Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage treatment of a cervical cancer in a patient unable to tolerate chemotherapy or an HDR boost due to medical commodities?
The first step is to be absolutely certain that brachytherapy is not feasible. In our experience this is extremely rare. The patient should have a thorough medical evaluation and have their medical conditions optimized as much as possible before the decision is made to withhold these standard elemen...
Is it beneficial to use fiducial markers if you are using daily cone-beam CT for prostate localization?
The answer to this question will be self-evident if one ever tries to align the prostate to the CBCT at the linac console. It's tough enough to contour the prostate on a planning CT, and the inferior quality of CBCT images only makes it harder to know where the base or apex are. This latter point ca...
Do you recommend PMRT and if so, do you treat the regional nodes, in patients who are cT4N0 (non-inflammatory) treated with neoadjuvant chemotherapy who have a pCR at the time of mastectomy?
I would recommend PMRT and treat chest wall and regional node comprehensively. At present those who present with clinical stage III disease like above and have pCR we recommend PMRT. Some of them are suitable for B51 also (stage III and node positive upfront converted to node negative) and we do off...
What is your preferred palliative radiation regimen for patients with painful bone metastasis?
Because of the great work of the BM Working Group led by Hartsell et al, and the Dutch, for examples, there are ample category 1 data supporting the use of Single Fraction (800cGyx1) EBRT for "uncomplicated" bone lesions. That is, the use of 800cGy x1 unless there is: a soft tissue component, an imp...
Do you do urethrogram at time of prostate simulation?
We don't perform a urethrogam. We do MRI with a pelvic coil and fuse it with the CT scan which helps to identify the base, lateral edge and apex appropriately.
In what settings do you routinely image the spine for work-up of an intracranial glioma?
I do not routinely image the spine following workup of an intracranial glioma. It is not because they are not common because in fact, it can be found in 25% of patients with supratentorial glioblastoma (Kaloshi et al. Acta Inform Med 2014). Rather, symptomatic spinal dissemination occurs in less tha...
What is your approach for a brachytherapy boost in prostate cancer patients with extracapsular extension?
In general for patients with documented extracapsular extension, the combination of external beam radiation along with brachytherapy is a very appropriate treatment intervention. For such patients, we generally initiate treatment with the brachytherapy and make sure that seed placement is well cover...
What strategies to you use for large breasted women receiving whole breast radiation?
If we can't do prone, we use a styroform wedge in the inframammary region to decrease the breast fold and thus, decrease the inferior margin and amount of inframammary fold we have to treat. I would initially try hypofractionation with mixed beam with a field-in-field technique and if the dose homog...
How do you approach isolated recurrence in a para-aortic lymph node following definitive radiation for localized prostate cancer?
This is a challenging situation with no data to guide therapy; it is not unreasonable to pursue novel PET imaging (PSMA on trial, fluciclovine) to ensure there is no evidence of other sites of metastatic disease. The treatment of oligometastatic disease continues to evolve. In this situation, I woul...
Do you routinely treat postoperative extremity soft tissue sarcoma with IMRT?
Historical tidbit: In the early days of IMRT, and I'm talking like ~2000-2003, there were actually approved diagnosis codes for IMRT (oropharynx was allowed e.g.). There were likewise codes that were exclusionary for IMRT (I remember breast and gastric cancer e.g. being disallowed early on). Soft ti...