Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you manage sarcomas of the hand or the feet?
This is a very difficult question. Please see my answer to the previous Mednet question: How would you optimize patient set-up and planning for the post-operative treatment of a distal lower extremity sarcoma? for general information on how I approach set-up for these patients.Hand and feet sarcomas...
What would be the approach for radiation treatment of a sarcoma of a finger?
The correct approach for definitive management is an amputation or perhaps, if possible, a digit-sparing resection with preoperative RT. As always, the crux with organ-sparing approaches is that we need to leave an organ that is both disease-free and functional, and I am skeptical that definitive-in...
How would you counsel a patient concerned about receiving IMRT rather than IMPT for oropharyngeal cancer?
I would tell the patient there is absolutely no concern at all with IMRT, and it is a very well-established SOC. I am personally unclear about the OS benefit with IMPT, as it was pointed out, unexpected. It is unusual to see no difference in PFS and no tox difference, and yet there is an OS differen...
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
When contouring gliomas, how do you distinguish true tumor-related FLAIR from ischemic changes from prior strokes?
FLAIR alone often cannot reliably distinguish infiltrative tumor from chronic/subacute ischemic change. In a patient with a glioma and a previous stroke, the distinction should be made using the pattern of the FLAIR, temporal evolution, diffusion, perfusion, and sometimes metabolic imaging. The temp...
Do the higher rates of grade 1–2 pulmonary fibrosis with hypofractionated PMRT in CHN HYPOPMRT change how you counsel patients about long-term lung toxicity when choosing between fractionation schedules?
The higher rate of grade 1-2 pulmonary fibrosis with hypofractionated postmastectomy radiotherapy in CHN HYPOPMRT does not change my recommendation. The excess toxicity is confined to grade 1-2 disease—largely radiographic or mildly symptomatic fibrosis. Importantly, the abstract reports grade 1-2 f...
For large HCCs, if the normal tissue complication probability is unacceptably high for a 5-fraction photon SBRT plan but is acceptable for a 5-fraction proton SBRT, would you recommend 5 fractions of protons or 15 fractions of photons?
No, this is not recommended in light of the unexpected finding that patients with tumors over 5 cm had a worse outcome with protons on multivariable analysis. This finding is puzzling, and we will be doing further analysis to understand it.
When treating resected brain metastases with post-op SRS, what dose, fractionation and PTV margin do you use for large (>3 cm) cavities?
I would refer you to Scott Soltys' work:Choi et al., PMID 22652105Soltys et al., PMID 17881139This is also useful:Brennan et al., PMID 24331659
Would you offer re-irradiation LDRT for someone with osteoarthritis or tendinitis if symptoms recur?
I have not personally offered a patient a third round of LDRT and do not know of any data that shows efficacy. However, I might offer a third round if a particular patient got adequate results with the first two and there was some separation in time (perhaps >1 year) since the last round.
Will patients who receive radiation to a large mediastinal nodal field have an increased susceptibility to COVID-19?
While the actual infection of COVID-19 has more to do with hygiene, social distancing, and prevention such as drugs or vaccines, the susceptibility for the patient to develop symptomatic progression of COVID-19, once infected, has a strong theoretical possibility. The factors that impact severe lymp...