Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach potential SBRT to liver metastases in a patient on a VEGF inhibitor?
For patients who are on VEGF inhibitors, I would be very careful with dosing of radiation to nearby bowel and I discuss holding VEGF inhibitors for a time before, during and after radiation. There have been multiple reports of in field toxicity, particularly with respect to bowel (liver SBRT frequen...
What is your preferred treatment for locally advanced poorly differentiated carcinoma of the nasopharynx with bulky neck nodes that is EBER negative and p16 negative?
To date, there is no data as to whether induction chemotherapy followed by chemoradiation vs chemoradiation followed by adjuvant chemotherapy should be administered. Moreover, either option is listed as standard of care treatment by the Head and Neck NCCN guidelines for locally advanced EBV (-), p16...
How would you manage a patient with distal rectal adenocarcinoma involving the anal canal and a single non-bulky inguinal nodal metastasis?
Patients with low rectal cancer and inguinal involvement at presentation should obviously be treated with curative intent because inguinal lymph nodes are first echelon drainage from the low rectum and anal canal. Standard dose neoadjuvant chemoradiation and limited surgical excision of the involved...
How do you manage internal vaginal burning during pelvic radiation?
I would start with a pelvic exam to rule out cuff dehiscence if post-op, easily treated candida infection and STI. If cuff intact, no white plaques or exudates are seen, would consider checking the plan for unintended hot spots that could lead to mucositis if that's noted. If post-operative non-endo...
What is the quickest palliative regimen you have tried for obstructing lesions in the lung in patients with stage IV disease?
I routinely use 1 or 2 fraction palliative regimens, and in my opinion, this is something that we should be considering more frequently. This has been the subject of dozens of randomized controlled trials, and meta-analyses by the Cochrane group. There is consistently no difference in symptom relief...
For a pathologic Stage I squamous cell carcinoma of the oral tongue with negative margins and adequate neck dissection, is perineural or lymphovascuar invasion alone an indication for adjuvant radiotherapy?
I think Dr Eisbruch is spot on- patients with PNI do worse in the surgical literature, but the benefit of XRT in this scenario to obviate recurrence is far from robust. My personal belief is that PNI is not a sign of neurotropism like in melanoma or adenoid cystic ca, but likely another surrogate fo...
What are magic mouthwash alternatives that you would recommend?
Many of our patients will make their own DIY MMW per Phil's My Pharmacist (YouTube) instructions -- uses benzocaine/Cepacol lozenges -- they say it's much more effective than the compounded one from the pharmacy. It is also more economical.If the majority of bothersome mucositis is in the oral cavit...
What dose constraints do you use for a young female patient with an anterior mediastinal mass being treated definitively with IMRT?
I would emphasize regardless of modality the importance of positioning and its impact on breast dose. The vast majority of anterior mediastinal masses are supracardiac and extend superior to the level of the breasts when the patient is upright. If the patient is simulated supine with the arms up, th...
What positioning and immobilization technqiues do you use for anal canal carcinoma radiotherapy in the era of IMRT?
Supine, frog-leg position facilities the use of a vaginal dilator which is critical for sparing the introitus during contouring. Patient reported outcomes from M.D. Anderson indicate 75% sexual satisfaction with the use of the dilator/IMRT versus 33% with IMRT alone. This is a good indicator of the ...
How would you treat a stage IIA NS HD patient with bulky disease who refuses chemotherapy?
If this patient presented 25-30 years ago, there would have been very little debate on how to proceed. The patient would have been treated with subtotal nodal irradiation. This would have consisted of a mantle field, treating all major lymph node-bearing areas above the diaphragm, typically to a dos...