Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you favor post op radiation therapy for soft tissue sarcoma if a positive margin were still expected despite pre-op radiation?
The key question here is whether you are dealing with tumor ON the plexus, expected to result in a microscopically positive (R1) margin, or tumor IN the plexus, expected to result in gross residual disease (R2). If tumor is ON the plexus, a planned R1 margin on a critical structure, with addition o...
What volumes would you treat and what dose constraints do you use for breast and lymphatic re-irradiation?
H&N cancer brachial plexus re-irradiation data, “Among patients with a Dmax greater than vs less than 106 Gy, the 1-year cumulative incidence of brachial plexopathy (BPP) was 42% vs 4% P = 0.005. V80 > 1cc (1-yr cumulative incidence BPP 34% vs 4% P = 0.03) and V90 > 0.3cc (32% vs 4%, P = 0.046) asso...
Would you offer postmastectomy re-irradiation in a patient with locally advanced, ER-/Her2+ disease with pathologic complete response after neoadjuvant chemo?
Our threshold for PMRT for reradiation is high because the therapeutic ratio changes. Stage III her2 neu positive non inflammatory breast cancer treated with dual her2neu therapy with pCR would avoid RT.
Does a negative neck dissection adequately cover the treatment of the neck for a patient that clearly needs PORT for an oral tongue cancer?
I do not feel comfortable omitting RT to the neck in cases of oral tongue cancer. The lymphatic drainage of the oral tongue is complex. The textbook on Head and Neck Cancer by Million and Cassisi (2nd ed., Figure 16-31) has a nice representation of the crossing lymphatics of the oral tongue. From th...
In which situations can you spare the contralateral neck for oropharyngeal carcinoma?
The controversy on contralateral neck disease is whether this is impacted by efferent lymphatics from the primary or collateral flow in the neck from involved nodes.Thus with regards to the primary tonsil cancers that are T1,T2 well lateralized without involvement of the base of tongue nor soft pala...
How would you treat an ipsilateral retropharyngeal node recurrence in a patient with history of early stage oropharyngeal cancer managed by surgery and no previous adjuvant radiation?
RT to primary site, positive RP, and bilateral neck and concomitant chemo.
Do you include the clinically negative contralateral neck in your field for a lateralized oral cavity who has N2b disease after LND?
There is early N2b and advanced N2b. Generally, no. Lots of disease and ENE, now N3, where obstructed lymphatics could result in crossover, then yes. Medial extension of the primary into the tongue base (unlikely) would also lead to contralateral neck RT. Dose would be 50 Gy in 25 fractions or equiv...
In fully resected oral scc pts with high risk factors that does not cross midline, would you radiate the contralateral neck if it is pN0?
I had responded to a similar question some time ago. I am copying my response below. I do not feel comfortable omitting RT to the neck in cases of oral tongue cancer. The lymphatic drainage of the oral tongue is complex. The textbook on Head and Neck cancer by Million and Cassisi (2nd ed., Figure 16...
What factors do you typically consider when deciding whether to include retropharyngeal lymph nodes within your treatment volumes for squamous cell carcinoma of the oral cavity or oropharynx?
I see no reason to treat the retropharyngeal nodal region prophylactically for oral cavity cancer as that is not pattern of spread for oral cavity. For oropharyngeal cancer we include the lateral retropharyngeal nodal region for all patients and include the medial retropharyngeals only if the latera...
In patients treated with the KEYNOTE A-18 regimen who later recur, would you rechallenge with immunotherapy again?
Limited data in this clinical scenario. Per A18 (Lorusso et al., PMID 38521086), 32 patients received ICI as post-progression therapy, 25 of whom received Pembro. I am unable to find in the supplements whether those were patients from the placebo arm or from the pembro arm.I think if the patient rec...