Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What techniques do you use to address fertility preservation in young female patients being treated with chemoradiation therapy for cancer in the pelvis?
The most important aspect of a fertility preservation strategy is to think of it early on in the discussions with your patient. Many medical centers now have a clinic or center to which patients can be referred and seen within several days. They are experts at explaining the options and outcomes wit...
Is 3D non-coplanar conformal radiotherapy preferable over arc therapy for lung SBRT?
To build on @Dr. First Last insights, which I appreciate very much, I want to note that for those who have been doing SBRT for some time, VMAT delivery is a relatively recent development that, as mentioned, may enhance the patient experience from the delivery standpoint. At Cleveland Clinic, we have...
How would you manage a local recurrence of a spinal hemangioblastoma following prior surgical resection alone?
Hemangioblastomas are benign rare tumors that arise from the linings of blood vessels (embryonically arrested hemangioblasts) and can form in the brain, spinal cord, and retina. When they occur in the spine, they have a tendency to recur ~25% of the time. The primary treatment for a recurrent spinal...
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...
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...
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...
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)...