Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
For low rectal adenocarcinoma that extends to the anus through the internal sphincter muscle, would you recommend neoadjuvant therapy in a patient who will undergo APR?
Yes, since the margin is positive and local recurrence rates are high for low rectal cancer patients such as this, they should be treated with neoadjuvant chemoradiation including the inguinals with IMRT.
When would you recommend adjuvant therapy for a patient with urethral adenocarcinoma after partial urethrectomy?
My first approach in this setting is to have the pathology reviewed by an expert tumor pathologist, and to be sure of the T stage, margins, N/M stage, and whether any tumor markers are heavily expressed. If there is a strongly expressed tumor marker, such as CEA, I will obtain baseline, and interval...
In breast cancer patients with a positive margin on permanent tissue but not on frozen, do you recommend re-excision or just proceed with radiation?
We would favor re-excision as the risk of IBTR is high.