Table Of ContentASSOCIATE EDITORS
Jeffrey A. Bogart, MD Abram Recht, MD
Professor and Chair Professor
Department of Radiation Oncology Department of Radiation Oncology
SUNY Upstate Medical University Harvard Medical School
Syracuse, New York Vice Chair
Department of Radiation Oncology
Minesh P. Mehta, MBChB, FASTRO Beth Israel Deaconess Medical Center
Professor and Chair Boston, Massachusetts
Department of Radiation Oncology
FIU Herbert Wertheim College of Medicine Christopher L. Tinkle, MD, PhD
Deputy Director and Chief Assistant Member
Miami Cancer Institute Department of Radiation Oncology
Baptist Health South Florida St. Jude Children’s Research Hospital
Miami, Florida Memphis, Tennessee
Andrea K. Ng, MD, MPH Akila N. Viswanathan, MD, MPH
Professor Professor
Department of Radiation Oncology Department of Radiation Oncology and Molecular Radiation Sciences
Harvard Medical School Johns Hopkins University School of Medicine
Dana-Farber Cancer Institute Baltimore, Maryland
Brigham and Women’s Hospital
Boston, Massachusetts
5
th
EDITION
Gunderson & Tepper’s
C L I N I C A L
R A D I AT I O N
O N C O L O G Y
SENIOR EDITORS
Joel E. Tepper, MD, FASTRO
Hector MacLean Distinguished Professor of Cancer Research
Department of Radiation Oncology
University of North Carolina Lineberger Comprehensive Cancer Center
University of North Carolina School of Medicine
Chapel Hill, North Carolina
Robert L. Foote, MD, FACR, FASTRO
Hitachi Professor of Radiation Oncology Research
Department of Radiation Oncology
Mayo Clinic College of Medicine and Science, Mayo Clinic
Rochester, Minnesota
Jeff M. Michalski, MD, MBA, FACR, FASTRO
Carlos A. Perez Distinguished Professor
Vice Chair of Radiation Oncology
Washington University School of Medicine in St. Louis
St. Louis, Missouri
Elsevier
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GUNDERSON & TEPPER’S CLINICAL RADIATION ONCOLOGY, ISBN: 978-0-323-67246-7
FIFTH EDITION
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9 8 7 6 5 4 3 2 1
To my wife Laurie, for her support and for teaching me what is important in
life, and who has made me a better person;
and to my family, including Miriam, Adam, Abigail, Agustin,
Zekariah, Zohar, Sammy, Marcelo, Jonah, and Aurelio
for the love and support they have given me for many years.
To my parents, who taught me the importance of education,
learning, and doing that which should be done.
To my many mentors who taught me in the past
and those who continue to teach me.
To my professional colleagues, both at the University
of North Carolina and around the country,
who have made me a better physician.
JET
To Kally, who, during our 40 years of marriage, has
made innumerable, selfless, personal sacrifices
for my patients and for my professional career.
To my father, Leonard, who introduced me to the art,
science, and practice of medicine.
To John Earle, Len Gunderson and John Noseworthy.
Their mentorship has enriched my professional life
with experiences, opportunities, and growth beyond my wildest dreams.
To the Mayo Clinic for providing a patient-centered,
collegial, cooperative, compassionate, respectful,
scholarly, integrated, professional, innovative,
and healing environment in which to work and serve.
RLF
To Sheila, my loving wife of 31 years, for her steadfast
support of my career and academic endeavors
while also encouraging me to enjoy life with our family.
To our children, Basia, Sophie, and Jeffrey, who have
enriched my life with their love and support.
To my parents, Richard and Rita, who both faced
their own challenges of cancer therapy
and taught me perspectives of care that you don’t get in medical school.
To my mentors, especially Drs. Jim Cox and Larry Kun,
who we lost this past year during the development
of this new edition. They inspired me to reach higher.
And finally, to my colleagues at Washington University
in St. Louis who have patiently given me
the time and support to contribute to this work.
