Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you always use a bolus when treating with postmastectomy radiotherapy?
It's important to note that today's PMRT patient (with her skin-sparing surgery and her tissue expanders and her small primary with just two nodes) is not the typical neglected/advanced ulcerated mess of yesteryear. I reserve bolus only for patients with high-risk for skin involvement (inflammatory ...
Would you offer prone APBI with IMRT/VMAT?
I am not sure one can do VMAT with a patient prone - I was told there are issues with gantry position and the table. As far as tangential IMRT, that is definitely possible and worth considering if you cannot meet homogeneity/V105 constraints. With prone breast, however, I rarely have any issues me...
Is it safe to administer Lu-177 therapies in patients with epidural disease in the spinal canal?
In general, yes, it's safe, but the specifics matter. The VISION trial excluded patients with unstable malignant cord compression. The lesson here is that if you have a developing malignant epidural compression, either cord or cauda, it should be dealt with urgently and separately from any considera...
How would you manage a Stage IV NLPHL that has residual hypermetabolic disease involving the bilateral neck/SCV following RCHOP x 4 cycles?
Nodular lymphocyte predominant Hodgkin lymphoma is an unusual disease, developing in ~450 patients each year in the United States. While the WHO classification still categorizes this entity as a Hodgkin lymphoma subtype, the International Consensus Classification refers to this disease as "nodular l...
How do you approach boosting a vaginal cuff recurrence of cervical cancer with brachytherapy that is tethered to small bowel?
Tough case. Controlling cancer is important. MRI guided brachy and making sure GTV is adequately covered even if bowel wall gets that dose. Warn the patient about bowel obstruction and the need to bypass in future.
Would you ever offer a simultaneous integrated boost to the lumpectomy cavity with 5 fraction ultra-hypofractionated whole breast radiotherapy (2600 cGy in 5 fractions)?
Yes, it was delivered in the trial although with conventional fractionation. In practice, we do 2.5 x 4 or 5.2 x 1-2 fractions like RCR guidelines.
How do you approach a patient with a radiographically proven recurrence in the prostate bed after prostatectomy?
We have been getting earlier referrals for salvage RT, so these types of cases have become less common for us to see. We would probably offer RT assuming there is no evidence of distant disease (we have begun using fluciclovine PETs selectively to see if it help with patient selection or alters trea...
For recurrent prostate cancer after prostatectomy with soft tissue mass in the prostate fossa, is hypofractionation an option or is standard fractionation recommended?
There is no standard, accepted modification of a treatment plan for the detection of gross residual/recurrent disease in the operative bed; however, a few common approaches have been reported. These options, as they pertain to hypofractionated treatment regimens are discussed below. Treatment of th...
For a young female (<40) with HR-/HER2+ cT1-2N1, ypT1aN0 s/p mastectomy with SLNB, would you offer PMRT?
Thanks for the question. In the seminal PMRT randomized trials of patients treated with adjuvant systemic therapy, PMRT improved overall survival. B-51 was not designed to evaluate the non-inferiority of PMRT omission. Beyond being less conservatively designed to test for superiority of "RNI" with r...
Will you offer patients urea-based creams or topical diclofenac for hand-foot prophylaxis with capecitabine after the D-TORCH trial results?
This study was presented at ASCO, Abstract 12005. Patients with breast or GI cancers treated with single agent capecitabine (1,000 mg/m2 bid) were randomized to treatment with prophylactic diclofenac cream bid x 12 weeks vs placebo. Primary endpoint was incidence of grade 2 or greater HFS. HR for th...