Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In what setting is PMRT indicated for T1-2N0 breast cancer?
In general, I do not offer PMRT to node negative patients with the exception of broadly positive margins. However, there is data to support the use of CW and RNI in the recently published EORTC 22922 trial in which more than 40% of patients were node negative (25% of patients were mastectomy patient...
What are your constraints when treating an abdominal site with SBRT?
There are many published guidelines and no single "right" answer for dose constraints when treating patients with abdominal SBRT. Guidelines should also always be taken with a grain of salt, as there may be relevant clinical factors for a specific patient that would make the general guidelines inapp...
Does liver-directed therapy (SBRT, Y-90, TACE, RFA, microwave ablation, etc.) improve overall survival?
This is a loaded question. The issue is that many of the studies detailing the use of TACE, RFA, and MWA do not collect QOL data. Survival is also not collected due to lack of long term follow up. SBRT data is mostly in the retrospective setting although there is some QOL data in Phase II prospectiv...
Do you use any particular dose constraints in patients receiving whole-brain radiation in the setting of prior SRS?
If a patient remains a candidate, I prefer to offer hippocampal sparing WBRT whenever possible, respecting the hippocampal constraints outlined in RTOG 0933 (Hippocampus D100% <= 9Gy; dmax <16Gy).In terms of other dose constraints, I don't typically enforce any constraints that would impact the cove...
For concurrent chemoradiation in head and neck cancers, how important is the timing of weekly radiosensitizing cisplatin early versus late in the week?
Our protocol for concurrent cisplatin-RT demands that the drug will be infused 1-2 hours before RT, usually on Mon. The assumption is that it will allow maximal drug concentration in the cancer cells at the time RT is delivered after chemo on that day, early in the week, while some radiosensitizatio...
Would you offer 12-16 Gy in a single fraction for a symptomatic, non-vertebral bone metastasis?
Yes.We have randomized, prospective studies indicating that dose-escalation with 1-2 fractions improves control of pain over conventional RT doses - here and here. We also have a meta-analysis showing higher chance of complete response of pain with SBRT. In addition, the Canadian investigators showe...
When do you offer adjuvant radiation therapy for a glomus tumor of uncertain malignant potential of the extremity resected with negative margins?
No, unless malignancy is documented.
How would you treat a second HPV related oropharyngeal squamous cell cancer in a patient previoulsy treated and cured of a HPV related SCC of the tonsil treated with chemoradiation?
At our institution, recurrent or second primary head and neck cancers are discussed at a multidisciplinary tumor board whenever possible. We review prior radiation records, physician's notes, and pre-treatment imaging to attempt to come to a consensus whether it is truly a second primary or perhaps ...
How do you manage anticoagulation for patients with DVT/PE who have brain metastases?
Not all brain metastases pose the same risk to patients. Rapid, numerous (even if tiny), new onset metastases from RCC or melanoma (especially BRAF mutant) can go from asymptomatic to life threatening hemorrhage within 1-2 weeks and I would strongly caution anti-coagulation in these patients. If the...
What surrogate(s) do you use to determine toxicity/safety for a SRS plan with numerous metastases?
Before we turn to surrogates let us look at the information that a plan carries and has valuable implications on the quality of the work being done.First we record and report coverage, selectivity, conformity and gradient indices for every patient and every lesion.Second we plan in a consistent mann...