA1 (with lymphovascular space invasion (LVSI)) and
IA2; Primary treatment: pelvic RT + brachytherapy
[Modify treatment based on normal tissue tolerance,
fractionation and size to target volume]
(2) Stage IB1, IB2 or IIA1 (including those who are not candidates
for hysterectomy): pelvic RT + brachytherapy ±
concurrent platinum-containing chemotherapy.

(3) Stage IB3, IIA2, stage IIB, III, IVA;
Primary treatment: → pelvic RT + concurrent platinum-
containing chemotherapy + brachytherapy (category 1) ±
selective completion hysterectomy (category 3).
[Traditional dose would be 75-80 Gy to total point A
dose]; [selective completion hysterectomy can be
considered in patients whose extent of disease or uterine
anatomy precludes adequate coverage by brachytherapy].
◎ Postoperative adjuvant RT ± concurrent platinum-containing
chemotherapy (category 2B for chemotherapy)

Stage IB1, IB2 or IIA1: surgery is category 1.
Stage IB3 or IIA2: surgery is category 2B.
■ Indication: FIGO stage IA1 (with LVSI) or IA2-IIA following

radical hysterectomy [node(-), and parametrium(-), and margin(-)]
have high-risk factors [primary tumor size, stromal invasion, and/or
LVSI that meet Sedlis criteria (category 1)]
Sedlis criteria for EBRT after radical hysterectomy in node(-),
margin(-), parametria(-) cases.
146
Tumor size (cm)
LVSI Stromal Invasion
(Determined by clinical palpation)
+ Deep 1/3 any
+ Middle 1/3 ≥2
+ Superficial 1/3 ≥5
- Middle or Deep 1/3 ≥4
◎ Postoperative adjuvant CCRT: pelvic RT (para-aortic LN RT if para-
aortic LN positive) + concurrent platinum-containing chemotherapy

(category 1) ± vaginal brachytherapy (if positive vaginal margin)
■ Indication: FIGO stage IA1 (with LVSI) or IA2-IIA following
radical hysterectomy have any one pathologic risk factors (1)
positive nodes, or (2) positive parametrium, or (3) positive surgical
margins
◎ Para-aortic LN positive by surgical staging (FIGO 2018 IIIC):
◼ Distant metastasis (-): Extended-field EBRT + concurrent

platinum-containing chemotherapy ± vaginal brachytherapy
◼ Distant metastasis (+): chemotherapy ± individualized RT
◎ Local/regional recurrence
◼ No prior RT: individualized EBRT ± chemotherapy ±

brachytherapy
◼ Prior RT: individualized EBRT ± chemotherapy, or resection ±
IORT (category 3)
◎ Distant metastases
◼ Local treatment: Resection ± individualized EBRT, or local
ablative therapies ± individualized EBRT, or individualized
EBRT ± chemotherapy
◼ Consider adjuvant chemotherapy
◼ Oligometastatic RT:
16-30Gy/1fr
24-60Gy/3fr
30-60Gy/5fr
147
RT techniques:
Simulation:
■ Patient in supine position with cast or cushion immobilization
■ Suggest half-full bladder (intake 300 cc of water 30 minutes before
simulation)
External-Beam Radiation Therapy (EBRT)
⚫ Target volume of EBRT: cover the gross disease (if present),
parametria, uterosacral ligaments, and sufficient vaginal margin from
the gross diseases (at least 3 cm), presacral nodes, and other nodal
volumes at risk.
 Negative nodes on surgical or radiologic imaging report:
radiation volume includes the entirety of the external iliac,
internal iliac, and obturator nodal regions.
 High risk of lymph node involvement (eg, bulky tumors, or
suspected or confirmed nodes confined to the low true pelvis):
the radiation volume should be increased to cover the common
iliac nodal area.
 Documented common iliac and/or para-aortic nodal involvement:
extended-field pelvic and para-aortic radiotherapy is
recommended up to the level of the renal vessels (or even more
cephalad as directed by involved nodal distribution).
 Lower 1/3 vaginal involvement: the bilateral groins should be
covered as well.
 For the majority of patients who receive EBRT for cervical
cancer, concurrent platinum-containing chemotherapy is given
during the time of EBRT
◼ IMRT and similar highly conformal methods of dose delivery may

be helpful in minimizing the doses to the bowel and other critical
structures in the post-hysterectomy setting and in treating the para-
aortic nodes.
◼ Conformal external beam therapies (such as IMRT) or stereotactic
body radiation therapy, SBRT) should not be used as routine
148
alternatives to brachytherapy for treatment of central diseases in
patient with intact cervix.
◼ Stereotactic body radiotherapy (SBRT) is not considered an
appropriate routine alternative to brachytherapy.
◼ SBRT is an approach that allows delivery of very high doses of
focused external beam radiation in 1-5 fractions (dose) and may be
applied to isolated metastatic sites. Consideration can be given for
limited disease in the re-irradiation setting.
Field design:
■ Conventional RT field:
◼ Superior: L4/5 junction
◼ Inferior: 3 cm below most inferior vaginal involvement
(often at inferior portion of obturator foramen) or include
lower 1/2 vagina
◼ Lateral: 1.5-2 cm lateral to pelvic rim
◼ Posterior: commonly situated 0.5 cm posterior to the
anterior border of the S2-3 vertebral junction, but this is
varied according to surgical and histological findings
◼ Anterior: pubic symphysis
* Inguinal lymph nodes treated if stage IIIA (lower one third
of vagina) and inferior border include vaginal introitus.
* If posterior vaginal wall extensively involved, peri-rectal
nodes could be treated.
* If common iliac nodes involved, raise the superior border to
about 1-2 cm margin for known nodes.
Delineation of target volume for IMRT in post-operative treatment of

cervical cancer (Consensus guideline---RTOG and GOG group):
149
Small et al. Int J Radiat Oncol Biol Phys, 2008; 71:428-434.
EBRT dose prescriptions:

■ Post-hysterectomy adjuvant RT:
➢ At a minimum, the following should be covered: upper 3 to 4 cm
of the vaginal cuff, the parametria, and immediately adjacent
nodal basins (such as the external and internal iliac, obturator,
and presacral nodes): 45 to 50.4Gy. (1.8-2.0Gy daily)
➢ Boost with additional 10~20Gy for grossly involved unresected
nodes
➢ HDR brachytherapy boost to submucosal 0.5 cm, doses of 3 to 5
Gy/2 fractions; target limited to the upper 3 to 4 cm of the
vagina.
■ Definite RT for an Intact Cervical:
◼ Primary tumor and regional lymphatics at risk treated with
definitive EBRT to approximately 40~50.4Gy). (1.8-2.0Gy
daily). Boost additional 10~15 Gy EBRT to grossly involved
unresected nodes.
➢ Primary cervical tumor is then boost HDR brachytherapy with
additional 17.5~30Gy to point A. (divided to 4-6 fractions)
HDR brachytherapy: (HDR point A dose of 30Gy/5fr is generally

accepted to be the equivalent to LDR point A 40Gy)
■ HDR brachytherapy is an essential part of therapy for all patients
with intact cervical cancer.
■ In post-hysterectomy patients (positive or close vaginal mucosal
surgical margins), vaginal HDR brachytherapy is used as a boost to
150
EBRT.
■ In highly selected very early disease (such as stage IA2), HDR
brachytherapy alone, with or without external-beam radiation, may
be an option
HDR Brachytherapy dose prescriptions: (Treatment should be
modified based on normal tissue tolerance or on biologic equivalence
calculations)
■ Point A dosing system (cervical cancer without hysterectomy):
➢ Multiple HDR brachytherapy schemes have been used, when
combined with EBRT.
*Limit urinary-bladder and rectal points to <80% of point A doseSBRT is
not considered an appropriate routine alternative to brachytherapy.
Intraoperative Radiation Therapy

