Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach a symptomatic patient with with a history of whole brain RT with new bilateral MRI enhancing lesions within the optic nerves?
The differential would be optic neuritis from immunotherapy or leptomeningeal disease. Is there any visual deficit? It appears there is a lesion as described above rather than enhancement which would favor disease. One would need to know the disease status outside brain and if there is any other sus...
What is your surveillance imaging schedule following treatment of a pituitary adenoma?
Pituitary adenomas usually change little in size after either fractionated RT or SRS, and they progress slowly. Therefore, yearly imaging to look for increase in size is sufficient. For secretory pituitary adenomas, periodic (every 3 to 6 months) measurement of the level of the hyper secreted hormon...
How do you improve compliance with TTFields for patients who would like to discontinue therapy?
I think that TTF can be an incredibly empowering adjuvant treatment, that I agree should be encouraged as standard. Engaging a patient who might otherwise feel that they have lost control amongst a myriad of treatment hurdles, for which they have little control, can be frustrating. The data now sugg...
How would you approach a high grade neuroendocrine carcinoma found in a mediastinal lymph node with unknown primary?
If this does not appear to be "Small Cell Lung Cancer", then one option may be to perform concurrent chest radiotherapy with chemotherapy using the "Locoregional, unresectable" pathway of the "Extrapulmonary Poorly Differentiated" Category of the "Neuroendocrine and Adrenal Tumors Guideline" as a st...
How do you counsel patients on TTFields if they have reservations about the aesthetics and inconvenience of the treatment?
Honesty is the best policy; we emphasize commitment and diligence. We describe the well-known skin side effects, and describe that they are very manageable. Often, patients report fatigue, but that is a very common and non-specific symptom in patients with GBM. We use visual props and models liberal...
How do you incorporate TTFields into your clinical practice?
I recommend TTFields to all patients with newly diagnosed glioblastoma. I generally approach this during the second or third week of radiation treatment. I present TTFields as part of standard treatment for glioblastoma, similar to the discussion of adjuvant temozolomide.
How would you manage locoregionally advanced NSCLC with extensive tracheal "mucosal malignant" skip lesions covering almost the entire trachea?
Although I've never encountered this exact situation in practice, I would say that this is very similar to cases that require extensive mediastinal radiation to cover all of their gross nodal disease. My prescription would remain 60Gy in 30 fractions and I would attempt to meet the standard esophage...
Do you hold pelvic radiation for patient with clostridium difficile-associated diarrhea?
No. I proceed with radiation unless the diarrhea is not treatable with fluids and treat the C difficile with antibiotics. I am not aware of any data showing worsened toxicity of radiation concurrent with C difficile infection.
Do you routinely prescribe PCP prophylaxis for patients who will be on steroids long-term?
Yes. This is something I don't think is emphasized enough given the ease of the intervention and seriousness of infection. In my first year of practice, I saw 3 fatal cases of PCP in patients that were receiving steroids from medical oncology without PCP prophylaxis. So I prescribe it for virtually ...
Is there any data to support SLNB instead of ALND in patients with clinically N2-3 breast cancer after neoadjuvant chemotherapy?
The sentina trial and acsog trial had Predominant N1 disease and negative predictive value Of SNLN is not known for N2 or N3 disease