JMM
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C O N T R I B U TO R S
Christopher D. Abraham, MD Jonathan B. Ashman, MD, PhD Philippe L. Bedard, MD, FRCPC
Assistant Professor Assistant Professor Medical Oncologist
Department of Radiation Oncology Department of Radiation Oncology Princess Margaret Cancer Centre
Washington University School of Medicine Mayo Clinic College of Medicine and Science Associate Professor
in St. Louis Phoenix, Arizona Department of Medicine
St. Louis, Missouri University of Toronto
Matthew T. Ballo, MD Toronto, Ontario, Canada
Ross A. Abrams, MD Professor
Department of Radiation Oncology Radiation Oncology Jonathan J. Beitler, MD, MBA, FACR,
Rush University Medical Center West Cancer Center and Research Institute FASTRO
Chicago, Illinois Memphis, Tennessee Professor
Departments of Radiation Oncology,
Aydah Al-Awadhi, MBBS Lucia Baratto, MD Otolaryngology, and Hematology and
Department of Cancer Medicine Research Fellow Medical Oncology
University of Texas MD Anderson Cancer Department of Radiology Emory University School of Medicine
Center Division of Nuclear Medicine and Molecular Georgia Research Alliance Clinical Scientist
Houston, Texas Imaging Winship Cancer Institute of Emory
Stanford University University
Kaled M. Alektiar, MD Stanford, California NRG Institutional Principal Investigator
Member Atlanta, Georgia
Department of Radiation Oncology Christopher Andrew Barker, MD
Memorial Sloan Kettering Cancer Center Radiation Oncologist Sushil Beriwal, MD, MBA
New York, New York Director of Clinical Investigation Professor
Department of Radiation Oncology Department of Radiation Oncology
Jan Alsner, PhD Memorial Sloan Kettering Cancer Center UPMC Hillman Cancer Center
Professor New York, New York University of Pittsburgh School of Medicine
Department of Experimental Clinical Pittsburgh, Pennsylvania
Oncology Adam Bass, MD
Aarhus University Hospital Associate Professor of Medicine Ranjit S. Bindra, MD, PhD
Aarhus, Denmark Dana-Farber Cancer Institute Associate Professor
Harvard Medical School Therapeutic Radiology
K. Kian Ang, MD, PhD† Boston, Massachusetts Yale Medical School
Professor and Gilbert H. Fletcher Endowed New Haven, Connecticut
Chair Brian C. Baumann, MD
Department of Radiation Oncology Assistant Professor Michael W. Bishop, MD
University of Texas MD Anderson Cancer Department of Radiation Oncology Assistant Member
Center Washington University School of Medicine Department of Oncology
Houston, Texas in St. Louis St. Jude Children’s Research Hospital
St. Louis, Missouri Memphis, Tennessee
Lilyana Angelov, MD, FAANS, FRCS(C)
The Kerscher Family Chair for Spine Tumor Beth M. Beadle MD, PhD Rachel Blitzblau, MD, PhD
Excellence Associate Professor Associate Professor
Head, Section of Spine Tumors Department of Radiation Oncology Department of Radiation Oncology
Professor, Department of Neurological Stanford University Duke University Medical Center
Surgery Stanford, California Durham, North Carolina
Cleveland Clinic Lerner College of Medicine
at Case Western Reserve University Staci Beamer, MD Jeffrey A. Bogart, MD
Rose Ella Burkhart Brain Tumor and Neuro- Assistant Professor Professor and Chair
Oncology Center Division of Cardiovascular and Thoracic Department of Radiation Oncology
Department of Neurosurgery Surgery SUNY Upstate Medical University
Neurological Institute and Taussig Cancer Mayo Clinic College of Medicine and Science Syracuse, New York
Institute Phoenix, Arizona
Cleveland Clinic James A. Bonner, MD
Cleveland, Ohio Chairman and Merle M. Salter Professor
Department of Radiation Oncology
The University of Alabama at Birmingham
Birmingham, Alabama
†Deceased
vii
viii CONTRIBUTORS
J. Daniel Bourland, PhD, MSPH Bruce A. Chabner, MD Stephen G. Chun, MD
Professor Clinical Director, Emeritus Assistant Professor
Radiation Oncology, Biomedical Massachusetts General Hospital Cancer Department of Radiation Oncology