•IORT is a specialized technique that delivers a single, highly focused
dose of radiation to an at-risk tumor bed or isolated unresectable residual

disease during an open surgical procedure. It is particularly useful in
patients with recurrent disease within a previously radiated volume. IORT
is typically delivered with electrons, brachytherapy, or miniaturized x-ray
sources using preformed applicators of variable sizes.
Dose constraints:
Organ Constraints
Small intestine Dmax < 54Gy ; V30Gy < 120c.c. ; V15Gy < 200c.c.
Rectum Dmax < 60Gy ; V50Gy < 50%
Functional kidney V20Gy < 30% ; Dmean < 15Gy
151
Four box fields radiotherapy technique for a case of cervical cancer.
152
IMRT technique for a case of cervical cancer.
153
References:
2. NCCN guidelines version 1.2022 clinical practice guidelines in oncology:
cervical cancer
3. Bhatla N, Aoki D, Sharma DN, et al. FIGO Cancer Report 2018. Cancer of the
cervix uteri. Int J Gynecol Obstet 2018;143(Suppl):22-36.
4. Consensus guideline---RTOG and GOG group.
5. Small W, et al. Consensus guidelines for delineation of clinical target volume for
IMRT in postoperative treatment of endometrial or cervical cancer. Int J Radiat
Oncol Biol Phys Int J Radiat Oncol Biol Phys, 2008; 71:428-434.
6. Lim K, SmallW, Portelance L, et al. Consensus guidelines for delineation of
clinical target volume for intensity-modulated pelvic radiotherapy for the
definitive treatment of cervical cancer. Int J Radiat Oncol Biol Phys
2010;79:348-355.
7. Gao K, Ding L, Li L. Analysis of clinical efficacy of intensity-modulated
radiation therapy and the prognosis factors in advanced cervical cancer.
Zhonghua Fu Chan Ke Za Zhi. 2014 Jan;49(1):30-5. Chinese.
8. Ioffe YJ, Hillen TJ, Zhou G, et al. Postradiation damage to the pelvic girdle in
cervical cancer patients: is intensity-modulated radiation therapy safer than
conventional radiation? Int J Gynecol Cancer. 2014 May;24(4):806-12. doi:
10.1097/IGC.0000000000000117.
9. Rotman M, Sedlis A, Piedmont MR, et al. A phase III randomized trial of
postoperative pelvic irradiation in stage IB cervical carcinoma with poor
prognostic features: follow-up of a gynecologic oncology group study. Int J
RadiatOncol Biol Phys 2006;65:169-176.
10. Morice P, et al. Results of the GYNECO 02 study, an FNCLCC phase III trial
comparing hysterectomy with no hysterectomy in patients with a (clinical and
radiological) complete response after chemoradiation therapy for stage IB2 or II
cervical cancer. Oncologist 2012;17:64-71.
11. Verma, et al. Dosimetric Predictors of Duodenal Toxicity After Intensity
Modulated Radiation Therapy for Treatment of the Para-aortic Nodes in
Gynecologic Cancer. 2014;88(2):357-362.
12. Klopp AH, et al. A phase III Randomized Trial Comparing Patient-Reported
Toxicity and Quality of Life (QOL) During Pelvic Intensity Modulated Radiation
Therapy as Compared to Conventional Radiation Therapy. Int J Radiat Oncol
Biol Phys 2016; 96:S3.
13. Choi CW, et al. Image-guided stereotactic body radiation therapy in patients with
isolated para-aortic lymph node metastases for uterine cervical and corpus
154
cancer. Int J Radiat Oncol Biol Phys 2009;74:147-153.
14. Higginson DS, et al. Stereostatic body radiotherapy (SBRT): Technological
innovation and application in gynecologic oncology. Gynecol Oncol
2011;120:404-412.
15. Safety and Survival Rates Assocciated With Ablative Stereotactic Radiotherapy
for Patients With Oligometastatic cancer. A systemic Review and Meta-analysis.
JAMA Oncol. 2021 Jan ;7(1):92-106.
155
Prostate Cancer
於放射治療前，應回顧該病人的病理報告、影像檢查…等；必要時於多專
科團隊會議時提出討論。
二、定位：
1. 體位設定：
仰躺姿勢，原則病人模擬定位姿勢為仰臥(supine) 。
2. 固定方法：
為求擺位重覆性高，選擇 cast 或真空墊(vacuum bag)作為固定模具。病人
前方之標記點約在恥骨聯合連線(pubic symphysis)之中心、側面之標記點約
在髖關節(hip joint)。在真空墊或 cast 的側面也要貼上標記。
3. 模擬攝影之要求：採取電腦斷層輔助之模擬攝影，在電腦斷層掃瞄定位
室，請病人依原姿勢躺在已製作好的固定模具上，對到定位雷射。金屬標
記在影像上呈現中心點之位置。
電腦斷層定位之掃描範圍及條件：
掃描範圍含攝護腺、儲精囊及骨盆腔淋巴腺(Pelvic Lymph Nodes):
約從 L5 到恥骨下 5 公分，切片厚度為 2.5-5 毫米。掃描範圍及切片厚度
條件，可由主治醫師自行訂定。將掃瞄完成後之電腦斷層影像傳送至治療
計劃室，供靶體積定義及放射治療計畫規劃使用。
4. 特殊注意事項：
(1)為減少小腸及膀胱之照射，病人需喝水漲膀胱，方法為在執行電腦斷層
掃描定位 30 分鐘前排空膀胱，並喝約 150- 300 ml 之開水後脹尿，但喝水
量及脹尿程度以病人能忍耐之舒適度為主，以 300ml CT 定位或 150ml MR
定位為原則。
(2)在執行電腦斷層掃描定位(Computed Tomography Simulation)前，教導病
人食用低渣食物(low residue diet)為原則。
靶體積定義(Target Volume Definition)及放射治療計畫規劃(Radiation
156
1.治療範圍如含攝護腺及儲精囊(IMRT)：
攝護腺位於恥骨聯合(Pubic Symphysis)及直腸壁前方(Anterior Rectal Wall)，
相鄰膀胱頸部(Bladder Neck)及儲精囊，攝護腺癌之侵犯程度，可由磁振照影影
像(Magnetic Resonance Imaging, MRI)或 CT 影像診斷。CTV 包含整個攝護腺
或儲精囊。
2.根治性放射線治療(definitive radiotherapy)治療範圍含攝護腺、儲精囊或骨盆腔
淋巴腺(Pelvic Lymph Nodes)：
(1).骨盆腔淋巴照射可依照病人實際狀況做調整(一般來說 low risk 以下不做
預防性骨盆腔淋巴腺照射)，另可參考 Roach Formula 計算骨盆腔淋巴腺侵犯之
風險，其公式為骨盆腔淋巴腺轉移機率= 2/3 PSA + [(GS–6)×10]。
(2). CTV 包括攝護腺、儲精囊、遠端總腸骨淋巴腺(Distal common iliac
lymph nodes)、內外腸骨淋巴腺(internal and external iliac lymph nodes)、薦骨前
區(S1-S3)淋巴腺(presacral lymph nodes)及閉孔淋巴腺(obturator lymph nodes)。淋
巴腺之 CTV 包含動靜脈血管及 7 毫米之放射狀邊緣(radial margin)，並小心修
正與腸子、膀胱、骨頭及肌肉重疊之區域。照射範圍包含從第五腰椎/第一薦椎
(L5/S1)界線至恥骨上緣(superior aspect of pubic bones)。
CTVhigh: prostate
CTVmid : prostate+seminal vescicle
CTVlow : pelvic lymph nodes
3.攝護腺切除術後放射治療(Post Prostectomy Radiation Therapy)：
(1). CTV 之照射範圍：
1.下緣(Inferior border):至陰莖球體(Penile bulb)上缘、
2.前緣(Inferior border)至恥骨聯合後方及
3.後緣(Posterior border)至直腸壁前方
4.側位(Lateral border)至 obturator internus and levator ani muscles 之內緣
5.上緣(Superior border)至儲精囊底部(base of SV)或儲精囊近端 1~2 cm
(Proximal 1~2 cm of SV)。
4. PTV 之範圍為 CTV 加上擺位誤差 set-up error(影像導航導引下可依情況縮減)
157
◎ Definitive RT
■ Indications: (Gleason grade group: group 1:GS≦6; group 2:GS 3+4;
group 3:GS 4+3; group 4:GS=8; group 5:GS 9-10)

