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Brain metastasis is seen in 10% to 20% of all adult cancer patients. One of the main modalities of treatment is stereotactic radiosurgery (SRS). Here, we describe the step by step procedure for stereotactic planning of brain metastasis by using a clinical scenario. The management of brain metastasis starts with the clinical evaluation of the patient followed by imaging and SRS treatment in the present case. The paper highlights the sequential process of radiation planning for SRS—starting from simulation, planning, evaluation of plan, and treatment.

Primary testicular lymphoma (PTL) is a rare variant of non-Hodgkin’s lymphoma that is predominant in old age group. Painless testicular swelling is the most common presentation. The standard of care is surgery in the form of radical orchiectomy followed by adjuvant chemotherapy and central nervous system prophylaxis. Because of blood-testis barrier, contralateral testis acts as a sanctuary site for chemotherapy to act and hence scrototesticular radiation is advocated in order to reduce the chance of testicular relapse. Due to lack of any consensus simulation procedure, we propose here a step-by-step procedure for simulation of a case of PTL using a case scenario.

Background Glomus jugulare is a rare, slow-growing tumor that arise within the jugular foramen of the temporal bone. In the past, surgery was the primary modality of treatment for glomus Jugulare, but it leads to many complications and increased mortality. Radiotherapy was indicated in adjuvant setting in post-operative residual disease. But, with the advent of highly conformal radiation planning, stereotactic radiosurgery (SRS), is now one of the main modalities of radiation treatment in glomus jugulare. Objective To describe the procedural steps for radiation planning of SRS of glomus jugulare. Methods The step-by-step procedure for stereotactic planning of glomus jugulare has been described using a clinical scenario of glomus jugulare. Results The stereotactic radiation planning of glomus jugulare starts with the basic history and relevant clinical evaluation, that is, visual testing. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain is the imaging modality of choice. The radiation planning of glomus jugulare starts with CT simulation. MRI of brain should be done in the prescribed format to achieve uniformity in radiation planning. After CT and MRI image fusion, contouring of target, organs at risk (OAR) and radiation planning should be done. The plan evaluation includes target and OAR coverage index, conformity, homogeneity and gradient index, and beam arrangement. After radiation plan evaluation, treatment is delivered after quality assurance and dry run. Conclusion The paper highlights the sequential process of radiation planning for SRS in glomus jugulare—starting from simulation, planning, evaluation of plan, and treatment.

Treatment of recurrent diseases in patients with cervical or endometrial cancers after primary treatment by radiotherapy is challenging due to limitations of treatment options and success rates. Results are variable with contrasting outcomes and toxicities. The authors reviewed all recent evidences and summarized the recent series of studies along with recent advancements and future possibilities. Surgical options were traditionally limited to extensive resections such as pelvic exenteration with or without intraoperative radiotherapy (IORT) or radical radiotherapy. IORT can be used as an adjunct to surgery in recurrent malignancies with positive margins. Recent interstitial brachytherapy (ISBT) studies for central recurrences have demonstrated a moderate 2 to 3 years local control of ~ 50%. Stereotactic body radiotherapy (SBRT) has also emerged as an attractive and apparently viable alternative, especially in treating relapsed nodes and pelvic sidewall disease, achieving 1- and 2-year local control rates of about 80 and 50%, respectively. The results of salvage re irradiation are reasonable. More upcoming evidences and ongoing technological innovations will guide us in more effective retreatment and addition to life in this group of patients.

We present a 53 year old woman initially diagnosed as hemangiopericytoma in the posterior fossa on the right side post excision with immunohistochemistry staining for CD34 being positive. Presently, the patient had difficulty in walking due to back pain and pain in left arm. Imaging with F-FDG PET showed low glucose avidity in disease sites but Ga-PSMA PET unequivocally demonstrated multiple skeletal and liver metastases with intense PSMA avidity. Patient received palliative radiotherapy to bone metastasis and was planned for chemotherapy. This report adds to the list of applications of Ga PSMA PET and a possible theranostic target.

Imaging of gliomas remains challenging. The aim of the study was to assess the feasibility of using Ga-PSMA-11 PET/CT for imaging gliomas.Fifteen patients with glioma from 2 centers were included in the study. Ten patients were treated cases of glioblastoma with suspected recurrence. Two patients were sent for assessing the nature (primary lesion/metastasis) of space-occupying lesion in the brain; 3 patients were imaged immediately after surgery and before radiotherapy. Target-to-background ratios (TBR) for the brain lesions were calculated using contralateral cerebellar uptake as background.Among the 10 cases with suspected recurrence, scan was positive in 9, subsequent surgery was done, and histopathology proved it to be true recurrence. In the scan-negative case on follow-up, no evidence of disease could be made clinically or radiologically. Among the other cases the presence or absence of disease could be unequivocally identified on the Ga-PSMA-11 brain scan and correlated with the histopathology or other imaging. Apart from the visual assessment quantitative assessment of the lesions with TBR also showed a significantly high TBR value for those with true disease compared with those with no disease.In the evaluation of gliomas, Ga-PSMA-11 PET/CT brain imaging is a potentially useful imaging tool. The use of Ga-PSMA-11 brain PET/CT in evaluation of recurrent glioma seems promising. Absence of physiological uptake of Ga-PSMA-11 in the normal brain parenchyma results in high TBR values and consequently better visualization of glioma lesions.

