Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For post-prostatectomy radiation, are there any special considerations if there is a bladder sling or artificial urinary sphincter?
Great question. I have treated patients with artificial sphincters and penile prosthesis, and the thing I noted was one of the most important thing to do: document the urinary status of his function. I can say that for the most part I typically saw my patients after they have developed PSA progressi...
Do you insist on biopsy confirmation of invasive disease in the setting of in situ pathology findings but otherwise clinical/radiographic evidence of invasive cancer?
Not necessarily. I recently had a case of cervical cancer which was called CIN 3 on 2 consecutive biopsies with a palpable mass approximately 3cm in size on clinical exam. PET/CT showed intense FDG avidity in the cervix with a 5cm mass and pelvic lymph nodes. We treated as a IIIC invasive SCC. While...
What would you recommend for a stage I follicular lymphoma of the bone?
Definitive treatment would be 24 Gy/12 to area of disease with margin (not entire bone). See ILROG guidelines for extranodal lymphoma (Yahalom et al., PMID 25863750).
How would you manage a patient with intact prostate cancer with metastases to a para-aortic node and single bone?
I would consider treating the primary site per STAMPEDE as well as possible SABR the other lesions, so long as he understands this is an evolving area and the benefit has not been conclusively demonstrated. Would recommend confirming the bone lesion by biopsy as well.
What bowel dose constraint do you recommend if you are boosting a pelvic lymph node for prostate cancer?
We generally use 55 Gy to < 5 cc based on Gyne literaturem and try to make sure the high prescribed dose is limited to one wall of bowel loop.
When treating NSCLC with SABR, if the preceding lung biopsy resulted in post-biopsy hemorrhage, how would you modify your target volumes, if at all?
Use pet activity to use actual tumor volume.
Would you forgo consolidation radiotherapy for a patient with stage 1EA diffuse large B cell lymphoma of the stomach who presented with a perforated ulcer?
Good Question! Based on recently published SWOG 1001 (Persky et al., PMID 32658627), patients can be treated for stage I/II DLBCL with RCHOPx3. If iPET is negative at that time, one more cycle of RCHOP and no RT yields excellent outcomes (5 year PFS = 87%). This is the new standard of care. Having s...
How do you obtain approval for an MRI prostate for radiation planning?
Approval of another MRI using diagnostic CPT codes (e.g. 72197) is unlikely. CPT 76498 (unlisted MRI procedure) is commonly used for radiation treatment-planning MRIs, such as for brain and prostate. As an example, see eviCore's Onc-1.5 policy on this. Have users seen repeated denials of CPT 76498 (...
In the setting of a recurrent Grade 1 liposarcoma of the spermatic cord that extended to the scrotum and was previously treated with surgery alone, what volume and dose would you use in following re-resection?
In my whole career, I've only had one patient who had about 4 recurrences before the urologist referred him. I personally had problems covering surgical beds from each procedure, but did it. I made a device to hold his penis away from the scrotum and treated the entire scrotum, warning him about tes...
How would you manage a patient with a superior sulcus tumor of the lung treated with upfront surgery, who achieves negative margins and has negative mediastinal nodes?
The guidelines are unfortunately unhelpful and conventional wisdom may be to consider tri-modality therapy. But, there is room for pause.Let us remember that surgery for superior sulcus tumors was initially deemed futile. That is until Chardack and MacCallum reported the first successful survivor wi...