Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you contour your elective obturator lymph node volume?
I favor stopping once the obturator vessel exits the pelvis and is lateral to internus muscle like NRG gyn atlas. Feel the extending contour below that exposes more rectum. We highlighted the differences between prostate and gyn atlas in this letter to the editor: Musunuru et al., International Jour...
What clinicopathologic features do you consider when deciding whether or not to use a PMRT scar boost?
We've discontinued all routine use of PMRT scar boost We offer chest wall boost only for R1/R2 margin, T4 disease (whether inflammatory or just skin involvement), and in the re-irradiation setting with an at risk or positive margin (repeat chest wall radiation for isolated chest wall recurrences wit...
When offering palliative radiation for spinal cord compression, do you ever "open up the field" if there is evidence of leptomeningeal disease on MRI?
Considering the urgency of the situation and the poor prognosis associated with LMD, my approach is to treat the area causing cord compression. I would treat the offending area of the spine, often using a "one vert body above and below" margin on the gross disease causing the symptoms that I intend ...
How would you approach a patient over the age of 40 with a sub-totally resected frontal oligodendroglioma, WHO Grade II, 1p/19q co-deleted, IDH mutant, with imaging concerning for second site in the pontomedullary junction?
The pontomedullary junction is not usually amenable to a biopsy (unless the lesion is exophytic); as such, there are 2 possibilities: a) the second lesion is related to the one that has undergone subtotal resection, or b) the lesion is of a different nature. Statistically, it is more likely to be a ...
How would you manage a very large diffuse skull base meningioma involving the olfactory groove, bilateral cavernous sinuses, and abutting optic chiasm that is not amenable to surgical resection?
Skull base meningiomas are the ones that are commonly referred to Radiation Oncology departments as they are difficult to treat surgically, especially when they involve cranial nerves compartments as is the case in this patient. Given the number of OARs at risk for this patient, if the meningioma wa...
When treating recurrent rectal cancer with re-irradiation using accelerated hyperfractionation (39-45 Gy at 1.2 or 1.5 Gy BID), what normal tissue constraints would you recommend for the bladder and bowel?
We have always been very careful about excluding the small bowel if it has been treated before. The initial experience from Mohuidin et al indicated that chronic diarrhea could happen if small bowel was treated. For this reason we have used smaller 3D treatment volumes but included the sciatic notch...
Would you consider SBRT for multiple bilateral lung primaries and/or a lung primary with metastases to multiple lobes?
This is a difficult situation. There is not a ton of information on SBRT for synchronous lung nodules. Ironically I'm on one of the articles (Owen et al. Radiation Oncology, 2015). We treated 60+ patients with multiple nodules but many of them were metachronus, which is a bit different situation. Si...
How have the results of RTOG 1112 influenced your opinion of Y90 and other IR ablative strategies vs SBRT for HCC not amenable to surgery?
My opinion has changed to a fact with RTOG/NRG 1112 (NCT01730937). RTOG/NRG 1112 now provides definitive evidence that treatment of the entire tumor with an adequate dose of radiation has a survival benefit in patients who are TACE refractory or have macrovascular invasion. The controversy now is wh...
When do you consider using ALK targeted systemic therapy in lieu of WBRT or SRS for patients with metastatic ALK-positive NSCLC?
The development of crizotinib in ALK positive patients led to incredible control rates systemically, but as is now well known, less ability to control CNS disease. When crizotinib was the sole FDA approved ALK directed therapy, this led to the concept of "treatment beyond progression" such that pati...
What is the evidence that there is a benefit to giving doses higher than 3060 cGy-3600 cGy in the elective treatment of uninvolved lymph nodes in the treatment of SCC of anal canal with chemoradiation?
The published data with dose varying from 30.6 to 45 Gy to uninvolved nodes has not shown any difference in regional control. The studies which did not treat the pelvis to an adequate volume or excluded inguinal region reported higher regional recurrence.