Engineering, and Physics Center The University of Texas MD Anderson
Wake Forest School of Medicine Massachusetts General Hospital Cancer Center
Winston-Salem, North Carolina Professor of Medicine Houston, Texas
Harvard Medical School
Joseph A. Bovi, MD Boston, Massachusetts Christine H. Chung, MD
Department of Radiation Oncology Chair, Department of Head and Neck–
Medical College of Wisconsin Michael D. Chan, MD Endocrine Oncology
Froedtert Memorial Lutheran Hospital Associate Professor and Vice Chairman Moffitt Cancer Center
Milwaukee, Wisconsin Department of Radiation Oncology Tampa, Florida
Wake Forest School of Medicine
Andrew G. Brandmaier, MD, PhD Winston-Salem, North Carolina Peter W. M. Chung, MBChB, MRCP,
Assistant Professor FRCR, FRCPC
Department of Radiation Oncology Samuel T. Chao, MD Radiation Oncologist
Weill Cornell Medical College Associate Professor Princess Margaret Cancer Centre
New York, New York Department of Radiation Oncology Associate Professor
Rose Ella Burkhardt Brain Tumor and Department of Radiation Oncology
John Breneman, MD Neuro-Oncology Center University of Toronto
Professor Cleveland Clinic Toronto, Ontario, Canada
Department of Radiation Oncology Cleveland, Ohio
University of Cincinnati Jeffrey M. Clarke, MD
Cincinnati Children’s Hospital Medical Anne-Marie Charpentier, MD, FRCPC Assistant Professor
Center Radiation Oncologist Department of Medicine
Cincinnati, Ohio Centre Hospitalier de l’Université de Division of Medical Oncology
Montréal Duke University School of Medicine
Juan P. Brito, MD Clinical Assistant Professor Durham, North Carolina
Assistant Professor of Medicine Université de Montréal
Division of Endocrinology, Diabetes, Montréal, Quebec, Canada Louis S. Constine, MD, FASTRO, FACR
Metabolism, and Nutrition The Philip Rubin Professor of Radiation
Mayo Clinic College of Medicine and Aadel A. Chaudhuri, MD Oncology and Pediatrics
Science, Mayo Clinic Assistant Professor Vice Chair, Department of Radiation
Rochester, Minnesota Department of Radiation Oncology Oncology
Washington University School of Medicine James P. Wilmot Cancer Center
Michael D. Brundage, MD, MSc, FRCPC in St. Louis University of Rochester Medical Center
Professor St. Louis, Missouri The Judy DiMarzo Cancer Survivorship
Oncology and Public Health Sciences Program
Queen’s University Nathan I. Cherny, MBBS, FRACP, FRCP James P. Wilmot Cancer Institute
Radiation Oncologist Norman Levan Chair of Humanistic University of Rochester Medical Center
Cancer Centre of Southeastern Ontario Medicine Rochester, New York
Kingston, Ontario, Canada Cancer Pain and Palliative Medicine Service
Shaare Zedek Medical Center Benjamin W. Corn, MD
Matthew R. Callstrom, MD, PhD Jerusalem, Israel Chairman
Professor of Radiology Department of Radiation Medicine
Mayo Clinic College of Medicine and Fumiko Chino, MD Shaare Zedek Medical Center
Science, Mayo Clinic Assistant Professor Jerusalem, Israel;
Rochester, Minnesota Department of Radiation Oncology Professor
Memorial Sloan Kettering Cancer Center Tel Aviv University School of Medicine
Felipe A. Calvo, MD, PhD New York, New York Tel Aviv, Israel
Professor and Chairman
Department of Oncology John P. Christodouleas, MD, MPH Allan Covens, MD, FRCSC
Clinica Universidad de Navarra Attending Physician Professor
Madrid, Spain Department of Radiation Oncology Department of Obstetrics and Gynecology
University of Pennsylvania Division of Gynecologic Oncology
George M. Cannon, MD Philadelphia, Pennsylvania Sunnybrook Health Sciences Centre
Adjunct Assistant Professor University of Toronto
Radiation Oncology Toronto, Ontario, Canada
University of Utah
Salt Lake City, Utah
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CONTRIBUTORS ix
Christopher H. Crane, MD Ryan W. Day, MD Hugues Duffau, MD, PhD
Department of Radiation Oncology Instructor of Surgery Professor and Chairman
Memorial Sloan Kettering Cancer Center Mayo Clinic Montpellier University Medical Center
