Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you define central lung cancers when considering SBRT?
Interestingly, I have never fully subscribed to the 2.0 cm "no-fly zone" concept and it was based on the need to ensure the safety of patients in our early experience. If one looks at the literature, the original All-Japan study did not differentiate between central and peripheral locations. The ori...
When giving hypofractionated ablative doses of radiation for cholangiocarcinoma, do you give concurrent Xeloda or hold chemo during radiation?
There is no direct evidence to answer this question. In general I have recommended giving concurrent capecitabine because I use a low dose PTV (BED of 50 or so), a high dose PTV (BED of 100 or so)... and sometimes also an ultra high PTV (BED 150 or so) in the center. The high dose PTV often has to b...
Should I use PET/CT for GE junction treatment planning?
I consistently find PET scans very helpful for defining the extent of disease in GE junction tumors.
How does your treatment of lymph nodes change for a breast cancer with limited (<2mm) vs more extensive ECE?
Extracapsular tumor extension (ENE) alone does not appear to increase the risk of axillary failure following axillary dissection (1, 2). There have been conflicting data on whether ENE increases the risk of local-regional failure (LRF) and whether the degree of ENE is important. Having ENE of 2 mm o...
Is there evidence that prostatectomy improves overall survival in local recurrence of prostate cancer post-definitive radiation?
I am not aware of any prospective clinical trial data to suggest that salvage prostatectomy for locally recurrent prostate cancer improves overall survival as compared to any other comparator. Such evidence would be very difficult to generate given that historically, most prospective studies have fo...
How would your recommendations for post-mastectomy radiation change for a patient with scleroderma?
Scleroderma poses challenges for post-mastectomy RT but patients can be treated if needed. 1. I have asked breast surgeons to not omit ALND and proceed with + SLN. If low ratio nodal disease can consider omitting RT, particularly with favorable biology and no other high risk features. For other case...
Do you taper memantine after completion of 24 weeks of therapy?
Tapering is recommended when discontinuing some medications used in the management of dementia such as cholinesterase inhibitors. There are anecdotal cases of “discontinuation syndrome” after abrupt cessation of memantine in patients with dementia. However, this alone does not prove that a slow tape...
What are your dose constraints for lung (V20, V5, MLD, etc.) in patients receiving postoperative radiation therapy after lobectomy?
It's recommended to use the LUNG-ART protocol for post-op cases. They utilized the Graham data for V20, but because there was no data for post-op cases where patients don't have part of their lungs, they just modified the contstraint to V20 < 31% for patients treated with lobectomy and V20 < 22% for...
Does the presence of perineural invasion in early-stage breast cancer post-lumpectomy affect the decision regarding partial breast vs whole breast radiation?
I have not used PNI as a risk factor to change local treatment options after BCS.
Under what conditions would you offer observation for asymptomatic low volume brain metastases?
This is becoming an increasingly more common scenario with patients undergoing routine brain MR for staging, even in the absence of symptoms, and also, with a very modestly small number of settings demonstrating excellent radiographic responses to targeted agent or immune checkpoint inhibitors (ICI)...