(1) Very low risk (T1c, GS≦6/Gleason grade group 1, PSA<10ng/mL,
Bx + less than 3 core, ≦50% in each core and PSA density <0.15
ng/mL/g): if life expectancy ≧20 years→ EBRT or brachytherpy
(2) Low risk (T1-2a, and Gleason score:≦6/Gleason grade group 1,
and PSA<10 ng/mL) if life expectancy ≧10 years → EBRT or
brachytherapy
(3) Intermediate risk (T2b-2c, or Gleason score: 3+4=7/Gleason grade
group 2 or 3, or PSA: 10-20 ng/mL)→ consider EBRT±ADT ±
brachytherapy
(4) High risk (T3a, or Gleason score: 8/Gleason grade group 4 or
Gleason score: 4+5/Gleason grade group 5, or PSA>20 ng/mL) →
consider EBRT+ADT ± brachytherapy
(5) Very high risk (T3b-T4 or Primary Gleason pattern 5 or 2-3 high
risk features or >4 cores with Grade Group 4 or 5):
EBRT+ADT±brachytherapy
(6) N1→ EBRT+ADT± abiraterone
158
◎ Adjuvant RT
■Indications:
(1) Positive margin
(2) Seminal vesicle invasion
(3) Extracapsular extension
(4) Detectable PSA after operation
(5) LN positive: ADT(category 1)+/-EBRT (category 2B)
(6) Monitoring, with consideration of early RT for a
detectable and rising PSA or PSA >0.1 ng/mL
◎ Salvage RT
■Indications:
(1) Post op salvage RT: undetectable PSA become detectable and
increased on 2 subsequent measurements.
(2) Post RT: phoenix definition: PSA rise ≧2ng/ml than nadir: local
salvage RT if indicated
◎Metastatic disease
Patient with distant metastasis: RT to primary site for palliative intent
159
RT techniques:
Simulation:
■ Patient in supine position with proper immobilization
■ Bladder preparation
Field design: (conventional RT)
■ For traditional whole-pelvic* RT, initial field borders are:
On the AP/PA field:
Superior: L5/S1
Inferior: 0.5-1 cm below the area where the dye narrow on the
urethrogram
Lateral: 1.5 cm lateral to the bony margin of the true pelvis
On the lateral field:
Anterior: anterior to the pubic symphysis
Posterior: splits the sacrum to S2/3
■ For the cone-down field (usually 6 fields)→non-uniform field edge
margins of 0.5-1.5 cm to cover the prostate + seminal vesicle or
prostate only.
*Indications for whole-pelvic RT: (1) nodal positive, (2) seminal
vesicle invasion, (3) a calculated risk of lymph node involvement > 15
% (using the Roach formula), (4) high-risk disease.
Dose prescriptions:
■Definitive RT:
PTV-High
■ For low risk, dose around 75.6-79.2Gy (1.8-2Gy/fr)
■ For intermediate-high risk, dose may escalate up to 81Gy (1.8Gy/fr)
⚫ Moderate hypofractionated image guided IMRT(70.2Gy/26Fr)
has the similar or non-inferior efficacy as conventional
fractionated RT and can be considered as an alternative when
clinically indicated.
⚫ For low risk and intermediate risk patients using EBRT + HDR
brachytherapy: EBRT dose 45Gy(range: 40-50.4Gy) +
160
brachytherapy 6Gy x 3 times(range: 5.5-6.5Gy/fr)
-PTVmid: 60Gy
-PTVlow: 46Gy(44-50Gy/20-25fr for moderate hypofractionated RT)
-Pelvic LN: 54-56Gy or higher
Stereotactic body RT (SBRT) is acceptable in practices with
appropriate technology, physics, and clinical expertise. SBRT for
metastases can be considered in the following circumstances:
1. In a patient with limited metastatic disease to the vertebra or
paravertebral region when ablation is the goal (eg, concern for
impending fracture or tumor encroachment on spinal nerves or
vertebra)
2. In a patient with oligometastatic progression where
progressionfree survival is the goal
3. In a symptomatic patient where the lesion occurs in or
immediately adjacent to a previously irradiated treatment field.
Radiation Therapy General Principles:
■ For post-operative adjuvant RT/salvage RT:

-PTV:64-72Gy in standard fractionation, biopsy-proven gross recurrence
may require higher dose
-Pelvic LN: 54-56Gy or higher
161
■ Palliative RT:
High-volume disease is differentiated from low-volume disease by
visceral metastases and/or 4 or more bone metastases, with at least one
metastasis beyond the pelvis vertebral column. Patients with low-volume
disease have less certain benefit from early treatment with docetaxel
combined with ADT.
Treatment of the primary site with definitive external beam dosing
regimens, or traditional palliative regimens (e.g. 8Gy/1fx, 30 Gy/10 fx or
37.5 Gy/15 fx)
Low-volume metastatic disease
Radiation therapy to the prostate is an option in patients with low-
volume castration-naïve metastatic disease, without contraindications
to radiotherapy. ADT is required unless medically contraindicated.
This recommendation is based on the STAMPEDE phase 3
randomized trial, which randomized 2,061 patients to standard
systemic therapy with or without radiotherapy to the primary.
The overall cohort had a significant improvement from the addition
of radiotherapy to the primary in failure-free survival, but not
overall survival. The prespecified low-volume subset had a significant
improvement in both failure-free survival and overall survival.
Dose escalation beyond biologically effective dose equivalents
of the two-dose prescriptions used in STAMPEDE (55 Gy in 20
fractions or 6 Gy x 6 fractions) is not recommended given the
known increase in toxicity from dose intensification without
overall survival improvement in localized disease.
Brachytherapy is not recommended outside of a clinical trial,
as safety and efficacy have not been established in this patient
population.
• High-volume metastatic disease
Radiation therapy to the prostate should NOT be performed in
patients with high-volume metastatic disease outside the context
of a clinical trial unless for palliative intent.
This recommendation is based on two randomized trials, HORRAD
162
and STAMPEDE, neither of which showed an improvement in
overall survival from the addition of radiotherapy to the primary
when combined with standard systemic therapy.
■Brachytherapy:
Brachytherapy boost, when added to EBRT plus ADT in patients
men with NCCN intermediate- and high-risk prostate cancer, has
demonstrated improved biochemical control over EBRT plus ADT
alone in randomized trials, but with higher toxicity.
HDR brachytherapy:can be used alone or in combination with EBRT

HDR treated alone regimen: 13.5Gy x2 times, 10.5Gy x 3 times or
9.5Gy x 4 times
HDR treated with EBRT regimen: 5.5-6.5Gy x 3 times or 4-6Gy x 4
times
Relative contraindications for brachytherapy: too large or too small
prostate, Bladder outlet obstruction symptoms (high IPSS), or
previous TRUS
Dose constraints for 1-8-2 Gy/fraction:

Organ Constraints
Femoral head Dmax<45Gy
Rectum V75Gy < 15% ; V70Gy < 20% ; V65Gy < 25% ; V60Gy < 40%
U- bladder V75Gy < 25% ; V70Gy < 35% ; V65Gy < 50%
Functional kidney V20Gy < 30% ; V50Gy < 5%
Dose constraints for brachytherapy:

