Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Is prior TURP a contraindication to SpaceOAR placement?
It's worth a try. Most of the time, I haven't had an issue. Occasionally, a TURP or other procedure can lead to more fibrosis in the rectoprostatic space that can make it hard to hydrodissect. But typically, it is not an issue.
How do you manage postoperative head and neck cancer patients who have difficulty completing simulation due to copious secretions?
In addition to elevating the head/shoulders as much as technically feasible, if there aren't contraindications, I've used a scopolamine patch applied two days before the sim with variable success.
In the Nebraska/Mayo transplant protocol for perihilar cholangiocarcinoma, do you ever offer prophylactic biliary drainage/stenting to prevent obstruction post-chemoradiation?
We use an ERCP-placed nasobiliary approach to biliary brachytherapy as part of our pre-transplant CRT regimen for patients with peri-hilar cholangiocarcinoma (Murad et al., PMID 22504095). Our technique is described by Deufel et al., PMID 29776892. Patients with baseline tumor and/or comorbid diseas...
How would you treat an elderly patient (ECOG 0-1) with locally advanced rectal cancer and synchronous Merkel cell cancer of the extremity requiring adjuvant RT?
Interesting - the flurry of activity came several months after I treated the patient. The patient was not going to get further surgery for either. I choose to treat with definitive CRT (Xeloda) to 54 Gy w VMAT. I treated the Merkel Cell with 30/10 at the same time, presuming the patient would have a...
Do you change your monitoring strategy for a high risk prostate cancer after XRT if the initial PSAs have never been very high?
In general, a patient whose volume of cancer is out of proportion to their PSA makes me nervous. So, I'm much more worried about the patient with a PSA of 5 and multiple cores positive for high volumes of Grade Group 4-5 cancer than I am about the patient with a PSA of 5 and a single positive core s...
Would you offer re-irradiation for a patient with a left sided medial DIEP flap recurrence with a history of prior whole breast radiation 25 years ago?
With all favorable features, would suggest exploring the option of systemic treatment alone. If treating, may assess localized field rather than comprehensive RT.
When treating locally advanced cervical cancer with concurrent chemoRT, do you contour the presacral LNs to the bottom of S3 or you stop your contour at S2-S3?
We contour up until we start seeing pyriform muscle like contouring guidelines for gynecological cancer. We address the differences between prostate and gyne in this letter Musunuru et al., PMID 33610294
How do you approach adjuvant radiation treatment planning for R1/R2, node-negative NSCLC?
There are no guidelines for this. Dose: I would go to 54-60 Gy for positive margins (lower for focal, higher for diffuse)/microscopic disease and a bit higher for gross disease, 60-66 Gy (lower if there is not a "mass", higher if there is visible gross disease). If KPS supports, I would want to cons...
How would you approach an atypical teratoid/rhabdoid tumor (AT/RT) in an adult patient?
For adults, it depends on the metastatic disease status regarding dose to the craniospinal axis. A lot of the kids diagnosed with this tumor are under age three, so up front aggressive chemotherapy is usually their treatment paradigm until they are old enough to get radiation. For adults, though, we...
How would you treat a late hilar recurrence of biopsy-proven small cell lung cancer within the previously irradiated volume?
This has come up twice recently in my clinic. In both cases, were able to generate proton RT plans delivering 60 Gy that seemed reasonably safe. Both patients, unfortunately, developed progressive disease in other sites, perhaps highlighting that we should not take on too much risk when delivering l...