Avoiding Severe Toxicity From Combined BRAF Inhibitor and Radiation Treatment: Consensus Guidelines from the Eastern Cooperative Oncology Group (ECOG)

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Avoiding Severe Toxicity From Combined BRAF Inhibitor and Radiation Treatment: Consensus Guidelines from the Eastern Cooperative Oncology Group (ECOG) Christopher J. Anker, MD, Kenneth F. Grossmann, MD, PhD, Michael B. Atkins, MD, Gita Suneja, MD, Ahmad A. Tarhini, MD, PhD, John M. Kirkwood, MD International Journal of Radiation Oncology • Biology • Physics Volume 95, Issue 2, Pages 632-646 (June 2016) DOI: 10.1016/j.ijrobp.2016.01.038 Copyright © 2016 Elsevier Inc. Terms and Conditions

Fig. 1 Cystic proliferation and underlying brisk dermatitis noted over right flank and axilla 1 month after palliative radiation therapy given concurrently with vemurafenib. International Journal of Radiation Oncology • Biology • Physics 2016 95, 632-646DOI: (10.1016/j.ijrobp.2016.01.038) Copyright © 2016 Elsevier Inc. Terms and Conditions

Fig. 2 Images of cutis verticis gyrata appearance obtained 2 weeks after starting vemurafenib; the BRAFi was started 4 days after whole brain radiation therapy. (A) Lateral view with biopsy site circled, showing follicular hyperkeratosis and syringosquamous metaplasia (B) Posterior view. International Journal of Radiation Oncology • Biology • Physics 2016 95, 632-646DOI: (10.1016/j.ijrobp.2016.01.038) Copyright © 2016 Elsevier Inc. Terms and Conditions

Fig. 3 (A) Axial, (B) sagittal, and (C) coronal views of radiation plan for patient with bowel perforation 1 month after dabrafenib and trametinib were started. These systemic agents were started 10 days after 20 Gy in 5 fractions using a 4 field technique with 10 MV photons to pelvic bone metastases (shaded red). The V18 Gy and V20 Gy of the large bowel loops (green), small bowel loops (orange), and bowel bag volume (not shown) were 180 and 90 cc, 460 and 230 cc, and 1450 and 750 cc, respectively. (A color version of this figure is available at www.redjournal.org.) International Journal of Radiation Oncology • Biology • Physics 2016 95, 632-646DOI: (10.1016/j.ijrobp.2016.01.038) Copyright © 2016 Elsevier Inc. Terms and Conditions