Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What would be the targets and dosing for a patient with p16+ unilateral neck disease and a small basaloid SCC of the BOT found after diagnostic tonsillectomy and BOT resection?
While detailed, often these questions are not detailed enough, and so I try to generalize and read between the lines to think what the specific question might be. The nuances are: Is the question p16+/basaloid SCC different from HPV+? The short answer is no. What is a diagnostic tonsillectomy and BO...
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...
How do you approach endometrial cancer in the setting of multiple pelvic lymph nodes with ITCs and/or micromets, but no macrometastasis?
We are still learning how best to manage these patients as limited data suggests their outcome is much better and not the same as macromets. One caveat is that if only SNLN done with no dissection, than the data suggest there is risk of additional nodes which could be more than 20 percent and would ...
How does number of ITC influence your approach to adjuvant RT for a surgically staged 1B endometrial cancer meeting HIR criteria?
Management of ITC only in the setting of SNLN is not defined well. We know ITC has a much better prognosis than micromets and macromets. We also know that even with ITC after SNLN bx only, there is risk of additional residual nodal disease left behind which may need to be addressed. What we don’t k...
Do you recommend adjuvant treatment for nodal isolated tumor cells in an otherwise low-risk endometrial cancer?
Do you recommend adjuvant treatment for nodal isolated tumor cells in endometrial cancer?No, I don’t recommend adjuvant treatment for endometrial cancer patients based on the presence of isolated tumor cells (ITCs) alone, in the absence of other poor prognostic factors. A recent survey on sentinel l...
What is your preferred dose and fractionation for muscle invasive bladder cancer and how do you decide between them?
I'm using 5,500 cGy in 20 fractions since the Lancet Oncology meta-analysis. If I treat nodes, treat 4,400 cGy in the same 20 fractions. Seems like the mild-moderate toxicity might be higher than with 180-200 cGy/day regimen. The paper referenced above only assessed Grade 3 or higher toxicity. But t...
What approach have you found works best in treating persistent acute radiation proctitis in patients undergoing pelvic EBRT?
Obviously, this is an important question, though I'm a little unclear on the meaning of "persistent acute" radiation proctitis. Though I am not certain, I believe @Dr. First Last's answer applies more to chronic (or at least sub-acute) radiation proctitis. As for the more traditionally "acute" radia...
Do you recommend omitting radiation therapy in young women with favorable DCIS?
If someone can get a screening mammogram, diagnostic mammogram, image-guided biopsy, segmental mastectomy, entertain a conversation about 5 years of ET, they can most certainly handle 5-15 days of PBI where the grade 0 toxicity rate is exceedingly high. Whole breast RT with the Whelan regimen is als...
When do you treat heterotopic ossification with radiation pre-operatively?
Can pre-op radiation be delivered more than 24 hours before surgery?No — this is not recommended and is generally ineffective.Why timing matters (biologic rationale):HO formation is driven by pluripotent mesenchymal progenitor cells that are recruited and activated by: Initial trauma Surgical manipu...
When planning definitive SBRT for localized RCC, how do you approach cases where OAR constraints (such as bowel) compromise PTV coverage?
SBRT for localized renal cell carcinoma is a good option when the patient is not a candidate for nephrectomy. In cases where the lesion is directly adjacent to important normal structures, dose reduction is reasonable. If you believe this to be too large of an area, you could consider neoadjuvant sy...