Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is the current role for genetic profile testing (e.g. DecisionDx-SCC) in the treatment paradigm for cutaneous malignancies?
This is a very cool test that has a lot of potential to help us make decisions in practice (full disclosure, I advise Castle and get research support from them, but am not directly compensated by them). The data published thus far shows that it is prognostic to predict nodal or distant mets. However...
How would you treat a hepatic dome HCC lesion in a patient with a history of ILD?
This depends on the other treatment options available to the patient. If technically feasible, one might favor either radiofrequency ablation (if accessible, though perhaps complicated in the dome) or TACE (transarterial chemoembolization), provided there is not significant blood supply from the phr...
When using short course fractionation for an elderly patient with glioblastoma (40 Gy in 15 fractions), what are appropriate dose constraints for chiasm, brainstem, optic nerves?
Dose constraints for normal tissues were not published in the randomized trial by Roa et al. of 40 Gy in 15 fractions vs. 60 Gy in 30 fractions for elderly patients with glioblastoma (Journal of Clinical Oncology, 2004). Given the apparent similar efficacy and tolerability of the hypofractionated an...
What dose do you use for palliation of a large lung mass invading ribs and causing pain?
30-35 in 10 is rarely wrong. I tend to favor shorter courses for palliation; however, when the mass is large, I still kinda believe in the Rs of radbio. If doing in 5 fx, would aim for 25 Gy rather than 20, approaches BED of 30 in 10, and if expecting limited life expectancy, unlikely to experience ...
Should a lumpectomy cavity boost be given to cN0 patients who receive neo-adjuvant chemotherapy and have a path CR, if planning to complete hypofractionated whole breast radiation?
There is no prospective or retrospective data in this setting but we routinely boost this patients, as usually NACT is used for triple negative, Her2-neu positive, or higher T disease and thus, the rationale for the boost.
What adjuvant therapy is recommended for a patient treated for a WHO grade 3 meningioma s/p GTR and adjuvant radiation one year ago, with negative brain MRI, who now presents s/p selective neck dissection of a enlarged lymph node with pathology confirming WHO grade 3 metastatic meningioma?
This is an uncommon but increasingly recognized scenario. In full disclosure, I have only treated a handful of cases of disseminated anaplastic (Grade 3) meningiomas.In the case described above, cervical lymph node metastasis from a WHO grade 3 (anaplastic) meningioma indicates systemic disseminatio...
What dose would you use to treat amyloidosis involving sciatic nerve for symptom relief?
20-24 Gy/10-12 fxs will likely be beneficial based on extrapolation from other reported sites. Cooper et al., PMID 28958583 Meier et al., PMID 27689460 Harris et al., PMID 33434319 Tracey et al., PMID 37732696 Monroe et al., PMID 14769766 Neben-Wittich et al., PMID 17625086 Truong et al., PMID 22270...
What is your radiotherapy approach for a patient presenting with simultaneous stage IIA limited stage SCLC and stage IIIC cervical SCC who is receiving standard treatment for both?
Tough case. I've done one for cervix and NSCLC in a similar situation where we treated simultaneously. The only difference is I would avoid concurrent etoposide during RT and would only add IO and etoposide after completion of radiation. The patient would need support with nutrition, especially if t...
How do you contour the cauda equina for a lumbar spine SBRT case below the spinal cord?
I typically contour the cauda equina at the level of the upper lumbar spine just below the spinal cord based on T2-weighted MRI and utilize a 2 mm PRV. If the entire spinal canal is instead contoured just below the cord, this may lead to underdosing of the posterior aspect of the vertebral body.At t...
How do you approach the treatment of de novo, brain-only metastatic HER2 positive breast cancer?
Patients who present with de novo, brain-only metastases of HER2+ breast cancer are rare, and hence, there is no good clinical experience or clinical trial basis upon which to base clinical practice recommendations. The current ASCO guidelines for the management of HER2+ brain metastases call for ap...