■ Maximal dose to the rectum would not exceed 75% of the prescribed
dose; the urethra dose was less than 125% of the prescribed dose
163
Four box field for a case of prostate cancer received definitive RT.
Isodose curves for patients with prostate cancer treated with IMRT
164
References:
1. NCCN 2023 年版 version -1: Prostate cancer.
3. Radiation Therapy Oncology Group, Protocol 0415, website: www.rtog.org
4. Parker CC, James ND, Brawley CD, et al. Radiotherapy to the primary tumour
for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised
controlled phase 3 trial. Lancet 2018.
5. James ND, Sydes MR, Clarke NW, et al. Addition of docetaxel,zoledronic acid,
or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE):
survival results from an adaptive, multiarm,multistage, platform randomised
controlled trial. Lancet 2016;387:1163-1177. Available
at:https://www.ncbi.nlm.nih.gov/pubmed/26719232..
6. Sydes MR, Spears MR, Mason MD, et al. Adding abiraterone ordocetaxel to
long-term hormone therapy for prostate cancer: directlyrandomised data from the
STAMPEDE multi-arm, multi-stage platformprotocol. Ann Oncol 2018;29:1235-
1248. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29529169.
7. Boeve LMS, Hulshof M, Vis AN, et al. Effect on survival of androgen
deprivation therapy alone compared to androgen deprivation therapy combined
with concurrent radiation therapy to the prostate in patients with primary bone
metastatic prostate cancer in a prospective randomized clinical trial: Data from
the HORRAD trial. Eur Urol 2019;75:410-418. Available at:
https://www.ncbi.nlm.nih.gov/pubmed/30266309..
8. Murthy V, Maitre P, Kannan S, et al. Prostate-Only Versus Whole-Pelvic
Radiation Therapy in High-Risk and Very High-Risk Prostate Cancer (POP-RT):
Outcomes From Phase III Randomized Controlled Trial. J Clin Oncol
2021;39:1234-1242.
9. Pollack A, Walker G et al. Randomized trial of hypofractionate external beam
radiotherapy for prostate cnacer J Clin Oncol 2013; 31:3860-3868
10. Thompson IM et al. Adjuvant and salvage radiotherapy after prostatectomy:
AUA/ASTRO Guideline. J URO 2013190(2): 441-9.
11. Kerkmeijer LGW, Groen VH, Pos FJ, et al. Focal Boost to the Intraprostatic
Tumor in External Beam Radiotherapy for Patients With Localized Prostate
Cancer: Results From the FLAME Randomized Phase III Trial. J Clin Oncol
2021;39:787-796..
12. Alessandro M, Eugenia M, Annarita T, et al. Hypofractionated simultaneous
integrated boost (IMRT-SIB) with pelvic nodal irradiation and concurrent
androgen deprivation therapy for high-risk prostate cancer: results of a
prospective phase II trial. Prostate Cancer Prostatic Dis. 2018 Jun;21(2):269-276.
165
13. Sergio F, Russel R, Marianna P, et al. Long-Term Results of Moderate
Hypofractionation to Prostate and Pelvic Nodes Plus Androgen Suppression in
High-Risk Prostate Cancer. Pract Radiat Oncol Nov-Dec 2020;10(6):e514-e520
14. Tilki D, Chen MH, Wu J, et al. Adjuvant Versus Early SalvageRadiation
Therapy for Men at High Risk for Recurrence Following RadicalProstatectomy
for Prostate Cancer and the Risk of Death. J Clin Oncol 2021;39:2284-2293.
166
Lymphoma
Hodgkin’s Lymphoma:
◎Definitive RT
■Indication:
(1) Preferred for nodular lymphocyte-predominant (NLPHL) stage IA,
IIA: ISRT (involve site RT)
(2) Patient who refuse chemotherapy or are unable to tolerate
chemotherapy
◎ Adjuvant RT
■Indication:
(1) Early stage I and II disease
(2) Advanced (stage III-IV) disease: Consider ISRT to initial bulky site or
residual site or PET positive site
(3) Bulky disease
◎ Palliative/Salvage RT
■Indication:
(1) Distant metastasis➔ RT for symptomatic relief
(2) Nodular lymphocyte-predominant (NLPHL) stage IIIA, IVA in
selected case
(3) Relapsed case. Initial stage IA-IIA with no prior RT: ISRT preferred
(4)Refractory disease
RT techniques:
CT based simulation:
■ Wire enlarged nodes
■In mediastinal HL, the use of 4D-CT for simulation and the adoption
167
of strategies to deal with respiratory motion and minimize dose to OAR
are essential, especially deep inspiration breath-hold techniques,
respiratory gating, and image-guided RT during treatment delivery.
Field design:
■ When possible, the high cervical regions (all patients) and axillae
(women) should be excluded from the radiation fields.
■ISRT is recommended as the appropriate field for HL. Possible
movement of the target by respiration as determined by 4D-CT or
fluoroscopy (internal target volume, ITV) should also influence the
final CTV.
■Definition of ISRT (involved-site RT): generally smaller than IFRT;
ISRT encompasses originally involved LNs, original suspicious
volume prior to chemotherapy or surgery, yet it spares adjacent
uninvolved organs (lungs, bone, muscle, or kidney,…etc.) when
LAP regresses following chemotherapy. The CTV cannot be reduced
to the same extent as with INRT.
* For nodular lymphocyte-predominant (NLPHL)
ISRT alone: The CTV should be expanded to include potential
microscopic disease in the immediate region of the FDG-PET-
positive disease.
CMT: Similar to CHL after chemotherapy [treating originally
involved lymph node(s) only]
■ Definition of IFRT (involved-field RT): encompasses a region, not an
individual lymph node.
(I) Neck: include ipsilateral cervical and supraclavicular fossa (SCF)
(II) Mediastinum: include bilateral hilar regions. If SCF involved,
included bilateral SCF and cervical regions
(III) Axillae: include ipsilateral SCF and infraclavicular regions
(IV) Inguinal: include external iliac and femoral regions
■ Margins: generally 2 cm superior and inferior to pre-chemotherapy
volume; 2 cm lateral to post-chemotherapy volume for mediastinal
and para-aortic fields.
■ Definition of extended field RT: (rarely used now)
168
(I)Mantle field: bilateral cervical, SCV, infraclavicular, mediastinal,
hilar and axilla
(II)Inverted Y: paraaortic, bilateral pelvic, inguino-femoral and
splenic
(III)Total lymphoid irradiation (TLI): mantle + inverted Y field
(IV)Subtotal lymphoid irradiation (STLI): TLI with exclusion of
pelvis
⚫ IMRT, breath hold or respiratory gating, IGRT, or proton therapy may
offer significant and clinically relevant advantages to spare important
organ at risk.
Dose prescriptions:
⚫ Combined modality-ISRT dose:
■ Non-bulky disease (stage I-II)
If treated with ABVD
(doxorubicin,bleomycin,vinblastine,dacarbazine): 20*-30 Gy;1.5-
2.0 Gy per fraction [*A dose of 20Gy following ABVD x 2 is
sufficient in non-bulky stage I-IIA patients with ESR<50, no
extralymphatic lesions, and only one or two LN regions
involved.]
If treated with Stanford V((12 weeks) weekly
(doxorubicin,bleomycin,vinblastine,Mechlorethamine,vincristine,
etoposide)): 30 Gy;1.5-2.0 Gy per fraction
■ Non-bulky disease (stage IB-IIB): 30 Gy;1.5-2.0 Gy per fraction
■ Bulky disease sites (all stages): 30~36 Gy;1.5-2.0 Gy per fraction
⚫ ISRT-alone dose (uncommon, except for NLPHL):

■ Involved regions: 30~36 Gy;1.5-2.0 Gy per fraction (the dose of
30Gy is mainly for nodular lymphocyte-predominant (NLPHL))
■ Uninvolved regions: 25~30 Gy;1.5-2.0 Gy per fraction
■ Relapsed case, previous irradiated sites: 15~25Gy, no RT before:
30~40Gy
169
⚫ Pallaitive RT:
◼ 4-30 Gy
⚫ Dose constraints:
■ Femoral head < 25Gy
■ Lung: V20 < 37%; mean lung dose < 20Gy
■ Heart: V30 < 46 Gy, mean < 26Gy
■ Thyroid: <20% to <26Gy
170
Illustration of lymph node group
Field comparison: ISRT(B) is generally smaller than IFRT(A)
171
AP-PA field for a case of Hodgkin’s lymphoma with right hilar and
supraclavicular involvement
172
173
Non-Hodgkin’s Lymphoma:
◎ Indication:
(1) Follicular lymphoma

