Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Is it safe to hypofractionate for whole breast RT in patients with a BRCA 1/2 or CHEK2 mutation to chose to have breast conservation for early stage breast cancer or DCIS?
There is no evidence that hypofractionation compared to conventional fractionation results in higher acute or long term toxicities in patients who have these mutations. Since a majority of these patients may also be in a younger age group many clinicians may appropriately feel uncomfortable in offer...
What is the appropriate approach to manage a patient with triple-negative, locally advanced breast cancer (LN+) who progresses on neoadjuvant chemo-immunotherapy (KEYNOTE-522 regimen)?
Given the aggressiveness of the KEYNOTE-522 regimen, second-line chemo seems unlikely to be effective. Assuming the patient is currently not resectable, recommend breast RT concurrently with a well-tolerated radiosensitizer, e.g., capecitabine, dose, and fractionation depending on the presence or ab...
When treating with chemo/RT for bladder cancer, how concerned are you with small bowel dose constraints when boosting the bladder to 60 Gy?
This is an excellent question, and something we struggle with. DVH parameters are important considerations, but I also feel that sometimes we put too much emphasis on dose contraints; as if the sky will fall if you pass a threshold. Exceeding a parameter is no guarantee of good or bad outcome, but m...
What is the best radiation technique for treating Kaposi sarcoma involving the irregular surfaces of the toes and soles of the feet?
As in the treatment of most cutaneous malignancies with radiotherapy, it depends on the extent and location of disease. For small tumors or those on relatively flat surfaces, superficial or orthovoltage xrays can be a very simple and effective modality. Given that many radiation oncology departments...
How do you counsel patients with locally advanced malignancies who have ECOG 3-4?
I agree with @Dr. First Last and @Dr. First Last's comments about the implications of PS and specific situations where medical therapies have the potential to improve PS (heme malignancies small cell) and/or extend quality of life. I have two goals in this conversation. To make sure I understand the...
How would you optimize patient set-up and planning for the post-operative treatment of a distal lower extremity sarcoma?
The fundamentals I take into consideration for every sarcoma patient I treat is:- Every sarcoma patient is very different but I try and keep my overriding paradigm very clear and consistent patient to patient so as to maximize my team's understanding of the patient's care and minimize risks of error...
How do you optimize nutrition for patients experiencing dysphagia while undergoing chemoradiation therapy for esophageal cancer?
Providing adequate nutrition for patients on treatment for esophageal cancer can be difficult. Evaluation and management should employ a multidisciplinary approach with individualized dietetic advice. In patients with the ability to swallow up-front, we start chemoradiation without employing other m...
Do you always biopsy suspicious liver lesions if you have a biopsy from the pancreatic mass showing PDAC?
I don’t always biopsy especially if the tumor marker is very high. I start with treatment and reassess. I do think a good liver MRI with contrast can be helpful here as well. One important caveat: I do biopsy if there is scant tissue from the pancreas biopsy so I can send the NGS panel.
Is there ever a role for adjuvant chemotherapy and/or immunotherapy for early stage, N0 non-small cell lung cancer treated with SBRT alone?
Excellent question. There is certainly a need! If we step back and take an honest look at our control rates with SBRT, while primary tumor control rates are high, we suffer the same viciousness of lung cancer that surgeons do - local control is trumped by a 2-3x rate of regional and distant failure....
Do you offer RNI to a T1N0 breast cancer patient who underwent inadequate axillary dissection?
I would not do RNI but include level 1 and 2 nodes for inadequate assessment of axilla with a tangential field for BCS.