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Image guided radiotherapy (IGRT) in pediatrics provides a means for reduction of treatment volumes by permitting for the use of highly conformal plans with smaller treatment margins. IGRT may additionally allow for dose escalation and adaptive radiotherapy strategies. Current practice patterns and clinical protocols support the use of weekly or daily IGRT as standard practice in pediatric brain-directed IGRT. However, the benefits of IGRT must be weighed against its costs including potentially significant additional radiation dose, supporting the need to study lower dose IGRT protocols in this population. This chapter reviews common modalities of IGRT and the literature regarding its use specific to pediatric brain radiotherapy.

Hodgkin lymphoma represents approximately 4% of childhood (0–14 years old) malignancies and 15% of adolescent (15–19 years old) malignancies [1]. Bimodal incidence peaks in adolescent and adult age ranges [2]. The Reed-Sternberg cell, CD15+/CD30+, is a key histologic feature in classic subtypes (nodular sclerosing, lymphocyte-rich, lymphocyte-depleted, and mixed cellular) but not nodular lymphocyte predominant Hodgkin lymphoma (NLPHL). Association with Epstein-Barr virus is highly variable (~30 to 40% in immunocompetent pediatric classical Hodgkin lymphoma, 80% + in immunocompromised patients) [3]. The radiation dose range in major North American trials has been 19.8–25.5 Gy in 1.5–1.8 Gy daily fractions, however, higher doses of 30 Gy are being employed among patients with imcomplete response following chemotherapy and in relapse studies.

This chapter describes altered fraction regimens used in the management of localized and metastatic soft tissue sarcomas. Rationale, disease outcomes, toxicity, and planning and delivery methodology are provided for stereotactic radiotherapy, interdigitated chemoradiation, intraoperative radiation therapy, and postoperative interstitial brachytherapy techniques.

Non-Hodgkin lymphoma (NHL) is a heterogeneous group of B-cell, T-cell, and natural killer (NK)-cell neoplasms that lack the pathologic characteristics seen in Hodgkin disease (HD).