New York, New York Scottsdale, Arizona; Institute for Neurosciences of Montpellier
Senior Fellow Hôpital Gui de Chauliac
Carien L. Creutzberg, MD, PhD Department of Surgical Oncology Montpellier, France
Professor University of Texas MD Anderson Cancer
Department of Radiation Oncology Center Thierry Duprez, MD
Leiden University Medical Center Houston, Texas Medical Imaging and Radiology
Leiden, Netherlands Universite Catholique de Louvain
Amanda J. Deisher, PhD Head of Neurology/Head and Neck Section
Juanita M. Crook, MD, FRCP Instructor Cliniques Universitaires Saint-Luc
Professor Department of Radiation Oncology Brussels, Belgium
Department of Radiation Oncology Mayo Clinic College of Medicine and
University of British Columbia Science, Mayo Clinic Peter T. Dziegielewski, MD, FRCS(C)
Radiation Oncologist Rochester, Minnesota Associate Professor
Center for the Southern Interior Chief, Division of Head and Neck Oncologic
British Columbia Cancer Agency Thomas F. DeLaney, MD Surgery
Kelowna, British Columbia, Canada Andres Soriano Professor of Radiation Microvascular Reconstructive Surgery
Oncology Kenneth W. Grader Professor
Brian G. Czito, MD Harvard Medical School University of Florida College of Medicine
Professor Associate Medical Director Gainesville, Florida
Department of Radiation Oncology Francis H. Burr Proton Therapy Center
Duke Cancer Institute Massachusetts General Hospital Charles Eberhart, MD, PhD
Duke University Boston, Massachusetts Professor
Durham, North Carolina Pathology, Ophthalmology, and Oncology
Phillip M. Devlin, BPhil, MTS, EdM, MD, Johns Hopkins University School of
Bouthaina S. Dabaja, MD FACR, FASTRO, FFRRSCI (Hon) Medicine
Professor Chief, Division of Brachytherapy Baltimore, Maryland
Section Chief, Hematology Dana-Farber/Brigham and Women’s Cancer
Department of Radiation Oncology Center David W. Eisele, MD, FACS
University of Texas MD Anderson Cancer Associate Professor of Radiation Oncology Andelot Professor and Director
Center Harvard Medical School Department of Otolaryngology–Head and
Houston, Texas Institute Physician Neck Surgery
Dana-Farber Cancer Institute Johns Hopkins University School of
Thomas B. Daniels, MD Boston, Massachusetts Medicine
Department of Radiation Oncology Baltimore, Maryland
Mayo Clinic Arizona James J. Dignam, PhD
Assistant Professor of Radiation Oncology Professor Suzanne B. Evans, MD, MPH
Mayo Clinic College of Medicine and Science Department of Public Health Sciences Associate Professor, Therapeutic Radiology
Phoenix, Arizona University of Chicago Associate Director, Residency Program
Chicago, Illinois Yale University School of Medicine
Marc David, MD Statistics and Data Management Center New Haven, Connecticut
Assistant Professor NRG Oncology
Department of Radiation Oncology Michael Farris, MD
McGill University Health Centre Don S. Dizon, MD Assistant Professor
Montreal, Quebec, Canada Associate Professor Department of Radiation Oncology
Warren Alpert Medical School of Brown Wake Forest Baptist Health
Laura A. Dawson, MD University Winston-Salem, North Carolina
Professor Head of Women’s Cancers at Lifespan
Department of Radiation Oncology Cancer Institute Mary Feng, MD
Princess Margaret Cancer Centre Director of Medical Oncology Professor
University of Toronto Rhode Island Hospital Department of Radiation Oncology
Toronto, Ontario, Canada Providence, Rhode Island University of California, San Francisco
San Francisco, California
Jeffrey S. Dome, MD, PhD
Chief Rui P. Fernandes, MD, DMD, FACS,
Hematology and Oncology FRCS(Ed)
Children’s National Health System Associate Professor
Washington, DC OMS, Neurosurgery, Orthopedics, Surgery
University of Florida College of Medicine
Jacksonville, Florida
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x CONTRIBUTORS
Gini F. Fleming, MD Adam S. Garden, MD Dennis E. Hallahan, MD
Professor Professor Elizabeth H. and James S. McDonnell
Department of Medicine Department of Radiation Oncology Distinguished Professor of Medicine
