Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When do you offer hyperbaric oxygen therapy to a pediatric brain tumor patient with radiation injury/necrosis?
I really think it depends as much on the clinical setting as it does the imaging appearance. If you have a case where you are on the early end of the timeline for a CNS RN event (i.e. 3-4 mo post-RT) and the patient is high risk (due to location dose, re-RT, concurrent chemo, etc), then it's worth c...
How would you approach a patient with advanced stage DLBCL with a single-site of residual FDG-avid disease after completion of R-CHOP in the frontline setting?
First would be to assess the residual activity level (e.g. PS 4 or 5), as sometimes a short-interval PET may show improvement. If concern is for residual disease in setting of PET showing partial response, I would consider biopsy of the residual site prior to making any changes in therapy. Once a d...
How would you approach therapy for a young, fit patient with alveolar rhabdomyosarcoma involving the anterior nasal vault/sinuses in the absence of available clinical trials?
The patient should be risk stratified (as per the Intergroup Rhabdomyosarcoma Study Group classifications) and treated with multimodality therapy, including chemotherapy and likely definitive radiotherapy, depending on the specific location. Surgery is also a consideration, but these are generally c...
Would you offer adjuvant chemotherapy for a large, high-grade radiation-induced malignant peripheral nerve sheath tumor following R1 resection?
I assume a post op scan shows no gross disease. Technically this is not "adjuvant" since there is known microscopic residual disease. In a young patient with good PS and organ function, it's reasonable to discuss risks and benefits of systemic chemotherapy (Doxorubicin + Ifosfamide) now vs. close f/...
Would you consider APBI in a primary breast adenoid cystic carcinoma?
I would be reluctant based on local spread pattern.
What is the management of residual bulky (~ 2cm) internal mammary lymph node metastasis from breast cancer after neoadjuvant chemotherapy?
This is relatively uncommon in our practice. However, if there is residual bulky IM adenopathy after chemotherapy, my first question would be whether or not there might be another systemic agent to consider trying before the patient goes to surgery. I would lean toward this approach when feasible. H...
What CTV margins do you use for indolent advanced stage lymphoma treated with palliative radiation alone?
If palliation for advanced indolent lymphoma, I use 2 Gy x 2 to gross disease with CTV of 0-1 cm. My goal is to palliate the clinically symptomatic disease and nothing more. Dose has virtually no side effects for most sites, and retreatment is possible in adjacent or same sites if needed.
How would you manage a positive deep margin in the setting of mastectomy and expander placement?
With these cases, I first discuss with the patient's surgeon if there is any role for re-excision. If not, then I look at whether it is prepectoral or subpectroal. With a subpectoral implant/expander, the at risk margin is in front of the implant/expander; while with a prepectoral implant/expander, ...
What elective lymph node areas do you cover for T4a rectal adenocarcinoma?
Here's my take: I think the spirit of this convention is really that involvement of more anterior organs raises the risk of external lymph node chain involvement. Visceral peritoneal involvement is certainly a marker for a more aggressive disease and certainly may also mean that the cancer involves ...
Would the presence of diverticulosis change your dose constraint for large bowel?
I have not changed the dose constraint for large bowel with or without diverticulosis. I use 0.5 cc to 33 Gy as my dose constraint, and I would make sure the 'tics are included in the colon volume.