Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For APBI, do you prefer a brachytherapy or external beam technique?
I offer a variety of PBI techniques depending on situation and patient preference.With respect to external beam, I primarily utilize a 30 Gy/5 fraction regimen delivered with VMAT (2-3 coplanar arcs). We use breath hold regardless of laterality and CBCT to reduce motion and reduce PTV expansions. Th...
Are there any types of sarcomas that you use induction and/or concurrent chemotherapy with radiation prior to surgery?
Neoadjuvant chemotherapy is controversial in extremity/trunk STS.Generally speaking, grade 2/3 tumors that are ≥5 cm are at high-risk for distant recurrence despite ~90% local control. For these patients, you can consider neoadjuvant chemoRT. When using neoadjuvant chemoRT, the more common approach ...
Are there any anatomical locations that you would consider omiting preoperative radiation for sarcoma due to toxicity concerns?
Its a risk benefit discussion. Groin tends to be location with significant risk of toxicity particularly in higher risk patients (elevated BMI, smoker, etc). However, for high grade sarcomas there is a clinical benefit and getting these same patients through post-op can be even more challenging. I u...
When treating node positive anal squamous cell carcinoma, dose your lymph node boost include only gross disease with margin or do you boost the entire nodal region?
Boost is to involved node with PTV margin and dose is a function of nodal size
Would you recommend consolidative RT for a mediastinal germ cell tumor with partial response after chemotherapy?
There is no evidence or logic in postchemotherapy radiotherapy for patients with residual mass with nonseminomatous germ cell tumor. Instead such patients should be referred to a thoracic surgeon with experience and skill in resecting residual masses. For mediastinal seminoma, there will almost alw...
How do you manage painful (non-sbrt) bone metastases in patients receiving nivolumab or other immunotherapy?
Patients on immune checkpoint inhibitors are at risk of developing serious adverse effects from the agents themselves, which can impact on the delivery of radiation. For example, they can develop an immune mediated colitis, which can mimic acute radiation enteritis, but the management is completely ...
In a patient with newly diagnosed high risk prostate cancer, how do you work up a bone scan showing suspicious areas of radiotracer uptake?
This a great question. In the setting of abnormalities on the bone scan, I would take 2 actions. First, I would certainly get local imaging of the abnormal site, with a CT, MRI or X-ray, depending on the location. I would also use the patient's clinical scenario and treatment response to help in the...
Are there specific high riks features for which you would offer palliative adjuvant head and neck radiation in the setting of metastatic disease but without residual gross head/neck disease?
This question is worded in a confusing way. As I understand it, the scenario relates to a patient with both local and distant disease who is treated with chemotherapy and has a clinical complete response at the primary site. The question then is whether to add RT to the primary site. We would do so ...
Would you offer whole abdominal irradiation to a pelvic recurrence of rhabdomyosarcoma with tumor rupture / spillage?
I would be less inclined to use a large field / volume approach like whole abdominal RT in the setting of recurrent disease. While I don't know if prior RT was delivered or not, the outcome for children with a pelvic recurrence (especially is a local recurrence) is overall very poor with only 20-30%...
If a patient develops a radiation recall reaction do you typically recommend avoiding the causative chemotherapy in the future?
Depends on severity and response to steroids. If grade 2 or less, might consider restarting the implicated agent (if no other options) at a low dose and titrate up if tolerated. Recently published an article on radiation recall pneumonitis secondary to immunotherapy