Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is the maximum electron energy you would consider using for a breast lumpectomy boost?
I don’t go higher than 12 MeV (normalized typically to 80-85%) and usually am more in the 9 MeV range nowadays if using pure electrons. I have moved to doing most lumpectomy boosts with photons as we can be pretty conformal and more homogeneous (although sometimes we end up treating more breast tiss...
Should IMPower010 results be extrapolated to superior sulcus tumors treated with chemoradiation and surgery?
No. Patients with superior sulcus NSCLC, for whom the standard of care is preoperative chemotherapy and radiation therapy followed by surgical resection, would all have been ineligible for IMpower010, which used chemotherapy +/- Atezolizumab in the purely adjuvant therapy setting. Therefore, the res...
What margin do you use when treating the prostate bed/fossa?
We use similar PTV margin of 5 mm. The only difference is in the definition, surgical bed CTV also includes ITV at the level of SV.
What dose constraints do you use when palliating pelvic structures in 5-10 fractions?
Very much depends on the total dose being delivered. If doing 20 in 5 or 30 in 10, I don't believe any structures in the pelvis are at risk for substantial toxicity, for acute or late. If going higher, then utilizing SBRT/VMAT constraints for the pelvis is reasonable. Can use @Dr. First Last' method...
What is your approach to CNS surveillance in resected superior sulcus tumors given high rates of intracranial metastasis in this population?
Despite the quantum improvement in complete surgical resection, pathologic complete remission, and overall survival rates in S9416/INT-0160 (the trial that established trimodality chemoradiation followed by surgery as the standard of care for superior sulcus NSCLC almost 2 decades ago), distant recu...
How do you approach a thoracic lymph node that is highly suspicious on CT and PET but negative on EBUS in patients with NSCLC?
Our institution is very privileged in having a very large, highly expert team of interventional pulmonologists. In the cases where we are conflicted over how to interpret imaging of concerning lymph nodes, and where we have had the chance for a deep dive at tumor board and accompanying expert radiol...
How would you treat a recurrent chylothorax in a patient with metastatic cholangiocarcinoma?
I would not expect radiation to improve the situation. The only time that I have treated a tumor that I thought was causing a chylothorax it did not improve. Generally, radiation does not open obstructions of veins, ducts, or the GI tract.
Would you offer consolidation RT to a young woman with bulky mediastinal DLBCL who achieved early and persistent CR to RCHOP on PET?
Dr. @Dr. First Last has modestly omitted one salient trial in his answer, namely the Duke trial which he led evaluating low dose consolidation RT (20 Gy) following CR to induction chemotherapy, i.e. PET negative response (Kelsey et al., PMID 30858144). To recapitulate briefly, 62 patients with stage...
Are there circumstances where you would use hemibody irradiation?
I have used hemibody radiation with some regularity for widely metastatic disease, particularly for relatively radiosensitive solid tumors such as breast and prostate, and have found it particularly helpful for multiple myeloma where it can and often does work wonders for pain relief. In addition to...
How would you manage mild SUV uptake at a 3 month PET/CT scan post chemoRT scan for a SCC of the cervix?
Typically at our institution, we would decide the next steps based on her exam findings. If there is concern for residual disease, we would either biopsy or see the patient back in a short period of time for a repeat exam. If there is nothing convincing to biopsy, we would likely repeat the PET/CT i...