Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
Is NF1 an absolute contraindication to intracranial radiation in pediatric gliomas?
I would consider a relative but not absolute contraindication. While we try to avoid radiation for NF1 patients with intracranial brain tumors because they tend to be more indolent, more responsive to systemic therapy and patients have pre-existing neurocognitive issues, radiation is sometimes the b...
How do you manage systemic therapy with SRS for brain or spine metastases?
This is an interesting and challenging question with limited data and a high degree of variability among providers. Thus clinical practice patterns and preferences vary even among our institution. For Gamma knife/intracranial SRS, the range of time with immunotherapy and targeted agents varies at ou...
Would you ever recommend a breast boost using BID fractionation due to patient scheduling?
We don't usually give the breast boost BID (due to patient scheduling or other reasons) but we will deliver a daily concomitant boost (270cGy to whole breast with simultaneous integrated daily boost of 320cGy to tumor bed for total dose of 4050cGy to whole breast and 4800cGy to tumor bed) as per our...
How do you manage a soft tissue sarcoma arising from neurofibromas (NF1)?
Great question! Sarcoma (STS) arising in the setting of NF1 can be challenging.I usually recommend for preop XRT, image-guided RT for STS should be 50 Gy in 2 Gy/fx:GTV = MRI T1 plus contrast imagesCTV for Intermediate-to-High Grade Tumors ≥ 8 cm: CTV = GTV and suspicious edema (defined by MRI T2 im...