Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What stage is bilateral orbital/conjunctival NHL (limited only to the bilateral orbit/conjunctiva)?
By the Ann Arbor staging system, this is stage IV disease because more than one extranodal site is involved at initial presentation. However, NCCN and other guidelines acknowledge that MALT lymphoma involving both paired organs (e.g., bilateral orbital/conjunctiva) is often best treated with RT alon...
Do you offer radiation to HCC with a single positive celiac node?
I think it's worth a discussion with the patient and evaluation in MDT and medical oncology. If the patient has good liver function (CPA, maybe B7 depending on primary size) - it is reasonable to consolidate. Node positive disease makes transplant unlikely. So in this case, I have done 15 fractions ...
At what point during first-line treatment with mono-immunotherapy for oligometastatic NSCLC is the ideal time to consider consolidative radiation/SBRT to the primary and oligometastatic sites?
What I do in general first and foremost is judge whether or not it’s appropriate to offer consolidation: reasonable indications thus far have been: oligometastatic disease status at presentation, oligoprogressive disease after therapy, limited # of sites to irradiate, safe to deliver SBRT in the ana...
In a patient with end stage renal disease and chronic oliguria, what strategies do you use to avoid excessive bladder irradiation when treating prostate cancer with external-beam radiotherapy?
If a patient has end-stage renal disease, the first question I would ask is what is the patient's life expectancy? According to several papers I have reviewed, the median life expectancy of a person with ESRD is about 4 years. I therefore would not perform localized therapy in a person with such a l...
What radiation dose, fractionation and volume would you use in an elderly patient with localized extensive anorectal malignant melanoma status post laparoscopic APR?
What a great question! This has come up a couple of times in my clinical practice. For anorectal mucosal melanoma that is completely excised and < 7 mm depth of invasion, I have done surface intra-cavitary brachytherapy with a Capri cylinder. For deeper lesions or LN involvement, I have used photon...
Do you wait a certain time period before initiating palliative or definitive radiation to NSCLC after airway interventions such as rigid bronchoscopy tumor debulking, APC, etc.?
Good question and the data is sparse. It really depends on the reason for the therapeutic bronchoscopy. If the patient has a collapsed lung due to endobronchial obstruction, it is reasonable to wait for lung reexpansion. Delivering radiation to a collapsed lung can commonly reduce the likelihood of ...
Would you offer adjuvant chemoRT to a patient with pancreatic adenocarcinoma who underwent neoadjuvant therapy with FOLFIRINOX and SBRT but had a positive (neck) margin on resection and is now s/p adjuvant chemotherapy?
This is why low dose, small volume SBRT is a flawed neoadjuvant treatment. This is possibly a marginal miss. It rarely happened in the past with conventional pre-op treatment but now it is happening commonly. Many patients are suffering because of it. It is important to assess the margin was in the ...
How do you approach CNS prophylaxis in patients with DLBCL?
I think the NCCN-CNS-IPI based on the German data is a reasonable place to start when it comes to making decisions regarding CNS prophylaxis. We typically do IT MTX for patients on the lower end of the risk spectrum and high-dose IV MTX for patients on the higher end of the risk spectrum.
How do you image when using DIBH with breast treatment?
For patients undergoing DIBH we use standard portal imaging only.
Do you attempt to spare a strip of skin for palliative 8 Gy x 1 fraction radiation treatments?
Great question. Do I attempt to spare some measure of skin during treatment course requiring palliative EBRT at 800cGy x1? Answer: NO. Generally, in my experience over the past few years with using single fractions palliatively, skin sparing is just not an issue, for the most part. Further, as I rec...