Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your treatment approach for p16+ oropharyngeal carcinoma with one positive node on neck dissection?
The question is quite broad and covers varying scenarios. My sense though is the question is asking about if/when would I recommend adjuvant radiation if an unirradiated patient has a neck dissection and 1 node is found. I will address the scenarios where the primary is either absent (ie unknown or ...
In clinically node positive vulvar cancer, are you recommending bilateral inguinal LND or nodal debulking followed by adjuvant radiotherapy?
I am sure there is wide variation in practice as there is no prospective study to guide care. Our approach is definitive chemo RT with the removal of only residual persistent node. Richman et al., PMID 32981696
When contouring locally advanced NSCLC, how do you define your ITV if your iGTV overlaps with an OAR?
For locally advanced lung, I have 2 slightly different approaches for primary vs nodes. For primary, GTV to iGTV (with 4DCT or DIBH scans x 3 at sim in certain cases) to CTV (5 mm expansion cropped to anatomical barriers to spread) to PTV (5 mm uniform expansion). I let the iGTV overlap the esophagu...
What is the appropriate treatment for marginal zone lymphoma of the parotid following surgery?
Definitive radiation therapy is the standard treatment for a patient with an uncomplicated case of localized marginal zone lymphoma of the parotid gland. The CTV would encompass the entire gland and the total dose would be 24 Gy. Occasionally patients will be diagnosed with MZL after parotidectomy, ...
What data is there for using SRS to treat more than 3 lesions?
The short answer to this is that there are no randomized trials supporting SRS alone for more than 4 lesions, in comparison to SRS and whole brain radiotherapy, or whole brain radiotherapy alone. This does not mean that SRS alone is contraindicated, and I believe that SRS alone can be used as up fro...
When is it appropriate to use adjuvant whole pelvis radiotherapy for Stage I endometrial adenocarcinoma?
The indications have been changing with the publications of GOG 99, PORTEC 1 and 2 , the Swedish and ASTEC studies, and the interpretation of data with the confounding factor of nodal dissection.At present, I would/do consider pelvic RT for Stage IB with grade 3 disease and Stage Ia with grade 3 and...
In light of the cosmesis and toxicity outcomes of the RAPID trial, should external beam partial breast irradiation be avoided?
The results of RAPID trial does raise the concern about worse cosmetic results which may not have been captured by the CTCAE score used in the NSABP study and one should be very cautious in using this schedule outside the context of a clinical trial. Whether it was because of spillover dose to uninv...
With a head and neck squamous cell of of unknown primary, do you typically treat the larynx?
Not routinely unless the clinical picture really strongly points to the larynx/hypopharynx e.g. p16- and the only nodes or the largest nodes are in level 3-4. It goes without saying that there should be an extensive search process with experienced surgical and radiologic input to try to find the pri...
Is it safe to give localized palliative spinal radiation with concurrent intrathecal cytarabine? If so, do doses need to be adjusted?
In past cases, we have avoided doing this due to concerns of excessive toxicity.
What is the maximum V20 on ipsilateral lung that can be safely accepted for 3 or 4-field breast plans?
We routinely treat the IM nodes so my comments reflect this practice: 1. I shoot for a mean ipsilateral lung V20 below 35%. This is achievable in most, though not all, plans. 2. The biggest driver of ipsilateral lung V20 is the amount of lung in the SCV field. 3. While it is tempting to raise the ma...