Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage a patient with locally advanced rectal cancer with an ileal conduit?
I don't claim to have extensive experience treating these, but I do still recommend the standard of care treatment of neoadjuvant chemoradiation for LARC patients with ileal conduits. I've made sure to keep the ileal conduit to small bowel tolerance doses, using IMRT to avoid as much as possible exp...
How would you manage a patient with a 2 cm forehead subcutaneous lesion s/p excision found to be a diffuse large B-cell lymphoma germinal center?
If this was known to be a DLBCL before the excision, the patient would have been recommended some variety of R-CHOP x3-4 +/- consolidative RT, given that it appears low risk IE and would've been eligible for the LYSA RCT (Lamy et al., PMID 29061568) showing only small PFS benefit (non-significant) o...
Would you consider a focal prostate boost per FLAME trial with treatment of the pelvis?
The FLAME III trial evaluated a focal dose boost to the prostate tumor if it could be achieved without exceeding dose constraints. By extension, if you can achieve escalated dose to the tumor without meaningfully affecting your plan quality from an OAR perspective, I think this is a very reasonable ...
How do you contour the pre-sacral elective nodes for prostate cancer?
This is an interesting question. There is some heterogeneity between cooperative groups in their recommendations for pre-sacral nodal coverage. For example, while the RTOG and the UK guidelines recommend coverage of the pre-sacral lymph node basins. The recent Indian POP-RT trial also included an 8-...
How do you approach imaging in the treatment planning of resected high grade gliomas/glioblastoma?
We typically obtain an MRI on the same day as the planning CT (whether or not the patient had a post-operative MRI). We are biased as we operate a dedicated MRI. If this were not the case, we would probably assess on a case-by-case basis (how long has it been since the last MRI, how visible is tumor...
How do you account for hot/cold spots generated by a metallic port used to inflate tissue expander in breast reconstruction?
There is dose heterogeneity in the area with 6MV because of port and unless high risk area we accept that. If you have 10MV photons that do decrease dose heterogeneity and some places, use high energy photon with bolus to reduce that uncertainty.Damast et al., PMID 16904530
Would you consider irradiating the prostate and a positive node noted on PET/auxumin while omitting elective pelvic nodal coverage?
I would not generally recommend that strategy, based on current evidence. POP-RT (Murthy et al., PMID 33497252) suggests better biochemical control with elective nodal irradiation in patients with PET-negative prostate cancer. EMPIRE-1 preliminary results presented at ASTRO 2020 also support treatme...
How would you approach radiation treatment of recurrent, BRAF-negative melanoma with left distal leg metastases and two isolated PET-avid inguinal nodes?
Excise gross disease. Consider adjuvant immunotherapy, and adjuvant RT to node basin if there are high risk nodes (>4 cm, extracapsular extension, >2 involved nodes).
When treating with adjuvant radiation to the neck after dissection for a nodal recurrence from a nonmelanoma cutaneous malignancy, would you include the primary tumor resection bed in the field if some time has passed since the primary resection?
I'm aware of no great data in keratinocyte carcinoma that is available to help answer this question. A prospective study of patients with cutaneous squamous cell carcinoma found that among patients with high-risk primary tumors, recurrence at the site of margin-negative excision occurred in 25% with...
What is the role of consolidative radiotherapy in a Stage IV triple hit lymphoma with partial response above and below diaphragm s/p 8 cycles of RCHOP?
The role of consolidation RT in advanced (stage III-IV) DLBCL and HGBCL continues to evolve. Presently, I often recommend consolidation RT in a few clinical circumstances including: Bulky disease (sites > ~7 cm) Disease in particularly sensitive locations (e.g., base of skull or epidural space) Ver...