Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage an elderly patient with GE junction adenocarcinoma who is not interested in surgery and who has ulcerative colitis (not currently on medication or symptomatic)?
Ulcerative colitis is generally a disease limited to the colon, and is an important distinction from Crohn's disease, which is truly anywhere from mouth to anus in the GI tract. These two diseases are on a spectrum of inflammatory bowel disease and there can be some overlap, but in general I would p...
In patients witih locally advanced pancreatic cancer, how long would you wait after 1st line induction chemotherapy with FOLFIRINOX before you image for assessment of response and deciding about 2nd-line therapy?
We image with Ca-19-9 every 3 months and consolidate with ablative chemoradiation after a minimum of 4 months of FOLFIRINOX. We do not give second line chemotherapy for locally advanced pancreatic cancer unless patients do not tolerate FOLFIRINOX in spite of dose reductions, or experience progressio...
What is your approach to mediastinal-only failure outside of the previous chemo/radiation field for SCLC?
I would treat involved nodal stations with concurrent chemo and radiotherapy. I don't feel it is necessary to cover the whole untreated mediastinum. In terms of margin, I would review the detail CT and PET/CT images and balance the chance of lymph node microscopic disease and toxicities of radiother...
When offering PCI for SCLC patient, do you include C1 in the treatment field or do you stop at the base of the skull?
I do bottom of C1 like most WBRT. I still go to bottom of C2 for LMD cases but I'm not sure that is necessary for PCI. Not aware of any direct level 1 evidence to address this, more of historical practice based on 2D. With FIF and VMAT CSI techniques and better IGRT, ensuring easy match line and fie...
Do you offer APBI to patients with PALB2 mutation who is a suitable candidate?
In our clinic, most patients with PALB2 end up getting mastectomy. However, if they choose to undergo breast conserving therapy, I usually discuss whole breast irradiation and the potential risk of new and contralateral primaries. While, I would not routinely offer APBI to such patients, if they wer...
How do you manage an anal SCC status post a non-oncologic excision of a 2-3 cm primary and positive excisional biopsy of an inguinal node with pathology revealing LVSI, positive surgical margins, and more regional lymph nodes on PET?
This was done prior to the referral for radiation but there is no role for an excisional biopsy of a lymph node and it can be harmful. It changes lymphatic drainage, shifting it to towards the genitalia and suprapubic area. Cells in transit to that nodal basin will now try to get to the other side. ...
How do you approach elderly patients with stage III NSCLC who have a reasonable performance status?
Prior to answering this question, I should be clear that I have no additional geriatric oncology training or expertise other than someone who has treated lung cancer patients for more than 25 years. Generally I approach elderly patients in the same way I approach the younger with the caveat that I f...
How do you approach prostate cancer patients who present with retroperitoneal lymphadenopathy (stage M1a)?
Interesting question because I have had similar patients with differing amounts/extent of retrop-adenopathy and, as such, had to get a 'plan' in all cases:1. For me, the easiest answer and first step is tissue confirmation of the adenopathy. That is, if tumor is the rumor, then tissue is the issue, ...
Would you recommend covering the dissected axilla in your radiation field in patients with cN2/N3 disease who had complete response to neoadjuvant chemo and an ALND?
It has been my practice to cover the dissected axilla in these cases with cN2/3 disease, even with a pCR and ALND. I have not seen huge volume reductions when you plan with 3D-CRT and have tangents and an AP SCV field, so Im not sure how much you gain in terms of volume irradiated and potential toxi...
Do you use the NM lymphoscintigram during sentinel node identification to decide whether to treat the internal mammary nodes?
NM lymphoscintigram is hardly done now a days for breast SNLN procedure. Besides since injection is not done in the tumor area but in periareolar area the migration of dye to internal mammary area is limited and hard to detect