Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach delivery of WBRT in the setting of SRS-induced radionecrosis?
If possible, I try to avoid whole brain radiation therapy in patients with radionecrosis, as well as for most brain metastasis patients in general. Depending on the volume of other brain lesions to be treated, I find a hypofractionated stereotactic approach is generally more successful (90%+ local c...
How do you predict the likelihood of radiotherapy causing lung re-expansion in a patient with advanced or metastatic NSCLC and complete lung collapse due to obstructive tumor?
This is a tough question! In situations where there is bronchial obstruction from tumor and lung collapse beyond the lesion, we are often asked to provide palliative irradiation. In those situations, I tend to think about two principles; how long has the distal lung been collapsed, and can intervent...
How do you manage a large surgical cavity following resection of a melanoma brain metastasis?
I've used 30 Gy in 5 fx before for a cerebellar melanoma cavity about 4.5x3 cm. It's much less likely to cause necrosis and edema than single fx. There may be some local enhancement of IO response. Regarding immunotherapy, I don't give steroids unless symptoms occur, and try to keep it to no more th...
How would you manage progressive diffuse (both cords and arytenoid) high grade dysplasia of the larynx, with no in-situ or invasive disease on biopsies?
High grade dysplasia is CIS and behaves like T1 invasive SCC. 63 Gy in 28 fractions larynx only.
What are the current official guidelines regarding COVID-19 vaccination for patients with cancer or for hematologic conditions?
There are a number of resources available to guide clinicians on these decisions. I recommend the COVID-19 Resources webpage curated by the American Society of Hematology (COI, I'm the editor of that website). https://www.hematology.org/covid-19 This website includes guidance on immunizations in the...
Would you treat the prostate per STAMPEDE in a patient who has oligometastatic disease after cryotherapy?
I agree with Dr. @Dr. First Last. This is one of the few scenarios that radiation has shown to improve overall survival for men with prostate cancer so you would not want to take important therapy off the table.
In a patient with ectopic splenic tissue causing symptomatic mass effect in the pelvis, would you approach radiation differently than you would splenomagaly due to a hematologic malignancy?
Yes, I would approach radiation differently. I would not choose to electively irradiate a patient with a splenunculus/splenunculi. If the ectopic splenic tissue is large enough to be causing mass effect or is otherwise anatomically situated so as to be causing other issues (e.g. acting as a lead po...
For a patient with H&N squamous cell carcinoma who underwent salvage neck dissection for residual disease following primary chemoradiation with weekly cisplatin, do you offer any adjuvant therapy thereafter if extranodal extension is found?
Here the situation should be clarified and can be nuanced. If the initial chemoradiation was unilateral and the relapse now in the unirradiated neck, then yes, adjuvant chemoradiation is indicated (radiation alone if frail or elderly). If that relapsed neck was already radiated then adjuvant re-irra...
How would you manage a patient with an early stage ER+ cancer of the accessory breast tissue in the axilla with clear margins and negative sentinel lymph nodes?
Like any other patient after BCS. Whole breast or APBI based on technical factor. If luminal type and plan APBI, may consider 5.2 Gy x5 to reduce OAR dose.
Do you allow your CTV expansion to go into lung for IMRT esophagus cases or do you crop CTV expansion out of lung?
This is an excellent question and to be frank, the panelists that formulated the 2015 guidelines I authored did not consider this issue explicitly, hence the implication that lung should NOT be cropped out of the CTV. I certainly agree with the comments above that the lung per se is unlikely to repr...