Comparison of different adjuvant radiotherapy approaches in childhood bladder/prostate rhabdomyosarcoma treated with conservative surgery

Image-Guided Brachytherapy for Pediatric Bladder and/or Prostate Rhabdomyosarcoma: Toward an Increased Personalization of Treatment

PURPOSE

Rhabdomyosarcoma (RMS) is the most common soft tissue cancer in children. Around 15% of RMS involve the bladder and/or prostate (BP). Overall survival is around 85%. After chemotherapy, patients receive local treatment based on surgery and/or radiation therapy. In recent decades, image guidance and pulsed-dose rate (PDR) brachytherapy have made it possible to personalize treatment and reduce radiation-related toxicity while maintaining good tumor control. We report one of the largest series of image guided brachytherapy for pediatric RMS BP.

METHODS AND MATERIALS

The clinical and dosimetric parameters of children treated with brachytherapy for BP RMS between July 2014 and September 2020 were retrospectively reviewed. Patients were treated with a multimodal conservative approach, combining partial conservative surgery (preservation of the bladder neck and urethra), followed by an interstitial brachytherapy procedure. Iridium-192 PDR treatment was administered on the basis of computed tomography and magnetic resonance imaging planning. Toxicities were reported according to version 4.0 of the Common Terminology Criteria for Adverse Events.

RESULTS

A total of 75 patients were identified, with a median age of 29 months (range, 2-84) at diagnosis. The median brachytherapy dose was 60.06 Gy (143 pulses, 0.42 Gy/pulse). With a median follow-up of 44.1 months (range, 0.7-90), the 5-year overall survival and progression-free survival rates were 97.3% and 92%, respectively. Median D50% for the bladder and D1cc for the rectum were 38.6 Gy and 49 Gy, respectively. The 5-year probability of survival without severe late urinary toxicity (grade 3 or higher) was estimated at 78.8% (95% CI, 68.1-91.1). A total of 9.3% of children experienced grade 2 or 3 late rectal toxicity.

CONCLUSIONS

Image guided PDR brachytherapy offers personalized treatment for pediatric BP RMS, with a favorable therapeutic index. No prognostic factors for urinary toxicity have been identified. Multicenter studies with larger numbers of patients are needed to clarify these data.

A pilot study to evaluate the combination of surgery and brachytherapy for local tumor control in young children with perianal rhabdomyosarcoma

Background

Perianal rhabdomyosarcoma ((P)RMS) are rare and have a poor prognosis. Data in young children are limited and local therapy is not well defined. Combined brachytherapy and surgery is routinely being used for RMS at other sites in children as it provides good oncologic outcomes and allows for organ-sparing surgery. The objective of this study was to evaluate this combination treatment for local tumor control and organ-sparing surgery in young children with (P)RMS.

Methods

A retrospective review of the medical records of all children who underwent surgery and brachytherapy for (P)RMS at our institution since 2009 was conducted.

Results

Surgery for (P)RMS was performed in 6 patients at a median age of 19 months (range 8-50). Embryonal RMS was diagnosed in 4 patients and alveolar RMS in 2 patients, of which 1 patient had FOXO1 fusion-positive RMS. All patients underwent postoperative high-dose rate (HDR) brachytherapy. Organ-preserving surgery was achieved in 5 of 6 patients (83 %). In 1 patient, the entire sphincter was infiltrated, making organ-preserving resection impossible. 5 of 6 patients (83 %) exhibited an event-free and overall survival at a median follow-up of 26 months (range 8-107). One patient died due to locoregional recurrence. Complications were urethral leakage in 1 patient followed by urethral stenosis and delayed wound healing and vaginal stenosis in another patient. No patient reported fecal incontinence.

Conclusions

Combined treatment with surgery and HDR brachytherapy is feasible in very young children with (P)RMS and leads to a favorable oncologic outcome. Preliminary data show a good functional preservation.

