Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you crop the mediastinal nodal CTV out of normal lung parenchyma when treating locally advanced NSCLC?
I do routinely crop the mediastinal CTV out of lung parenchyma—while a node may physically expand into the lung tissue (displacing the lung tissue)—there should not be microscopic invasion of the parenchyma. I similarly shave this nodal CTV out of other mediastinal structures such as bone, esophagus...
Are you routinely considering treating p16 positive, nonsmokers, occult primary with pharyngeal sparing technique in patients who have undergone extensive TORS workup?
Sparing the pharyngeal constrictors in unknown primary cases should not differ from standard practice in which only the lateral RPN nodes are considered at risk. The only cases where the medial retropharyngeal nodes are at risk (which would prevent constrictor sparing) are cases of posterior pharyng...
In light of the COVID-19 pandemic, would you consider SBRT for appropriately selected early stage breast cancer patients?
No.If I'm interpreting the question correctly, it poses using definitive/ablative SBRT in lieu of breast surgery. There is no high level evidence to suggest that this is as efficacious as initial surgery. Definitive breast SBRT is being very actively studied in many smaller Phase I/II.While some ret...
How do you approach treatment for a patient who develops a nodal recurrence years after primary resection of NSCLC?
I agree with @Dr. First Last's approach re mediastinal relapse; we consider delayed limited nodal relapse as a manifestation of microscopic disease that has had the opportunity to manifest itself, and the implication would be that this was Stage III disease to begin with, and our salvage strategy th...
How do you distinguish between radiation necrosis, abscess, or disease recurrence in head and neck cancer patients?
This is a difficult clinical situation. I find physical exams including laryngoscopy to be of most use. If there are sharp borders and ulcers are soft with signs of infection, I will more likely suspect necrosis with super-infection. In this case, I will try antibiotics, antifungal, and antiseptic m...
What are your policies/practices for physician role of SBRT/SABR treatment delivery?
Do your post-operative rectal fields differ from pre-operative fields?
You must wire and include the perineal scar. This is counterintuitive because APR is a "big surgery". But there can be surgical marginal miss and recurrences there. Often, the inguinal nodes will be at risk if the tumor was below the dentate line. Be especially careful to exclude small bowel as much...
Does the presence of DCIS in conjunction with invasive breast cancer require consideration of adjuvant RT where invasive disease alone may allow for omission?
I'm not sure there is a lot of data in the PRIME II/CALGB 9343 subset of patients looking at impact of associated DCIS in conjunction with invasive disease and its impact on recurrence with and without radiation therapy. I have not considered this an additional risk factor and have offered omission ...
What oral alternatives would you recommend as opposed to injectable GnRH agonists for those who do not wish to come to clinic due to COVID-19?
Casodex is an option. Due to liver toxicity, they would need LFTs checked before and at a future interval, effectively requiring them 3 visits to a health care facility—labs, pharmacy, labs. A single 6 month injection seems like a better proposition.
Would you offer consolidative radiation for metastatic small cell bladder cancer with good response to immunotherapy?
With the value of consolidation RT in extensive stage small cell lung cancer being questioned in immunotherapy era, I would hold off on any RT for consolidation for extra thoracic site also.