Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is an acceptable upper limit for ipsilateral lung V8 Gy when using the FAST-Forward regimen with high tangents to cover limited axillary disease?
I would say ipsilateral V8 is more for the ALARA principle and not based on risk of Pneumonitis, and thus would accept a higher number to cover low axillary if needed.
How would you approach radiation for node-positive prostate cancer in a patient with an aortic and/or common iliac arterial aneurysm not meeting criteria for surgical repair?
Literature has shown a correlation of brain irradiation associated with the development of intracranial aneurysms - I believe that is the concern this question is raising.The good news is that other studies have shown that, at least for the aorta, existing large artery aneurysms are not worsened by ...
How do you manage a symptomatic primary breast tumor in a patient with metastatic disease?
It’s much harder to treat patients palliatively than to cure. The art of palliation generally requires weighing the acute and subacute toxicities of alternative treatments much more heavily and chronic toxicities less than we do for potentially curative care. It also requires assessing whether patie...
How do you counsel a young man receiving EBRT as part of TNT for rectal cancer about risk of infertility?
I counsel male patients that, although the testes are outside the target dose volume, they will receive enough radiation that it could, at least temporarily, impair their ability to conceive. I offer to refer them for sperm banking prior to starting treatment.
What if any, is your radiation approach to treating hepatic metastases abutting/invading luminal GI structures?
My approach to hepatic metastases abutting luminal GI structures is fundamentally conservative. When liver metastases abut or threaten invasion of the stomach, duodenum, or bowel, I do not treat this as a classic SBRT scenario. The priority shifts from local ablation to durable local control and pre...
When do you start adjuvant radiation with areas of delayed wound healing after reduction mammoplasty?
Great question. I have cared for many patients with delayed healing post-lumpectomy (e.g., from infection, wound failure, etc.), and that experience is likely pertinent to the mammoplasty setting. Once the wound is open, it is going to take many weeks/months to “fully” heal, and it is not practical...
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
What dose and fractionation do you utilize for node positive HCC?
First thing to point out is that the evidence for an oligometastatic state for HCC is limited. In general, however, I would still recommend definitive RT for limited hilar or infradiaphragmatic nodal spread. The 2 approaches are: 5 fraction SBRT with dose reduction based on the mean liver dose and ...
How would you treat a young patient with an EGFR 19 deletion and a locally advanced lung mass who had a brain metastasis that was resected?
The technically correct, textbook answer would be 1st line EGFR therapy for metastatic NSCLC, which would be osimertinib + carboplatin/pemetrexed (FLAURA2) or amivantamab/lazertinib (MARIPOSA). However, given the unique circumstances here, I would treat this patient slightly differently.I've written...
Would you offer empiric lung SBRT for two growing FDG-avid lung lesions in a patient with severe COPD on oxygen?
This is a good question! The short answer is yes, most likely. Many patients are too high-risk to receive biopsies; this is decided by surgery/pulm/IR. Unless the patient has contraindications to RT or something like severe IPF (where treatment may be worse than the disease), I would likely offer th...