Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach hotspots/heterogeneity for palliative radiation plans?
For whole brain, hotspots are usually located superiorly, where the head narrows.Some options to reduce include: higher energy/mixed beams and supplementing the laterals with field in fields to keep the hotspots lower than 110%. Mixed energy plans look very nice, but consider contouring a brain CTV ...
For a patient otherwise suitable for APBI, would neoadjuvant endocrine therapy administered for extemporizing reasons (e.g., COVID diagnosis and recovery, rather than downstaging) preclude consideration of APBI?
I have not typically treated patients with APBI if undergoing neoadjuvant therapy (chemotherapy or endocrine therapy). In theory, if endocrine therapy was a short amount of time, PBI could be considered but I have favored HWBI in these situations.
When would you include the superior mediastinal lymph nodes when treating head & neck cancer and how do you define the target volume?
Low level 4 and/or 6 nodes.
How do you approach H&N radiation in a patient who recently had carotid endarterectomy (cancer incidentally found during surgery)?
I’m guessing in a lymph node. It would depend on the location. External jugular think skin. Internal jugular think mucosa. Close, heal, work up for unknown primary. CT and PET. Check path for HPV. Treatment depends on whether it’s likely a mucosal vs skin primary.
In what situations do you utilize motion management of the optic structures?
A paper published in Br J Radiol. 2019 (Xiang et al., PMID 31067077) showed, based on MRI, an average physiological motion of the optic chiasm to be 0.5-0.75mm. We have used at least 1mm expansion of the optic nerves and chiasm in our stereotactic radiosurgery treatment planning.
How do you approach management of a young inflammatory breast cancer patient after a CR to neoadj chemo but refuses surgery?
I would first review the NCDB study showing the best outcomes for trimodality therapy (Reuth et al). Then explore why. If it is a belief CR means cured highlight imaging can be discordant. There will often be cancer found at surgery. If there is a pCR that is the best chance for cure but even with t...
How will you counsel patients receiving radiation therapy regarding COVID-19 vaccine administration?
Encourage to take the vaccine as scheduled (both during or after RT).
Is there a role for RT in localized nodal relapse of stage IV follicular lymphoma with the goal of delaying the need for additional systemic therapy?
Indolent lymphomas like follicular lymphoma typically present with diffuse disease and therapy for the disease is not curative. Oncologists vary in the aggressiveness of their treatment approach, but almost all medical oncologists would advocate for administration of systemic therapy before the pati...
Do you avoid adding high energy photons (with associated neutrons) for younger breast cancer patients, out of concern for secondary malignancy risk?
We used mixed, whenever appropriate, with optimization of dose distribution using field within field technique (no wedges).
How would you approach an early inguinal recurrence after surgical resection of Merkel Cell carcinoma in the popliteal region?
I would make sure there is no distant metastases with a PET-CT. Would try to enroll this patient in a trial. Current approach if localized in surgery followed by radiation, but with availability of immunotherapy, I would recommend at least an adjuvant immunotherapy after surgery. No one knows if rad...