Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you skip adjuvant RT in post prostatectomy patients?
I suspect that once the paper is published and we get a chance to review the data that we may begin to hold off on routine use of adjuvant RT for prostate cancer patients after radical prostatectomy with higher risk features. That said, it should be noted that the study did randomize to early salvag...
How would you manage a patient who received neoadjuvant CRT per the CROSS trial for esophageal cancer, but refuses surgery after imaging shows a good radiographic response?
That's a great question. It is not evidence based, but with carbo/taxol (CROSS approach), I sometimes will go to 50.4 in case this very situation occurs. It's very well tolerated with conformal approach (the study treated with 41.4 Gy with AP-PA fields). If it has already happened, and too much ti...
How would you manage a patient with oligometastatic colon cancer status post resection of the primary whose single unresectable liver lesion has had a complete response to FOLFOX chemotherapy by PET?
This could be a pathologic complete response, so I would observe and recommend hepatic directed treatment if it progressed. If this were solitary nodule still, surgical resection would be the treatment of choice, followed by thermal ablation if feasible, and SABR (100Gy BED) is the third choice beca...
Do you use bolus for the lumpectomy cavity boost when the seroma is within 5mm of the skin?
I agree with the above that this is very rarely necessary. When it is required, it may be hard to define where the bolus is to be placed on an intact breast. One neat trick is to have dosimetry create an en face setup field with an aperture equivalent to where you want the bolus to be (cavity plus m...
How do you approach the work up and surgery for H&N SCC of unknown primary?
CT max, face, neck and chest. PET is ok but has a high false positive rate in the oropharynx where the primary is likely located in the US. Direct laryngoscopy and ipsilateral tonsillectomy. Bilateral tonsillectomy is ok but low yield (less than 5%). Biopsy base of tongue. Lingual tonsillectomy is o...
Would you recommend salvage RT in a patient who previously had prostatectomy for high risk prostate cancer who is no longer tolerating his intermittent hormonal therapy?
Why was hormone therapy started. BCr or adjuvant ? if adjuvant doesn’t need any treatment and just psa surveillance
Do you offer ADT in patients with intermediate risk prostate cancer who receive hypofractionated EBRT?
There is no good evidence that with different radiotherapy dose/fx or other RT modalities that the relative benefit of ADT is any different. This applies also to SBRT, brachy, and combo-brachy. The basic evidence and logic is as follows:1. ADT improves MFS and OS in multiple RCTs using lower dose co...
If tumor is stradling the peritoneal reflection how do you decide whether to treat with neoadjuvant chemo/RT vs just surgery?
There are many definitions used to delineate the sigmoid colon from the rectum. The peritoneal reflection is only one of these, and it may not be the most clinically useful. The location of the peritoneal reflection varies with age and gender, and it typically extends more inferiorly on the anterior...
How do you account for tumor growth from pre-operative to intra-operative ultrasound for uveal melanoma?
On B scan, measure the thickness from apex AP and also do basal measurements. Base measurements are done through indirect ophthalmoscope also. At each visit, pre-op and postop, both B scan measurements (for tumor thickness) are done and also indirect ophthalmoscope measurements. My twin sister is an...
Would you require pre-RT dental evaluation and clearance for a patient who is being treated with ISRT to Waldeyer's ring/BOT area to 30 - 36Gy?
Yes. In the pre IMRT days, we certainly experienced some dryness and dental issues at dose of 30Gy, albeit much less severe than with typical carcinoma doses. With IMRT and salivary gland sparing the problem is clearly less, but it's hard to argue against a good dental evaluation pre RT. Talk with t...