Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How does the management of nasopharyngeal cancer in kids/young adults differ from adult patients?
The approach for managing pediatric patients with NPC has generally followed the recently published COG trial, at least in the United States. This approach uses induction chemotherapy with CDDP/5FU, followed by chemoradiation for the higher risk patients. Lower risk patients—Stage I/IIa or T2N0—can ...
In patients who had a lumpectomy alone without nodal evaluation for early stage breast cancer, how do you determine whether additional surgical LN evaluation is necessary?
In general, unless a patient is 70 and above with favorable phenotype breast cancer where choosing wisely favors no assessment of axilla surgery, everybody at this point gets SNLN bx. There are ongoing studies exploring skipping SNLN in clinically negative early stage breast cancer for other age gro...
How do you approach treatment of a non-seminoma brain metastasis with a partial response to chemotherapy?
Assuming one rules out leptomeningeal spread, I would still prefer to treat the non-seminoma brain metastasis with either stereotactic radiosurgery (18 Gy in one fraction if max. diameter is less than 2 cm), or fractionated stereotactic radiation (8 to 9 Gy per fraction x 3 if the metastasis is larg...
Do you use hippocampal avoidance techniques when delivering PCI for high-risk leukemia?
I do not recommend hippocampal sparing cranial irradiation in leukemia patients. Unlike patients with solid malignancies, CNS failure in hematologic malignancies often involve eloquent areas like thalamus, hippocampus, hypothalamus, posterior chamber of the globe and the CSF. So these patients reall...
What dose and fractionation would you recommend for anal melanoma that is localized but refusing surgery?
I have treated patients with 30 Gy / 5 fractions with 2 fractions per week. There is some proctitis, for sure; and this is adapted from the adjuvant experience from MDACC. Patients have tolerated it well. We will then start immunotherapy after the radiation. On the other hand, if the patient has a B...
Do you take any special precautions when radiating the mediastinum of a patient with moderate or severe aortic valve stenosis?
Yes, but this is challenging to quantify. For patients with lung cancer, I generally try to minimize dose to the heart (particularly the left ventricle and coronary arteries) when possible. With aortic stenosis, the left ventricle is particularly “strained”, so one might be particularly-diligent abo...
For patients with breast cancer who are otherwise excellent candidates for omitting radiation based on their age and pathology; does a strong family history of breast or ovarian cancer influence your recommendation?
If gene testing is negative, then it would be fine with AI alone, if the patient is otherwise suitable.
How would you treat a stage IE diffuse large B-cell lymphoma of the adrenal gland in an elderly patient who is not a candidate for systemic therapy?
This is an extremely tough situation if the patient cannot get systemic therapy. These tend to be non-GCB subtype with a generally poor prognosis even with R-CHOP based chemotherapy regimen with high rates of systemic and CNS relapses. Typically, I would recommend R-da-EPOCH, CNS directed chemothera...
When would you consider radiation for a Sertoli-Leydig tumor of the ovary with a bulky mass and peritoneal metastases after surgery and BEP chemotherapy?
With peritoneal mets, I would treat only for palliation. If it was an isolated recurrence, then I would have done definitive RT.
How do you approach G-CSF use when offering neoadjuvant chemoRT for lower extremity soft-tissue sarcoma?
We don't use concurrent chemo and XRT so it is not an issue for us. I suppose the detrimental effect of XRT on cycling progenitors would depend on the field that is being irradiated. Typical extremity STS may not pose a big risk, but pelvis would.