Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you deliver SRS/XRT for isolated asymptomatic CNS metastasis before start of immunotherapy for stage IV lung cancer (negative for driver mutation) with high positive PDL1?
Good question. To my knowledge, we still do not have large prospective studies of combination SRS and ICI in NSCLC, but we do have several retrospective studies. Overall, patients with brain metastases from NSCLC treated with ICI seem to do better than we would expect for patients treated with chemo...
When completing radiation treatment planning on a 4D scan do you prefer the average or free breathing scan for dose calculation?
We always plan on the average. If we are treating while the patient is free breathing, we plan on the average of all phases. If we are treating with gating, we plan on the average of the phases we are treating on (30-70 is our most common).
How do you approach treatment of brain metastases in a patient with Behçet's disease?
I have never encountered such a patient. I would think the first thing to do is to make sure what one sees on MRI are indeed brain metastases, rather than areas of inflammation. Otherwise if the brain mets are suitable for radiosurgery, I would proceed. Just be mindful that the patient may be more l...
How do you incorporate advanced imaging into cranial radiosurgery?
We have routinely incorporated dynamic contrast enhanced MRI into our practice for patients getting cranial radiosurgery. In particular, plasma volume has been very useful in helping to distinguish between tumor necrosis and recurrence. A previously treated lesion that demonstrates increased enhance...
What constraints do you use for the gallbladder when giving liver SBRT to lesions close to the gallbladder?
I am not aware of any published data of toxicity to the gallbladder organ proper, and when we do liver SBRT we do not contour the gallbladder. I'd be interested if others have noted what could be called radiation induced gallbladder toxicity. The bile duct is a much more significant OAR given risk o...
Do you offer adjuvant radiation therapy for a patient with a > 5 cm resected malignant peripheral nerve sheath tumor with 1 cm negative margin?
MPNST typically treated as an ext/trunk STS and we prefer neoadj RT unless pt has uncontrolled DM or other comorbidities that would lead to poor wound healing. In this case, we first need to know the grade. If G2 or 3, then this patient is Stage II-III and will require adj RT regardless of margin s...
Would you offer radiation therapy to a patient with unresectable intracranial Rosai-Dorfman disease?
I recently treated a patient with this rare histiocytic entity. There is simply no consensus given its rarity. Having combed through PubMed and having read the relevant literature, most helpful was a guidelines article in Blood, which states that a reasonable approach for unresectable disease is 30-...
For metastatic small cell cervix cancer, would you consider adding immunotherapy up front (per a small cell lung cancer paradigm)?
I agree that it is "not unreasonable." It is also reasonable NOT to give it. Given that these agents can have their own toxicities, which can be significant, and the potential benefit is certainly not a "home run" (and the cost is enormous) I would not add an immunotherapy agent at present.
What dose and fractionation would you recommend for adjuvant radiation treatment of a giant cell tumor of the tendon sheath in the hand?
The best paper I've seen that specifically addresses giant cell tumor of the tendon sheath is this one from the Journal of Hand Surgery in 2012 by Coroneos et al, with whom Brian O'Sullivan was a co-author. Coroneos et al., PMID 22386549The paper includes a good review of the limited literature and ...
Do you offer definitive chemoradiation for a primary duodenal adenocarcinoma?
Rare cancer with murky recommendations and little data. I favor a management pathway similar to pancreas cancer. Neoadjuvant chemotherapy followed by re-imaging. Then resection for clearly resectable disease and radiation therapy for borderline or unresectable disease. Radiation dose: Traditional do...