Clinical Insight on Proton Therapy for Paediatric Rhabdomyosarcoma

This paper offers an insight into the use of Proton Beam Therapy (PBT) in paediatric patients with rhabdomyosarcoma (RMS). This paper provides a comprehensive analysis of the literature, investigating comparative photon-proton dosimetry, outcome, and toxicity. In the complex and multimodal scenario of the treatment of RMS, clear evidence of the therapeutic superiority of PBT compared to other modern photon techniques has not yet been demonstrated; however, PBT can be considered an excellent treatment option, in particular for young children and patients with specific primary sites, such as the head and neck area (and especially the parameningeal regions), genito-urinary, pelvic, and paravertebral regions. The unique depth-dose characteristics of protons can be exploited to achieve significant reductions in normal tissue doses and may allow an escalation of tumour doses and greater sparing of normal tissues, thus potentially improving local control while at the same time reducing toxicity and improving quality of life. However, access of children with RMS (and more in general with solid tumors) to PBT remains a challenge, due to the limited number of available proton therapy installations.

Increasing Patient Safety and Treatment Quality by Using Intraoperative MRI for Organ-Preserving Tumor Resection and High-Dose Rate Brachytherapy in Children with Bladder/Prostate and Perianal Rhabdomyosarcoma

In children with bladder/prostate (BP) and perianal rhabdomyosarcoma (RMS), we use a hybrid treatment concept for those suitable, combining organ-preserving tumor resection and high-dose rate brachytherapy (HDR-BT). This treatment concept has been shown to improve outcomes. However, it is associated with specific challenges for the clinicians. The exact position of the tubes for BT is a prerequisite for precise radiotherapy. It can finally be determined only with an MRI or CT scan. We evaluated the use of an intraoperative MRI (iMRI) to control the position of the BT tubes and for radiotherapy planning in all patients with BP and perianal RMS who received the above-mentioned combination therapy in our department since January 2021. iMRI was used in 12 children. All tubes were clearly localized. No adverse events occurred. In all 12 children, radiotherapy could be started on time. In a historical cohort without iMRI, this was not possible in 3 out of 20 children. The use of iMRI in children with BP and perianal RMS improved patient safety and treatment quality. This technology has proven to be successful for the patient population we have defined and has become a standard procedure in our institution.

Detailed functional results after bladder-preserving surgery and high-dose-rate brachytherapy in pediatric bladder/prostate rhabdomyosarcoma

PURPOSE

In pediatric bladder/prostate-rhabdomyosarcoma, the rate of bladder preservation after neoadjuvant chemotherapy is high, with an excellent oncological outcome. Information about functional urological long-term outcomes is rare.

METHODS

Data of all patients who had undergone bladder-preserving surgery with or without brachytherapy at our institution between 2009 and 2020 were analyzed retrospectively. Detailed urological function was assessed focusing on age-related continence, bladder capacity and urodynamic findings.

RESULTS

We identified 40 patients, median age at surgery of 27 months (range 9-191), and 32 patients additionally received postoperative high-dose-rate brachytherapy. The median follow-up was 32.5 months (range 6-125). The bladder capacity increased from median 66.7% (21.1-180) of expected bladder capacity related to age 3 months after surgery to 87.4% (58.1-181.8) 9 months after surgery. In the group of aged > 6-year-old, continence was 94% (83% with brachytherapy, 100% without brachytherapy). Erectile function was normal in 92% (90% with brachytherapy, 100% without brachytherapy). Bladder capacity was more than 65% expected bladder capacity related to age in 70% (60% with brachytherapy, 86% without brachytherapy). 65% of all patients need neither anticholinergic drugs nor low-dose antibiotics (63% with brachytherapy, 71% without brachytherapy).

CONCLUSIONS

Bladder preservation with good functional outcome can be achieved in localized bladder/prostate-rhabdomyosarcoma. In selected cases, supportive brachytherapy additionally contributes to an improvement in the oncological outcome with calculable risks for bladder and erectile function. Careful urological aftercare should be a fixed priority after oncological follow-ups.

