Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you typically prescribe dose to a PTV for standard IMRT plans?
Each PTV has three constraints: >/= 95% of PTV receives 100% of RX dose Max hot spot </=110% >/=99% of PTV receives >/= 93% of Rx Dose
How would you approach patients with primary cardiac sarcomas for adjuvant systemic treatment?
Majority of these primary cardiac sarcomas tend to be angiosarcomas or UPS-variants. They inherently have a poor prognosis with high risk of metastases and death. Adjuvant XRT is generally difficult in this location. These also generally affect young individuals with o/w good PS/organ function. So w...
In what situations (if any) would you recommend ENI for a low grade parotid mucoepidermoid carcinoma?
Not sure if I understand the question correctly but I will give the best answer I can. There aren’t many reasons to treat low-grade parotid mucoep. If you’re treating for positive margins only, I wouldn’t do ENI. If you’re treating for PNI, cover nerves to skull base. If there are positive nodes, tr...
How do you decide between high tangents or regional nodal radiation in patients with small, ER+ breast cancers who have a single positive sentinel node?
I tend to look at factors such as age, LVSI as well as number of SLN (1/1 vs. 1/2,3,4). After lumpectomy, for cases like this, my bias is to offer whole breast and RNI. I have also started offering more 40/15 to breast and lymph nodes so this approach doesn't lengthen course of treatment as compared...
When using chemoRT for bladder preservation in muscle invasive bladder cancer after maximal TURBT, how should the mid-point (40 - 45 Gy) cystoscopy be utilized?
The thought is that medically inoperable patients go straight through (since no point in evaluation, b/c they won't be getting cystectomy), but for medically operable patients, they may be better served by cystectomy after a cystoscopy that does not show a CR, and that has been the RTOG approach. Ho...
In what scenario would you recommend induction chemotherapy prior to chemo-radiation in head and neck cancers and what would be the preferred regimen?
The use of a sequential approach to treating locally advanced SCC of the head and neck is not generally recommended since three studies from Spain, the Dana Farber Cancer Institute, and the University of Chicago failed to demonstrate a survival benefit from three cycles of TPF (platinum, paclitaxel/...
How do you approach a NSCLC case with extensive nodal disease that results in a radiation plan that cannot meet normal tissue constraints?
This is an interesting question as there are multiple, complementary approaches that can be taken: If using > 60 Gy, drop the dose down to 60 Gy in 2 Gy fractions. Some practitioners continue to use > 60 Gy in the post-RTOG 0617 era, which is not unreasonable based on retrospective data and first pr...
How would you approach a cT4 cN2 (22 cm in size) TNBC that shrank to 9 cm with KN-522 regimen but remains inoperable at the end of treatment?
This sounds like a tough situation. I will offer up an opinion but I know others will have their thoughts and more than one is important here. Obviously, this person is at very high risk to have occult metastatic disease. However, I think this biology is also interesting. For a tumor to have reached...
What criteria do you use for choosing (or, pointedly, not choosing) parotid sparing with IMRT in patients with bilateral neck nodal disease from a mucosal head and neck cancer?
When I prepared for our oral board exam, we knew that certain examiners felt that patients with bilateral neck disease were not true candidates for parotid sparing IMRT. You may have had to back down on IMRT with certain examiners and say that there wasn't a strong rationale for treating with that t...
Do you hold osimertinib when delivering partial or whole brain 3D radiation?
I typically don't mandate holding osimertinib while administering SRS for brain metastases unless my medical or neuro-oncologist has concerns. In such cases, I might consider delaying the initiation of osimertinib for about a week. Notably, there are two prospective studies (NCT03769103 and NCT03497...