Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you routinely use PRVs for CNS planning?
We do not use PRVs specifically for primary CNS planning or for brain mets treated with Gamma Knife. We have PRV constraints for Spine SRS specifically for the spine.
Do you routinely use any type of motion management or breathing techniques when treating a lower esophageal cancer?
I obtain a 4DCT scan at simulation with free breathing. I do not use abdominal compression, gating, or other motion management techniques. There is certainly room for more data here to fully evaluate the potential value of these techniques. But for now, I don't use them in this situation. In my expe...
Is there any upper limit of volume or shape of a prostate gland which would be a red flag to cytoreduce prior to treatment?
Astro/aua consensus guidelines based on published data limits to 100cc or less
How would you manage an elderly patient with metastatic breast cancer with locally advanced bilateral primaries?
It depends on symptoms. If no impeding skin breakdown, ulceration or pain/lymphedema, I will see how they respond on endocrine therapy. If symptomatic, I will consider 30 Gy/10 fx using opposed tangents or in some cases with rapidly progressive disease 20 Gy/5 fx
How do you manage new brain metastases in patients on trastuzumab emtansine (TDM-1) who has controlled extracranial disease?
This is an increasingly common clinical scenario, because systemic control with antibodies is quite good, but HER2+ disease still has a strong predilection for the brain. There is a third treatment option here, which may have lower toxicity than either whole brain or SRS.Particularly where larger vo...
What dose constraint do you use for the spinal cord in the setting of re-irradiation?
Dr. Arjun Sahgal published the dose constraints in Red J.Reirradiation human spinal cord tolerance for stereotactic body radiotherapy.Sahgal A, Ma L, Weinberg V, Gibbs IC, Chao S, Chang UK, Werner-Wasik M, Angelov L, Chang EL, Sohn MJ, Soltys SG, Létourneau D, Ryu S, Gerszten PC, Fowler J, Wong CS,...
In a thin patient with anal cancer, do you use bolus over the inguinal nodal volume when treating with an IMRT technique?
Rarely, only if the tumor is involving the skin, but I always sue 6MV photons and more than enough dose. The skin gets plenty of dose with IMRT and 6MV photons. When there is gross node in a thin patient, it doesn't add morbidity to do so, however. The only inguinal recurrence I have ever had, gross...
How would you re-irradiate a breast recurrence in a patient treated with prior whole breast radiotherapy?
In setting where the patient is refusing surgery and systemic therapy, I would evaluate if there are local symptoms. If not, one can consider not offering RT until symptomatic. Alternatives: 1. If post-mastectomy, or superficial recurrence can consider hyperthermia and smaller field. Alternatively, ...
At what point do you refer patients to see a pain specialist?
Great question. In these instances, where the patient comes in for palliative RT for painful bone mets, for example, I tend refer back to the 'involved' palliative care professional or the pain specialist. In the last few years, I have rarely had to become involved with directly prescribing opiates...
Is it safe to start immunotherapy concurrently with radiation to a bone metastases?
Retrospective data for palliative RT and immunotherapy doesn’t suggest increased complications with concurrent use