Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
What are the anesthesia risks for pediatric patients undergoing radiation treatments, given it's repetitive use throughout the treatment course?
Thankfully, the risk for anesthesia related complications during pediatric radiotherapy is very low. The high frequency of sedated procedures during radiotherapy for pediatric patients requires a comprehensive team approach to minimize that complication risk and discussion between parents, providers...
When would you recommend delaying PMRT until after breast reconstruction is completed?
"The main thing is to keep the main thing the main thing" -Stephen Covey. We're now, as a multidisciplinary specialty, about a decade into the wide adoption of "elective mastectomy and immediate implant-based reconstruction". During this period of time, we've ironically seen an increased utilization...
When would you add an extra radiation dose to compensate for treatment breaks?
There is no absolute answer for this situation and additional dose is a function of the site we are treating, indication, modality of treatment, and the potential morbidity of additional treatment Like in cervical cancer, newer data suggest adding 5 Gy EQ2 with brachytherapy can mitigate effect of o...
What dose fractionation would you recommend for large (>5 cm) perianal Bowen's disease (squamous cell CIS)?
I think that peri-anal lesions such as this (and most invasive anal skin cancers as well) are almost always better managed surgically. It would be the very rare patient who would not tolerate the surgery but would tolerate an aggressive RT course directed to the anal/perianal lesion. If put in some ...
Would you consider catheter-based APBI in the setting of a recurrent Stage I breast cancer in a patient who has received whole breast radiotherapy and is refusing mastectomy?
I have done case by case based on affect of previous RT on breast and expected cosmetic and disease outcome after re-irradiation. Our default preference for patient suitable for re-irradiation is 1.5 BID to 45 Gy treating partial breast like RTOG study although in few patients have used balloon base...