Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For a patient with H&N squamous cell carcinoma who underwent salvage neck dissection for residual disease following primary chemoradiation with weekly cisplatin, do you offer any adjuvant therapy thereafter if extranodal extension is found?
Here the situation should be clarified and can be nuanced. If the initial chemoradiation was unilateral and the relapse now in the unirradiated neck, then yes, adjuvant chemoradiation is indicated (radiation alone if frail or elderly). If that relapsed neck was already radiated then adjuvant re-irra...
How would you manage a patient with an early stage ER+ cancer of the accessory breast tissue in the axilla with clear margins and negative sentinel lymph nodes?
Like any other patient after BCS. Whole breast or APBI based on technical factor. If luminal type and plan APBI, may consider 5.2 Gy x5 to reduce OAR dose.
Do you allow your CTV expansion to go into lung for IMRT esophagus cases or do you crop CTV expansion out of lung?
This is an excellent question and to be frank, the panelists that formulated the 2015 guidelines I authored did not consider this issue explicitly, hence the implication that lung should NOT be cropped out of the CTV. I certainly agree with the comments above that the lung per se is unlikely to repr...
How do you decide on the timing of neoadjuvant chemoRT or short course radiation for a patient with mid-upper rectal cancer with resectable liver only metastases?
Upfront multiD discussion is really essential for a case like this as I do think we need to be selective of ideal candidates. If the group consensus is to proceed along a pathway involving “curative intent” local therapies, I do favor starting with systemic therapy to establish disease biology/pheno...
How would you manage a p16 positive small cell carcinoma of the tonsil?
Assuming it is indeed small cell (undifferentiated, neuroendocrine pathological features), extrapulmonary small cell cancer rarely metastasizes to the brain as venous drainage to the brain must first go through the lungs and produce subclinical lung metas. Therefore, there is a very low rate of brai...
With the RAPIDO trial demonstrating efficacy of short course XRT as part of TNT for locally advanced rectal cancer, is there a role for short course XRT to be integrated into watch and wait programs?
Great question, and one our group has discussed extensively. Our group currently uses short course radiation nearly exclusively in the treatment of locally advanced rectal cancer. One notable exception (at least so far) is if the patient desires NOM. Our rationale is that there aren’t as many data f...
How do you manage acute tenesmus related to SpaceOAR?
Fortunately, this does not happen very often. First, make sure there is no mucosal injury by inquiring about significant hematochezia. If there is, then delay sim, consult colorectal surgeon or GI just to be safe, but usually, this will resolve with conservative management. If there is no hematoche...
Would you give post-mastectomy radiation for a T2N1 triple negative BRCA 2+ patient who had a complete response from neoadjuvant chemo?
When B51 was opened, we offered that. Otherwise, outside clinical trial triple negative with node positive disease recommend PMRT irrespective of response to NACT.
How would you approach treatment of a patient with asymptomatic, oligometastatic basal cell carcinoma?
This is an unusual situation. I would want to clarify whether this is regional versus distant metastasis, and what is meant by "oligometastatic". I would also want the diagnosis of metastatic basal cell carcinoma confirmed histopathologically (and possibly even molecularly) for both a putative prima...
What is an appropriate steroid regimen for a patient treated with RT for spinal cord compression?
I don't believe there is a specific answer to the question; this represents the art of medicine. The highest dose that I recommend is 16 mg of dexamethasone a day. This would be for the patient who has severe neurologic symptoms (weakness, numbness, and/or bladder or bowel symptoms). However, often ...