Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you boost a positive parametrial margin in endometrial cancer after TAH BSO?
For a patient with a positive margin, we would first want to image post-operatively to make sure there isn't any gross disease. MRI is most helpful for this. The goal for the dose would be to treat this region to about 60 Gy. We would initially treat the pelvis to 45 Gy with an integrated boost at t...
Is it ethical to still prescribe conventionally-fractionated treatments for breast cancer, prostate cancer, and osseous metastatic disease for patients that do not have contraindications to hypofractionation?
Wow - one of the most interesting questions on the platform.Zooming out: what’s the motivation behind asking this?Is it agenda-driven? An attempt to “finger wag”? Or confusion around why the zeitgeist hints that 1.8 Gy fractions are “unethical”?"Ethical" needs a contextual definition here. In genera...
What dose/fractionation scheme would you employ for treatment of a bone with impending fracture prior to surgical fixation?
There are several advantages to pre-op RT. For example, the target is much better defined pre-op, and normal tissue exposure can be minimized compared to post-op RT. However, treatment fields should be constructed to minimize the risk of RT-related post-op complications including delayed wound heali...
How do you approach a patient with inoperable urothelial carcinoma of the bladder with persistent non-muscle invasive disease despite intravesical BCG/IFN and intravesical chemotherapy?
T1 high grade urothelial carcinoma, with persistent disease after intra-vesicular therapy (e.g., BCG) is an aggressive disease and progression to invasive urothelial cancer is common. This entity tends to be multifocal / diffuse and transurethral resection (TURBT) alone is often inadequate as defini...
Are there any patient characteristics that make you change fractionation when treating per STAMPEDE?
I generally favor 55/20 for patients where I am treating just the prostate in the setting of non-oligometastatic disease, and not treating the other metastases. It is a relatively low dose and I can't think of a scenario where I would turn the dose down for any patient factors. 6 Gy x 6 is very reas...
How would you treat a postoperative pT4a NX larynx who had TL without node dissection and no suspicious nodes on pre-surgical imaging, specifying nodal volume and dose levels?
Laryngeal T4a may consist of different entities with different LN involvement risks. If it involves the supraglottic larynx, it requires RT to levels II-IV bilaterally. If it is transglottic and extends to the subglottic larynx, include also level VI. If it is confined to the glottic larynx and the ...
How would you manage a patient with limited dural-based metastases?
Pachymeningeal (dural) metastases come in 3 varieties – distinguishing these entities is important therapeutically. Calvarial metastases with secondary pachymeningeal (dural) extension – these tumors can be thought of as bony metastases and can sometimes be monitored on systemic therapy if modest in...
How would you approach unresectable cutaneous angiosarcoma of the scalp?
These patients can have good outcomes with definitive chemoRT. PET and MRI brain for staging. Shave hair and have derm examine for any satellite lesions. Induction taxane-based chemo. Then chemoRT with concurrent taxol. CTV volume is controversial but needs to be generous. At a minimum, 3-5 cm in sk...
How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?
These are often challenging questions/issues in our multimodality discussions. A couple of "general" principles/considerations. I would try, if at all possible to prove the presence of metastatic disease, however in the case of sub cm contralateral nodules, this is, as the question alludes to, not a...
Is there evidence to support the use of definitive CRT in patients with NSCLC in separate ipsilateral lobes and mediastinal lymph node involvement?
Challenging question. I am not aware of any level I evidence to answer this. In the absence of randomized data, I would allow common sense to prevail. Staging of this went from M1 to T4 from AJCC 6th edition to 7th edition mostly because these patients do better by survival then the traditional stag...