Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is the best IGRT strategy in treating the prostate bed (adjuvant or salvage): Daily anatomy KV images vs. fiducial seed kv images vs. CBCTs?
For our post-prostatectomy men, we use daily kV and line up to surgical clips if available (contouring out a clip each quadrant of the prostate bed if possible) with a PTV expansion of 5 mm. If clips are not present, then we use CBCT to evaluate soft tissue alignment and use a slightly larger PTV of...
Can you give Pluvicto with concurrent palliative EBRT?
Short answer: Yes, you can, and I do not modify my dose. I have no issues with this and have done it multiple times for patients who need more immediate symptom relief (pain, bleeding, etc.).Why? Because Pluvicto is a medium energy isotope with a relatively short path length of around 2 mm. Even nea...
What strategies do you use for large breasted women receiving whole breast radiation?
If we can't do prone, we use a styroform wedge in the inframammary region to decrease the breast fold and thus, decrease the inferior margin and amount of inframammary fold we have to treat. I would initially try hypofractionation with mixed beam with a field-in-field technique and if the dose homog...
How would you proceed when a cervical cancer undergoing brachytherapy has exceeded the rectal dose but not met the target dose?
Rectal dose and target dose have range. Preferred rectal dose for D2cc < 65 Gy but can accept up to D2cc < 75 Gy, provided you understand expected risk of complications with increased dose. Preference would be to do hybrid applicator with 3D imaging to optimize HRCTV and OAR.
What are your dose constraints for SBRT pancreas (absolute and relative) when treating with 5 fractions?
We contour duodenum, other small bowel, and stomach separately and for each allow V33 < 1cc and max 0.035 cc < 36-38 Gy. We will sometimes also add a 3mm PRV for these organs (if close) and try to keep this v35 < 1-2 cc. Of note, some protocols allow for higher dose to these structures...but on prot...
Does a history of ipsilateral breast atypia preclude APBI when otherwise suitable?
It would not preclude APBI if otherwise suitable.
When do you consider using protons for breast cancer?
I think there is a limited role for protons in breast cancer outside of prospective studies at this time.With respect to partial breast irradiation, while initial trials showed some higher skin toxicities, modern institutional series have shown much better outcomes. That being said, the total number...
For a patient who previously underwent PBI and then developed a second ipsilateral primary, would you offer repeat PBI?
If this is a younger patient, I would confirm that they have negative genetic testing before considering re-irradiation, and, in any case, ideally, the management options would be discussed with the patient and surgeon prior to offering breast conservation surgery. Considerations would be the locati...
How do you approach axillary radiation in a patient with breast cancer who did not have a sentinel node biopsy?
Choose wisely. The message from the surgery group discourages SNLN bx in 70 and above with low to intermediate grade pathology. As far as RT is concerned, AI alone, APBI, and 5 fraction whole breast are all reasonable options in those patients, and not having SNLN would not change recommendations. T...
How would you treat an early-stage ER/PR+ Her-2 negative breast cancer s/p lumpectomy in an elderly patient who had sentinel node biopsy omission?
I consider these patients as being managed appropriately surgically based on CALGB and current guidelines. As such, I routinely offer these patients APBI.Unless there are other features, I do not think these patients need WBRT just because they didn't have a SLN. If they are eligible for omission of...