Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For rectal adenocarcinoma initially staged as T2N0 and treated with upfront surgical resection, but pathologically upstaged to pT3N0 without high risk features, how do you approach adjuvant therapy?
It is not uncommon for a rectal cancer which was initially felt to be T1-2 and node negative to be revealed to be more advanced stage after surgery. To know what to do in these settings, we have to go “old school” and revisit trials reported in the 1990s, combined with lessons learned in the 2000s.S...
How would you treat an upper extremity high grade neuroendocrine carcinoma s/p 6 cycles of cisplatin and etoposide followed by resection ypT0 ypN1?
I would be suspicious. I recently treated a patient with the same diagnosis who was diagnosed with cutaneous small cell carcinoma on an inguinal node excision, recurred during adjuvant chemo with inguinal, external iliac, and common iliac adenopathy. Path was reviewed and diagnosis changed to Merkel...
What length of ADT do you recommend in a patient with a very low risk prostate cancer who otherwise has a PSA >20?
I would start by confirming that I feel comfortable with their biopsy results:1) ensuring that there appears to be adequate sampling of the prostate on biopsy,2) obtaining an MRI to make sure there is not a concerning appearing lesion that was not sampled (for instance, anterior disease),3) would al...
For a patient with HER2+ breast cancer with progressive but asymptomatic disease in the brain, would you hold off on WBRT to do a trial of tucatinib, or proceed with WBRT then tucatinib?
The trial allowed both treated and untreated brain mets, and showed response rate and improved survival. If the patient is not a candidate for SRS, it’s reasonable to watch brain lesions with serial MRIs.
How would you plan adjuvant radiation for a N+ breast cancer in a patient who had received prior lung SBRT near the treatment field?
I have had cases with SBRT and started off with CT planning for the breast; I have used DIBH. I then fuse previous dose plan to current plant. For these cases, I have not always used VMAT. If this is lung SBRT, typically OAR constraints are not drastically affected for breast RT with respect to ipsi...
How do you manage a supratentorial anaplastic ependymoma in an adult?
Unfortunately, given the rarity of this tumor, we'll never know for sure. However, I do treat those patients similar to high grade gliomas in adults. Having said that, in high grade gliomas, I use smaller margins 0.5-1 cm (GTV --> CTV) and I think it would be appropriate in this setting as well. A b...
What small bowel dose constraints do you utilize when treating resected pancreatic cancer?
Questioning the normal tissue tolerance in the setting of a resected pancreatic cancer raises a number of issues. To answer the question of which of the listed dose constraints I use, the answer is neither. There has been a general trend in the field to use less conventional radiation therapy postop...
What duration of ADT do you recommend for a patient with otherwise favorable intermediate risk features but a mpMRI showing gross extracapsular extension?
All of the responses so far are reasonable to me. I am assuming the patient is Gleason 3+4 with PSA <10 ng/mL. I am wary of applying a new technology to categorize patients to older trials (i.e., T3 on mpMRI and assuming that is the same as clinical T3 prior to MRI). That said, I can't call a patien...
Do you alter your management of ADT in a patient with high-risk prostate cancer who is a transwoman receiving estradiol hormone therapy?
We published a case report several years regarding a transwoman who developed prostate cancer who had been on estradiol therapy in JAMA. She presented with a PSA of over 100. She continued on her estradiol therapy. We did not use LHRH since she had a bilateral orchiectomy for her transition. She was...
In what clinical scenarios would you cover the optic nerves when treating with whole brain radiotherapy?
In general, for brain metastases (assuming not a candidate for hippocampal avoidance) standard whole brain radiotherapy fields would cover part of the optic nerves. If whole brain is for primary CNS lymphoma, I would cover the orbits which would encompass the entire optic nerves. If whole brain RT i...