Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What radiation dose and fractionation is appropriate for hairy cell leukemia presenting as an isolated skeletal lesion, where systemic treatment is not recommended?
If the patient is not a candidate for any systemic therapy like cladribine or pentostatin, treatment of the bone lesion to 20-30 Gy with conventional fractionation is a reasonable approach. Some of the older case series would treat lesions up to 60 Gy, but HCL is ultimately a radiosensitive B-cell l...
For head and neck cancers do you ever reduce PTV coverage in the post-op setting to meet an OAR constraint?
There is no real clinical constraint regarding parotid glands doses. The threshold of 26 Gy mean dose was based on forward-planning IMRT in the early 1990s, which could spare the contralateral but not the ipsilateral glands. Once inverse planning was available and partial sparing of the ipsilateral ...
Would you omit a boost in a patient with an indication if a very large (>200cc) post-op seroma obscures the actual tumor bed?
Generally for these patients with seroma > 100 cc, prefer aspiration and settling of seroma before starting RT. Also in general, we tend to rescan for boost most of the time as favor lateral decubitus position and also account for change in size of seroma. Kannan et al., PMID 23006598
Would you consider treating an adult patient with severe claustrophobia with daily anesthesia for 35 fractions if the goal is larynx preservation?
This is an anecdotal case. I did this once for a patient. T3N0 SGL. Anesthesia wanted a trach to secure the patient's airway (was placed prior to starting treatment). General anesthesia for 35 treatments. Trach was removed soon after completing treatment. The patient is now 8 years post-treatment, l...
Would you offer definitive XRT for muscle invasive bladder cancer arising within a bladder diverticulum?
A diverticulum is a common location for bladder cancer to arise. I am not aware of any association between RT diverticula and increased risk of bladder perforation. I have personally never had an issue treating diverticula to full dose (either 64 Gy in 2 Gy fractions or 55 Gy in 20 fractions) in ter...
Will the recent publication of the KROG 08-06 trial change your practice in node positive breast cancer patients?
I would encourage listening to Dr. @Dr. First Last's ASTRO discussion of this trial.KROG 08-06 was powered to detect a 10% DFS advantage for inclusion of the IM chain. Meanwhile, RNI trials have demonstrated a 3-5% advantage in DFS for RNI such that even if irradiation of the IM chain were responsib...
How would you approach unresectable synovial sarcoma of the heart ?
The specific situation described is rare and I'm not aware of any data addressing it directly, but there are general principles for cardiac sarcomas that can be helpful.For cardiac sarcomas, subsite matters for prognosis and treatment. Left-sided more prone to non-lung visceral mets. (In resectable ...
Do you recommend ADT for all patients who are unfavorable intermediate risk prostate cancer?
I recommend ADT for unfavorable intermediate risk patients who are not treated with a brachy boost. ADT is probably unnecessary for those treated with brachy boost. Of course, I also take into account the patient's concerns and preferences regarding sexuality, cardiac risk, and desire for maximal tr...
In what situations would you consider focal irradiation for nodular leptomeningeal disease?
So in general, for patients with LMD, I would recommend WBRT - if RT were indicated. A recent paper in the red journal (Turner et al., PMID 31605786) separated "classical LMD" versus "nodular LMD" and provided a training module to improve interrater reliability. In my practice, even patients who pre...
Do you treat the normal pancreas as an organ at risk when delivering abdominal radiation therapy?
This is a great question. We do not do that because we have not seen any convincing evidence of exocrine or endocrine insufficiency caused by radiation at any dose. In fact, from surgical patients, we know that only a small volume of residual pancreas is needed to prevent insulin dependence. The pan...