Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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.
What criteria do you use for induction chemotherapy in advanced head and neck cancers?
We were advocates of IC for patients felt to be at higher risk for DM in oropharynx cancer. We believed these were patients with N2b-N3 disease. However, the recent PARADIGM and DeCIDE trials were negative for a survival advantage for IC, so personally my enthusiasm for IC for advanced oropharynx ca...
For ablative treatment of intrahepatic cholangiocarcinoma, what dose constraints do you recommend for the IVC when the tumor is adjacent to it?
The IVC is the lowest pressure vessel in the body, is thin walled, and not susceptible to pseudoaneurysm or atherosclerosis. According to the evidence and my experience, you can give way more than it takes to control any tumor to any vein. There has never been a venous complication related to radiat...
What factors affect your decision to offer adjuvant RT for thymoma s/p R0 resection?
First, I would review the pre-operation image to understand how extensive is the thymoma involved and then talk with the surgeon to find out where the high-risk area is. If the margin is negative and there is no trans-capsular invasion, I would not recommend post-OP RT. If there is a positive margin...
Do you place asymptomatic patients being treated for brain metastasis with SRS on prophylactic steroids?
We do not use steroids routinely for asymptomatic patients being treated for brain metastases except if there is a concern based on anatomic location, volume, and/or presence of edema (e.g. adjacent to motor strip with significant edema, in or adjacent to brain stem, V12 brain receiving > or near 10...
Would you routinely offer IMRT to the entire pleural cavity in patients who undergo pleurectomy/local resection for mesothelioma without EPP?
I do not, and wouldn't recommend, routine IMRT to the entire pleural space in patients with mesothelioma s/p pleurectomy/decortication outside of a clinical trial. If we have learned anything from this disease, it is that "less" is often "more". About 15 years ago there was a surge of interest in ag...
When is it considered inappropriate to omit pathological mediastinal lymph node staging for non-small cell lung cancer?
This is a very good question often debated by thoracic radiation oncologists with their thoracic surgery colleagues and can get complicated. The best way to look at it, in my opinion, is to understand the sensitivity and specificity of FDG PET/CT to detect true mediastinal nodal disease. For example...
What is your approach to adjuvant radiotherapy for head and neck cancer after resection and reconstruction with a free tissue (muscle and bone) flap?
I work closely with our reconstructive surgeons to get their opinion on the health of the flap. In most cases, I am able to start radiation within the recommended 4-6 week window. There may be occasional cases where the flap has not been "taken" or the patient had to go back to the OR for a failed f...
What ratio of lumpectomy cavity volume to normal breast tissue do you consider reasonable for treating a patient with APBI?
In the Italian study, they used 50% prescription dose to 50% or less of breast volume outside PTV. I generally limit PTV volume to the total breast volume ratio of <25-30% to decide if PBI is an appropriate treatment, as dose constraints to the uninvolved breast get harder as PTV volume percentage o...