University of Chicago Medical Center University of Texas MD Anderson Cancer Chair, Department of Radiation Oncology
Chicago, Illinois Center Washington University School of Medicine
Houston, Texas in St. Louis
John C. Flickinger, MD Barnes Jewish Hospital
Professor Lilian T. Gien, MD St. Louis, Missouri
Department of Radiation Oncology Associate Professor
University of Pittsburgh Division of Gynecologic Oncology Christopher L. Hallemeier, MD
Radiation Oncologist Odette Cancer Center Associate Professor
Department of Radiation Oncology Sunnybrook Health Sciences Centre Department of Radiation Oncology
UPMC Presbyterian-Shadyside Toronto, Ontario, Canada Mayo Clinic College of Medicine and
Pittsburgh, Pennsylvania Science, Mayo Clinic
Mary K. Gospodarowicz, MD, FRCPC, Rochester, Minnesota
Robert L. Foote, MD, FACR, FASTRO FRCR (Hon)
Hitachi Professor of Radiation Oncology Professor and Chair Michele Y. Halyard, MD
Research Department of Radiation Oncology Professor
Department of Radiation Oncology University of Toronto Department of Radiation Oncology
Mayo Clinic College of Medicine and Princess Margaret Hospital Mayo Clinic College of Medicine and
Science, Mayo Clinic Toronto, Ontario, Canada Science, Mayo Clinic
Rochester, Minnesota Phoenix, Arizona
Cai Grau, MD, DMSc
Silvia C. Formenti, MD Professor Marc Hamoir, MD
Sandra and Edward Meyer Professor of Department of Oncology and Danish Centre Head and Neck Surgery
Cancer Research for Particle Therapy Chairman of the Executive Board of the
Chairman, Department of Radiation Aarhus University Hospital Cancer Center
Oncology Aarhus, Denmark Saint-Luc University Hospital Cancer Center
Associate Director, Meyer Cancer Institute Brussels, Belgium
Weill Cornell Medical College Vincent Grégoire, MD, PhD, FRCR
Radiation Oncologist in Chief Radiation Oncology Department Timothy P. Hanna, MD, MSc, PhD,
New York Presbyterian Hospital Centre Léon Bérard FRCPC
New York, New York Lyon, France Clinician Scientist
Cancer Care and Epidemiology
Benedick A. Fraass, PhD, FAAPM, Chul S. Ha, MD Cancer Research Institute at Queen’s
FASTRO, FACR Professor University
Vice Chair for Research, Professor and Department of Radiation Oncology Radiation Oncologist
Director of Medical Physics University of Texas Health Science Center at Cancer Centre of Southeastern Ontario
Department of Radiation Oncology San Antonio Kingston General Hospital
Cedars-Sinai Medical Center San Antonio, Texas Kingston, Ontario, Canada
Health Sciences Professor
Department of Radiation Oncology Michael G. Haddock, MD Paul M. Harari, MD
University of California, Los Angeles Professor of Radiation Oncology Jack Fowler Professor and Chairman
Los Angeles, California; Mayo Clinic College of Medicine and Human Oncology
Professor Emeritus Science, Mayo Clinic University of Wisconsin School of Medicine
Department of Radiation Oncology Rochester, Minnesota and Public Health
University of Michigan Madison, Wisconsin
Ann Arbor, Michigan Ezra Hahn, MD, FRCPC
Radiation Oncologist Joseph M. Herman, MD, MSc, MSHCM
Carolyn R. Freeman, MBBS, FRCPC, Department of Radiation Oncology Professor
FASTRO Princess Margaret Cancer Centre Department of Radiation Oncology
Professor of Oncology and Pediatrics Sunnybrook Health Sciences Centre of the The University of Texas MD Anderson
Mike Rosenbloom Chair of Radiation University of Toronto Cancer Center
Oncology Toronto, Ontario, Canada Houston, Texas
McGill University
Montreal, Quebec, Canada Matthew D. Hall, MD, MBA Michael G. Herman, PhD
Radiation Oncology Professor
Miami Cancer Institute Department of Radiation Oncology
Baptist Health South Florida Mayo Clinic College of Medicine and
Miami, Florida Science, Mayo Clinic
Rochester, Minnesota
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CONTRIBUTORS xi
Caroline L. Holloway, MD, FRCPC Patricia A. Hudgins, MD Brian D. Kavanagh, MD
Clinical Assistant Professor Professor Professor and Chair
