Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage a primary dural low-grade lymphoma?
Primary dural low grade lymphoma is a rare presentation, usually marginal zone lymphoma, mostly scattered case reports in the literature but one recent series from Memorial Sloan Kettering (de la Fuente et al., PMID 27649904). I would rx similarly for other marginal zone sites. Local rx only, usuall...
What dose constraint do you use for the proximal bronchial tree for when treating NSCLC to 60 Gy/8 fx?
The Canadian LUSTRE trial (which randomizes patients to 48/4 or 60/8 versus 60/15) accepts a dose limit of 64 Gy max, and 60 Gy to 5 cc to the PBT for a 60/8 fractionation schedule. Typically we aim to keep the dose relatively less heterogeneous within the target so as not to draw any significant ho...
Why is it more preferable to perform SLNB after neoadjuvant systemic chemotherapy versus before therapy?
Rationale For clinically negative node, the negative predictive value of SNLN is similar before and after chemo. Chemo type and Indication is now based on phenotype rather than nodal status. Doing SNLN after chemo would increase likelihood of node negative disease and this avoid more treatment to a...
When treating an inoperable patient with squamous cell carcinoma of the thoracic esophagus, do you ever dose escalate beyond 50.4Gy?
Given the results of INT-0123/RTOG9405 failed to demonstrate an improvement in overall survival with dose escalation, I do not treat above 50.4 Gy when giving definitive chemoradiation. There is no other randomized evidence to support doses greater than 50-50.4 Gy at 1.8-2.0 Gy/day.Patients treated ...
Would you consider treating elective cervical nodal volumes for a highly invasive pituitary adenoma with high-risk features?
I think this depends on what is considered high risk. In general I do not routinely cover cervical lymph nodes. I’d take into account the size, functional/secretory status of the tumor, and whether pharmacological/surgical options have been pursued.
What is your preferred palliative regimen for pancreatic cancer with pain related to celiac plexus involvement?
I prefer to use 36Gy in 12 fractions, which can be given AP/PA as long as it is homogeneous. Even though the GI rad onc academic community promotes SBRT techniques for palliation, the use of an SBRT technique in this setting is unnecessary for such low doses. I only use an SBRT technique when I woul...
Would you recommend hypofractionated treatment for early stage, bilateral breast cancers?
yes as i don't see any reason and have done multiple times
In which patients do you prescribe Marinol?
The short answer to this question is I prescribe dronabinol to patients who are requesting medical marijuana but don't have a state-issued medical marijuana card yet. It can take 2-3 months for Illinois to issue the card (hooray for bureaucracy!) unless the patient is deemed "terminal" (i.e. <6 mont...
How long after high-dose IV methothrexate for chemo-refractory CNS lymphoma do you wait before giving brain radiation?
As was taught by my mentor- "As long as possible!". Of course, the prognosis is extremely poor if the patient is chemo-refractory to IV MTX and longer-term risks of WBRT may be less relevant than present-day symptoms requiring palliation. While I do recommend WBRT, as what is visualized on MRI is ju...
How would you approach a patient with locally recurrent esophageal carcinoma who is s/p previous chemoRT and refuses salvage surgery?
There is little data to guide treatment in this situation and well founded fear of toxicity with repeat radiation. In a recent report from China, patients with locoregional recurrence after definitive treatment that involved RT had impressively longer OS with repeat RT to a median dose of 50 Gy. The...