Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Are there any whole breast RT techniques or modifications to optimize cosmesis for patients who had prior breast augmentation?
There are various approaches one can take. If not suitable for APBI then one can do partial breast with tangent beam like IMPORT LOW which also decreases exposure of implant and can help reduce the probability of worsening of cosmetic outcome. The goal is to deliver as homogenous dose as possible wi...
How do you position patients in a prone belly board for reproducibility and optimal small bowel sparing for rectal cancer treatment?
The bowel either falls forward or it doesn't on the commercially available belly board device. I don't think that you can position patients differently to achieve better displacement of small bowel, but we have never studied this question. The patient's position is very reproducible day to day makin...
Are there situations in which neoadjuvant chemoimmunotherapy + surgery would be preferred over chemoradiation + consolidative immunotherapy for stage III lung cancer?
We are good at controlling tumors of one billion cells (1 cm size), less so for one trillion (10 cm). From a radiobiology point of view, when I see a resectable T4 tumor due to size over 7 cm, I usually ask my surgeons if they can please take it out. You suddenly get rid of half a trillion tumor cel...
Should IMPower010 results be extrapolated to superior sulcus tumors treated with chemoradiation and surgery?
No. Patients with superior sulcus NSCLC, for whom the standard of care is preoperative chemotherapy and radiation therapy followed by surgical resection, would all have been ineligible for IMpower010, which used chemotherapy +/- Atezolizumab in the purely adjuvant therapy setting. Therefore, the res...
What margin do you use when treating the prostate bed/fossa?
We use similar PTV margin of 5 mm. The only difference is in the definition, surgical bed CTV also includes ITV at the level of SV.
What is your approach to CNS surveillance in resected superior sulcus tumors given high rates of intracranial metastasis in this population?
Despite the quantum improvement in complete surgical resection, pathologic complete remission, and overall survival rates in S9416/INT-0160 (the trial that established trimodality chemoradiation followed by surgery as the standard of care for superior sulcus NSCLC almost 2 decades ago), distant recu...
How do you approach a thoracic lymph node that is highly suspicious on CT and PET but negative on EBUS in patients with NSCLC?
Our institution is very privileged in having a very large, highly expert team of interventional pulmonologists. In the cases where we are conflicted over how to interpret imaging of concerning lymph nodes, and where we have had the chance for a deep dive at tumor board and accompanying expert radiol...
How would you treat a recurrent chylothorax in a patient with metastatic cholangiocarcinoma?
I would not expect radiation to improve the situation. The only time that I have treated a tumor that I thought was causing a chylothorax it did not improve. Generally, radiation does not open obstructions of veins, ducts, or the GI tract.
Would you offer consolidation RT to a young woman with bulky mediastinal DLBCL who achieved early and persistent CR to RCHOP on PET?
Dr. @Dr. First Last has modestly omitted one salient trial in his answer, namely the Duke trial which he led evaluating low dose consolidation RT (20 Gy) following CR to induction chemotherapy, i.e. PET negative response (Kelsey et al., PMID 30858144). To recapitulate briefly, 62 patients with stage...
Are there circumstances where you would use hemibody irradiation?
I have used hemibody radiation with some regularity for widely metastatic disease, particularly for relatively radiosensitive solid tumors such as breast and prostate, and have found it particularly helpful for multiple myeloma where it can and often does work wonders for pain relief. In addition to...