Long-term disease-free survival following salvage brachytherapy for recurrent pediatric rhabdomyosarcoma: Two case reports and review of relevant literature

PURPOSE

Rhabdomyosarcoma (RMS) is the most common pediatric soft-tissue sarcoma, mostly involving the genitourinary (GU) tract, head and neck, and extremities. This study reports the long-term outcome of two infants with recurrent GU-RMS who underwent combination therapy with chemotherapy (ChT) and salvage brachytherapy (BT).

METHODS AND MATERIALS

An 18-month-old girl with vaginal bleeding and a 7-month-old boy with urinary retention presented with a diagnosis of vaginal, and bladder/prostate embryonal RMS, respectively. Surgical resection and ChT were done for both patients. However, both developed local recurrences after one year and subsequently, underwent second-line ChT and salvage interstitial high dose rate BT.

RESULTS

The clinical target volumes for the first and second patients were treated to a totaldose of 32 Gy in 10 fractions and 35 Gy in 10 fractions, respectively, with two fractions delivered per day with a 6-h interval between fractions. After 9 years of follow-up, both patients are alive with natural growth and no late complication or evidence of recurrence.

CONCLUSIONS

Our report shows that BT (for patients with no prior history of irradiation) could result in long-term disease-free survival in well-selected pediatric patients with recurrent GU embryonal RMS without inflicting expected adverse effects of external beam radiotherapy.

Brachytherapy in children, adolescents, and young adults: An underutilized modality in the United States?

BACKGROUND

Brachytherapy (BT) delivers highly conformal radiation and spares surrounding tissues, which may limit late effects in pediatric, adolescent, and young adult (AYA) patients. We aimed to characterize trends in BT use for this population in the United States, focusing on patients with rhabdomyosarcoma (RMS).

METHODS

The National Cancer Database was queried to identify patients ≤ 21 who were treated for solid tumor malignancies in the United States from 2004 to 2016. We obtained disease, treatment, and outcome data for patients treated with BT, in particular for RMS.

RESULTS

99 506 pediatric and AYA patients met study inclusion. Of these, 22 586 (23%) received radiation therapy (external beam radiation therapy [EBRT] and/or BT) and 240 (0.2%) received BT. Among patients treated with BT, 139 (58%) underwent surgery and 58 (24%) received EBRT. A total of 3836 patients were treated for RMS during this period. Of these, 2531 (66%) received any radiation and 37 (1%) received BT (EBRT + BT in 3, BT in 34). Of patients treated with BT for RMS, 28 (76%) underwent surgery + BT. Survival data were available for 31 patients treated with BT for RMS. With a median follow-up of 63 months, overall survival was 100% for patients with RMS of a favorable site treated with BT.

CONCLUSIONS

BT is rarely used to treat pediatric and AYA patients in the United States. Patients treated with BT for RMS experienced favorable survival, suggesting that this approach may not compromise oncologic outcomes and warrants further study as a therapeutic option in pediatric and AYA patients, specifically in RMS.

Innovative Techniques Associated with Traditional Abdominal Surgery in Complex Pediatric Cases: A Tertiary Center Experience

Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery.

New aspects and innovations in the local treatment of renal and urogenital pediatric tumors

Local treatment plays a key role for patients' outcome in tumors of the urogenital tract in children. Despite a great variety of different etiologies, the specific localization of pediatric urogenital tumors renders several characteristic demands to the treating personnel. Surgery and radiotherapy are the main elements of local treatment in this group of neoplasms. Numerous new guidelines and innovative technical developments of surgery and radiotherapy have recently been integrated into treatment concepts for pediatric urogenital tumors. Due to the broadness of the field it is not possible to give a full overview over all aspects. Therefore, this article highlights the most important innovations and new guidelines of surgery and radiotherapy of pediatric urogenital tumors.

American Brachytherapy Society (ABS) consensus statement for soft-tissue sarcoma brachytherapy

PURPOSE

Growing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS.

METHODS AND MATERIALS

Members of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience.

RESULTS

Brachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure.

CONCLUSIONS

These updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.

