Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
Do you use traditional bony landmarks or contoured nodal volumes when designing breast and supraclavicular treatment fields?
The classic field borders and blocks that I was trained with in the 2-dimensional era, result in almost the same field as those achieved by laboriously contouring the nodal volumes and expanding them. That is a testimony to our predecessors’ knowledge of anatomy, clinical examination of patients wit...
What volume would you treat with radiation in the setting of high risk oral tongue cancer completely resected with surgery and negative bilateral neck dissections?
Despite negative margins and pN0, the risk of LRR in this pT4 patient is high, regardless of whether or not the number of dissected nodes was adequate. Moreover, the chance of surgical salvage if recurrence happens in a previously dissected neck is small, as such recurrent tumors tend to encompass t...
For head and neck cancer radiation requiring boost, do you plan using simultaneous integrated boost technique vs cone down technique?
SIB always provides more conformal dose distributions compared with sequential boost IMRT, as the beam placement and intensity of the sequential boost do not take into account the dose distributions of the first plan. This issue, as well as the lower fraction doses to the normal tissue embedded in t...
How do you approach patients with osteosarcoma of the maxilla for neoadjuvant chemotherapy?
The SOC treatment for “jaw” OS is a margin negative surgical resection. If indeed feasible (not always the case), this applies to maxillary tumors. Jaw OS does respond poorly to standard chemotherapy. In our experience, HD Ifosfamide may be a better choice than standard Dox/CDDP. We use this approac...