Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What approach do you take to determine dose constraints for SBRT reirradiation of the head and neck?
There is likely no "safe" dose when delivering full-dose SBRT overlapping tissue that previously received 40-70 Gy. The best you can do is make sure the patient understands the risks, that this strategy fits their goals of care, that you've considered all alternatives, and that you approach planning...
When starting HN radiation, which start day do you prefer to add most value to the treatment course?
Not sure there is really strong data on the preferred day to start. With a 35 conventional fraction HN plan, starting on a Monday ends on a Friday (assuming no holidays or missed treatments). With the same assumptions, starting on a Tuesday ends on a Monday, etc. So personally, haven't been dogmatic...
What is the role for molecular agents alone for medically inoperable NSCLC who is not a good candidate for chemoRT?
If medically inoperable and deemed not a chemo candidate, my preference would be definitive RT alone using a hypofractionated approach to account for the absence of radiosensitizing chemotherapy even for patients with targetable driver mutations. The best data we currently have would then say to con...
For patients with peritoneal carcinomatosis and minimal response to neoadjuvant chemotherapy, is there a benefit to palliative cytoreductive surgery followed by whole abdominal radiotherapy?
The prognosis for individuals with peritoneal carcinomatosis is generally bleak. Administering radiation therapy to manage gastric, colon, or appendiceal cancer is exceptionally challenging due to the imperative to safeguard the delicate large and small intestine. One potential exception arises when...
What is your preferred palliative radiation regimen for patients with painful bone metastasis?
Because of the great work of the BM Working Group led by Hartsell et al, and the Dutch, for examples, there are ample category 1 data supporting the use of Single Fraction (800cGyx1) EBRT for "uncomplicated" bone lesions. That is, the use of 800cGy x1 unless there is: a soft tissue component, an imp...
Do you do urethrogram at time of prostate simulation?
We don't perform a urethrogam. We do MRI with a pelvic coil and fuse it with the CT scan which helps to identify the base, lateral edge and apex appropriately.
In what settings do you routinely image the spine for work-up of an intracranial glioma?
I do not routinely image the spine following workup of an intracranial glioma. It is not because they are not common because in fact, it can be found in 25% of patients with supratentorial glioblastoma (Kaloshi et al. Acta Inform Med 2014). Rather, symptomatic spinal dissemination occurs in less tha...
What is your approach for a brachytherapy boost in prostate cancer patients with extracapsular extension?
In general for patients with documented extracapsular extension, the combination of external beam radiation along with brachytherapy is a very appropriate treatment intervention. For such patients, we generally initiate treatment with the brachytherapy and make sure that seed placement is well cover...
What strategies to you use for large breasted women receiving whole breast radiation?
If we can't do prone, we use a styroform wedge in the inframammary region to decrease the breast fold and thus, decrease the inferior margin and amount of inframammary fold we have to treat. I would initially try hypofractionation with mixed beam with a field-in-field technique and if the dose homog...
How do you approach isolated recurrence in a para-aortic lymph node following definitive radiation for localized prostate cancer?
This is a challenging situation with no data to guide therapy; it is not unreasonable to pursue novel PET imaging (PSMA on trial, fluciclovine) to ensure there is no evidence of other sites of metastatic disease. The treatment of oligometastatic disease continues to evolve. In this situation, I woul...