Analysis of Radiation Dose/Volume Effect Relationship for Anorectal Morbidity in Children Treated for Pelvic Malignancies

PURPOSE

To examine dose-volume effect relationships for anorectal morbidity in children treated with image-guided brachytherapy for pelvic tumors.

METHODS AND MATERIALS

Medical records of all consecutive children with pelvic tumors treated in our center and receiving image-guided pulsed-dose-rate brachytherapy with or without external beam radiation therapy (EBRT) between 2005 and 2019 were reviewed. The effect of the minimal doses to the most exposed 0.5 cm³, 1 cm³, and 2 cm³ of the anorectum (respectively: D_0.5cm³, D_1cm³, and D_2cm³), total reference air kerma (TRAK), and volume of 100% isodose was examined for anorectal toxicities.

RESULTS

Seventy-eight consecutive children were included. Median age was 2.9 years (range, 0.8-14.9 years). Most of the tumors were bladder or prostate (67%) or vaginal (22%) rhabdomyosarcoma. Six patients received EBRT in addition to brachytherapy. Median follow-up was 21.3 months. At last follow-up, 30 children (38%) had experienced Common Terminology Criteria for Adverse Events version 5 grade ≥1 acute or late anorectal events: 24% had grade 1 events, 7.7% had grade 2 events, and 6.4% had grade 3 events. No toxicity greater than grade 3 was observed (eg, fistula or stricture). In univariate analysis, the D_0.5cm³ and D_1cm³ were significant for probability of grade 1 to 3 (P = .009 and P = .017, respectively) and grade 2 to 3 anorectal morbidity (P = .007 and P = .049, respectively). There was no significant correlation for D_2cm³ (P = .057 for grade 1-3; P = .407 for grade 2-3). A 10% probability (95% confidence interval, 4%-20%) for anorectal toxicity of grade 2 or greater was reached for a D_0.5cm³ = 52 Gy. The age, EBRT use, TRAK, and treated volume values were not significant.

CONCLUSIONS

To our knowledge, this study is the first to show a significant dose-volume effect relationships for anorectal morbidity in children undergoing treatment with brachytherapy. Integrating these data into brachytherapy treatment planning could help to optimize the therapeutic index in these young patients.

Interventional radiotherapy (brachytherapy) achieves very good long-term quality of life in children and adolescents with soft-tissue sarcoma

BACKGROUND

Effective local therapy (surgery, radiation) and systemic multidrug chemotherapy are mandatory for curing childhood sarcoma. The standard radiation therapy for pediatric patients with soft-tissue sarcoma (STS) is external beam radiotherapy (EBRT). Because EBRT may cause long-term side effects with adverse effects on the patients' health and quality of life (QoL), alternative strategies are required. Interventional radiotherapy (IRT; brachytherapy) is established as a standard treatment for several tumors in adulthood. Single-center series have reported low levels of late effects and improved QoL in survivors treated with IRT in childhood. However, IRT is still applied infrequently in pediatric patients.

METHODS

Thirty patients with STS were treated with IRT between 1992 and 2012 at the University Hospital Schleswig Holstein, Germany. Five patients were lost to follow-up, and 25 patients (mean age at time of data collection 24.8 years [range, 10.7-36.1]) could be analyzed focusing on overall survival and QoL (EORTC-C30 questionnaire). For more detailed information regarding general and health-specific questions, a separate questionnaire was developed.

RESULTS

Nineteen of 25 patients were alive 13.4 [1.6-25.2] years after first cancer disease, and the three-year overall survival was 76% (SE, 0.09). The score of QoL/global health status (76.2 [16.6-100]) in our patients outvalues the European (66.1) and equals the German (75.9) reference value.

CONCLUSION

IRT is an effective treatment option for pediatric patients with localized STS. Its role among other radiation dose-sparing techniques such as proton beam therapy has to be defined in prospective studies.