Stage I or contiguous stage II → ISRT± anti-CD20 monoclonal
antibody± C/T
Non-contiguous stage II→ anti-CD20 monoclonal antibody ± C/T ±
ISRT
Stage III/IV or bulky stage II→ local RT if symptomatic
(2) Marginal zone lymphoma
Gastric MALT (mucosa-associated lymphoid tissue) lymphoma:
Stage I and II, H. pylori negative or do not respond to antibiotic
therapy→ISRT
StageIIE/IV gastric MALT lymphoma→local RT if symptomatic
Non-gastric Marginal zone lymphoma stage I or II or IV
disease→ISRT
Nodal marginal zone lymphoma: Stage I/II→ISRT
(3) DLBCL (Diffuse large B-cell lymphoma)
Nonbulky(<7.5cm)Stage I, II DLBCL after RCHOP 3-6
cycles→ISRT, consider higher dose if partial response
Bulky or stage III,IV: consider RT to initial bulky sites or IFRT to
residual nodal masses after chemotherapy
(4) Primary Cutaneous B cell lymphomas (Additional imaging studies
during the course of treatment are not needed)
solitary or regional T1-3 (Ann Arbor stage IE)→consider local RT;
Diffuse large B cell type→ local RT
generalized extent tumors→total skin electron beam therapy (TSEBT)
(5) NK/T cell lymphoma
Nasal type: CCRT or sequential CRT or Sandwich CRT,
If unfit for chemotherapy: RT alone
Extranasal type: CCRT or chemotherapy with or without RT
174
(6)Mantel cell lymphoma: stage I, II (extremely rare)→ISRT
(7)Peripheral T cell lymphoma: (ALK+) stage I,II and others stage I-IV
→ISRT
(8) Localized SLL (Small Lymphocytic Lymphoma) grade I→locoregional
RT
(9)Distant metastasis, CNS/CSF involvement→palliative RT
RT techniques:
(treatment with photon (IMRT, IGRT), electron, or protons may all be
appropriate, depending on clinical circumstances; in mediastinal
lymphoma the use of 4D-CT for simulation is also important)
CT based simulation:
Field design:
■Definition of ISRT (involve site RT): generally smaller than IFRT,
ISRT encompasses pre-chemotherapy or pre-surgery site, spares
adjacent uninvolved organs when LAP regresses following
chemotherapy.
■ISRT for extranodal NK/T-cell lymphoma
The ISRT CTV should include the entire involved cavity and
adjacent structures due to the high risk for submucosal spread.
◊ For unilateral anterior or mid-nasal cavity, the CTV should
include the bilateral nasal cavities, ipsilateral maxillary sinus, and
bilateral anterior ethmoids.
◊ For bilateral nasal cavity involvement the CTV should
include both maxillary sinuses.
◊ If there is posterior nasal cavity involvement, the nasopharynx
should be included in the CTV.
◊ If there is anterior ethmoid involvement, the posterior
ethmoids should be included in the CTV.
◊ All involved paranasal sinuses should be included in the CTV.
◊ Any areas of soft tissue extension should be included in the
CTV.
175
◊ Prophylactic irradiation is not required for uninvolved lymph nodes.
■ IFRT (involved-field RT)
(I) Neck: include ipsilateral cervical and supraclavicular fossa (SCF)
(II) Mediastinum: include bilateral hilar regions. If SCF involved,
included bilateral SCF and cervical regions
(III) Axillae: include ipsilateral SCF and infraclavicular regions
(IV) Inguinal: include external iliac and femoral regions
■ Margins: generally 2 cm superior and inferior to pre-chemotherapy
volume; 2 cm lateral to post-chemotherapy volume for mediastinal
and para-aortic fields.
General Dose Guidelines:
◼ Localized CLL (Chronic lymphocytic leukaemia) /SLL (Small
Lymphocytic Lymphoma) : 24-30Gy
◼ B-Cell Lymphomas
* Follicular Lymphoma: for locally bulky or locally symptomatic ISRT
24-30Gy±additional systemic therapy.
* Marginal Zone Lymphomas (MZL): Gastric: 30Gy(most commonly
uses 1.5Gy daily fractions); cutaneous marginal zone lymphoma:
24-30Gy; Nodal MZL: 24-30Gy; other extranodal sites: 24-30Gy
* Early stage mantle Cell Lymphoma: 24-36Gy
* Diffuse Large B-Cell Lymphoma: Consolidation after C/T CR(PET
Five-Point Scale (5-PS): 1-3): 30-36Gy, PR(PET Five-Point Scale
(5-PS): 4): 36-50Gy; Complementary after PR: 40-50Gy; RT as
primary treatment for refractory or non-candidates for C/T: 40-
55Gy; In combination with stem cell transplantation: 20-36Gy,
depending on sites of disease and prior RT exposure. Prophylactic
testicular irradiation 25-30Gy
* Primary Cutaneous B-Cell Lymphomas: 24-30Gy, generally treat
with 6-9MeV electron beam with surface bolus
◼ Palliation/local control
◆ FL, MZL, MCL (Mantle cell lymphoma): 2Gy x 2fx or 4Gy
x 1fx which may be repeated as needed, doses up to 30Gy
176
◆ DLBCL, HGBCL, PMBCL, Burkitt lymphoma: 20-30Gy/5-
10fx, higher doses/fraction typically appropriate
General Dose Guidelines:

T-Cell Lymphomas
*Peripheral T-Cell Lymphoma: Consolidation after C/T CR: 30-36Gy;
Complimentary after PR: 40-50Gy; RT as primary treatment for
refractory or non-candidates for C/T: 40-55Gy; In combination
with stem cell transplantation: 20-36Gy, depending on sites of
disease and prior RT exposure.
* Extranodal NK/T-Cell Lymphoma, nasal type: Unfit for C/T, RT
alone: 50-55Gy; CCRT: 50Gy + 3 courses x DeVIC
(dexamethasone, etoposide, ifosfamide, carboplatin); 50-54Gy +
cisplatin followed by 3 courses x VIPD (etoposide, ifosfamide,
cisplatin,dexamethasone); Sequential CRT for stage I, II: 2-4
cycles SMILE followed by 45-50.4Gy; Sandwich CRT: GELOX x
2 cycles→56Gy→GELOX x 2-4 cycles
* NK-T cell lymphoma: RT as primary treatment: 50-55Gy; RT in
combined modality therapy: 45-56Gy
* Palliative RT: 20-36Gy/5-18fx
* Primary cutaneous anaplastic large cell lymphoma: 24-36Gy
◼ CNS lymphoma
■CNS lymphoma:
For patients who are not candidates for chemo: WBRT 24~36Gy, and
consider boost to gross disease for 45Gy
For patients treated with chemotherapy
if CR: WBRT 23.4 Gy in 1.8 fractions
if PR: WBRT 30~36Gy, consider boost gross disease to 45Gy
■CSF(+) or leptomeningeal spread:
Consider intra-CSF systemic therapy + focal spinal RT
Or
ITCT
177
Or
Consider CSI 39.6Gy with additional 5.4-10.8Gy to gross disease
Dose constraints:
■ Femoral head < 25Gy
■ Lung: V20 < 37%; mean lung dose < 20Gy
■ Heart: V30 < 46 Gy, mean < 26Gy
Pelvic field for non-Hodgkin’s lymphoma
178
References:
1. NCCN guidelines version 2.2023 clinical practice guidelines in oncology:

Hodgkin Lymphoma
2. NCCN guidelines version 1.2023 clinical practice guidelines in oncology: B-cell
Lymphomas
3. NCCN guidelines version 1.2023 clinical practice guidelines in oncology: T-cell
Lymphomas
4. NCCN guidelines version 1.2023 clinical practice guidelines in oncology: primary
cutaneous Lymphomas
5. Chera BS et al: Dosimetric comparison of three different involved nodal
irradiation techniques for stage II Hodgkin's lymphoma patients: conventional
radiotherapy, intensity-modulated radiotherapy, and three-dimensional proton
radiotherapy. International journal of radiation oncology, biology, physics 2009,
75(4):1173-1180.
6. Specht L et al.: Modern radiotherapy for hodgkin lymphoma-field and dose
guidelines from the International Lymphoma Radiation Oncology Group(ILROG).
International journal of radiation oncology, biology, physics 2013 epub
7. Campbell BA et al.: Limited stage diffuse large B cell lymphoma treated with
abbreviated systemic therapy and consolidation radiotherapy: involved field
versus involve node radiotherapy. Cancer 2012;118:4156-4165
8. Campbell BA et al.:Longterm outcomes for patients with limited stage follicular
lymphoma: involved regional radiotherapy versus involve node radiotherapy.
Cancer 2010;116:3797-3806
9. Filippi AR, et al. Involved-site image-guided intensity modulated versus 3D
conformal radiation therapy in early stage suprdiaphargmatic Hodgkin lymphoma.
Int J Radiat Oncol Biol Phys 2014;89(2):370-375.
10. Tse E, et al. Radiotherapy and PGEMOX/GELOX regimen improved prognosis in
elderly patients with early-stage extranodal NK/T-cell lymphoma. Ann Hematol
2015;94:1525-1533.
11. Yahalom J, et al. Modern Radiation Therapy for Extranodal lymphomas: field
anddose guidelines from the international Lymphoma Radiation Oncology Group.
Int J Radiat Oncol Biol Phys. 2015;92:11-31.
179
Palliative Radiotherapy
Brain metastases
◎ Indication: All patients with metastatic brain lesions
◎ Limited brain metastases

■ Newly diagnosed or stable systemic disease
(1) SRS
(2) Hippocampal avoidance (HA)-WBRT
(3) WBRT without HA
■ Disseminated systemic disease with poor systemic treatment options
(1) HA-WBRT
(2) SRS in select patients
(3) WBRT without HA
◎ Extensive brain metastases

