Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What dose constraints, if any, would you use when administering TBI?
I use lung blocks to keep the lung dose <9 Gy, no other dose constraints.
Do you consider younger patients with NF2 to have a relative contraindication to radical pelvic RT due to risk of secondary malignancy?
Yes, I would consider NF2 to be a relative contraindication in a young patient. In the situation presented (borderline indications for post-op RT), I would likely lean toward up-front radical hysterectomy. However, if clear indications for post-op RT are present following surgery, I would not hesita...
Do you recommend inguinal hernia repair before or after chemoRT for inguinal node positive anal cancer?
I would strongly recommend doing this after chemoradiation. The reason is that the dermal lymphatic drainage will be altered after surgery and any in-transit cancer cells will attempt to go to the contralateral inguinal nodes. I have seen dermal lymphatic recurrences five times in my career after in...
How would you manage a patient with epithelioid hemangioendothelioma?
This is typically an indolent tumor, often with multi organ system involvement. Starting point mostly is close observation at 3 mo intervals to get a feel for the pace of growth, and extend intervals as appropriate. For bulky liver disease, one could consider liver directed therapies (ablation/embol...
How would you approach an early stage II unfavorable Hodgkins lymphoma following 6 cycles ABVD with persistent Deauville 5 with negative biopsy?
This is an active disease and should be treated accordingly. I would not wait. RT is certainly option number one now, but the patient has a considerable risk for recurrence even after RT, since he/she has Hodgkin‘s that is not responding adequately to treatment. Continuing with ABVD in a patient who...
How would you approach a bulky 9 cm DLBCL of the axilla following an excisional biopsy to negative margins?
This is a valid question that is encountered with some regularity in clinical practice. It has also been reported in clinical trials. For example, in the landmark SWOG study, 29% of patients had all gross disease resected at the time of diagnostic biopsy. This was in the pre PET-CT era. In the more ...
How do you manage metastatic breast cancer to the uterus/ovaries that is symptomatic?
Management would be based on overall disease status, performance status, systemic treatment options, and expected survival. It tends to be seen more so in lobular carcinoma. Options could be from surgical debunking to quad shot based on the above.
Would you recommend definitive XRT with extensive lymph node involvement of prostate cancer?
In cases of lymph node positive disease, I favor RT to the prostate and lymph nodes (with long termADT ± abiraterone) if I believe all the gross disease can be encompassed in a tolerable radiation treatment plan. In STAMPEDE, RT was mandated in all N0 cases and encouraged in N+ cases, which resulted...
In which clinical scenarios would you prefer to sequence chemotherapy prior to radiation therapy in total neoadjuvant therapy for locally advanced rectal cancer?
Our institutional preference has been to use long course chemoradiotherapy prior to chemotherapy due to the enhanced clinical response rate. The exceptions have been for patients with obstructive physiology, where chemotherapy first can potentially generate a safer and more rapid response. Chemother...
How do you manage recurrent inoperable chest wall pleomorphic liposarcoma with prior radiation therapy?
Palliatively. But review the case and see if anything could be done differently next time. Local control of STS with proper surgery and radiation should be excellent. Perhaps there was a positive surgical margin that should have been re-resected, perhaps postop RT wasn't properly designed, etc. With...