Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you counsel patients with an ileostomy about significant diarrhea when treating the pelvis with radiotherapy?
For patients with an ileostomy, they should be told that they are expecting to have an ileostomy output of approximately 1 to 1.5 L per day immediately after recovery from surgery. However, the output may decrease over time.If a large amount of small bowel is in the pelvic radiation field and/or the...
What concurrent dose/fractionation regimen do you prefer when treating large cell neuroendocrine tumor of the lung?
This is an interesting problem. Assuming the pathologist reports this as "large cell neuroendocrine", essentially this is a non-small cell lung carcinoma and we treat as such recognising the significant concern for brain metastasis. We do not do PCI for these patients and a pre-treatment MRI brain i...
How would you treat an adenoid cystic carcinoma (well-diff, +extensive PNI) of the vulva s/p excision with positive margins?
Great question. I would not necessarily ask for re-excision, as I don't think it will change the recommendation for post-operative RT to the vulva. There does need to be some kind of inguinal node assessment, and PET is an acceptable approach if the nodes were not sampled or dissected. If PET is neg...
Would you administer pelvic radiation therapy to a post-menopausal patient with locally advanced carcinosarcoma with high risk features s/p TAH/BSO with a vesico-urethral fistula that would be in the radiation therapy field?
Although the role of adjuvant RT in uterine carcinosarcoma is unclear, it does appear that local control is enhanced. So my answer depends on "how high risk is high risk?". The question suggests that the risk of local recurrence is quite high ("locally advanced" is the descriptor), so I do think it ...
Do you electively cover any nodal volumes for superior sulcus tumors?
No. I grew up with the Fletcher textbook and the Lindberg frequency diagrams in head and neck. The logical extension to lung was assumed. My middle name is Thomas, and I am a doubter. For practical reasons at the dawn of CT treatment planning and dose escalation (pre-VMAT), including supraclavicular...
What dose-fractionation and clinical target volume do you use when treating tenosynovial giant cell tumor (TGCT), historically known as pigmented villonodular synovitis (PVNS), of the knee?
4500 cGy at 180cGy/fx.
Do you hold ADT prior to biopsy of possible prostate cancer metastatic disease?
ADT can affect the ability to assign a Gleason score, but I am assuming this is not an issue here. We biopsy new sites of metastatic disease in people on ADT all the time to confirm progression and to get tissue to identify potentially actionable targets. The only time I would deliberately hold ADT ...
In what situations, if any, is it appropriate to forego surgery for nodal recurrence (intraparotid and/or ipsilateral neck) of cutaneous SCC and definitively treat with chemo-RT?
I would consider definitive chemoradiation therapy if a patient was medically inoperable or the cancer was surgically unresectable. Otherwise, I would advocate for therapeutic lymphadenectomy, and usually, adjuvant radiotherapy, unless the pathologically evaluated nodal disease was low risk (only on...
How would you approach a young patient with stage I follicular lymphoma of the mesenteric lymph nodes?
This is an excellent question that is often discussed in guideline panel meetings- with a fair amount of disagreement among parties. As radiation therapy leads to long-term disease control in ~50% of patients with stage I FL (and is not cured with either chemotherapy or immunotherapy), my preference...
Would you recommend the addition of radiation to neoadjuvant chemotherapy in unresectable cT4b sigmoid adenocarcinoma (at or above the peritoneal reflection) adherent to the bladder?
Yes. It’s unresectable in the pelvis. This is not an uncommon scenario. I haven’t found it any more problematic than treating a rectal cancer invading the bladder.