Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you offer a patient over 70 years old with early stage, favorable breast cancer adjuvant whole breast radiation if her sentinel node biopsy shows a single node with isolated tumor cell (ITC)?
ITC would not change my decision about AI alone vs. RT plus AI. If you decide to treat, then make some adjustment of the angle to include low lying nodes in the tangential beam but dont chase the nodal region.
How would you approach isolated inguinal lymph node squamous cell carcinoma of occult primary?
Most of these are probably anal cancers, just based on the incidence and anatomy. One could certainly argue this either way (local only vs comprehensive). It is tempting to treat local only fields knowing that the salvage rate is probably high, but what has kept me from doing that is that comprehens...
Would you recommend partial breast irradiation using LDR seeds after lumpectomy for a suitable candidate with early stage breast cancer?
LDR is an appropriate consideration for patients eligible for partial breast irradiation; it's important to recognize that LDR was included on RTOG 9517 and more modern series have also evaluated new LDR techniques.There is limited data comparing HDR and LDR, and this would also be dependent on HDR ...
How would you manage a patient with low risk prostate cancer on active surveillance who develops high risk features but absolutely refuses a repeat biopsy?
In the setting of a suspicious mpMRI lesion, we start by acknowledging the patient's likely negative experience with their transrectal biopsy. We ask if they are referring to the one where they were rolled on their side, had a probe inserted in their rectum, and heard a bunch of loud CLICKs. We empa...
How would you manage a cN0 penile cancer with a moderate risk of nodal metastasis?
Pathologic nodal stage is such a strong prognostic factor that patients with moderate or high risk of nodal involvement, even if cN0, should have surgical nodal staging. This includes those patients with MD and PD tumours, and T1b or higher. PET-CT cannot show microscopic involvement. If the patien...
What is your surveillance strategy for locally advanced HPV+ oropharynx cancer after PET CR?
PET scan at 12 weeks after chemoradiotherapy. Endoscopic exam by ENT q 2-3 months in year 1; q 3-4 months in year 2; q 6 months in years 3-5. I reiterate time and again the importance of these in light of temporal pattern of local recurrence for HNSCC (usually in first 1-2 years). If appreciate any...
For women receiving breast RT who develop a severe skin reaction during treatment, what is your threshold for giving a treatment break?
I would for symptomatic grade 3 Reaction although in era of hypofractination it is very uncommon. Sometimes would do boost RT in the break period
How would you manage palliation in a patient with postobstructive pneumonia caused by a mediastinal mass?
I'm guessing you're thinking of a lung cancer patient with hilar obstruction, lobar atelectasis, and 2nd pneumoia. These patients often get great palliation from RT. The primary challenge is finding the obstructing mass (which benefits from RT) and separating it from the infection (doesn't benefit)....
What are the best strategies to obtain good simulation CT imaging for prostate cancer patients who have had hip replacements?
For bilateral hip replacements, I have obtained/fused a cone beam CT as it often does not have as much artifact, and also fused an MRI with the cone beam image.
Do you think it makes a difference to fractionate at 2 Gy versus 1.8 Gy per fraction?
This is a great question and is an example of how a single clinical decision can change practice. In the era of radiation alone the standard fractionation was 2 Gy/day. With the introduction of concurrent chemoradiation the radiation dose was decreased to 1.8 Gy/day. This 10% dose attenuation was su...