Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage a patient with oligometastatic colon cancer status post resection of the primary whose single unresectable liver lesion has had a complete response to FOLFOX chemotherapy by PET?
This could be a pathologic complete response, so I would observe and recommend hepatic directed treatment if it progressed. If this were solitary nodule still, surgical resection would be the treatment of choice, followed by thermal ablation if feasible, and SABR (100Gy BED) is the third choice beca...
Do you use bolus for the lumpectomy cavity boost when the seroma is within 5mm of the skin?
I agree with the above that this is very rarely necessary. When it is required, it may be hard to define where the bolus is to be placed on an intact breast. One neat trick is to have dosimetry create an en face setup field with an aperture equivalent to where you want the bolus to be (cavity plus m...
How do you approach the work up and surgery for H&N SCC of unknown primary?
CT max, face, neck and chest. PET is ok but has a high false positive rate in the oropharynx where the primary is likely located in the US. Direct laryngoscopy and ipsilateral tonsillectomy. Bilateral tonsillectomy is ok but low yield (less than 5%). Biopsy base of tongue. Lingual tonsillectomy is o...
Would you recommend salvage RT in a patient who previously had prostatectomy for high risk prostate cancer who is no longer tolerating his intermittent hormonal therapy?
Why was hormone therapy started. BCr or adjuvant ? if adjuvant doesn’t need any treatment and just psa surveillance
Do you offer ADT in patients with intermediate risk prostate cancer who receive hypofractionated EBRT?
There is no good evidence that with different radiotherapy dose/fx or other RT modalities that the relative benefit of ADT is any different. This applies also to SBRT, brachy, and combo-brachy. The basic evidence and logic is as follows:1. ADT improves MFS and OS in multiple RCTs using lower dose co...
If tumor is stradling the peritoneal reflection how do you decide whether to treat with neoadjuvant chemo/RT vs just surgery?
There are many definitions used to delineate the sigmoid colon from the rectum. The peritoneal reflection is only one of these, and it may not be the most clinically useful. The location of the peritoneal reflection varies with age and gender, and it typically extends more inferiorly on the anterior...
How do you account for tumor growth from pre-operative to intra-operative ultrasound for uveal melanoma?
On B scan, measure the thickness from apex AP and also do basal measurements. Base measurements are done through indirect ophthalmoscope also. At each visit, pre-op and postop, both B scan measurements (for tumor thickness) are done and also indirect ophthalmoscope measurements. My twin sister is an...
Would you require pre-RT dental evaluation and clearance for a patient who is being treated with ISRT to Waldeyer's ring/BOT area to 30 - 36Gy?
Yes. In the pre IMRT days, we certainly experienced some dryness and dental issues at dose of 30Gy, albeit much less severe than with typical carcinoma doses. With IMRT and salivary gland sparing the problem is clearly less, but it's hard to argue against a good dental evaluation pre RT. Talk with t...
What is the role of consolidative RT to initially bulky sites (>8cm) in a patient with stage III triple hit lymphoma who has tolerated only 4 cycles of DA-EPOCH-R?
I am going to expand the question to consider the role of RT in the curative rx of stage III/IV DLBCL triple hit or not. Conventional wisdom, e.g. NCCN guidelines suggest no role but I respectfully disagree. We reviewed the data in 2014 (Oncology 1074-1082, Dec 2014) and also recommend Dabaja et al ...
What dose-fractionation would you use for a recurrent basal cell carcinoma of the right ear concha close to the tympanic membrane status-post multiple Mohs surgeries with close/positive margins?
I would get a second surgical opinion. Any dose/fractionation scheme given with curative intent will cause terrible wet desquamation and likely complete hearing loss. This patient needs a curative-intent surgery by a base of skull surgeon who will get adequate margins around this and the patient wil...