Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In a patient with ypN+ breast cancer with an adequately dissected axilla, do you omit radiation to the dissected axilla when treating the regional nodes?
I usually omit radiating adequately dissected axilla even in ypN+. Exceptions may include macroscopic ENE (>2mm), extra-nodal infiltration of tumor cells, surgeon's concern about disease clearance (usually matted nodes etc so that's also ENE), large number of nodes positive (I usually consider for N...
Following mastectomy with a SNB and single positive axillary lymph node, would you refer a patient back for an axillary dissection if she has borderline indications for PMRT?
For macromets: If there is no indication for PMRT, then patients are referred back for ALND. That being said, there are patients who decline ALND because of lymphedema and in these patients do perform PMRT with RNI in lieu of ALND . For micromets: No additional axillary intervention and no addition...
Is there any situation where hypofractionation of post-mastectomy radiation (CW and regional nodes) is absolutely contraindicated?
While not absolute given some phase 2 data, I am not currently offering hypofractionated PMRT to patients with reconstruction, as I am awaiting results of the Alliance trial. I do offer hypofractionated PMRT to patients who are not undergoing reconstruction. However, I am cautious in patients with c...
Would you ever consider a nonoperative approach for cutaneous angiosarcoma when a patient achieves a complete or near-complete clinical response after chemoradiotherapy?
Some limited surgery is generally favored, especially if the original site is still present after induction chemotherapy or chemo-RT. Extensive surgery and prolonged healing times are less favored, in particular if they will become barriers to prompt adjuvant RT delivery or systemic therapy delivery...
Would you use adjuvant hypofractionation (15-20 fractions) after BCT with negative margins for a patient with malignant phyllodes tumor?
We conventionally fractionate all our phyllodes patients given there is really no data currently (that I’m aware of) that supports hypofractionating this uncommon disease entity.The Dartmouth-led series studied patients using conventionally fractionated radiation.Barth Jr. et al. PMID 19424757Their ...
How do you prevent radiation induced colitis?
My primary strategy to prevent radiation-induced acute large bowel injury is to try to minimize the dose delivered to the bowel as much as possible. In patients who I think might be at high risk of developing this problem, I will give them written instructions about diet modifications (low fiber, lo...
Which early-stage breast cancer patients who are candidates for 3-week hypofractionated whole breast EBRT are not good candidates for 1-week whole breast EBRT?
One important dosimetric criteria for 5.2 x 6 is V105 of 5% or less and v 107 of 2% or less. For 3-week RT, our data suggest v105 < 10% caused less morbidity. These dose homogeneity constraints are sometimes hard to meet for moderate or large size breasts, and one needs to be careful. Also, if a bo...
What is the most appropriate dose-fractionation for an early stage, progressive cutaneous squamous cell carcinoma of the nose in an elderly/frail patient in the setting of the COVID-19 pandemic?
30 Gy/5 fractions or 40 Gy/10 fractions. I prefer 250 kvp. Increase dose by 10% with electrons and increase margins from 1 to 2 cm. Collimate on skin with a lead mask.
Do the 8-year PACE-A results support a claim of equivalent long-term cancer control between SBRT and prostatectomy?
The PACE-A trial is a phase 3 trial that randomized 123 patients with low- and intermediate-risk prostate cancer to a prostatectomy or prostate SBRT (36.25 Gy in 5 fractions) without androgen deprivation therapy (ADT). Overall, 94% had intermediate-risk disease and 84% of prostatectomies were roboti...
Does your threshold for the duration of induction chemotherapy differ if opting for neoadjuvant SBRT vs chemoradiation in resectable pancreatic cancer?
No, most patients treated in the LaBahn/MCW pancreatic cancer program undergo treatment on a clinical trial. Outside of a trial, total neoadjuvant therapy typically starts with systemic therapy given for at least 2-4 months. While most patients are treated in the setting of a clinical trial, when pa...