Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How long can you delay the start of radiation in a patient who has received adjuvant chemotherapy after lumpectomy/mastectomy?
I generally start radiation between 3 and 8 weeks following the last dose of chemotherapy. Since most protocol guidelines specify radiation should start within 12 weeks of the last day of chemo is within the last surgical procedure, I use that as an outside window I am comfortable with for the most ...
Do you still routinely offer post-op radiation after bone fixation?
I'm a little nervous about the phrasing of the question as it implies that there is an ongoing evolution in practice here. I don't think there is. To emphasize, PORT is--and remains--the standard of care following orthopedic stabilization of bony metastases: Alcorn et al., PMID 38788923Now, it is fa...
What if any, is your radiation approach to treating hepatic metastases abutting/invading luminal GI structures?
My approach to hepatic metastases abutting luminal GI structures is fundamentally conservative. When liver metastases abut or threaten invasion of the stomach, duodenum, or bowel, I do not treat this as a classic SBRT scenario. The priority shifts from local ablation to durable local control and pre...
When do you recommend patients get vaccinations with respect to their RT course?
I agree with @Dr. First Last's reply, and find that some patients are under the impression they are immunocompromised during radiation therapy and thus should avoid vaccines, when in fact the opposite is true. The skepticism behind the science of vaccination also can lead to avoidance, and so I try ...
How do you approach the management of basal cell carcinoma with single lymph node involvement?
If all the tumor has been resected, I would recommend adjuvant XRT on the nodal basin, depending on the age of the patient. For very old patients or patients with comorbidities, observation might be warranted. If there is remaining BCC visible on examination or scans, I would treat systemically with...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
When treating chestwall + RNI with VMAT, how much do you crop the PTV into lung as is done with the PTVeval in 3D contouring guides?
We don’t edit PTV for VMAT plans. Chest wall contour (CTV) only includes pec muscles (not intercostal muscles or ribs like RTOG ATLAS) so the amount of PTV (3-5 mm expansion of CTV) overlap with lung is minimal to begin with. We do use a dummy bolus to create skin flash.
Is is okay to offer SBRT for central lung tumors in direct contact with the esophagus?
My short answer is: probably not, if you are considering standard regimens like 10Gy x 5. The risk of fistula appears to be significant if you expose the esophagus to full prescription dose. My group described two patients receiving lung SBRT who developed significant esophageal complications (fistu...
What dose-fractionation scheme and esophageal constraints should be used to treat an ultra-central, medically inoperable, stage I NSCLC abutting the esophagus?
For lesions abutting the esophagus, SBRT with BED >100 Gy should NOT be used due to high risk for ulceration and even fistula. Instead of SBRT, more fractionated radiotherapy with BED <84 Gy should be considered (60 Gy in 15 FX is still too high for the esophagus). In addition to maximal point dose,...
When contouring locally advanced NSCLC, how do you define your ITV if your iGTV overlaps with an OAR?
For locally advanced lung, I have 2 slightly different approaches for primary vs nodes. For primary, GTV to iGTV (with 4DCT or DIBH scans x 3 at sim in certain cases) to CTV (5 mm expansion cropped to anatomical barriers to spread) to PTV (5 mm uniform expansion). I let the iGTV overlap the esophagu...