Department of Radiation Oncology Department of Radiology and Imaging Department of Radiation Oncology
BC Cancer Agency, Vancouver Island Centre Sciences University of Colorado School of Medicine
Victoria, British Columbia, Canada Emory University School of Medicine University of Colorado Comprehensive
Atlanta, Georgia Cancer Center
Bradford S. Hoppe, MD, MPH Aurora, Colorado
Associate Professor Christine A. Iacobuzio-Donahue, MD,
Department of Radiation Oncology PhD Kara M. Kelly, MD
Mayo Clinic College of Medicine and Director, David M. Rubenstein Center for Waldemar J. Kaminski Endowed Chair of
Science, Mayo Clinic Pancreatic Cancer Research Pediatrics
Jacksonville, Florida Department of Radiation Oncology Department of Pediatric Oncology
Memorial Sloan Kettering Cancer Center Roswell Park Cancer Institute
Michael R. Horsman, PhD, DMSc New York, New York Division Chief, Pediatric Hematology/
Professor Oncology and Research Professor
Department of Experimental Clinical Andrei Iagaru, MD Department of Pediatrics
Oncology Assistant Professor University of Buffalo School of Medicine
Aarhus University Hospital Department of Radiology and Biomedical Sciences
Aarhus, Denmark Division of Nuclear Medicine and Molecular Buffalo, New York
Imaging
Janet K. Horton, MD Stanford University Amir H. Khandani, MD
Adjunct Associate Professor Stanford, California Associate Professor of Radiology
Duke University Medical Center Chief, Division of Nuclear Medicine
Durham, North Carolina Nicole M. Iñiguez-Ariza, MD Department of Radiology
Division of Endocrinology, Diabetes, University of North Carolina at Chapel Hill
Julie Howle, MBBS, MS, FRACS, FACS Metabolism, and Nutrition Chapel Hill, North Carolina
Surgical Oncologist Mayo Clinic College of Medicine and
Westmead Private Hospital Science, Mayo Clinic Deepak Khuntia, MD
Westmead, New South Wales, Australia; Rochester, Minnesota; Vice President, Medical Affairs
Clinical Senior Lecturer Department of Endocrinology and Oncology Systems
Department of Surgery Metabolism Varian Medical Systems, Inc.
The University of Sydney Instituto Nacional de Ciencias Médicas y Palo Alto, California;
Sydney, New South Wales, Australia Nutrición Salvador Zubirán Radiation Oncologist
Mexico City, Mexico Valley Medical Oncology Consultants
Brian A. Hrycushko, PhD Pleasanton, California
Assistant Professor Jedediah E. Johnson, PhD
Department of Radiation Oncology Assistant Professor Ana Ponce Kiess, MD, PhD
UT Southwestern Medical Center Department of Radiation Oncology Assistant Professor
Dallas, Texas Mayo Clinic College of Medicine and Departments of Radiation Oncology and
Science, Mayo Clinic Molecular Radiation Sciences
David Hsu, MD, PhD Rochester, Minnesota Johns Hopkins University School of
William Dalton Family Assistant Professor Medicine
Division of Medical Oncology Joseph G. Jurcic, MD Baltimore, Maryland
Department of Internal Medicine Professor of Medicine
Duke Cancer Institute Director, Hematologic Malignancies Section Joseph K. Kim, MD
Duke University Department of Medicine Resident Physician
Durham, North Carolina Columbia University Irving Medical Center Department of Radiation Oncology
Attending Physician New York University
Chen Hu, PhD New York-Presbyterian Hospital/Columbia New York, New York
Assistant Professor of Oncology University Irving Medical Center
Division of Biostatistics and Bioinformatics New York, New York Susan J. Knox, MD, PhD
Sidney Kimmel Comprehensive Cancer Associate Professor
Center John A. Kalapurakal, MD, FACR, Department of Radiation Oncology
Johns Hopkins University FASTRO Stanford University
Baltimore, Maryland Professor Stanford, California
Statistics and Data Management Center Department of Radiation Oncology
NRG Oncology Northwestern University Wui-Jin Koh, MD
Chicago, Illinois Senior Vice President and Chief Medical
Officer
National Comprehensive Cancer Network
(NCCN)
Philadelphia, Pennsylvania
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