(1) HA-WBRT
(2) WBRT without HA
(3) SRS
◎ Leptomeningeal metastases
■ Volumes and dose depend on primary source and sites requiring
palliation
■ Good risk
(1) SRS or RT (IFRT ± WBRT) to bulky disease and neurologically
symptomatic or painful sites
(2) with CSF obstruction: Fractionated EBRT to metastatic or painful
sites of obstruction
■ Poor risk
Consider IFRT to neurologically symptomatic or painful sites for
palliation
180
R/T techniques:
Simulation:
■ Patient in supine position
■ Immobilized
Field design:
■ Adequate coverage of all intracranial contents by ensuring that
blocked edges sufficiently cover the anterior cranial fossa, middle
cranial fossa, and skull base.
■ Bottom of R/T field at foramen magnum. Sometimes, whole brain
RT portals are extended inferior to C1, or to the junction of vertebral
bodies C2 and C3.
■ Use eye block. When patients have leptomeningeal disease, the field
may be modified to include coverage of the posterior orbits.
■ For patients with a better prognosis, consider hippocampal-sparing
WBRT.
Metastases in the inferior aspects of the temporal and frontal lobes

require that the inferior border of the portal be at the line drawn from the
inferior orbital ridge to the mastoid tip. A lens or orbital block should be
used.
181
Dose prescriptions:
◊Whole brain RT (WBRT):
◼ 30 Gy in 10 fractions
◼ 30 Gy in 10 fractions to the whole brain and 45 Gy in 10 fractions
to individual brain metastases
◼ 37.5 Gy in 15 fractions
◼ 37.5 Gy in 15 fractions to the whole brain and 45 Gy in 15
fractions to individual brain metastases
◼ 20 Gy in 5 fractions for poor predicted prognosis
◊SRS/fSRT:
◼ Maximum marginal doses 15-24 Gy based on tumor volume

◼ Consider fractionated SRS for brain tumor > 2-3 cm
Most common fSRT doses: 27 Gy/3 fx and 30 Gy/5 fx
◼ Postoperative SRS or SRT: 16-20 Gy/1fx, 27 Gy/ 3fx, 30 Gy/ 5fx
182
References:
1. NCCN guideline for Central Nervous System Cancers: 2022 version 2.
2. NCCN guideline for Palliative Care: 2022 version 1.
3. Tsuji, S. Y.; Wara W. M. Palliation and Benign Conditions. In Handbook of
Evidence-Based Radiation Oncology; Hansen, E. K., Roach, M., Eds.; Springer:
New York, 2nd Ed, 2010; Chapter 42.
4. Gibbs, I. C.; Soltys, S. G. Central Nervous System Metastases. In Radiation
Oncology: An Evidence –Based Approach; Lu, J. J., Brady, L. W., Eds.; Springer:
Verlag Berlin Heidelberg, 1st Ed, 2008; Chapter 44.
5. Knisely, J. P. S.; Suh, J. H.; Tsien, C. Central Nervous System. In Handbook of
Radiation Oncology: Basic Principles and Clinical Protocols; Haffty, B. G.,
Wilson, L. D., Eds.; Jones and Bartlett Publishers, 1st Ed, 2009; Chapter 10.
6. Gondi V, Tolakanahalli R, Mehta MP et al: Hippocampal-sparing whole-brain
radiotherapy: a "how-to" technique using helical tomotherapy and linear
accelerator-based intensity-modulated radiotherapy. International journal of
radiation oncology, biology, physics 2010, 78(4):1244-1252.
183
Bone metastases
◎ Indication: All patients with symptomatic metastatic bone lesions
RT techniques:
Simulation:
■ Patient in supine or prone position with proper immobilization
Field design:
Spine metastases
■ Posterior-anterior (PA) single portal: it is usual to include one or two
vertebrae above and below the site of involvement
■ When treating a bone postoperatively, the entire prosthesis or
intramedullary nail should be covered with a margin of normal bone.
Pelvic bone or shoulder bony metastases
■ AP/PA field: whole structure should be treated
Dose prescriptions:
■ 30 Gy in 10 fractions
■ 37.5 Gy in 15 fractions
■ 20 Gy in 5 fractions
■ 8 Gy in 1 fraction
■ Consider SBRT for patients with oligometastases
Spine SRS/SBRT:
16~30Gy/1fx
24Gy/2fx
24~30Gy/3fx
30~40Gy/5fx
184
AP-PA field for a case of lung cancer with left pelvic bone metastases
References:
1. Tsuji, S. Y.; Wara W. M. Palliation and Benign Conditions. In Handbook of
Evidence-Based Radiation Oncology; Hansen, E. K., Roach, M., Eds.; Springer:
New York, 2nd Ed, 2010; Chapter 42.
2. NCCN guideline for Central Nervous System Cancers: 2022 version 2
3. NCCN guideline for Palliative Care: 2022 version 1
4. Ricardo L, Benjamin O S, James V, et al. MRI-guided stereotactic ablative
radiation therapy of spinal bone metastases: a preliminary experience. Br J Radiol.
2020 Jan;93(1105):20190655
5. Poonam Y, Hima B M, Jacob S W, et al. Dosimetric study for spine stereotactic
body radiation therapy: magnetic resonance guided linear accelerator versus
volumetric modulated arc therapy. Radiol Oncol. 2019 Sep 24;53(3):362-368.
185
Central nervous system cancers
於放射治療前，應回顧該病人的病理報告、影像檢查…等；於多科團隊會
議時提出討論。
二、定位：
1. 體位設定：
除非有特殊需求，所有病患模擬定位姿勢皆為仰臥(supine)。
2. 固定方法：將雙手置放於兩側，並以臉部模具等輔具固定。治療中心標記
在塑型面膜上。膝關節固定器視情況而放。
應採取電腦斷層輔助之模擬攝影，在電腦斷層掃瞄定位室，請病患依原姿
勢，在已製作好的固定模具上，根據定位雷射對到病患模具標記點。影像
擷取時電腦斷層之上下緣視腫瘤部位而定，上緣需至少包含頭骨上緣 2-3
公分以上，下緣至 C2。掃描範圍及切片厚度條件，可由主治醫師自行訂
定。
4. 腦脊髓照射(Craniospinal irradiation; CSI):
病患仰躺，製作面具及視情況製作身體之固定裝置，在電腦斷層掃瞄定位
室，請病患依原姿勢，在已製作好的固定模具上，根據定位雷射對到病患
模具標記點。影像擷取時電腦斷層之上下緣視腫瘤部位而定，上緣需至少
包含頭骨上緣 2-3 公分以上，下緣至 thecal sac。
靶體積定義 (Target Volume Definition) 及放射治療計畫規劃 (Radiation
1. 巨觀腫瘤體積(Gross Tumor Volume)：指肉眼或影像診斷可見之腫瘤。(以
下簡稱為 GTV) 應包含由 CT 影像、臨床資訊、MRI 影像可判讀之原發
腫瘤(primary tumor)。如果治療前開過刀或有腫瘤旁水腫，需考慮原來部
位之腫瘤或範圍皆應考慮治療。
2. 臨床靶體積(Clinical Target Volume)：指腫瘤及其可能侵犯之範圍，通常
由影像輔助圈選。(以下簡稱為 CTV)為包含 GTV 可能侵犯之範圍，可
分為 CTV-H、CTV-M。
3. 計劃靶體積(Planning Target Volume)：考慮擺位誤差，內部器官移動及其
186
他可能產生誤差在 CTV 加上範圍之體積。(以下簡稱為 PTV)
格雷(Gray)：為放射線吸收劑量之單位。(以下簡稱為 Gy)

◎ Glioma: low grade
⚫ Adjuvant RT/CCRT/RT+adjuvant treatment:

◼ WHO grade 1 (pilocytic astrocytoma, pleomorphic
xanthoasstrocytoma, ganglioglioma) with incomplete
resection and significant growth or neurologic symptoms
◼ Oligodendroglioma (IDH mutant, 1p 19q codeleted)
◆ WHO grade 2 with high risk (>40yrs, STR, tumor size,
neurologic deficits…)
◆ Poor performance status (KPS <60)
◼ IDH-mutant Astrocytoma
◆ WHO grade 2 with high risk (>40yrs, STR, tumor size,
neurologic deficits…)
◆ WHO grade 3 or 4
◆ Poor performance status (KPS <60)
⚫ Reirradiation for recurrence or progressive disease: Highly
focused RT
Field design:
GTV = T2FLAIR and T1 post contrast enhanced MRI
CTV = GTV + 1-2 cm margin
PTV: CTV+0.3cm
Dose prescriptions:
⚫ 45-54Gy in in 1.8-2Gy fractions
⚫ Consider 59.4-60Gy for IDH wild type or patients with
aggressive course of disease
⚫ Reirradiation: high focused SRS or fractionated schedule
35Gy/10fr, more extended fractionation schedule may be
considered
187
◎ Glioma: High grade
⚫ Adjuvant RT/CCRT/RT+adjuvant treatment:

