Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is the best way to manage severe claustrophobia and anxiety for Thermoplastic masks?
I’ve found that P.O. uptake of benzodiazepines is notoriously unreliable, and often the severity of patients’ anxiety isn’t apparent until after the process has begun. Because of this, I stock IM hydroxyzine (a.k.a. Atarax or Vistaril), which is a great non-narcotic old-school anxiolytic with a reli...
If treating a patient with prior breast augmentation with whole breast radiation, would you alter your field setup?
With prior breast augmentation, I think you have a few options. Whole breast irradiation with tangents - I typically cover the entire chest wall and don't move the field edge forward. With respiratory motion (unless using DIBH or other respiratory techniques), I do worry about missing areas at risk...
For postmastectomy patients who have >2 sentinel nodes involved, would you recommend a completion axillary dissection or proceed with PMRT?
This is a question that is still debated. I am comfortable extrapolating AMAROS/Z011 to mastectomy patients despite the limited number of patients undergoing mastectomy in AMAROS.In patients with 2-3 SLN involved (that were cN0), I would be ok with PMRT and omitting ALND as long as no ECE. If > 3 LN...
How would you simulate and ensure set-up reproducibility for a patient with head and neck cancer and severe claustrophobia and unable to tolerate a thermoplastic mask?
Options: Make a mask and cut out the face area, keep the chin and forehead. Use cushion tape at the edge to make it more comfortable. Use surface imaging device (Identify, VisionRT, C-rad) with good custom vaclok of the head and neck area. Use of anti-anxiety meds and music therapy (patient's own m...
How do you approach image-guidance and creation of ITV/PTV margins for rib SBRT?
Delineation of rib lesions indeed can be difficult on planning CT. First step is to determine if patient's clinical symptoms correlate with the target area - I have encountered situations wherein collateral history (whether referring doc, or trainee) can bias treatment intent before meeting the pati...
Would you omit radiation in ER/PR negative DCIS patients who are otherwise low risk?
I have usually favored RT in this setting.
What is your preferred PMRT dose/fractionation for patients with implant reconstruction?
I stated in a post in July 2022, that I switched to using hypofractionation for patients with both autologous and implant-based reconstructions after the FABREC trial closed, which we participated in. The results of FABREC presented at ASTRO showed no significant difference between the hypofractiona...
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
This would be an unusual presentation for marginal zone lymphoma (MALT lymphoma) and not one I've actually encountered. In a large series from MSKCC, "soft tissue/bone" comprised 2% of cases treated with radiation therapy (IJROBP 2015;92:130). Case series from Princess Margaret (Cancer 2010;116:3815...
How would you treat a patient with retroperitoneal lymphadenopathy that has been biopsy proven metastatic seminoma, who is not a candidate for orchiectomy, RPLND, or systemic therapy?
Very unusual case, but primary seminomas can be found in sites other than the testes. Of non-testicular primary sites, the mediastinum is probably the most well-known but other sites including the retroperitoneum have been described in the literature. Various theories for how these develop include l...
How would you approach a patient with malignant spindle cell neoplasm of the scalp excised with a focally positive deep margin?
Although I agree that a re-excision would be helpful for margin clearance, it is probably unlikely that more tissue (which may be negative for Ca) would help delineate the pathology. An immunosuppressed transplant patient most likely has a cutaneous SCCa (with spindle cell features) and our surgeons...