Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
For patients undergoing breast conservation therapy, how do you ensure dose to the skin during treatment planning?
When possible, we use the lowest energy beam for our tangents (6 MV) to ensure dose to the skin. In larger patients or those with larger separations,we may add in higher energy beams which will reduce skin dose. In light of growing data on partial breast, I down worry about under dosing the skin. Th...
How would you manage a patient with a MALT lymphoma (H. Pylori negative) found incidentally in the surgical specimen at the time of sleeve gastrectomy?
MALT lymphoma tends to be a multifocal disease. Furthermore, imaging is often suboptimal in delineating the true extent of disease within many extranodal sites, including the stomach. For these reasons, the entire organ is typically treated during a course of radiation therapy. Historically, radical...
Would you offer radiation therapy for pleural- or peritoneal-based pseudomyxoma peritonei?
There are no published data that clearly support the use of radiation in this disease. In general, the best one could hope to achieve is to slow or arrest the mucin production from the cellular component of the disease. I have tried this with variable success using palliative doses.
How do you manage soft tissue necrosis in a patient who underwent TORS followed by RT?
Close observation Minimize trauma Don’t biopsy unless something very suspicious