Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you evaluate and constrain the cumulative lung DVH for inoperable patients who have received multiple courses of lung SBRT and now require fractionated mediastinal RT?
This is an increasingly common problem and there are few data to guide decision making.However, some have looked at dosimetric-toxicity relationships in the reirradiation setting (either re-SABR or conventional radiation after SABR).It's suggested that composite high dose to a previously irradiated ...
Do you do a CT simulation for post op heterotopic ossification prophylaxis?
Yes, we treat a fair amount of HO cases at our institution in NJ, and in most cases, at least that I know of, we have always obtained CTs for planning. Honestly, because the anatomy is so straightforward in the hip area to be treated, just plain 2D imaging will suffice. In the old school way, we use...
Would you treat unfavorable intermediate risk prostate cancer in the setting of recently resected NSCLC?
This greatly depends on the stage of the lung cancer. If stage IIIA resected NSCLC, I would not treat the prostate cancer immediately, and effectively enter them into active surveillance until the patient is 2 years free of NSCLC on follow-up imaging. If they recur from NSCLC within 2 years, they ha...
Would you include the regional nodes when treating with PMRT in a patient with a high grade, large primary tumor, but low burden axillary disease with a complete axillary dissection (e.g. 1/20 nodes involved)?
This is a question we are seeing more and more. I break these cases down into two situations: 1. Postmastectomy, no neoadjuvant: In these cases, I extrapolate from MA20 which looked at patients undergoing breast conservation with ALND and a large percentage had low nodal burdens. RNI was associated ...
How long after prostate radiation do you recommend waiting for routine screening colonoscopy?
Good question. In this regard, I would say that the timing would depend on the nature of the acute reaction in the area of the rectum adjacent to the prostate. This may be patient dependent. Further, the local reaction erythema can last for weeks to months depending on the reaction. Also, if it's >1...
How do you manage limited intracranial disease from a metastatic large cell neuroendocrine tumor?
In our practice we are moving to focal management of limited intracranial disease for all pathologies, pushing WBRT out to last resort status.LCNEC is a heterogeneous disease (Hiroshima K, Mino-Kenudson M. Transl Lung Cancer Res. 2017) with variable response to chemo therapy. Even more unclear is it...
Which criteria do you follow to recommend low-dose CT screening in patients at high risk for lung cancer?
At this time, I still follow the USPSTF/NLST guidelines, but believe the criteria for screening should be updated to include more patients. The current recommendations from the USPSTF based on the National Lung Screening Trial demonstrating an improvement in lung cancer and all cause mortality inclu...
Are there specific radiographic features that would alter your management of a presumed meningioma?
This question is particularly relevant for a patient who has a history of a cancer and a dural-based lesion that may represent metastasis or meningioma. Edema, as @Dr. First Last related, may suggest atypical histology. Necrosis may suggest a more malignant tumor, including malignant meningioma or d...
How would you manage a patient needing PMRT with a history of severe burn to the chest?
In these cases, its important to consider risk and benefit. I would also discuss with the plastic surgeon with respect to skin flap. If the patient has advanced disease, I would offer PMRT, but counsel patient on increased toxicity risk and risk of infection. I would try to quantify improvement in l...
What is the effect of IV contrast on dosimetry for thoracic RT planning?
The requirement for a non-contrast CT or manual region overrides of HU prior to calculation for lung IMRT was the subject of much debate when I came to Wash U. So, we ran a simple prospective trial where we scanned 8 patients with and without contrast.Intuitively, contrast scans provided better targ...