Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you consider clinically node negative patients who have been on neoadjuvant endocrine therapy eligible for omission of axillary dissection if their sentinel node is positive?
No good data and we have proceeded with regional nodal RT instead of ALND in these patients who are imaging negative and post endocrine SNLN node positive disease.
Would you offer RT for a nodal recurrence of NSCLC that has resolved radiographically after chemotherapy?
Nodal recurrences are bad. When addressing nodal disease that "disappears" after chemotherapy, I have modeled my decision making on the premise used in small cell lung cancer treatment where even in the face of CRs on imaging after chemotherapy, radiotherapy was always added to the mediastinal (noda...
Is extramural venous invasion (EMVI) alone an indication to treat rectal cancer patients with total neoadjuvant therapy as opposed to neoadjuvant chemoradiation therapy or short course radiation therapy alone?
EMVI detected on a staging pelvic MRI for rectal cancer has been shown to be a poor prognostic factor with an increased risk for distant metastases (Siddiqui et al., PMID 28449006). EMVI was also independently associated with a positive circumferential resection margin in low rectal tumors based on ...
What is the best way to approach adjuvant therapy for a FIGO Stage IIIB clear cell carcinoma of uterus s/p TAH BSO, with pathology showing extensive involvement of LUS, the cervix, and bilateral parametria with positive parametrial margins?
I wound get MRI imaging for pelvis to rule out gross disease and assuming staging is negative, would favor chemo RT to 50.4 Gy if not gross residual disease, followed by vaginal brachy boost and then additional chemo.
How would you manage a patient with PSA relapse 10 years after salvage radiotherapy with PSA doubling time<6 months?
Depending on PSA, would image with PSMA PET - typically, will do around PSA 0.5 or higher (given most insurances will not cover multiple PETs in a short timespan, and detection rates of ~50% at PSA 0.5-1 per CONDOR). If no targetable (by XRT) disease on that, would discuss ADT given increased risk o...
What dose constraints, if any, would you use when administering TBI?
I use lung blocks to keep the lung dose <9 Gy, no other dose constraints.
Do you consider younger patients with NF2 to have a relative contraindication to radical pelvic RT due to risk of secondary malignancy?
Yes, I would consider NF2 to be a relative contraindication in a young patient. In the situation presented (borderline indications for post-op RT), I would likely lean toward up-front radical hysterectomy. However, if clear indications for post-op RT are present following surgery, I would not hesita...
Do you recommend inguinal hernia repair before or after chemoRT for inguinal node positive anal cancer?
I would strongly recommend doing this after chemoradiation. The reason is that the dermal lymphatic drainage will be altered after surgery and any in-transit cancer cells will attempt to go to the contralateral inguinal nodes. I have seen dermal lymphatic recurrences five times in my career after in...
How would you manage a patient with epithelioid hemangioendothelioma?
This is typically an indolent tumor, often with multi organ system involvement. Starting point mostly is close observation at 3 mo intervals to get a feel for the pace of growth, and extend intervals as appropriate. For bulky liver disease, one could consider liver directed therapies (ablation/embol...
How would you approach an early stage II unfavorable Hodgkins lymphoma following 6 cycles ABVD with persistent Deauville 5 with negative biopsy?
This is an active disease and should be treated accordingly. I would not wait. RT is certainly option number one now, but the patient has a considerable risk for recurrence even after RT, since he/she has Hodgkin‘s that is not responding adequately to treatment. Continuing with ABVD in a patient who...