Radiation oncologists have long understood the potential benefit of radiation therapy (RT) in palliating the distressing symptoms of advanced abdominal and pelvic cancers. Often, the role of external beam radiation therapy (EBRT) or brachytherapy in controlling bleeding or obstructive symptoms finds only a passing reference and most palliative medicine texts are silent on this important topic. Palliative RT achieves hemostasis in patients with unresectable gastric carcinoma not fit for systemic chemotherapy and is associated with a statistically significant rise in their hemoglobin levels. RT has been used for symptom relief in gynecological malignancies for many years. For abdominal malignancies, bony landmarks are less reliable for treatment planning, as compared to pelvic malignancies. This chapter discusses some case scenarios which illustrate the role of palliative radiation therapy in the treatment of bladder cancer, vaginal bleeding, rectal cancer, vulvar cancer, and liver metastasis.

An adaptive design is a clinical trial design that allows adaptations or modifications to aspects of the trial after its initiation without undermining the validity and integrity of the trial. Adaptive trial designs represent a systematic approach to designing trials at different phases. This chapter discusses adaptive and innovative clinical trial designs and its types. Types of adaptations may include, but are not limited to: a group sequential design; a sample-size adjustable design; a drop-losers design; an adaptive treatment allocation design; an adaptive dose-escalation design; a biomarker-adaptive design; an adaptive treatment-switching design; an adaptive dose-finding design; and a combined adaptive design. Clinical trial simulation (CTS) is a process that mimics clinical trials using computer programs. Bayesian designs and CTSs provide alternative, powerful tools for optimizing trial development. Together, this family of novel methodologies forms a powerful statistical instrument for the most successful development of new cancer therapies.

This chapter reviews the emerging literature on stereotactic body radiation therapy (SBRT) for primary adrenocortical carcinomas and metastatic lesions in the adrenal glands. The use of SBRT, though infrequent, is an effective and safe treatment option for tumors of the adrenal gland when delivered appropriately. SBRT is a good alternative for patients who are considered poor surgical candidates or who decline surgical adrenalectomy for adrenal metastases. SBRT is a highly technical treatment modality and should be planned and delivered by experienced radiation oncologists, physicists, dosimetrists, and therapists. Patient immobilization, respiratory/motion management, image guidance, and careful dosimetry are imperative for safe delivery of SBRT. SBRT should continue to explored and used in treatment of patients with adrenal metastases, and further investigations should be performed to evaluate combining SBRT with novel approaches such as immunotherapy to further improve local control and potentially even impact on systemic control in patients with adrenal metastases.

Hodgkin’s lymphoma accounts for 10% of lymphomas in the United States and is broadly grouped into classical and nodular lymphocyte predominant types. Risk stratification of classical Hodgkin’s determines treatment and broadly includes early-stage favorable, early-stage unfavorable, and advanced (stage III–IV) disease. Painless adenopathy is most common. B symptoms include drenching night sweats, fever >38.0°C, weight loss >10% in 6 months. Most recent trials use positron emission tomography response as judged by Deauville criteria to guide treatment. For early-stage favorable disease, despite multiple large trials, chemotherapy alone is not noninferior to combined chemotherapy and radiation therapy (RT). Late effects with RT are of particular concern due to the disease’s excellent prognosis. Although most trials delivered involved-field RT, involved-site RT is well-accepted internationally and may reduce toxicity. Nodular lymphocyte predominant patients are treated similar to early stage low-grade non-Hodgkin’s lymphoma. Treatment paradigms are different in children.