Squamous cell carcinoma (SCC) of external auditory canal (EAC) is extremely rare. Although surgery followed by radio (chemo) therapy is the contemporary standard of care, radical radio (chemo) therapy has been successfully used as an anatomical as well as functional organ preservation modality. Radical brachytherapy is a promising alternative in early-stage SCC-EAC. We report our initial experience on the feasibility of using commercially available plastic earbud along with soft flexible earpiece of stethoscope as a radioactive source career applicator of remote after-loading high-dose rate radioactive sources (Ir192).

Ipsilateral breast or chest wall recurrence remains one the most common site of disease recurrence and significantly increases the morbidity and mortality. The current standard of care for ipsilateral breast tumour recurrence has been mastectomy. However, various recent studies showed that there is feasibility of repeat breast conservation surgery with reirradiation. Reirradiation in breast cancer is complicated approach. Many physicians are reluctant to reirradiate breast with restricted data available. This paper will review the current literature on reirradiation for locally recurrent breast cancer

The treatment options for recurrent tumors are limited. Re irradiation is being increasingly considered as an option, in view of the advances in treatment techniques, particularly the ability to document doses, overlay plans, intensity modulation, and image guidance. preclinical and clinical studies has been to estimate the total cumulative doses (EQD2) also termed as normalized total dose (NTD) that can be delivered to various tissues. In this review article reirradiation radiobiology of different tissues and dose fractionation have been discussed.

Reirradiation, in combination with systemic therapy or biologicals, in recent years, has become a popular option for locally recurrent cancers and for infield second malignancies in cases where surgical salvage is not feasible. However before embarking onto such a course of second radiation a systematic approach is needed to avoid undesirable consequences and to gain meaningful advantage in terms of survival and local control. An decision making approach for common cancers where re-irradiation is commonly used like the head and neck cancers, the gliomas and in cases of gynecological cancers has been discussed. Proper selection of the cases and the choosing the intention for re-irradiation is probably most important initial step. Care of the details of the initials course of radiation like the dose fractionation schedule, volume irradiated, dose to the Organs at risk along with patient's present general condition is of utmost importance. Issues like dose memory, threshold time interval, maximum effective cumulative dose etc are still areas of research and their importance in each individual site needs to ascertain in future. Finally, the aim is to have a perceived benefit over the potential of harm in a successful course re-irradiation.

Radiotherapy (RT) in relapsed brain tumors has been used sparingly because of the risk of toxicity, particularly white matter necrosis. However, evidence from preclinical animal models and increasing data from clinical series show that brain and spinal cord have marked repair potential, and re irradiation should be considered a valid option in selected patients. The choice of technique and dose fractionation for re irradiation depends on tumor characteristics (volume and location), previous RT dose and volume, and patient characteristics (age and performance status). For small volume tumors in noneloquent areas, single fraction SRS and brachytherapy may be good options. For small and intermediate volume tumors in eloquent areas, FSRT or hypofractionated RT may be used. For large volume recurrences, requiring partial brain irradiation, conventional fractionation is safer and offers palliation with minimal risk of radiation induced toxicitie.

In the last few decades, there have been major improvements in diagnosis, staging, and management of cancer which has translated into better disease outcomes and longer survival rates and with better quality of life. This improvement in the quality of life is by better normal tissue sparing caused by the increasing use of newer techniques and technologies, especially in surgery and radiotherapy. Along with higher survival, there is now greater acknowledgment of the need to treat local recurrences and hence the increased use of re-irradiation. Better technology such as intensity modulated radiotherapy translates into better sparing of normal tissue, but at the same time, late toxicity is still of concern. Factors such as residual late damage, total dose, fraction size, technique, type of tissue, and time interval to re-irradiation still guide prescription of the re-irradiation dose. Knowledge of long-term recovery of organ at risk is hence of importance in re-irradiation. This review article has emphasized on the recovery and tolerance of organs at risk such as Spinal cord, Brainstem, and Brain. This is important in prescribing doses for the target volume for re-irradiation and in setting constraints for surrounding critical organs during the planning process.

Renal cell carcinoma (RCC) is an aggressive malignancy that carries a poor prognosis, especially in patients presenting with advanced stage. Primary treatment for localized RCC is surgical resection however, a significant number of patients still develop locoregional and distant metastasis after curative resection. In metastatic disease, radiation therapy (RT) has been used for palliation routinely for brain and other extracranial lesions with respectable response rates. However, RT for primary RCC has questionable benefit. In this article, the authors discuss the evidence with regards to the role of RT in primary RCC either as a primary treatment, adjuvant treatment, or preoperatively to improve resection outcomes. In addition, novel RT techniques such as stereotactic body radiation therapy and its use in RCC management are also addressed. Finally, the authors discuss the techniques and doses of RT for primary RCC.