Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach a bulky 9 cm DLBCL of the axilla following an excisional biopsy to negative margins?
This is a valid question that is encountered with some regularity in clinical practice. It has also been reported in clinical trials. For example, in the landmark SWOG study, 29% of patients had all gross disease resected at the time of diagnostic biopsy. This was in the pre PET-CT era. In the more ...
How do you manage metastatic breast cancer to the uterus/ovaries that is symptomatic?
Management would be based on overall disease status, performance status, systemic treatment options, and expected survival. It tends to be seen more so in lobular carcinoma. Options could be from surgical debunking to quad shot based on the above.
Would you recommend definitive XRT with extensive lymph node involvement of prostate cancer?
In cases of lymph node positive disease, I favor RT to the prostate and lymph nodes (with long termADT ± abiraterone) if I believe all the gross disease can be encompassed in a tolerable radiation treatment plan. In STAMPEDE, RT was mandated in all N0 cases and encouraged in N+ cases, which resulted...
In which clinical scenarios would you prefer to sequence chemotherapy prior to radiation therapy in total neoadjuvant therapy for locally advanced rectal cancer?
Our institutional preference has been to use long course chemoradiotherapy prior to chemotherapy due to the enhanced clinical response rate. The exceptions have been for patients with obstructive physiology, where chemotherapy first can potentially generate a safer and more rapid response. Chemother...
How do you manage recurrent inoperable chest wall pleomorphic liposarcoma with prior radiation therapy?
Palliatively. But review the case and see if anything could be done differently next time. Local control of STS with proper surgery and radiation should be excellent. Perhaps there was a positive surgical margin that should have been re-resected, perhaps postop RT wasn't properly designed, etc. With...
How would you approach a patient with symptomatic spinal cord compression who is a poor surgical candidate and has a radio-resistant primary tumor?
Radiosurgical decompression of metastatic epidural spinal cord compression has been demonstrated (Ryu et al., PMID 20209611). In this report, significant decompression was achieved in 80% of the patients. This decompression is assessed in 2 months' MRI scan since radiosurgery takes time for tumor co...
Would you recommend biopsy of a bone met noted on PSMA PET after definitive prostate radiation?
There is no simple answer to this. The following are some relevant considerations: What was the original risk category? What was the Gleason score? What was the pre-treatment workup? Was there anything noted there previously? Was or is the patient on ADT? Pre-treatment and current PSA values? How l...
What is your simulation setup and dose fractionation for DLBCL of the hand with Deauville 4 residual disease following R-CHOP?
This is a difficult question which I will break into 2 parts: 1) Rx of primary refractory (i.e. chemotherapy resistant) localized DLBCL and 2) special considerations for a hand site. I presume the recurrent/persistent disease is still localized.Treatment of primary refractory DLBCL is a very difficu...
Do you employ a phrenic nerve dose constraint with conventional fractionation?
No.
When planning prostate brachytherapy, do you use a bladder neck constraint?
With real time planning, try to limit it to 85 percent of the prescription dose. Smith et al., PMID 20888139