Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Will the recent publication of the KROG 08-06 trial change your practice in node positive breast cancer patients?
I would encourage listening to Dr. @Dr. First Last's ASTRO discussion of this trial.KROG 08-06 was powered to detect a 10% DFS advantage for inclusion of the IM chain. Meanwhile, RNI trials have demonstrated a 3-5% advantage in DFS for RNI such that even if irradiation of the IM chain were responsib...
How would you approach unresectable synovial sarcoma of the heart ?
The specific situation described is rare and I'm not aware of any data addressing it directly, but there are general principles for cardiac sarcomas that can be helpful.For cardiac sarcomas, subsite matters for prognosis and treatment. Left-sided more prone to non-lung visceral mets. (In resectable ...
Do you recommend ADT for all patients who are unfavorable intermediate risk prostate cancer?
I recommend ADT for unfavorable intermediate risk patients who are not treated with a brachy boost. ADT is probably unnecessary for those treated with brachy boost. Of course, I also take into account the patient's concerns and preferences regarding sexuality, cardiac risk, and desire for maximal tr...
In what situations would you consider focal irradiation for nodular leptomeningeal disease?
So in general, for patients with LMD, I would recommend WBRT - if RT were indicated. A recent paper in the red journal (Turner et al., PMID 31605786) separated "classical LMD" versus "nodular LMD" and provided a training module to improve interrater reliability. In my practice, even patients who pre...
Do you treat the normal pancreas as an organ at risk when delivering abdominal radiation therapy?
This is a great question. We do not do that because we have not seen any convincing evidence of exocrine or endocrine insufficiency caused by radiation at any dose. In fact, from surgical patients, we know that only a small volume of residual pancreas is needed to prevent insulin dependence. The pan...
How does the presence of CABG affect your radiotherapy approach for definitive management of locally advanced NSCLC with mediastinal involvement?
This is a great question. The short answer is we don’t exactly know – but the longer answer would be that while CABG graft dosimetry hasn’t been explicitly defined, we can make a few reasonable extrapolations and assumptions. We know that patients with +CAD are at very high risk of cardiac events, a...
How would you treat unresectable angiosarcoma of the extremity in a patient who is inoperable due to underlying comorbidities?
Radiation and taxane therapy are both active agents for angiosarcoma. Administering weekly paclitaxel is supported by the ANGIOTAX study (Penel et al., PMID 18809609), and @Dr. First Last and colleagues are conducting a phase II trial evaluating the efficacy of induction chemotherapy followed by pac...
How do you approach decision making in terms to adjuvant chemotherapy after CSI in adult medulloblastoma?
Medulloblastoma is a chemotherapy sensitive disease. The NCCN guidelines have options for CSI alone or followed by chemotherapy for standard risk disease (M0, residual disease <1.5cm2, classic or desmoplastic histology) and recommend post-CSI chemotherapy for high risk disease. Unfortunately, 25% of...
How would you manage a large grade 2 endometrial adenocarcinoma with invasion into the parametria and upper vagina without nodal or metastatic disease?
PETCT and MRI. Preoperative chemo RT with EBRT plus brachy followed by surgery. Vargo et al., PMID 25218303
What dose constraints are appropriate for SBRT treatment to a 5 cm neck metastasis from renal cell carcinoma?
Constraints for thyroid cartilage are not well defined. Trachea/skin one could certainly look up RTOG/NRG, SABR UK consortium, COMET-10 constraints as these are all publically accessible. To me, the most important questions are as follows:1. 5 cm is a large met, are there any other mets? Would the e...