This chapter focuses on side effects from therapy that impact the quality of life and lifespan of patients with metastatic prostate cancer. Patients with prostate cancer on androgen deprivation therapy (ADT) can develop insulin resistance, diabetes mellitus, hyperlipidemia, osteoporosis, and cardiovascular disease. Men initiating ADT should be counseled on lifestyle modifications, including diet, exercise, smoking cessation, and weight loss for patients on ADT. Pharmacologic therapy for these comorbidities should also be initiated if indicated and reasonable within the clinical setting. The chapter also describes common palliative care challenges in patients with metastatic prostate cancer, including fatigue, pain from bone metastases, vasomotor symptoms, sexual dysfunction and osteoporosis. Fatigue, vasomotor symptoms, and sexual dysfunction can greatly impact the patient’s quality of life.

This chapter describes the controversies in management of metastatic prostate cancer: timing of initiation of systemic therapy for patients with elevated prostate-specific antigen (PSA) as only evidence of disease when local therapies are no longer available; timing of initiation of therapy for patients with asymptomatic low-volume metastases; and the role of first-generation antiandrogens in castration- sensitive disease. For patients with PSA-only disease who are not candidates for salvage therapy, deferred ADT seems to be a reasonable option, particularly for patients with low baseline PSA and low doubling time (<10 months). For patients with asymptomatic metastatic prostate cancer with low-volume disease, there is some suggestion of prostate-cancer-related mortality benefit of early ADT. First-generation antiandrogen monotherapy or combined androgen blockade should not be routinely used for patients with castration-sensitive prostate cancer.

Non-Hodgkin’s lymphoma (NHL) is a heterogeneous disease. Aggressive NHL is a loosely defined group of B-and T-cell histologies with survival measured in months for those untreated. It most commonly presents with a painless enlarging lymph nodes. Multi-agent chemotherapy is indicated in almost all cases of aggressive NHL. Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive NHL and the subject of the majority of clinical data. Limited-stage DLBCL is typically treated with R-CHOP for either three cycles followed by involved-site radiotherapy (ISRT) to 30–36 Gy or R-CHOP for six cycles Advanced-stage DLBCL can be treated with R-CHOP for six to eight cycles with consideration of consolidation RT. Relapsed or refractory DLBCL is typically managed with salvage chemo-immunotherapy followed by autologous stem cell transplant. Further relapse may be managed with chimeric antigen receptor T cell therapy or allogeneic stem cell transplant.

This chapter highlights the historical basis as well as the significant contributions to the evolution of regional chemotherapy of the extremity. Regional therapy, both isolated limb perfusion (ILP) and isolated limb infusion (ILI), were developed with the goal of controlling extremity disease. Melphalan is the most commonly employed agent used in both ILI and ILP and was first described in Creech’s original perfusion. Cisplatin is an agent that has been used in ILP. Cisplatin, an inhibitor of DNA synthesis with significant potential for nephrotoxic and neurotoxic side effects, showed preclinical and clinical potential as a regional chemotherapeutic agent. The role for regional therapy is likely to expand further as new immunotherapeutic agents and targeted molecular therapies are administered systemically with regional therapy to overcome tumor resistance. Oncolytic virotherapy (OV) is a form of immunotherapy that may be potentially combined with regional therapy.

This chapter reviews the most contemporary topical and intralesional therapies used in the treatment of melanoma. In addition to melanoma in-situ, imiquimod has also been used for treatment of locally advanced metastatic melanoma both as monotherapy and as combination therapy with cryotherapy, 5-fluorouracil, topical retinoids, intralesional IL-2, intralesional Bacille Calmette-Guerin (BCG), and radiation therapy with varying degrees of success. While imiquimod is the mainstay topical agent used in the treatment of melanoma in-situ or in-transit metastases, several case reports and series document the use of topical 5-fluorouracil, azelaic acid, and the contact sensitizer diphencyprone (DPCP) for patients with in-transit metastases. In the treatment of melanoma, electrochemotherapy (ECT) has been used with intralesional bleomycin and cisplatinum as a secondary option, as well as systemic chemotherapy. Intralesional treatment with IL-2, T-VEC, Rose Bengal, BCG, interferon, and bleomycin with ECT are all feasible options for treatment of locally advanced melanoma.