Whole brain radiotherapy (WBRT) is the standard non-surgical treatment for brain metastatic disease, but rarely eradicates bulky metastases from most common cancers. Recent literature has demonstrated the safety and efficacy of delivering very high focal doses of radiation (by radiosurgical techniques) to the gross tumour volume of bulky brain metastases, thereby obtaining more certain local control than is achieved by WBRT. In this paper we report a study of 11 patients with bulky brain metastases in whom an intensity-modulated radiation therapy (IMRT) facility has been used to concomitantly boost the gross tumour volume of bulky brain metastatic disease (to 40 Gy) during a standard 30 Gy in 10 fractions WBRT schedule. No acute or subacute morbidity was encountered, and good early control data were noted. We discuss the perceived advantages of such a technique.

Objectives To identify consensus on patient prioritisation for rectal hydrogel spacer use during radiation therapy for the treatment of prostate cancer in the UK. Design Delphi study consisting of two rounds of online questionnaires, two virtual advisory board meetings and a final online questionnaire. Setting Radical radiation therapy for localised and locally advanced prostate cancer in the UK. Participants Six leading clinical oncologists and one urologist from across the UK. Interventions Rectal hydrogel spacer. Primary and secondary outcome measures None reported. Results The panel reached consensus on the importance of minimising toxicity for treatments with curative intent and that even low-grade toxicity-related adverse events can significantly impact quality of life. There was agreement that despite meeting rectal dose constraints, too many patients experience rectal toxicity and that rectal hydrogel spacers in eligible patients significantly reduces toxicity-related adverse events. However, as a consequence of funding limitations, patients need to be prioritised for spacer use. A higher benefit of spacers can be expected in patients on anticoagulation and in patients with diabetes or inflammatory bowel disease, but consensus could not be reached regarding patient groups expected to benefit less. While radiation therapy regimen is not a main factor determining prioritisation, higher benefit is expected in ultrahypofractionated regimens. Conclusion There is a strong and general agreement that all patients with prostate cancer undergoing radical radiation therapy have the potential to benefit from hydrogel spacers. Currently, not all patients who could potentially benefit can access hydrogel spacers, and access is unequal. Implementation of the consensus recommendations would likely help prioritise and equalise access to rectal spacers for patients in the UK.

Anorectal malignant melanoma is a rare culprit of malignancies in the anorectal region. With a presentation that mimics the vastly more common colorectal tumours, clinical misdiagnosis and diagnostic delays often occur, contributing to a dismal prognosis. The authors report a case of metastatic anorectal malignant melanoma presenting as seizures. Though our standard diagnostic pathway for suspected anorectal malignancies was followed, and despite the patient having computerized tomography (CT) of the head earlier, this presentation nonetheless led to a prolongation of time needed to reach histological diagnosis and delay in commencing definitive treatment. It also highlights the paucity of research into the pathophysiology and management of this infrequent but aggressive disease, and the need for raising awareness about this condition to the medical community so that it is considered as a plausible differential diagnosis from the outset and diagnostic pathways adjusted accordingly.