◼ Oligodendroglioma (IDH mutant, 1p 19q codeleted)
◆ WHO grade 3
◼ IDH-mutant Astrocytoma
◆ WHO grade 3 or 4
◼ Glioblastoma/Gliosarcoma
◼ Glioblastoma, IDH wild-type, WHO grade 4
⚫ Reirradiation for recurrence
Field design:
GTV_H = T1 enhancement + T2/FLAIR MRI.
CTV_H = GTV_H + 1-2 cm margin
PTV: CTV+0.3-0.5cm
Boost: GTV_M = gross residual tumor and resection cavity
Dose prescriptions:
⚫ 60Gy in 1.8-2Gy fractions,
⚫ Lower dose (54-59.4Gy in 1.8Gy or 57Gy in 1.9Gy) to large
tumor,brainstem/spinal cord involvement or Gr III astrocytoma
⚫ Hypofractionation schedule:
◼ 34Gy/10fr, 40.05Gy/15fr for > 70 yrs old, good
performance status
◼ 25Gy/5fx may be considered for elderly and/or frail patients
with smaller tumors or for whom a longer course of
treatment would not be tolerable
⚫ Reirradiation: highly focused SRS or fractionated schedule
35Gy/10fr
◎ Intracranial and spinal ependymoma (excluding subependymoma)
⚫ Adjuvant RT:
◼ Grade 2 and 3 intracranial ependymoma
◼ Spinal ependymoma less than GTR
◼ Myxopapillary spinal ependymoma GTR but capsule
188
violation
⚫ Adjuvant craniospinal irradiation: evidence of metastasis (brain,
spine or CSF)
⚫ Reirradiation: for unresectable localized recurrence
Field design:
⚫ Limited field:
GTV: T1 enhancement or T2/FLAIR MRI
CTV: GTV+1-2cm
PTV: CTV+0.3-0.5cm
⚫ CSI: whole brain + spinal field to bottom of the thecal sac
Dose prescriptions:
⚫ Limited field: 54-59.4Gy
⚫ Craniospinal field: Whole brain and the spine 36Gy+ limited field
to spine to 45Gy or to primary brain site 54-59.4Gy (high dose of
54-60Gy may be given to tumor below the conus)
⚫ **for spine ependymoma: 45-54Gy
◎ Medulloblastoma
⚫ Adjuvant RT
⚫ Additional RT after resection for recurrence
Field design:
⚫ Craniospinal field followed by boost to primary brain site
GTVCSI: not defined
CTVCSI: area contained by the dura mater with a margin 0.5-0.8cm,
cribriform plate should be covered by minimum 0.5cm, do not fully cover
the sacrum laterally to shield SI joint
PTVCSI: CTV +0.3-0.5cm, field width typically 4cm but can vary,
discuss with physicist GTVboost: tumor bed and residual tumor
CTVboost: GTVboost+1-1.5cm margin
PTVboost: CTVboost+0.3-0.5cm margin (depend on clinicians)
Dose prescriptions:
⚫ Standard risk of recurrence: CSI 30-36Gy (consider reduced dose
189
23.4Gy with adjuvant chemotherapy) + boost the primary brain
site to total dose 54-55.8Gy
⚫ High risk of recurrence: CSI 36Gy + boost the primary brain site to
total dose 54-55.8Gy
◎ Primary CNS lymphoma
⚫ Definitive RT if systemic therapy not feasible

⚫ Adjuvant RT
Field design:
⚫ WBRT if CR to prior chemotherapy
⚫ WBRT + boost to gross disease if less than CR to prior
chemotherapy
⚫ WBRT or involved field RT if recurrence or no response or short
duration (less than 12 months)
⚫ Focal spinal RT if CSF positive or spinal MRI positive
⚫ If eye involvement, RT extends to globe
Dose prescriptions:
⚫ Not candidate for chemotherapy: WBRT: 24-36Gy + boost to
gross disease for a total dose of 45Gy
⚫ CR to chemotherapy: low dose WBRT 23.4Gy
⚫ <CR to chemotherapy: WBRT: 30-36Gy + boost to gross disease
or residual disease for a total dose of 45Gy
◎ Spinal cord tumors
⚫ Definitive RT: unresectable tumors

⚫ Adjuvant RT:
◼ Grade 2-3 Meningioma, symptomatic grade 1 meningioma,
◼ symptomatic partial resected PA and hemangioblastoma
◼ Recurrent tumor
Field design:
GTV: T1 enhanced MRI
CTV: GTV+1-2cm sup. And inf.
190
PTV: CTV+0.3-0.5cm
Dose prescriptions:
⚫ 45-54Gy using fractions of 1.8Gy
⚫ For tumor below the conus medullaris, dose may be up to 60Gy
◎ Meningiomas
⚫ Definitive RT
⚫ Adjuvant RT:
◼ Symptomatic grade 1
◼ Grade2-3
◼ Decision based on multiple factors
⚫ Reirradiation if recurrence or progression
Field design:
GTV: T1 enhanced MRI
CTV: for WHO grade 2, margin: 0.5-2cm
For WHO grade 3, margin: 2-3cm
PTV: CTV+ 0.3-0.5cm
Dose prescriptions:
◼ WHO grade 1: 50-54Gy
SRS 12-16 Gy or hypofractionated SRT 25-30Gy/5fx may be
considered in selected cases (close to critical structures)
◼ WHO grade 2: 54-60Gy
SRS 12-16 Gy or hypofractionated SRT 27.5-30Gy/5fx in selected
cases
◼ WHO grade 3: 59.4-60Gy
◎ Brain metastases: Limited and extensive
⚫ SRS
◼ Single dose: 15-24Gy
◼ Fractionated SRS: 27Gy/3fx, 30Gy/5fx
⚫ Post-op single and multi-fraction SRS: 16-20Gy /1fx, 24-
27Gy/3fx, 30-35Gy/5fx, less commonly 30-40Gy/10fx for larger
resection cavity
191
⚫ WBRT with or without hippocampal avoidance+- memantine:
◼ 20Gy/5fx, 30Gy/10fx, 37.5Gy/15fx
◼ ** HA-WBRT (hippocampal avoidance with WBRT) +
memantine is preferred for patient with better prognosis (≥4
months) and no metastases within 5mm of the hippocampi
⚫ Reirradiation
◎ Leptomeningeal metastases
⚫ Palliative RT (SRS, IFRT, WBRT): Dose and volume depend on

primary source and sites requiring palliation
◎Metastatic spinal tumor
⚫ Emergent RT: spinal cord compression

