Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What radiation dose should be used for definitive chemoradiation for an unresectable pancoast tumor?
For Pancoast tumor, brachial plexus damage caused by the progression of tumor is more common than radiotherapy-induced neuropathy. In fact, many patients present with brachial plexus neuropathy before any therapy. Due to significant symptoms caused by local tumor invasion, the chance of distant meta...
What are your volumes for a patient undergoing total neoadjuvant chemotherapy for rectal cancer who has initially bulky disease and is node positive and has a complete response on restaging MRI after neoadjuvant chemotherapy and before chemoradiation?
The most important thing to keep in mind when deciding on treatment volumes in rectal cancer is to remember the reason that we are treating these patients - and that is to get rid of small volume disease near the margins of resection. The primary purpose is not to treat the luminal rectal mass - tha...
When treating definitive bladder cancer, would you ever utilize a bladder boost first, prior to the larger bladder/pelvic field?
The ongoing NRG/SWOG phase III trial S1806 comparing chemoradiation to chemoradiation plus atezolizumab for MIBC does allow patients to receive their boost prior to the large-field phase of radiation therapy. I too have found that patient compliance with bladder filling is easier at the start of rad...
If patient had a significant treatment break during breast/chest wall radiation, would you consider boosting?
There are instances when I have had patients have a significant treatment break. In those cases, I have added a fraction for every 5 fractions they miss. So in the case of 2 weeks, I would add 2 additional fractions and have used this to the whole field.
Is there a role for orchiectomy in a patient with stage IV DLBCL who presents with a testicular mass?
Primary testicular lymphoma, almost always DLBCL, is primarily a disease of older men. The typical presentation is an enlarging testicular mass. Patients are referred to Urology, an orchiectomy performed, and the diagnosis is confirmed. The patient then undergoes a PET-CT for staging. Many patients ...
Why are skin reactions better with hypofx breast RT vs standard fx breast RT?
The breast hypofx trials were designed to be isoequivalent for 1) tumor control, and 2) late effects. Here is an excerpt from the UK START trialists introduction section:Normal and malignant tissues vary in their responses to radiotherapy fraction size, termed fractionation sensitivity. Responses ar...
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.