Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Under what circumstances do you offer post-operative spine SRS over standard EBRT?
We typically consider post op SBRT for previously irradiated lesions, radioresistant histologies (renal cell, melanoma, sarcoma, GI primaries, for example), or patients with good prognosis (oligometastatic for example). These patients will have excellent and durable tumor control, low risk of toxici...
When would you include uninvolved nodal stations when treating patients with locally advanced NSCLC with definitive CRT?
You bring up a good point. Sometimes there are 'at risk' nodes in locally-advanced NSCLC (LA-NSCLC) that may not be FDG-avid and sit between two or more masses that are FDG-avid or perhaps are enlarged but not FDG-avid. Judgement does come into play when contouring targets. For background, RTOG 0515...
Are the conformality constraints still important when organ at risk constraints are met for lung SBRT?
Conformality constraints required in some lung SBRT clinical trials served as useful treatment planning guides that obliged attention to reducing the exposure of adjacent normal lung tissue to high dose.I am unaware of data specifically validating any of the indices mentioned in the question as a pr...
In which Her2+ breast cancer patients would you recommend extended adjuvant therapy with neratinib?
The benefit is largely in estrogen receptor positive patients and the gains are modest. Although with extensive and extended anti-diarrheal medications the almost intractable diarrhea seen with this agent can be made tolerable. On the other hand, it would take a VERY motivated patient, probably with...
How do you simulate a patient with a large beard who needs a thermoplastic mask?
I just sim these patients as normal. I assume you're talking about a H&N Ca patient. I counsel these patients that radiation "shaves" their beard, eventually and sparsely/unattractively at that, so it's usually not a big deal to get someone to shave if you so desired it. Also, you can't predict if t...
Should density overrides for VMAT lung SBRT planning be utilized for small mobile tumors?
I don't think it's a huge issue to change it, but I/we don't usually do that. VMAT plans are very robust to density changes so I bet if you looked between the plans it would be a very subtle difference....like less than 5% if I had to guess. We don't do it that way because it's a bit of a cheat (or,...
Would you offer breast conservation or PMRT (if clinically warranted) to someone with breast cancer in the context of Li Fraumeni syndrome?
I would be very reluctant as the benefit has to be weighed against the high risk of a second cancer that has been reported in limited published literature .
How do you approach treatment for isolated lung recurrences in patients that did not tolerate chemotherapy after lobectomy?
For non-small cell lung cancer recurrences after lobectomy I approach them the same way as a newly diagnosed NSCLC. If the lymph nodes are negative and the recurrence is small and away from the hilum and central structures, I would recommend SBRT, 50 Gy in 5 fractions. If the lymph nodes are negativ...
When treating with high tangents, do you use conventional fractionation or hypofractionation?
When treating level 1 and 2 nodes only we routinely use hypofractationation. Here is link to our approach http://www.sciencedirect.com/science/article/pii/S1879850017302072
How do you approach SRS for a brain metastasis in an eloquent area of the brain?
Short of metastases in the brainstem or next to the optic nerve/chiasm, we do not routinely decrease the dose or hypofractionate SRS in other eloquent areas such as the motor strip. While radiation necrosis is the main concern, the risk of recurrence which is shown to be higher with diminished doses...