Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach oligometastatic (solitary) recurrence with previously resected pancreatic adenocarcinoma and adjuvant chemotherapy with a prolonged disease-free interval?
This is very different from colon cancer with a solitary recurrence after a long disease-free interval. In this case, before considering any local therapy, I would treat with a course of systemic therapy to establish favorable disease biology. The vast majority of patients with recurrent, oligometas...
At what field size would you consider splitting a palliative spine treatment into two different courses?
I usually don’t treat radiograph only. I usually ask for a detailed pain history and limit the size of RT to correlate with the pain and target MRI areas that are problematic (epidural, impending cord or fracture). I usually limit the sections if pt complains of pain involving many regions regions (...
What is your strategy for image surveillance for occult breast cancer after treatment?
As the are occult with all imaging including MRI there is no good strategy for imaging . Also risk of IBTR in modern era after RT in these patients is low and would just do routine annual mammogram for screening
When do you add an adjuvant bone-modifying agent in patients with history of localized breast cancer?
In my opinion this is controversial question. The meta-analysis performed by EBCTG 2016 of over 11,000 post-menopausal women, and over 6000 premenopausal women, clearly shows a benefit for the postmenopausal subset. The absolute overall survival improvement was 3.3% (p=0.002) for postmenopausal wome...
How would you approach treatment in recurrent, localized rectal mucinous adenocarcinoma?
Well-differentiated mucinous rectal adenocarcinoma is relatively treatment resistant. In general if there is an in-field local recurrence after prior radiation (ie: is not a marginal miss), then that is very good evidence that it is radiation resistant. There are many studies now showing that re-irr...
What dose do you try to keep the contralateral breast when treating a PMRT inflammatory breast cancer that is extending across midline?
You follow the principal of ALARA as it is more important to control aggressive IBC and you need to treat volume required adequately.
Can you skip elective inguinal treatment in PET negative squamous cell carcinoma of anal canal?
This is an interesting question. There are a few small series that suggest that the negative predictive value of a PET-CT may be quite high (100% in the study by Mistrangelo, IJROBP, 2012). However, the gold standard in these results was sentinel lymph node biopsy, not inguinal lymph node dissection...
Can bicalutamide be used instead of LHRH agonist in intermediate to high risk prostate patients receiving EBRT who want to preserve erectile function?
The short answer is yes, BUT with some serious reservations: 1. This is not considered standard of care in this patient population, so patients should be made aware of that fact and that conversation should be documented in the medical record; 2. There are data to indicate that bicalutamide plus EBR...
How do you counsel patients on multivitamin use during therapy?
I tell patients to stop intake of anti-oxidant multivitamins (A,C and E) at the time of consultation, and if they so wish, they can resume them no sooner than 6-8 weeks after course completion because "radiation continues to work after we're done." I simplify how radiation attacks/kills the cancer D...
What do you consider to be the regional nodal bed for a Merkel cell carcinoma of the thigh with a positive sentinel node in the inguinal chain?
There's no clear right or wrong answer here - I would favor treating the superficial and deep inguinal nodes, capturing the chain as it extends superiorly and inferiorly with a generous margin above and below the site of the sentinel node. I would probably include the external iliac nodes if this co...