Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you consider treating a patient who has an unresectable slowly growing PET avid lung mass with concurrent chemo RT when multiple biopsy attempts have only resulted in pathology "suspicious" for adenocarcinoma of the lung?
I would consider treating the patient if they have a highly suspicious biopsy with the proper clinical context and after speaking with the pathologist to understand why the report indicates only "suspicion" rather than "confirmation". The patient in question had "multiple biopsy attempts" and demons...
Would you recommend hypofractionated salvage or adjuvant prostate XRT in the COVID setting?
The short answer is no. It's getting harder to justify recommending adjuvant RT these days in light of the recently published randomized trials and meta-analysis showing no benefit to adjuvant over very early salvage. I would monitor patients in this category. As for salvage, unlike primary RT, ther...
In locally advanced EGFR-mutated NSCLC with initial good response to osimertinib, how do you manage local progression of the primary?
In this context, local progression at one site after a good response to osimertinib makes good clinical sense. Given that the next line of therapy is chemotherapy, being able to continue the TKI as long as possible while addressing oligoprogression with RT for local control is appealing. However, we...
When, if ever, would you cover the clinically uninvolved contralateral oropharynx when treating a well-lateralized oropharyngeal cancer of the head and neck?
The main concern regarding another occult primary in the contralateral OPC is whether or not the ca is smoking/alcohol-related, in which case field cancerization is common and there is a risk of secondary HNC. This risk is much less in HPV+ with little smoking. A SEER study from 1975-2006 found that...
Is it safe to treat a recurrent esophageal SCC with definitive chemoradiation after a prior endoscopic mucosal resection?
I would not be concerned about perforation or fistula formation. With an EMR, the resection takes off the mucosa/submucosa and leaves the wall intact. There should be sufficient time from the prior procedure to have full mucosal regrowth and the wall integrity should be well maintained.
When is pelvic lymph node dissection indicated in vulvar cancers?
GOG 37 established adjuvant RT to pelvis and groins better than PLND for inguinal node positive patients. Pelvic recurrence rates were similar in both arm with the predominant difference being in inguinal recurrence. PLND as part of routine management in vulvar ca is hardly indicated.
Do you contour the abdominal para-aortic nodes in your elective CTVnodes for T3N1 adenocarcinoma of the GEJ getting preop chemoRT?
A related question was also asked: Do you include subcarinal, AP window, and mediastinal paraaortic nodes in your CTV for esophageal cancer? Although I am very respectful of the time and effort that goes into writing treatment guidelines, and I frequently consult them in my own practice, it is worth...
Do you include subcarinal, AP window, and mediastinal paraaortic nodes in your CTV for esophageal cancer?
Unfortunately, this is essentially a data free zone. There are certainly no clinical trials to answer the question - it is hard enough to prove the value of radiation therapy without going into second order effects such as on the exact size of the RT field. I personally do not extend the fields prox...
How would you manage a patient with Stage IVB DLBCL with refractory disease in the retroperitoneum and spleen after 6 cycles of RCHOP?
The management of primary refractory stage IV DLBCL is complex and generally not successful. See NCCN Guidelines for details. I would distinguish, however, between those patients who are clinically refractory and those who have clinically responded well but may have residual disease by imaging, i.e....
Do you recommend elective nodal irradiation when treating unresectable pancreatic adenocarcinoma?
Yes. For consolidative radiotherapy following chemotherapy, we have been treating the majority of our patients with SBRT. Off trial, we treat the GTV and tumor vessel interface to 40 Gy/5 fractions via simultaneous integrated boost. The elective nodal volume (pancreatic, porta hepatis, para-aortic -...