Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you treat node positive (pN+) prostate cancer with undetectable post-op PSA after radical prostatectomy and pelvic LND?
The short answer is, YES I would, in general, recommend treatment. I also respectfully disagree that ADT monotherapy is the standard of care. It is an option of course, but rarely performed given it is non-curative and the data to support its use is of minimal relevance today.Some key points of reas...
If an asymptomatic patient requires a delay up to a week before starting chemotherapy for Stage III lung cancer, do you also push back the radiation start date?
Typically, the reason for B12 and folate prior to chemotherapy is related to the drug that will be used, pemetrexed. Giving the premedication reduces hematologic and gastrointestinal toxicity to tolerable levels. One week typically will not make a difference and I would usually wait to start. Howeve...
How have you incorporated gene expression profiling tests for melanoma or SCC into your practice and has it changed your approach to treatment and/or monitoring?
This is a controversial topic for sure, but most emerging technologies in medicine are. I do use gene-expression profiling in the treatment of cutaneous SCC and invasive melanoma. My theoretical framework for using GEP testing is that it is a forward looking test, while clinical staging is backward...
What is the maximum dose that you would give to residual unresectable gross disease in the axilla in the setting of recurrent breast cancer s/p ALND?
The FAST-Forward boost trial will be informative here, and I would recommend reading the protocol, because one can consider using the standard arm now, which is 40 Gy to the breast (and nodes, when RNI is indicated), and a 48 Gy boost, all in 15 fractions. This dose is recognizable as the breast boo...
How do you counsel families of pediatric patients regarding risk of secondary malignancy or IQ changes with cranial radiation using photons?
It’s a great question as these are two of the scariest things that families face when you relay the potential risks of cranial radiotherapy. Simple things like timing of these topics in the consent discussion can make a difference. Don’t start with the scariest potential risk when doing the consent,...
What is your approach to post-operative radiation (when to offer, volume, dose, fractionation) for a primary intraosseous squamous cell carcinoma (PIOCC) of the head & neck?
I probably would. 60 Gy in 30 fractions for negative margins and electively treat the neck.
What dose of radiation do you use for neoadjuvant chemoradiation in esophageal cancer?
The CROSS trial does not exist in a vacuum. We have a long history of esophageal trials by the RTOG and other cooperative groups that consistently used chemoradiation to 5040 cGy, and this remains the standard of care in the U.S. That said, if I have to treat a very long tumor, resulting in lung met...
Should axillary imaging be routinely performed in all patients with a new diagnosis of breast cancer?
This issue has been debated but I would argue that patients with a new diagnosis of breast cancer should not undergo routine screening US of the axilla to look for clinically occult disease. The axillary US should be limited to diagnostic imaging for clinically suspicious nodes on clinical exam or b...
How would you approach a triple negative carcinoma of the axilla with unknown primary and a CR after neoadj chemo followed by ALND?
Breast plus RNI excluding dissected axilla.
How do you manage symptomatic radiation necrosis not responsive to steroids?
I agree with the above recommendations. We review these cases at our brain tumor board. We often start off with confirming the diagnosis using MRI with perfusion. If perfusion is equivocal (hard to interpret or lesion is too small) and the patient is asymptomatic, we follow. If the patient is sympto...