**Part 4**

**Scope of Radiation Therapy for Specific Diseases** 

178 Modern Practices in Radiation Therapy

Veronesi U, Marubini E, Mariani L et al (2001) Radiotherapy after breast-conserving surgery

Veronesi U, Orecchia R, Luini A et al (2005) Full-Dose Intraoperative Radiotherapy With

Veronesi U, Orecchia R, Luini A et al (2010) Intraoperative radiotherapy during breast

Veronesi U, Orecchia R, Luini A et al (2001) A preliminary report of intraoperative

Vicini F, Arthur D, Wazer D et al (2011) Limitations of the American Society of Therapeutic

Vicini FA, Baglan KL, Kestin LL et al (2001) Accelerated treatment of breast cancer. *J Clin* 

Vicini FA, Kestin L, Chen P et al (2003) Limited-Field Radiation Therapy in the Management of Early-Stage Breast Cancer. *JNCI Journal of the National Cancer Institute* 95:1205-1210

partial breast irradiation. *Int J Radiat Oncol Biol Phys* 79:977-984

Electrons During Breast-Conserving Surgery. *Ann Surg* 242:101-106

12:997-1003

*Treat* 124:141-151

*Oncol* 19:1993-2001

*Eur J Cancer* 37:2178-2183

in small breast carcinoma: long-term results of a randomized trial. *Ann Oncol*

conserving surgery: a study on 1,822 cases treated with electrons. *Breast Cancer Res* 

radiotherapy (IORT) in limited-stage breast cancers that are conservatively treated.

Radiology and Oncology Consensus Panel guidelines on the use of accelerated

**11** 

*USA* 

**Enhancing Therapeutic Radiation** 

Multiple myeloma (MM) is hematologic malignancy characterized by the accumulation of malignant plasma cells in the bone marrow. The annual incidence of newly diagnosed MM cases in the United States is 3 to 4 per 100,000 people and accounts for approximately 1% of all malignant diseases (Jemal et al., 2011). MM is diagnosed at an advanced stage in 95% of patients and the median age at diagnosis is 65 years. It is a progressive malignancy that begins with monoclonal gammopathy of undetermined significance (MGUS), progresses to asymptomatic or smoldering myeloma and then symptomatic MM. MGUS is a disorder that exhibits clonal proliferation of plasma cells and can eventually evolve into MM or other Bcell disorders (Landgren et al., 2011). Clinically, patients with symptomatic myeloma have 10% or more malignant plasma cells in bone marrow, abnormal levels of serum free light chain, osteolytic bone disease, and show damage to other tissues or organs. Smoldering myeloma has the same plasma cell and M-protein characteristics of symptomatic but lacks evidence of organ damage. A rare type of MM, nonsecretory myeloma, has no detectable Mprotein and accounts for only 1-5% of MM cases. Solitary plasmacytoma is a plasma cell neoplasm that has a single bone or extramedullary lesion (Mendenhall et al., 2003). MM is characterized by significant heterogeneity at the molecular level (Herve et al., 2011) and the bone marrow microenvironment plays an active role in supporting tumor growth, angiogenesis, bone disease, and drug resistance (Anderson and Carrasco, 2011). The disease initially responds to alkylating agents, corticosteroids, and thalidomide but eventually becomes refractory (Sirohi and Powles, 2004). High dose melphalan combined with peripheral blood stem cell transplant has improved the response rate in myeloma patients, but is not curative (Fassas and Tricot, 2001). To date, MM remains uniformly fatal with a

MM is extremely susceptible to radiation treatment and targeted radiotherapy including bone-seeking radiopharmaceuticals, monoclonal antibodies conjugated to radionuclides (radioimmunotherapy), and radiotargeted gene therapy using recombinant oncolytic viruses (radiovirotherapy) now offers a new paradigm to target this systemic malignancy. Combining targeted radiotherapy with radiation-sensitizing chemotherapeutic drugs provides additional benefit by improving treatment efficacy and extends the clinical use of

median survival of approximately 50 months after diagnosis.

**1. Introduction** 

 **Responses in Multiple Myeloma** 

Kelley Salem and Apollina Goel *Free Radical and Radiation Biology Program,* 

> *Department of Radiation Oncology, University of Iowa, Iowa City,*
