Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When treating locally advanced cervical cancer with concurrent chemoRT, do you contour the presacral LNs to the bottom of S3 or you stop your contour at S2-S3?
We contour up until we start seeing pyriform muscle like contouring guidelines for gynecological cancer. We address the differences between prostate and gyne in this letter Musunuru et al., PMID 33610294
How do you approach adjuvant radiation treatment planning for R1/R2, node-negative NSCLC?
There are no guidelines for this. Dose: I would go to 54-60 Gy for positive margins (lower for focal, higher for diffuse)/microscopic disease and a bit higher for gross disease, 60-66 Gy (lower if there is not a "mass", higher if there is visible gross disease). If KPS supports, I would want to cons...
How would you approach an atypical teratoid/rhabdoid tumor (AT/RT) in an adult patient?
For adults, it depends on the metastatic disease status regarding dose to the craniospinal axis. A lot of the kids diagnosed with this tumor are under age three, so up front aggressive chemotherapy is usually their treatment paradigm until they are old enough to get radiation. For adults, though, we...
How would you treat a late hilar recurrence of biopsy-proven small cell lung cancer within the previously irradiated volume?
This has come up twice recently in my clinic. In both cases, were able to generate proton RT plans delivering 60 Gy that seemed reasonably safe. Both patients, unfortunately, developed progressive disease in other sites, perhaps highlighting that we should not take on too much risk when delivering l...
Do you recommend surveillance for secondary malignancies of the rectum and bladder after prostate XRT?
I think it's important to be sure that patients are up to date with screening for colorectal cancer before beginning a course of prostate XRT. I have had an occasional patient who was found to have a colorectal cancer on colonoscopy performed pre-treatment because they were out of compliance with sc...
How would you manage the axilla of a patient with a recurrent ipsilateral breast cancer treated with lumpectomy, sentinel node biopsy, and IORT?
Generally, I am unenthusiastic about reirradiation of breast cancer patients who've been treated with BCT. Even if one can avoid critical structures such as heart and lungs, brachial plexus, etc. Cosmesis is likely to be compromised, given sufficient length of follow-up. In this instance, presumably...
Does Oncotype score affect your decision to do regional nodal irradiation in a patient with early-stage breast cancer?
For ITC, would not change based on genomic testing and treat like node negative disease.
Do you consider the duration of lung/lobar atelectasis in your decision making while offering airway stents for malignant central airway obstruction?
Yes, always. We review old imaging to determine when there is a post obstructive pneumonia or collapsed lobe/lung secondary to endobronchial obstruction (extrinsic or intrinsic). The old teaching was that, if a lobe is down for more than two months, it is unlikely to be salvaged, even after the endo...
Would you consider SBRT for a patient with a solitary HCC lesion, with SLE/lupus previously on immunosuppression?
This one is a little bit tough, because there are other treatments for a solitary HCC lesion (surgery, TACE, RFA...), it may be better to use those options and avoid the risk of potentially enhanced toxicity. However, I suspect the risk is not very large as the risk from SBRT to the liver is so smal...
Do you cover the sacral foramen when treating pelvic lymph nodes for prostate cancer?
I don’t cover the sacral foramen when treating the presacral nodal region for prostate or gynecological cancer - this reduces the dose to the sacrum and thus risk of insufficiency fracture. However, I do try to cover the foramen for locally advanced rectal cancer, especially with posterior mesorect...