Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach retreatment of a small central lung lesion after an infield recurrence within the high dose region after conventionally fractionated chemoRT?
There aren't any good established dose constraints in this reirradiation setting. Pertinent open issues include the specific role of time in recovery of the bronchus and other central structures (e.g. what is the time threshold at which retreatment becomes more safe?) and the impact of combining dif...
Do you prefer to use the FAST or FAST-Forward regimen when treating stage I breast cancer with an ultra-hypofractionated approach?
We favor APBI like the Florence regimen but if technically not suitable, then FAST-Forward.
What bowel dose constraints do you use when treating bladder cancer with moderate hypofractionation?
Two additional steps I take when using hypofractionation doses as noted above is to 1) ensure that the V55 Gy to small bowel is limited to less than 5 cc (based on some data in gynecological cancers) and 2) make sure the full thickness bowel loop is not in the PTV2 volume.
How would you approach a patient with metastatic breast cancer with extensive skin involvement?
The issue of extensive skin involvement in metastatic breast cancer can be very challenging. Many factors come into play including whether the patient has had a mastectomy or has an intact breast as well as whether previous radiation has been delivered. For a previously untreated intact breast: Sur...
What is your approach to prescribing gabapentin for oral mucositis prophylaxis during chemoradiation?
It can be a useful adjunct therapy, especially for patients getting radiation for oral cavity cancer. Randomized trials have been conflicting but some have shown benefit in a prophylactic setting. In my experience, patients tend to need less narcotic medication (usually able to get by with gabapenti...
What is your approach to treating inoperable mucosal melanoma of the head and neck region?
It is often nasal cavity/paranasal sinuses, so 1.2 Gy BID to 74.4 Gy and electively treat the neck. Otherwise 70 Gy/35 fx/30 treatment days SIB.
Are there any recommendations on ways to reduce capsulitis in patient with implants receiving adjuvant whole breast radiation?
There are no specific ways, but based on clinical factors, consider options to reduce volume of RT by PBI with EBRT or brachy, if the patient is suitable for partial breast RT. For whole breast, try to have good dose homogeneity like V105 in single digit (<10%), and with V110 as zero. Avoid any hot ...
Do you have a maximum size cutoff for lung SBRT in central NSCLC?
The bigger the tumor size, the lower the efficacy of SBRT. Typically, I wouldn’t treat lesion of size >7 cm for the following reasons: The local control is lower even with BED>100 Gy; There is high chance that the PTV overlaps with critical structures so toxicities could be high. There is high poss...
How would you manage a gastric MALT patient with anemia and peri-gastric and abdominal retrocaval nodal involvement?
Of course, I would first want to know if the disease was H. pylori+. Studies have shown that involved perigastric lymph nodes and deep invasion of the gastric wall are associated with a lower chance of achieving a complete response with triple therapy, but in most patients with gastric MALT (a very ...
How would you manage a bulky primary exophytic vulvar SqCC in a patient with uncontrolled but very long standing HIV disease?
I would first optimize HIV management and then plan for definitive RT (chemo) based on the CD4 count.