Turn it up.

45-50 Gy just doesn’t do it for pancreatic cancer. And while there’s been a surge in SBRT, many in the field wonder whether limiting dose-escalated radiation to 5 fractions or less makes biological sense. The big problem is that there is often considerable overlap of the target with adjacent stomach, duodenum, and/or small bowel. So, you’ll almost always have part of the target receiving less than prescription dose. More fractions allows that overlapping dose to be higher (biologically) and more comprehensive of microscopic disease. Here we have a manifesto of sorts from many of the experts in pancreas radiation that presents approaches to both dose-escalated SBRT and hypofractionated RT. The paper contains two important tables you’ll want to tape near your desk. The approach to creating target and planning volumes also deserves several thorough reads. But the fundamental takeaway is to think beyond the CPT-definition of SBRT. TBL: Ablative radiation can come in 5, 15, or even 25 fractions. | Koay, Pract Radiat Oncol 2020