Anne W Lee1, Wai Tong Ng2, Jian Ji Pan3, Chi-Leung Chiang1, Sharon S Poh4, Horace C Choi5, Yong Chan Ahn6, Hussain AlHussain7, June Corry8, Cai Grau9, Vincent Grégoire10, Kevin J Harrington11, Chao Su Hu12, Dora L Kwong13, Johannes A Langendijk14, Quynh Thu Le15, Nancy Y Lee16, Jin Ching Lin17, Tai Xiang Lu18, William M Mendenhall19, Brian O'Sullivan20, Enis Ozyar21, Lester J Peters22, David I Rosenthal23, Giuseppe Sanguineti24, Yoke Lim Soong4, Yungan Tao25, Sue S Yom26, Joseph T Wee27. 1. Department of Clinical Oncology, University of Hong Kong Shenzhen Hospital and University of Hong Kong, China. 2. Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong. 3. Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China. 4. Division of Radiation Oncology, National Cancer Centre Singapore, Oncology ACP, Duke-NUS Medical School, Singapore. 5. Department of Clinical Oncology, University of Hong Kong, Hong Kong. 6. Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 7. Department of Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia. 8. Radiation Oncology, GenesisCare, St. Vincent's Hospital, Melbourne, Victoria, Australia. 9. Department of Oncology, Aarhus University Hospital, Aarhus, Denmark. 10. Center for Molecular Imaging, Oncology and Radiotherapy, Université Catholique de Louvain, Brussels, Belgium and Department of Radiation Oncology, Centre Léon Bérard, Lyon, France. 11. The Royal Marsden/The Institute of Cancer Research National Institute for Health Research Biomedical Research Centre, London, UK. 12. Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China. 13. Department of Clinical Oncology, University of Hong Kong and Queen Mary Hospital, Hong Kong. 14. Department of Radiotherapy, University Medical Center Groningen, University of Groningen, Groningen, Netherlands. 15. Department of Radiation Oncology, Stanford University, NRG Oncology and Head and Neck Cancer International Group, California. 16. Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York. 17. Department of Radiation Oncology, Taichung Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan. 18. Department of Radiation Oncology, Cancer Center of Sun Yat-Sen University, Guangzhou, China. 19. Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida. 20. Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Canada. 21. Department of Radiation Oncology, Acibadem University School of Medicine, Istanbul, Turkey. 22. Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia. 23. Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. 24. Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy. 25. Department of Radiation Oncology, Institut Gustave Roussy, Paris-Saclay University, Villejuif, France. 26. Department of Radiation Oncology, University of California-San Francisco, San Francisco, California. 27. Division of Radiation Oncology, National Cancer Centre Singapore, Oncology ACP, Duke-NUS Medical School, Singapore. Electronic address: joseph.wee.t.s@singhealth.com.sg.
Abstract
PURPOSE: The treatment of nasopharyngeal carcinoma requires high radiation doses. The balance of the risks of local recurrence owing to inadequate tumor coverage versus the potential damage to the adjacent organs at risk (OARs) is of critical importance. With advancements in technology, high target conformality is possible. Nonetheless, to achieve the best possible dose distribution, optimal setting of dose targets and dose prioritization for tumor volumes and various OARs is fundamental. Radiation doses should always be guided by the As Low As Reasonably Practicable principle. There are marked variations in practice. This study aimed to develop a guideline to serve as a global practical reference. METHODS AND MATERIALS: A literature search on dose tolerances and normal-tissue complications after treatment for nasopharyngeal carcinoma was conducted. In addition, published guidelines and protocols on dose prioritization and constraints were reviewed. A text document and preliminary set of variants was circulated to a panel of international experts with publications or extensive experience in the field. An anonymized voting process was conducted to rank the proposed variants. A summary of the initial voting and different opinions expressed by members were then recirculated to the whole panel for review and reconsideration. Based on the comments of the panel, a refined second proposal was recirculated to the same panel. The current guideline was based on majority voting after repeated iteration for final agreement. RESULTS: Variation in opinion among international experts was repeatedly iterated to develop a guideline describing appropriate dose prioritization and constraints. The percentage of final agreement on the recommended parameters and alternative views is shown. The rationale for the recommendations and the limitations of current evidence are discussed. CONCLUSIONS: Through this comprehensive review of available evidence and interactive exchange of vast experience by international experts, a guideline was developed to provide a practical reference for setting dose prioritization and acceptance criteria for tumor volumes and OARs. The final decision on the treatment prescription should be based on the individual clinical situation and the patient's acceptance of optimal balance of risk.
PURPOSE: The treatment of nasopharyngeal carcinoma requires high radiation doses. The balance of the risks of local recurrence owing to inadequate tumor coverage versus the potential damage to the adjacent organs at risk (OARs) is of critical importance. With advancements in technology, high target conformality is possible. Nonetheless, to achieve the best possible dose distribution, optimal setting of dose targets and dose prioritization for tumor volumes and various OARs is fundamental. Radiation doses should always be guided by the As Low As Reasonably Practicable principle. There are marked variations in practice. This study aimed to develop a guideline to serve as a global practical reference. METHODS AND MATERIALS: A literature search on dose tolerances and normal-tissue complications after treatment for nasopharyngeal carcinoma was conducted. In addition, published guidelines and protocols on dose prioritization and constraints were reviewed. A text document and preliminary set of variants was circulated to a panel of international experts with publications or extensive experience in the field. An anonymized voting process was conducted to rank the proposed variants. A summary of the initial voting and different opinions expressed by members were then recirculated to the whole panel for review and reconsideration. Based on the comments of the panel, a refined second proposal was recirculated to the same panel. The current guideline was based on majority voting after repeated iteration for final agreement. RESULTS: Variation in opinion among international experts was repeatedly iterated to develop a guideline describing appropriate dose prioritization and constraints. The percentage of final agreement on the recommended parameters and alternative views is shown. The rationale for the recommendations and the limitations of current evidence are discussed. CONCLUSIONS: Through this comprehensive review of available evidence and interactive exchange of vast experience by international experts, a guideline was developed to provide a practical reference for setting dose prioritization and acceptance criteria for tumor volumes and OARs. The final decision on the treatment prescription should be based on the individual clinical situation and the patient's acceptance of optimal balance of risk.
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