Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What dose is required to gross disease in the definitive treatment of vulvar cancer?
As with all gynecologic carcinomas, the optimal dose is at least to some extent dependent on the volume of disease. However, our experience suggests that a minimum of 60 Gy should always be given for gross diasease, even when concurrent chemotherapy is being given. That said, for gross disease that ...
How do you manage a head and neck cancer patient with the presence of high grade dysplasia at a margin?
This is an excellent question. According to some pathological literature, a margin positive for in situ carcinoma or high grade dysplasia has a similar recurrence risk as a frankly positive margin with invasive disease. NCCN guidelines define carcinoma in situ or invasive disease as a "positive marg...
Under what circumstances would you pursue completion ALND in a patient with multiple positive sentinel nodes after breast-conserving surgery?
For clinical/imaging node-negative disease with 1-2 positive nodes, now there are 7 plus clinical studies (ACOSOG Z0011, AMAROS, OTOASOR, SENOMAC, IBCSG 23-01, AATRM, SINODAR-ONE) which have shown no difference in axillary recurrence, DFS with dissection, but higher lymphedema as expected. The most ...
Would you include the tract in your treatment field in a patient with squamous cell carcinoma of the anal canal presenting with an ano-cutaneous fistula?
I don't know that there is an evidence-informed answer, but I just had this in a patient recently. We had him get a diverting colostomy prior to starting CRT, then treated him with standard CRT with 5FU/MMC. I included the fistula tract in an intermediate dose, but with a margin on the boost to tumo...
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...
Do you offer consolidation durvalumab in a patient who had pneumonitis requiring steroids following chemoradiation for LS-SCLC?
In the ADRIATIC trial, pneumonitis or radiation pneumonitis occurred in 38.2% of durvalumab-treated patients, and 8.8% discontinued treatment due to pneumonitis (Cheng et al., PMID 39268857). While there is emerging interest in immune checkpoint inhibitor rechallenge after successful management of i...
Is there additional concern for late cardiac toxicity when using ultrahypofractionated breast radiation protocols, given that the BED to the heart is higher?
The BED to the heart isn't actually higher in this setting.Dr. @Dr. First Last explained this below, but I'll just explain it another way. Imagine that you place the block edge so that it is touching the heart (i.e., the heart is completely covered by the MLCs, and there is no margin between the MLC...
Can symptomatic radiation pneumonitis ever improve spontaneously without corticosteroids?
As “pneumonitis” has always been difficult to pinpoint, and relies on “inflammatory radiologic findings” confined to XRT portals, fever, cough without positive bacterial cultures, and shortness of breath, the diagnosis is even more difficult with 3D-directed and multiple portals or mostly IMRT-deliv...
Do you utilize the same radiosurgery constraints for each substructure of the brainstem?
I typically do use the same SRS constraint but with the caveat that I would be much more concerned personally at the medulla/upper cervical cord junction as opposed to the midbrain/thalamic junction.
For a patient with clinically node positive pancreatic cancer, do you simply boost the involved nodes to full dose or treat additional adjacent nodal regions electively?
I would recommend including an elective target volume. In your boost/high dose volume, you can include the involved primary and involved nodes with margin. The elective volume may include regions at risk for occult nodal involvement and pathways of peri-neural spread. This would align with the NRG c...