Appraisal of the role of radical prostatectomy for rhabdomyosarcoma in children: oncological and urological outcome

The latest multimodal protocols for treatment of bladder/prostate rhabdomyosarcoma (RMS) have shifted the goal of treatment from patient survival to bladder preservation. Consistently, partial resections, such as radical prostatectomy (RP), are favoured when surgery is deemed necessary. We sought to determine the oncological risks - that is, failure to achieve disease control - and the possible benefits in terms of urinary continence associated with RP in RMS patients based on a review of our experience and the data reported in the literature. We identified 18 children undergoing RP for RMS (3 at our institution, 15 in the literature). In five cases, a pubectomy/symphisiotomy was performed to improve surgical exposure. Two cases experienced local relapse, suggesting that this approach can be viable to achieve local control. No clear-cut indications could be extrapolated from the literature, however, to determine how to select the patients most suitable for this approach. We offered this treatment to patients with evidence of disease localized only within the prostate on radiological and endoscopic re-assessment after chemo-/radio-therapy. Eight of the 18 cases (44%) eventually required lower urinary tract reconstruction, suggesting that often this approach does not allow for the preservation of urinary continence with volitional voiding. Finally, data about additional interesting outcomes such as erectile function and fertility in RMS patients undergoing RP are extremely sparse.

Conservative surgery with combined high dose rate brachytherapy for patients suffering from genitourinary and perianal rhabdomyosarcoma

BACKGROUND AND PURPOSE

Outcome of patients with genitourinary rhabdomyosarcoma has been improved in the past, but organ preservation rates are too low. Conservative surgery with LDR-brachytherapy has been advocated, but LDR-brachytherapy is often not available. We wanted to establish a novel treatment modality combining HDR-brachytherapy and conservative surgery.

MATERIAL AND METHODS

We performed an organ preserving tumor resection with intraoperative placement of brachytherapy tubes. Suitable patients were selected following assessment of response to neoadjuvant chemotherapy where organ preserving surgical resection was deemed feasible. In bladder-prostate rhabdomyosarcoma, only tumors located below the bladder neck could be treated by brachytherapy. After surgery, high dose rate brachytherapy was carried out for 30-36Gy total dose.

RESULTS

A total of 11 patients were treated up to now (embryonal histology n=10, alveolar histology n=1) with a median follow-up of 18months [4-80]. All patients were IRS group III. There were no significant side effects. One patient had local relapse and was successfully treated with re-excision. All other patients are in the first complete remission. One patient developed a neurogenic bladder and required creation of a Mitrofanoff stoma.

CONCLUSION

Combined conservative surgery and high dose rate brachytherapy is a treatment option for selected rhabdomyosarcoma patients. The paper highlights the essential technical challenges and clearly shows limitations of this treatment approach.

Current standards of care in bladder and prostate rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common soft tissue tumor in children, and 15% to 20% arise from the genitourinary tract. Multicenter collaborative studies have improved survival substantially, and in addition to excellent oncologic control, current treatment focuses on organ preservation and minimization of late treatment effects. The multiple modalities needed to treat RMS dictate that treating physicians must be familiar with the disease as well as the goals and possible sequelae of treatment with chemotherapy, radiotherapy, and surgery. This article discusses the current standards of care for bladder and prostate RMS.

Focusing on organ preservation and function: paradigm shifts in the treatment of pediatric genitourinary rhabdomyosarcoma

OBJECTIVE

Pediatric genitourinary rhabdomyosarcoma (RMS) accounts for 25 % of all pediatric soft tissue sarcomas. The treatment of these tumors has shifted over time from debilitating radical exenteration to organ-sparing techniques using multimodal therapy. Our review aims to summarize recent relevant literature regarding the current treatment practices of pediatric genitourinary RMS and how these practices have shifted over time.

METHODS

PubMed database search was utilized to identify relevant literature from 1997 to 2015 relating to the treatment of pediatric genitourinary RMS with emphasis on organ preservation and maintaining organ function.

RESULTS

A total of 31 articles from 1997 through 2015 were identified relating to current management concepts in pediatric genitourinary sarcomas. Relevant articles were reviewed in detail and discussed.

