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Prostate cancer afflicts a substantial portion of the male population with increasing incidence each decade after the age of 40. Standard of care for localized disease at presentation includes prostatectomy and/or radiation therapy which can include management of pelvic lymph nodes. However, the selection of lymph nodes treated by radiotherapy remains variable among practitioners including individual practitioners in the same institution. We present a patient with prostate adenocarcinoma who underwent radical prostatectomy with adjuvant radiotherapy for lymph node involvement and developed mesorectal failure secondary to metastatic spread to untreated tissue.

Radiation therapy delivered post-prostatectomy can provide durable disease-free clinical outcomes. There remains debate as to whether the radiation should be applied to patients with high risk features post-surgery or deferred until there is biomarker evidence of clinical recurrence. Prior to the development of advanced-technology metabolic and anatomic imaging, the radiation therapy treatment fields were applied based on historical models of patterns of failure including the former capsule region, undersurface of the bladder, and the bladder urethral anastomosis. Although outcomes of therapy were good, the choice of the target was not image directed. Modern imaging has provided an advantage for targeting as radiation oncologists can be more secure of high-risk areas and in turn titrate dose to regions deemed of intermediate and low risk. In this paper we describe strategies for application of modern axumin imaging for patient care with radiation therapy post prostatectomy.

As treatment for prostate cancer matures with many options for local, regional and systemic care, patients are living longer. Coupled with aggressive therapy for oligometastatic disease and improvements in multiple treatment pathways including radiopharmacy, both disease-free and overall survival are improving for many patients. Success can also bring new challenges that require new thought processes for care. In this paper we present two patients who had undergone previous radiation therapy for adenocarcinoma of the prostate with curative intent who required consideration for re-irradiation each more than 15 years away from primary management.

Radiation therapy remains important in the modern management of both Hodgkin and non-Hodgkin lymphoma. Radiation is applied as both consolidation therapy post chemotherapy and primary therapy for selected limited volume clinically favorable histology. Application of modern therapy techniques permits more sparing of normal tissue in all anatomical locations. Modern image guidance permits both security in daily patient treatment set up and permits strategic titration of the planning target volume to further spare normal tissue. Four-dimensional planning makes certain targets are fully treated in all phases of the breathing cycle. Dose painting with altered fractionation permits identification of low, intermediate, and high-risk areas of concern and treat each in a single plan with multiple fractionation schemes saving both time of treatment and cost of therapy. In this paper we present multiple examples of the application of modern therapy techniques in lymphoma management and demonstrate advantages of modern radiation in several anatomical regions.

Radiation therapy has undergone an extraordinary transformation in treatment technology. Daily patient care is vastly different today than the past with less normal tissue in the treatment field and fewer acute sequelae during and immediately post therapy. It is anticipated that modern therapy will decrease acute effects during treatment. Modern primary care physicians and internal medicine/emergency physicians will encounter more patients in their practice who are survivors of therapy. In this paper we review current expectations for clinical sequelae of management and strategies to both identify and manage treatment effects moving forward including what is needed in the medical record for evaluation of late effects.