Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you use specific scalp dosimetry constraints to prevent chronic alopecia when treating partial brain volumes with VMAT?
I do try to be mindful of scalp dose for partial brain VMAT, mainly to reduce the risk of alopecia. If feasible, I generally try to keep the scalp/skin max dose around 39 Gy to D0.03 cc or lower. That said, I would prioritize target coverage and overall plan quality if there is a tradeoff. In my pra...
Do you taper memantine after completion of 24 weeks of therapy?
Tapering is recommended when discontinuing some medications used in the management of dementia such as cholinesterase inhibitors. There are anecdotal cases of “discontinuation syndrome” after abrupt cessation of memantine in patients with dementia. However, this alone does not prove that a slow tape...
How should you manage a pediatric oncology patient who has an ANC > 500 and a normal chest x-ray but is confirmed to be infected with COVID-19 and is immunosuppressed from chemotherapy?
The treatment for pediatric patients with cancer who develop COVID-19 is very poorly defined. The risk of severe disease is unknown because although adults with cancer appear to have worse outcomes than those without, non-immunocompromised children seem to have few severe outcomes from the disease a...
Should we delay adjuvant breast radiotherapy for early stage breast cancers as the COVID-19 situation evolves?
This is a very tough question given the unprecedented nature of this pandemic and the fact that its duration is unknown. Recommendations will likely vary based on the density of cases in a specific geographic location and will undoubtedly change frequently given the rapidly evolving nature of this s...
In light of the SHAPE trial results, how would you manage a patient with an incidentally diagnosed FIGO IA1 cervical cancer after simple extrafascial hysterectomy/BSO?
Without question, I would recommend that this patient receive pelvic RT and probably cuff brachytherapy as well. The SHAPE trial (NCT01658930) enrolled "low risk" patients, but they allowed LVSI patients into the trial, even though this is a high risk feature for local recurrence. There were approxi...
Do you offer palliative whole liver radiation for patients with diffuse liver metastases?
Whole liver radiation is a very good palliative treatment for diffuse hepatic metastases causing pain or severe nausea/vomiting. I treat the whole liver plus a 1 cm margin to 7-8 Gy/1 fraction per the Phase II trial from Princess Margaret Hospital (Soliman et al., PMID 24062394). In this trial of 41...
How do you check surface dose when treating post-mastectomy patients with radiation?
We have stopped using bolus except for T4b disease, dermal involvement, or extensive LVSI, pathologic dermal involvement, or positive margins. In cases where we use bolus check with in vivo dosimetry and aim for 90% or above dose. Another situation where a bolus may be used is in a very thin chest w...
What measures should we take regarding routine follow-up visits for well patients in surveillance during the coronavirus pandemic?
3-6 months.
In the wake of the COVID-19 pandemic, are there any hypofractionated regimens (without concurrent chemotherapy) that could be utilized for head /neck cancer in a post operative setting?
A very recent paper by Eric Hall and David Brenner’s group (Shuryak et al., Int J Radiation Oncol Biol Phys 2019) is titled “optimized hypofractionation can markedly improve tumor control and decrease late effects for head and neck cancer”. Using a recently improved model, they concluded that an opt...
What screening tools or signs do you use to predict if a cancer patient is near end-of-life?
For most of us, long-time practicing oncologists, all we have to do to determine that one of our patients is at the end of their life is to be in the same room with them. No special computer programs or calculators are needed. Just look closely at the patient's current weight, their level of conscio...