Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you decide when to electively cover ipsilateral level IB or V in a node positive neck?
The primary site of most concern would be the oropharynx and what to do with level IB if the patient is cN+ and the reason is that sparing the submandibular region may lead to decreased toxicity, as it's function provides baseline moisture in the oral cavity (as opposed to the parotid gland, which i...
Would you recommend reirradiation in a patient who has extensive subcutaneous chest wall nodules and axillary recurrence after previous PMRT?
These are very difficult clinical situations that have nuances that make it hard to give a definitive answer. I would first ask what the status is of any distant disease, and if systemic therapy options have been exhausted. If this is localized disease, if it is symptomatic or about to be, if perfor...
What anatomical sites would you electively cover to intermediate dose for an oropharyngeal primary with clear extension into the nasopharynx?
I have had a case like this and I have to admit, I was not sure what the right thing to do was. How extensive is the NP disease component? Is there perineural spread on MRI? Hpv status? Ultimately, my patient was a light smoker with hpv related disease. I decided to treat more like an oropharynx an...
What is your recommended dose-fractionation when treating with SBRT for a non-spine bone metastasis?
On my non spine SBRT vs standard 10 fxn randomized protocol, we would treat this 5 cm acetabulum lesion to 12 Gy single fraction on protocol with that dose. Interim analysis is 1 patient away but I am comfortable with that dose in the acetabulum
Is it possible to have diffuse, bilateral pulmonary fibrosis as a late side effect of unilateral radiation therapy for breast cancer?
The only context you may see this is in a patient with underlying Interstitial Lung Disease (ILD). I had a woman with a small pulmonary nodule adjacent to the heart and was unresectable. She had moderately severe ILD, and I used a proton plan to try and keep the low dose RT out of the rest of the lu...
What postop volume would you treat for for cutaneous squamous cell carcinoma of the upper neck with perineural invasion of multiple nerves?
The answer relies on the caliber of nerves involved. If they are small nerves (<0.1mm), an argument could be made to forgo radiotherapy to the site of the resected tumor altogether. If they are large caliber nerves, or clinically detectable signs or symptoms of dysfunction (so called, perineural spr...
What dose constraint(s) would you use for a patient with a pelvic kidney transplant getting pelvic RT?
It depends on whether it is only a kidney (transplanted) or an unascended pelvic kidney with a second normal kidney. In the transplanted kidney, if the indication is adjuvant RT, then I would weigh the benefit of pelvic RT vs. long-term risk. If planned course is definitive or need to treat, I do mo...
What dose-fractionation would you use to treat a single large melanoma lung metastasis?
Given the radioresistant nature of melanoma, for a 4 cm lung oligometastasis, I would carry the dose to 50 Gy in 5 fractions. Even if the tumor is abutting the lateral parietal pleura, I do not reduce the prescribed dose. I understand that one may be concerned about rib fractures. However, in my exp...
Is ADT alone appropriate for high risk prostate cancer patients without evidence of metastasis and limited life expectancy?
I disagree with ADT alone as an option for any patient with non-metastatic prostate cancer. For high-risk patients, 2 randomized trials have compared ADT alone vs ADT+RT. In the MRC UK PR07 trial (Mason MD et al, JCO 2015), RT improved overall survival and disease specific survival. Notably, the dis...
How would you approach a low-lying rectal cancer wtih para-aortic lymphadenopathy?
I will assume that the question is one of management for oligometastatic nodal M1 disease--i.e. one or two para aortic lymph nodes and no other extrapelvic disease. In the past I've treated a few cases like this, as well as a few that were M1 by virtue of inguinal or iliac nodal metastases. The comb...