Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For a patient receiving postmastectomy IMRT to chest wall with expander and regional nodes including IMN, what constraint would you use for dose to the contralateral chest wall/implant if the patient also had a mastectomy and reconstruction on that side?
I use similar numbers and tend to accept a more generous approach to achieve coverage if the patient has undergone a contralateral mastectomy vs intact breast.
Does delay to the time of lumpectomy impact your decision to omit radiation?
There seem to be two issues to consider in this situation. One is whether patients undergoing neoadjuvant endocrine therapy, then lumpectomy without RT, have an acceptable local recurrence rate. The only study I know of directly addressing this issue was presented at a poster session of the 2017 San...
How do you approach breast hypofractionation RNI with the results of the Skagen Trial 1?
There are multiple prospective/randomized studies showing non-inferiority for complications or cancer outcome with hypofractionation and RNI, including Wang et al., PMID 30711522, HypoG-01, FABREC, RT-CHARM, and the subset arm of STARTb. The primary endpoint of DKSG was also lymphedema, which was no...
Are there situations in which you would definitely recommend radiation in an elderly patient with ER+, early stage breast cancer?
I always have a little trepidation in answering questions whereby I would “definitely†recommend any therapeutic path as clinical decision making needs to be a bit more nuanced. Every situation requires a careful weighing of multiple inputs including clinical trial data and patient-specific fact...
How do you counsel families of pediatric patients regarding risk of secondary malignancy or IQ changes with cranial radiation using photons?
It’s a great question as these are two of the scariest things that families face when you relay the potential risks of cranial radiotherapy. Simple things like timing of these topics in the consent discussion can make a difference. Don’t start with the scariest potential risk when doing the consent,...
What is your approach to post-operative radiation (when to offer, volume, dose, fractionation) for a primary intraosseous squamous cell carcinoma (PIOCC) of the head & neck?
I probably would. 60 Gy in 30 fractions for negative margins and electively treat the neck.
What dose of radiation do you use for neoadjuvant chemoradiation in esophageal cancer?
The CROSS trial does not exist in a vacuum. We have a long history of esophageal trials by the RTOG and other cooperative groups that consistently used chemoradiation to 5040 cGy, and this remains the standard of care in the U.S. That said, if I have to treat a very long tumor, resulting in lung met...
How do you manage symptomatic radiation necrosis not responsive to steroids?
I agree with the above recommendations. We review these cases at our brain tumor board. We often start off with confirming the diagnosis using MRI with perfusion. If perfusion is equivocal (hard to interpret or lesion is too small) and the patient is asymptomatic, we follow. If the patient is sympto...
How do you modify the management of an SLE patient with active systemic lupus for a gynecological cancer that normally requires pelvic radiation and brachytherapy?
I have not done any specific modification for SLE. I would treat with VMAT and IGRT with a 5 mm PTV margin and ensure EBRT and HDR meet ideal dose constraints for OARs.
How would you treat a small cell carcinoma with a 4 cm right Bartholin's gland primary and a single small right inguinal adenopathy?
It’s like limited-stage SCLC would be treated with cis plus etoposide and RT (60-66 Gy). Will favor no elective pelvic node RT if pure small cell carcinoma and no mixed component.