Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you treat a bone oligometastasis that required surgical fixation for pathologic fracture?
It really boils down to the clinical scenario and the approach of the operation. Any time there is a possibility that the surgical procedure may shove the tumor/ tumor cells into the medullary cavity, one will need to include the whole surgical hardware in the RT field. A cone-down or simultaneous b...
Would you consider SBRT for an intraocular/choroidal metastasis?
For solitary choroidal metastasis, I would recommend eye plaque brachytherapy using I-125 seeds with a dose of 4000 cGy at the apex in about 90 +/- hours. If the tumor is abutting or close to the optic disc, use a notched plaque instead.
How would you approach a small, node-negative (cT1-2N0) nasopharyngeal cancer in a patient with prior H&N cancer treated with surgery and radiation?
RT to primary and RP nodes. Positive nodes in previously irradiated neck likely 10% or less, so I’d observe neck.
How do you approach treatment of an unresectable sacral chordoma?
Definitive RT, preferably with protons.
What GTV to CTV expansion do you use for limited stage small cell lung cancer with IMRT?
It seems to me that in stage III NSCLC cases, the CTV of the primary tumor in the lung and the CTV of the nodal volumes would be drawn differently for maximum efficiency: Primary: GTVp --> iGTVp --> + 5-7 mm = CTVp --> + 5 mm = PTVp Nodal: GTVn --> + 5-7 mm + entire nodal station (if desired) + el...
How you approach treatment of a glioblastoma in the setting of prior WBRT for a metastatic non-CNS malignancy?
I think treatment to 25 Gy in 5 fractions or 40 Gy in 15 fractions to areas of enhancement and/or post-op bed can be safely delivered after whole brain (assuming the patient was treated to 30 Gy in 10 fractions). We commonly treat with SRS after whole brain RT. Just be cognizant of cumulative dose t...
What dose should you treat the anal canal after excision of a T1 anal cancer with positive margins?
I would, under no circumstance, treat this patient to a dose of 50 Gy. For a T1 tumor (even unresected) that is likely an excessive dose. Keep in mind that the initial reports of RT and chemo used a dose of about 30 Gy with complete pathological response. There are data to suggest that doses of abou...
What is the best treatment for a squamous cell carcinoma of the palpebral conjunctiva with persistently positive margins after resection?
Ideally, would be managed by an Oncologist Ophthalmologist with high experience in ocular plaque brachytherapy. A "boomerang" plaque loaded with I-125 seeds calculated to the deepest margin (1, 2 mm deep, and 2-3 mm around the tumor or tumor bed). Total dose at the deepest point, 3,000 cGy. Jorge E....
How would you approach early stage unfavorable classical Hodgkin lymphoma with metabolic CR apart from a single residual positive node after 6 cycles of ABVD?
If a patient with early-stage, unfavorable HL had an excellent response to 6 cycles of ABVD, but had a single lymph node that only achieved a PR (Deauville 4), then there are two primary options.1. If you judge that the patient has achieved a reasonable response to chemotherapy, suggesting that syst...
What adjuvant therapy would you recommend for a T3N0, grade 3, undifferentiated sarcoma of the mandible with positive margins that is not amenable to re-resection?
Not much in the mandible is unresectable. I would get the patient a second surgical opinion with an experienced ENT surgical oncologist. Regardless of use of RT, R0 margins are necessary for optimal local control in STS so would want to evaluate for any possibility of re-resection. (A nuance to this...