Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
Should indications for postmastectomy radiation be different after a Goldilocks mastectomy?
Not a lot of data though there is this abstract which included a small number of patients receiving RT (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5959682/) In general, I would not use different indications for PMRT with patients undergoing Goldilocks mastectomy. For T3N0 cases, I tend to look mo...
Is there a role for adjuvant radiotherapy for a symptomatic vertebral body hemangioma following debulking surgery?
Yes. 45 Gy in 25 fractions
Should you offer radiation therapy to a low risk prostate cancer patient on active surveillance so that he may receive testosterone supplementation?
Great question. In my experience I can recall at least 3 or 4 patients who were subsequently dx'ed with PC after starting a testosterone supplementation.So, serious treatment and future considerations must be the matter of both doctor and patient in terms of the potential for tumor progression while...
In patients with low metastatic burden receiving prostate directed therapy with MRI confirmed invasion of the seminal vesicles, would you include the SV in your field?
Yes, as one of principals of local treatment helping with survival in stage IV disease is eliminating it's source of future metastatic clones not sensitive to ongoing treatment. Thus, makes sense to treat all visible local disease with RT.
How would you manage a patient with T3N0 rectal cancer status post transanal excision, who is not a surgical candidate, and who received pelvic radiation for prostate cancer 20 years ago?
Abdominal or abdominoperineal resection. T3 tumors have a 20+% risk of recurrence despite radiation and local excision. If truly T3N0, the risk may be the same with surgery. And reirradiation is fraught with risk.
What ITV to PTV expansions do you use for free-breathing NSCLC SBRT using CT sim with 4DCT?
5mm concentric PTV margins. Even with daily IGRT and fluoro, I find 3mm to be very tight and adding a little more margin does not change the OAR doses much unless PTV is touching. If 4DCT not available in sim, I do 7mm sup/inf and 5mm in other directions. I do not specifically add a CTV margin, but ...
What is the optimal management of patients with stage II lung cancer without nodal metastasis, but unresectable due to poor pulmonary reserve?
This population of stage II patients without nodal involvement would include T2bN0 (stage IIA) or T3N0 (stage IIB) disease. NCCN 2020 lists either CRT or hypofractionated RT/SBRT as acceptable options. In my experience, if these patients are nonsurgical, then they typically also have multiple co-mor...
What ITV to PTV expansions do you use for free-breathing definitive IMRT for locally advanced NSCLC using CT sim with 4DCT?
This seems like a simple question, but it is not! It is missing something...the concept of the CTV (clinical target volume) is missing within the question. The idea of the CTV is to include microscopic disease within the region receiving full dose. In the case of locally-advanced lung cancer, CTV is...