CONCLUSION

The treatment of pediatric genitourinary RMS has shifted from debilitating pelvic exenteration to a multimodal treatment approach involving surgery, chemotherapy, and radiation therapy in an effort to preserve genitourinary organs and reduce treatment morbidity. Continued research is required to improve post-treatment organ function. Further studies utilizing objective urodynamic evaluation are necessary to better characterize bladder function after treatment for RMS. Exciting recent developments in RMS research of fusion proteins that induce cell transformation and inhibit apoptosis and myogenic differentiation may result in future management changes to treatment protocols.

Mesenchymal tumours of the bladder and prostate: an update

Mesenchymal tumours of the urinary bladder and prostate are infrequent neoplasms. The body of literature is growing with isolated case reports and short series, and the majority of cases are benign neoplasms. Other than stromal tumour of uncertain malignant potential and prostatic stromal sarcoma, both neoplasms derived from the specific prostatic stroma, the mesenchymal neoplasms in these locations are identical to their counterparts seen in other organs. However, the limited amount of tissue generated by biopsy and rarity of mesenchymal lesions in these sites create unique diagnostic difficulties, while correct classification of the neoplasm often bears significant impact on prognosis and therapeutic strategy. In this review we summarise the diagnostic features, focus on the differential diagnosis, and highlight the potential diagnostic pitfalls of mesenchymal tumours of the bladder and prostate.

Clinical results of proton beam therapy for advanced neuroblastoma

PURPOSE

To evaluate the efficacy of proton beam therapy (PBT) for pediatric patients with advanced neuroblastoma.

METHODS

PBT was conducted at 21 sites in 14 patients with neuroblastoma from 1984 to 2010. Most patients were difficult to treat with photon radiotherapy. Two and 6 patients were classified into stages 3 and 4, respectively, and 6 patients had recurrent disease. Seven of the 8 patients who received PBT as the initial treatment were classified as the high risk group. Twelve patients had gross residual disease before PBT and 2 had undergone intraoperative radiotherapy before PBT. Five patients received PBT for multiple sites, including remote metastases. Photon radiotherapy was used in combination with PBT for 3 patients. The PBT doses ranged from 19.8 to 45.5 GyE (median: 30.6 GyE).

RESULTS

Seven patients are alive with no evidence of disease, 1 is alive with disease progression, and 6 died due to the tumor. Recurrence in the treatment field was not observed and the 3-year locoregional control rate was 82%. Severe acute radiotoxicity was not observed, but 1 patient had narrowing of the aorta and asymptomatic vertebral compression fracture at 28 years after PBT, and hair loss was prolonged in one patient.

CONCLUSION

PBT may be a better alternative to photon radiotherapy for children with advanced neuroblastoma, and may be conducted safely for patients with neuroblastoma that is difficult to manage using photon beams.

Pediatric bladder rhabdomyosarcoma: report of organ sparing treatment of two cases

Pediatric rhabdomyosarcoma cases require multimodality therapy. Here, we present two cases treated by tumor resection followed by chemotherapy, and discuss the bladder preserving treatment of this uncommon disease.

American Brachytherapy Society (ABS) consensus statement for sarcoma brachytherapy

PURPOSE

To present recommendations for the use of brachytherapy (BT) in patients with soft tissue sarcoma (STS).

METHODS

A group of practitioners with expertise and experience in sarcoma BT formulated recommendations for BT in STS based on clinical experience and literature review.

RESULTS

The indications for adjuvant BT are discussed. There is no consensus on the use of BT alone or in combination with external beam radiation therapy (EBRT), but factors that influence the selection of this modality include tumor grade and size, prior surgeries, and tumor recurrence. Low-dose-rate, high-dose-rate, and pulsed-dose-rate radiation are all acceptable BT modalities to use for STS. Recommendations are made for patient selection, techniques, dose rates, and dosages. Outcome data and toxicity data are reviewed.

CONCLUSIONS

BT is a useful component of the treatment of STS. The advantages of BT are the targeted dose distribution, low integral dose, and short treatment times. Ultimately the clinician should select the modality or combination of modalities that are most familiar to the treatment team and suitable to the patient.