Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you routinely recommend SRS to the surgical bed after resection of a single brain metastasis?
At our institution it is routinely done although local control reported in literature varies from 60 to 85 percent. One problem with this approach is defining the surgical cavity target accurately. To overcome this, retrospective data suggests giving 2mm margin around the cavity to improve local con...
What is your technique for simulating and treating patients who have difficulty lying fully supine (due to shortness of breath, pain, or other symptoms despite optimal medical management)?
For this situation we designed and prototyped a slantboard in collaboration with Q-Fix that can immobilize in a full head and shoulder mask in a up-tilted position. We published a case report of our first patient treated clinically in this way. Qu, Singer, Chen et al. Slant board immobilisation of h...
How do you contour and dose definitive CRT target volumes for an unresectable NSCLC invading vertebral bodies?
This is both an excellent and a complicated question. While I do not typically favor elective nodal radiation in NSCLC, I do think this is a case where some degree of elective coverage is warranted.Different imaging modalities yield very different contours when it comes to bone invasion in NSCLC, a...
How do you select the concurrent cisplatin dose and schedule when treating locally advanced endometrial cancer with chemoradiation?
For locally advanced endometrial cancer treated with pre operative or definitive intent, we use weekly cisplatinum at 40mg/m2. Vargo et al., PMID 25218303
When treating pancreatic body/tail lesions that result in significant dose spread to the spleen, what is your threshold to offer pneumococcal, hemophilus influenza, and meningococcal vaccines?
A really great question, and one that we don’t necessarily have a lot of data for guidance. There are some guidelines out there, though, that I think can be helpful to consider. The first is the recent guideline from ASCO on the vaccination of adults with cancer (Kamboj et al., PMID 38498792). In li...
What dose and fields would you use to treat a low grade CNS lymphoma that presents as an isolated single mass in the brain?
De novo presentations of low-grade lymphomas in the brain parenchyma are very, very rare. Suppose a patient had a relatively small, well-localized, low-grade NHL such as FL or MZL in the brain parenchyma, without any evidence of disease elsewhere (negative PET-CT, bone marrow biopsy, etc.). In that ...
Is there any role for palliative radiation in patients who are intubated due to malignant airway obstruction?
The literature is limited, but this small series showed about 1/4 of patients can have reversal of intubation.If the patient/family is interested in attempting, it occasionally works, but my own experience is less successful than 1/4. It is unlikely to worsen the situation, so after explaining that ...
Is there a time frame between surgery and radiation, after which, the benefit of adjuvant radiation is lost and no longer indicated for head and neck cancers?
Unfortunately, there are some patients that have post-operative delays. I don't know that the value of adjuvant RT "is lost" beyond 6-8 weeks, but we know the oncologic outcome can be worse. I would consider getting a high quality reassessment imaging either with CT, MRI and/or PET/CT of head and ne...
What would be your approach in a patient who presented with a solitary brain metastasis that resolved after chemo without local therapy?
While I have not had this happen with my patients receiving chemotherapy alone, in the era of targeted therapies for oncogenic driver mutated NSCLC, we have had some great intracranial response rates with systemic alone, and for these, I have held off SRS to evaluate response. In someone with a comp...
Would you recommend cardiac radiotherapy for malignant pericardial effusion refractory to pericardial fenestration?
Yes. I have done this several times and have gotten some reasonable palliative responses. Typically one cannot determine the exact source for the malignant cells, and one presumes that there are tumor deposits throughout the pericardium, in which case the target is the whole heart. This then limits ...