Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In what situations would you consider focal irradiation for nodular leptomeningeal disease?
So in general, for patients with LMD, I would recommend WBRT - if RT were indicated. A recent paper in the red journal (Turner et al., PMID 31605786) separated "classical LMD" versus "nodular LMD" and provided a training module to improve interrater reliability. In my practice, even patients who pre...
Do you treat the normal pancreas as an organ at risk when delivering abdominal radiation therapy?
This is a great question. We do not do that because we have not seen any convincing evidence of exocrine or endocrine insufficiency caused by radiation at any dose. In fact, from surgical patients, we know that only a small volume of residual pancreas is needed to prevent insulin dependence. The pan...
How does the presence of CABG affect your radiotherapy approach for definitive management of locally advanced NSCLC with mediastinal involvement?
This is a great question. The short answer is we don’t exactly know – but the longer answer would be that while CABG graft dosimetry hasn’t been explicitly defined, we can make a few reasonable extrapolations and assumptions. We know that patients with +CAD are at very high risk of cardiac events, a...
How would you treat unresectable angiosarcoma of the extremity in a patient who is inoperable due to underlying comorbidities?
Radiation and taxane therapy are both active agents for angiosarcoma. Administering weekly paclitaxel is supported by the ANGIOTAX study (Penel et al., PMID 18809609), and @Dr. First Last and colleagues are conducting a phase II trial evaluating the efficacy of induction chemotherapy followed by pac...
How do you approach decision making in terms to adjuvant chemotherapy after CSI in adult medulloblastoma?
Medulloblastoma is a chemotherapy sensitive disease. The NCCN guidelines have options for CSI alone or followed by chemotherapy for standard risk disease (M0, residual disease <1.5cm2, classic or desmoplastic histology) and recommend post-CSI chemotherapy for high risk disease. Unfortunately, 25% of...
How would you manage a large grade 2 endometrial adenocarcinoma with invasion into the parametria and upper vagina without nodal or metastatic disease?
PETCT and MRI. Preoperative chemo RT with EBRT plus brachy followed by surgery. Vargo et al., PMID 25218303
What dose constraints are appropriate for SBRT treatment to a 5 cm neck metastasis from renal cell carcinoma?
Constraints for thyroid cartilage are not well defined. Trachea/skin one could certainly look up RTOG/NRG, SABR UK consortium, COMET-10 constraints as these are all publically accessible. To me, the most important questions are as follows:1. 5 cm is a large met, are there any other mets? Would the e...
How do you manage anaplastic thyroid cancer that is progressing through radiation therapy?
The algorithms for ATC, a rare disease, have gotten relatively complex including the incorporation and timing of XRT. It is unclear from the question what the presentation scenario is, i.e., localized disease or metastatic, and the mutational status, as ideally at a minimum BRAF status is known. Now...
Do you consider 10MV beams safe in a patient with an implantable cardiac device?
I follow the AAPM TG-203 which considers beams up to 10 MV photons to be non-neutron producing. For example, in a lung, abdominal, or pelvis tumor, I find the reduction in total body dose worthwhile to use 10 MV.
What dose can you give the axilla after 5040 cGy of prior radiation?
I have cases where the patient has previously received axillary RT (45-50 Gy usually) and end up with a recurrence where we would like to re-RT. If they have surgery and have factors such as multiple nodes, ECE, I will re-irradiate to a dose of 45 Gy/1.8 Gy fx. There are data suggesting low rates of...