Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you ever consider SRS or WBRT in an asymptomatic pregnant patient with multiple brain metastases?
I agree with @Dr. First Last that radiation can be deferred in an asymptomatic patient and should be considered. However, brain progressive brain metastases can be neurologically debilitating and radiation may need to be considered for a patient that is not delivering soon. The patient will need to ...
How would you approach a patient that did not have preoperative axillary imaging and was found to have macromets on sentinel node biopsy, and on radiation planning scan has abnormal appearing nodes?
Prominent node on planning CT is common after SNLN. However, in this situation based on the pathology, would favor sonogram and biopsy, and if positive, dissection followed by RT. The probability that the node is additional macromets is high based on the pathology.
Is it reasonable to offer APBI in an obese patients with large breasts and N1mi disease?
Most published data with micromets and no nodal RT (most are small series) show a risk of regional recurrence is very low and varies from 0 to 5%. For that reason, micromets would not be contraindications to APBI because if the same patient has a mastectomy done, we would not offer any RT for node.
What cumulative dose constraints would you use for the normal liver when repeating SBRT for liver metastases with a longer time interval (i.e. 2-3 years)?
I will assess cumulative dose within the normal liver with retreatment but if the interval is 2-3 years, I think there has been enough repair in a non cirrhotic liver that one could consider it nearly de novo treatment. There has been very little literature directly examining the impact of re-irradi...
Would you treat a patient with evidence of prostate cancer who refuses biopsy?
No. I cannot think of a situation where I would treat localized prostate cancer with radiotherapy without biopsy confirmation.In the scenario provided above (PSA>15, PI-RADS 5), we cannot be positive the patient even has cancer. A meta-analysis (Barkovich et al., PMID 30807218) found PI-RADS 5 repre...
What is your planning approach for SBRT when the tumor abuts the great vessels such as aortic arch or SVC?
I think there are several reasonable approaches here. The first part is whether this is curative intent (early stage) vs non-curative but for local control (i.e. oligometastastic/oligoprogression). I lean towards being more aggressive in the curative intent setting while trying to be a little more c...
How would you treat a newly diagnosed hormone sensitive high risk prostate cancer with one small lung metastasis and no other evidence of metastatic disease per PSMA PET?
I think there is no solid answer to this. De-novo visceral metastases are very rare in mHSPC, and lung-only oligometastases on PSMA-PET are even more rare. Since lung metastases is expected to be visible on CT, this is undeniably a high-volume disease based on the CHAARTED criteria. Patients with vi...
How do you construct your target volumes for superior sulcus tumors?
This is one of my favorite topics, so I apologize in advance for my verbosity. Tumors invade: I worry that our RT fields, in general, are getting too tight (i.e., cancer often invades beyond what we can see on our imaging, and our CTV margins are often small). This is especially true for Pancoast tu...
What dose and fractionation would you recommend for treating the primary site of a patient with metastatic anal melanoma?
There is little data that defines the best approach to radiotherapy for the primary tumor in mucosal melanoma of the anal canal. In the context of metastases, a hypofractionated regimen seems most appropriate. Investigators from MDACC have published on a regimen of 30 Gy in 5 fractions given twice a...
In a patient with amyloidosis and abnormal liver function but child Pugh A, would you still proceed with SABR for a liver metastasis?
No great data regarding the impact of amyloidosis on liver tolerance, but if the patient was a CP Class A patient, I would feel comfortable offering SABR for a liver metastasis.