Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you offer local therapy to a patient with GEJ adenocarcinoma with FDG-avid para-aortic node oligometastasis?
I have favored induction systemic therapy and interval re-assessment. If responsive or at least stable disease, I have offered extended field CRT as long as the treatment volume seems reasonable and my perception is that it would be tolerable when assessed in the context of a patient’s performance s...
Do you hold histone deacetylase (HDAC) inhibitors for patients receiving palliative radiation therapy for cutaneous lymphomas?
Histone deacetylase (HDAC) inhibitors are often used in the management of mycosis fungoides, the most common cutaneous lymphoma. NCCN guidelines include two HDAC inhibitors in their list of recommended systemic therapies- romidepsin and vorinostat. Romidepsin was FDA approved for CTCL in 2009 and vo...
What volumes would you cover for cT3N0, ypT2N0 breast cancer s/p neoadjuvant chemotherapy and lumpectomy/SLNB?
There is still little information about the patterns of failure in patients treated with neoadjuvant systemic therapy. The NSABP study of this issue found the 10-year rate of nodal failure for patients with cT3N0 lesions who had residual breast disease but negative nodes at surgery was 3.2% for the ...
How do you treat non-melanomatous skin cancers in poorly vascularized tissue?
BCC/SCC? An unusual differential. Was it biopsied? If it meets anatomic, size, and depth criteria, radiation oncology options would include electronic brachytherapy. Would likely offer 40 Gy in 10 fractions, twice weekly. Of course, would need to travel to an appropriate facility.
When do you consider the insertion of nephrostomy tubes for gynecologic malignancies without fistulas?
Indication of nephrostomy for gyn cancer depends on the stage of cancer and renal function. If creatinine is normal range, nephrostomy may not be needed but if abnormal, nephrostomy is indicated. In the early stage of cancer, nephrostomy is more likely indicated than late stage of cancer.
Do you consider a solitary IHC+ sentinel inguinal node lymph node to have the same implication for treatment as a single positive node or multiple positive nodes?
Implication and outcome are different but what intervention is needed is uncertain. In view of Merkel cell histology, would favor adjuvant RT to primary and nodal region.
How would you approach an ulcerative non-melanomatous skin cancer of the lower extremity s/p Mohs surgery with gross disease left behind?
If there is gross disease, then the wound is less likely to heal. Need to explore surgery with flap or RT as definitive management.
Does "preoperative rupture" always necessitate whole abdomen RT for Wilms' tumor?
This is controversial. Theoretical arguments aside, our committee (COG) feels strongly that for any preoperative rupture, whole abdomen RT is required.
For a rectal cancer with questionable T3 or questionable N+ by MRI, can short course radiation be given followed by surgery and the pathology still be interpreted to guide adjuvant chemotherapy?
This is a somewhat common scenario. In these situations, I have strongly favored short course RT followed by immediate surgery such that there is not a sufficient time interval between RT and surgery to allow any significant pathologic response. I think you can be confident in that the pathology aft...
How would you treat an elderly patient with T1 glottic laryngeal cancer who refuses 28 fractions?
I would suggest using 52 Gy in 16 fractions. This is NCCN-supported for T1 glottic lesions and has a long track record of success and tolerability (Gowda et al., PMID 12972304). I have used this regimen exclusively with VMAT. That said, it predates IMRT and 3-D conformal is very reasonable. I would ...