⚫ Palliative RT: pain relief
⚫ SBRT for oligometastases or radioresistant histologies
recommended
Dose prescriptions:
⚫ Conventional dose: 8Gy/1fx, 20Gy/5fx, 3Gy/10fx
⚫ SRS/SBRT dose: 16-24Gy /1fx, 24Gy/2fx, 24-27Gy/3fx, 30-
35Gy/5fx
⚫ Retreatment: interval ≥6 months, doses ranging from 15Gy/1fx to
40Gy/20fx, if prior lower BED (BED ≤60Gy: 20Gy/5fx but does
not include 30Gy/10fx) regimen utilized, retreat with similar BED
192
Dose constraints for conventional RT:
Organ Constraints
Chiasm Dmax < 54Gy
Hippocampal avoidance whole brain radiotherapy
SRS for meningioma
193
MR guided radiotherapy for glioma
Craniospinal irradiation. Use of CT simulation
194
195
196
References:
1. NCCN 2022 version 2 clinical practice guidelines in oncology: central nervous
system cancers.
2. Target Volume Delineation and Field Setup A Practical Guide for Conformal and
Intensity-Modulated Radiation Therapy Lee, Nancy Y.; Lu, Jiade J. (Eds.) 2013,
Chap 28, 247-254
3. Target Volume Delineation and Field Setup A Practical Guide for Conformal and
Intensity-Modulated Radiation Therapy Lee, Nancy Y.; Lu, Jiade J. (Eds.) 2013,
Chap 32, 295-316
4. Practical essentials of intensity modulated radiation therapy 3rd ed. Chap 3. 43-77
5. Handbook of evidence-based radiation oncology 2nd edetion, Part II Central
nervous system
6. Shaw E, Scott C, Souhami L et al. Int J Radiat Oncol Biol Phys. 2000 May
1;47(2):291-8. Single dose radiosurgical treatment of recurrent previously
irradiated primary brain tumors and brain metastases: final report of RTOG
protocol 90-05.
7. Packer RJ, Gajjar A, Vezina G et al. J Clin Oncol. 2006 Sep 1;24(25):4202-8.
Phase III study of craniospinal radiation therapy followed by adjuvant
chemotherapy for newly diagnosed average-risk medulloblastoma.
8. Rodríguez D1, Cheung MC, Housri N, et al. J Surg Res. 2009 Oct;156(2):340-51.
doi: 10.1016/j.jss.2009.04.024. Epub 2009 May 14. Outcomes of malignant CNS
ependymomas: an examination of 2408 cases through the Surveillance,
Epidemiology, and End Results (SEER) database (1973-2005).
9. Van Den Bent MJ et al. Lancet 2005;366 (9490):985-90. Long term efficacy of
early versusdelayed radiotherapy for low grade astrocytoma and
oligodendroglioma in adults: the EORTC 22845 randomized trial.
10. Yamamoto M, et al. Lancet Oncol 2014;15(4): 387-95. Stereotactic radiosurgery
for patients with multiple brain metastases (JLGK0901): a multi-institutional
prospective observational study.
11. Brown PD et al. Neuro Oncol 2013; 15: 1429-1437. Memantine for the prevention
of cognitive dysfunction in patients receiving whole-brain radiotherapy: a
randomized, double-blind, placebo-controlled trial
12. Gondi V et al. J Clin Oncol 2014;32:3810-3816 Preservation of memory with
conformal avoidance of the hippocampal neural stem-cell compartment during
whole-brain radiotherapy for brain metastases (RTOG 0933): a phase II multi-
institutional trial.
13. Cabrera AR et al. Pract Radiat Oncol 2016; 6:217-225 Radiation therapy for
glioblastoma: executive summary of an American Society for Radiation Oncology
197
Evidence-Based Clinical Practice Guideline
14. Roa W et al. J Clin Oncol 2015;33:4145-4150 International Atomic Energy
Agency randomized phase III study of radiation therapy in elderly and/or frail
patients with newly diagnosed glioblastoma multiforme.
15. Aghi MK et al. Neurosurgery 2009;64:56-60 discussion 60. Long-term recurrence
rates of atypical meningiomas after gross total resection with or without
postoperative adjuvant radiation.
16. Rogers et al. Int J Radiat Oncol Biol Phys 2020; 106: 790-799. High-risk
meningioma: initial outcomes from NRG Oncology/RTOG 0539.
17. Brown PD et al. J Clin Oncol. 2020; 1;38(10): 1019-1029. Hppocampal
Avoidance During Whole-Brain Radiotherapy Plus Memantine for Patients With
Brain Metastases: Phase III Trial NRG Oncology CC001
18. Brown PD et al. Lancet Oncol. 2017 18(8): 1049-1060. Postoperative stereotactic
radiosurgery compared with whole brain radiotherapy for resected metastatic
brain disease (NCCTG N107C/CEC·3): a multicentre, randomised, controlled,
phase 3 trial
19. Minniti G et al. 2016 95(4): 1142-1148. Int J Radiat Oncol Biol Phys. Single-
Fraction Versus Multifraction (3 × 9 Gy) Stereotactic Radiosurgery for Large (>2
cm) Brain Metastases: A Comparative Analysis of Local Control and Risk of
Radiation-Induced Brain Necrosis
20. Palma DA et al. J Clin Oncol 2020; 38:2830Stereotactic Ablative Radiotherapy
for the Comprehensive Treatment of Oligometastatic Cancers: Long-Term Results
of the SABR-COMET Phase II Randomized Trial
21. Vogelbaum MA, Briwn PD et al. Clin Oncol . 2022 Feb 10;40(5):492-516
Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline
22. Mahajan A et al. Lancet Oncol. 2017 Aug;18(8):1040-1048. Post-operative
stereotactic radiosurgery versus observation for completely resected brain
metastases: a single-centre, randomised, controlled, phase 3 trial
23. Miniti G et al. Int J Radiat Oncol Biol Phys. 2013 Jul 15;86(4):623-9. Multidose
stereotactic radiosurgery (9 Gy × 3) of the postoperative resection cavity for
treatment of large brain metastases
24. Gutin PH et al. Int J Radiat Oncol Biol Phys. 2009 Sep 1;75(1):156-63. Safety and
efficacy of bevacizumab with hypofractionated stereotactic irradiation for
recurrent malignant gliomas
25. Fogh SE et al. J Clin Oncol. 2010; 20;28(18): 3048-53. Hypofractionated
stereotactic radiation therapy: an effective therapy for recurrent high-grade
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Stereotactic Radiosurgery for Brain Metastases
199

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放射線治療政策與程序之指引

Department of Radiation Oncology

Kaohsiung Medical University Chung-Ho Memorial Hospital

➔ Definitive radiotherapy (RT) to nasopharynx and elective RT to

➔ Definitive RT ± concurrent systemic therapy if high risk features

➔ Concurrent systemic therapy/RT

➔ Induction chemotherapy followed by systemic therapy/RT

➔ Systemic therapy (if PS 0–1) followed by RT or cisplatin/RT

➔ Systemic therapy → Consider RT if CR or near CR after systemic

➔ Best supportive care

PTV:≧95% dose to 100% PTV, <10% PTV-h receive≧107%

Basic Principle for Primary Radiotherapy

Supportive Care during Radiotherapy

三 、 靶 體 積 定 義 (Target Volume Definition) 及 放 射 治 療 計 畫 規 劃 (Radiation

➔ RT for symptomatic relief as palliative intent

suspicious lymph nodes should be included

■ Priority 1: Critical organ at risk

PTV: ≧95% dose to 100% PTV, <10% PTV-h receive ≧107%

三、靶體積定義(Target Volume Definition)及放射治療計畫規劃(Radiation Therapy

■ Priority 1: Critical organ at risk

三、靶體積定義(Target Volume Definition)及放射治療計畫規劃(Radiation Therapy

三、靶體積定義(Target Volume Definition)及放射治療計畫規劃(Radiation Therapy

➔ RT for symptomatic relief

■ Priority 1: Critical organ at risk

PTV: ≧95% dose to 100% PTV, <10% PTV-h receive ≧107%

➔ RT for symptomatic relief

Normal Organ Constraints:

■ Priority 1: Critical organ at risk

PTV: ≧95% dose to 100% PTV, <10% PTV-h receive ≧107%

➔ RT for symptomatic relief

■ Priority 1: Critical organ at risk

PTV: ≧95% dose to 100% PTV, <10% PTV-h receive ≧107%

➔ RT for symptomatic relief

■ Priority 1: Critical organ at risk

PTV: ≧95% dose to 100% PTV, <10% PTV-h receive ≧107%

Treatment recommendations for radiotherapy:

(1) Inoperable or recurrent disease

■ Simulate patient supine with neck extended using a thermoplastic

(1) Advanced differentiated or medullary thyroid cancer:

nodes should be included

Gross disease: 66–70 Gy in 1.8–2 Gy per fraction

■ Spinal cord < 45Gy

為求擺位再現性高，可盡量選擇使用真空墊(vacuum bag)或 cast 作為固定

➔Symptomatic relief, ie. Bone metastasis, dysphagia, obstruction,

# Respiratory motion may be significant for distal esophageal and

Examples of IMRT-based planning for upper esophageal tumor

14. Lettmaier S, et al. Intraluminal brachytherapy in oesophageal cancer: defining its

➔ C/T (palliative RT for symptomatic relief)

1) Resectable/Borderline resectable (neoadjuvant)

If patients present with biliary obstruction (jaundice/elevated direct

可選擇真空墊(vacuum bag)和 wing board 作為固定模具，提高擺

位重複性，建議 NPO 三小時。

四 、 靶 體 積 定 義 (Target Volume Definition) 及 放 射 治 療 計 畫 規 劃

(Radiation Therapy Planning)：

(1) GTV 應包含由 CT 影像(在最短軸直徑大於 1 公分之腫瘤)

(2) CTV 為包含 GTV 可能侵犯之範圍，為包含 GTV 可能侵

犯之範圍，可由 GTV 加 0.5~1.5 公分之範圍形成。

(3) PTV：包含 CTV，於周圍加上 0.5-2.0 公分範圍，形成

◼ 胰臟癌頭部包含：腫瘤加上 2-3 公分，胰十二指腸、上胰腺、腹

suprapancreatic, celiac nodes, porta hepatis, entire duodenal loop）

◼ 胰臟癌體部或尾部包含：腫瘤加上 2-3 公分，胰十二指腸、橫向

suprapancreatic nodes, nodes of splenic hilum）

■ Resectable/Borderline Resectable (Neoadjuvant):

■ Stent should be placed before RT in obstructive jaundice patients

三、靶體積定義 (Target Volume Definition) 及放射治療計畫規劃 (Radiation

四、靶體積定義 (Target Volume Definition) 及放射治療計畫規劃