Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
Would you consider radiation alone or chemoradiation therapy for a small vulvar cancer near the urethra or clitoris?
Yes, I think radiation is worth considering in this situation. However, the morbidity of radiation is also significant with potential for edema and fibrosis in high dose volume. The consequence of that may arguably be worse than surgery. If we do treat with radiation, I would still add chemotherapy ...
What dose is required to gross disease in the definitive treatment of vulvar cancer?
As with all gynecologic carcinomas, the optimal dose is at least to some extent dependent on the volume of disease. However, our experience suggests that a minimum of 60 Gy should always be given for gross diasease, even when concurrent chemotherapy is being given. That said, for gross disease that ...
How do you manage a head and neck cancer patient with the presence of high grade dysplasia at a margin?
This is an excellent question. According to some pathological literature, a margin positive for in situ carcinoma or high grade dysplasia has a similar recurrence risk as a frankly positive margin with invasive disease. NCCN guidelines define carcinoma in situ or invasive disease as a "positive marg...
Under what circumstances would you pursue completion ALND in a patient with multiple positive sentinel nodes after breast-conserving surgery?
For clinical/imaging node-negative disease with 1-2 positive nodes, now there are 7 plus clinical studies (ACOSOG Z0011, AMAROS, OTOASOR, SENOMAC, IBCSG 23-01, AATRM, SINODAR-ONE) which have shown no difference in axillary recurrence, DFS with dissection, but higher lymphedema as expected. The most ...
Is there additional concern for late cardiac toxicity when using ultrahypofractionated breast radiation protocols, given that the BED to the heart is higher?
The BED to the heart isn't actually higher in this setting.Dr. @Dr. First Last explained this below, but I'll just explain it another way. Imagine that you place the block edge so that it is touching the heart (i.e., the heart is completely covered by the MLCs, and there is no margin between the MLC...
Can symptomatic radiation pneumonitis ever improve spontaneously without corticosteroids?
As “pneumonitis” has always been difficult to pinpoint, and relies on “inflammatory radiologic findings” confined to XRT portals, fever, cough without positive bacterial cultures, and shortness of breath, the diagnosis is even more difficult with 3D-directed and multiple portals or mostly IMRT-deliv...
Do you utilize the same radiosurgery constraints for each substructure of the brainstem?
I typically do use the same SRS constraint but with the caveat that I would be much more concerned personally at the medulla/upper cervical cord junction as opposed to the midbrain/thalamic junction.
For a patient with clinically node positive pancreatic cancer, do you simply boost the involved nodes to full dose or treat additional adjacent nodal regions electively?
I would recommend including an elective target volume. In your boost/high dose volume, you can include the involved primary and involved nodes with margin. The elective volume may include regions at risk for occult nodal involvement and pathways of peri-neural spread. This would align with the NRG c...
What nodal volumes would you cover for a melanoma of the posterior scalp with poor response to immunotherapy, s/p wide excision and occipital nodal dissection with multiple positive nodes and ENE?
With multiple involved nodes and no pathologic response to neoadjuvant immunotherapy, I would suggest adjuvant radiotherapy. I would target the suboccipital, postauricular, and posterior cervical lymphatics (2B, 5B). If the tumor was midline, I would cover bilaterally, and if it was well lateralized...