Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What dose/fractionation do you like to use for palliation of bulky LAD from CLL/SLL?
I have treated patients with bulky mass(es) - mostly parotids of recent. Bulky mass(es) -> I like either 400cGy x1 but most use 200cGy x2 (mostly used by me) -> (Electrons for structures like the parotid, but photons for deeper stuff.) For example, when I treated a few parotids glands, they were swo...
What clinical parameters determine when you treat a large HCC lesion with ablative radiation vs Y-90?
Based on 3 negative randomized trials that have compared Y-90 to relatively inactive targeted therapy (Sorafenib), Y-90 has no evidence-based role in the treatment of HCC. In fact, systemic therapies have improved and 3 regimens have shown a survival benefit for locally advanced and metastatic HCC. ...
How do you manage intramedullary spinal cord metastases in the presence of previous radiotherapy?
This is an unusual presentation but can be treated when approached correctly and provide important palliative effect especially in good performance patients. First and foremost, a neurosurgical evaluation including the possibility of a cordotomy should be undertaken. Should the patient be deemed a n...
Do you consider the undissected ipsilateral level IV neck a high or low risk nodal station after selective neck dissection of levels I-III revealed positive node(s)?
Our general philosophy for the postoperative neck is 3 dose levels: 60 - tumor bed (+ margin), 57 - operative bed, 54 - undissected neck. These doses are based on treatment in 30 fractions. Naturally, though, there is the proverbial art versus science. In post op the tumor bed is virtual, often base...
Does the use of A+AVD versus ABVD affect your decision for consolidation RT for bulky Hodgkin lymphoma?
A+AVD is an acceptable regimen for advanced HL based on results from the ECHELON-1 study (Ansell et al., PMID 35830649) showing an improvement in both PFS (82% vs 75% at 6 years) and OS (94% vs 89%) compared with ABVD. Radiation therapy was not incorporated into this study.In advanced HL, regardless...
Do you use a comprehensive volumetric, rather than numeric, cutoff in consideration of SRS vs WBRT for brain metastases?
I think there is quite a bit to unpack from this question. First, I would contend that there is a whole world between SRS & WBRT. There are even active multi-institutional randomized studies being performed to better define this world. Many institutions, including mine, have largely shifted away fro...
What cochlear dose constraint (if any) would you use when treating an acoustic neuroma without serviceable hearing on that side?
I don't think it's necessary to spare the cochlea when treating an acoustic neuroma in a patient who has no serviceable hearing left on the same side of the neuroma. Even if the patient has residual hearing, radiation treatment is likely to lead to complete hearing loss. However, when hearing preser...
For a patient post-prostatectomy with a high PSA (>1), a negative MRI pelvis, and a negative PSMA PET scan, do you pursue any other imaging?
The sensitivity of PSMA scan for PSA above 1 is about 75-90%. I would proceed with salvage RT plus ADT like we did in the era when PSMA was not available.
How would you manage a patient with a high-risk asymptomatic bone metastasis with a driver mutation?
It seems that the unexpected outcome of a survival benefit was likely due to the prevention of fractures that likely led to hospitalization then death. This was a phase II study and OS was a secondary outcome, but it does make sense. Complicating metastatic cancer with a femur fracture leading to ho...
How do you manage a patient who presents with a tracheoesophageal fistula from a lung or esophageal primary that is non-metastatic?
My experience with this has typically been with primary esophageal cancer presenting with TEF. It's obviously a challenging and individualized situation requiring multidisciplinary input and extensive clinical assessment and discussion. I generally recommend induction chemotherapy since the ideal sc...