Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is an appropriate dose for definitive radiation of a stage IE EBV+ polymorphic B-cell lymphoproliferative disorder?
This is a very unusual presentation for EBV associated polymorphic B-cell lymphoproliferative disorder as most cases are seen in the post-transplant or other immune-compromised patients. In immuno-competent patients, this condition is felt to be related to immune senescence. The range of clinical be...
If a patient develops intermittent painless hematuria during standard prostate RT do you attribute this to cystitis or would you work it up further?
While acute mucosal deepithelialization may be to blame, painless hematuria may unfortunately mark the beginning of a conundrum. It's good medicine to always develop a broad DDx and remember that radiation injuries are waste basket diagnoses. It's also wise to start with a UA/UCx, and if negative do...
What dose and fractionation is safe to use for palliation of a large pelvic mass several years after definitive prostate brachytherapy?
The prescription, technique and modality would depend on histology, size and involvement/distance from organs at risk. At our institution we have often utilized high-dose spatially fractionated radiation therapy (GRID) for large tumors followed by a traditional hypofractionated palliative RT regimen...
How would you approach a biopsy proven NSCLC patient with mediastinum negative disease and contralateral suspicious spiculated PET avid nodule without pathologic diagnosis?
This is a scenario I have faced before. Sometimes unfortunately in spite of staging studies, the stage a lung cancer patient has might remain a bit unclear. In this situation if this is a functioning patient with good PFTs who is a surgical candidate I would consider treating him like he has 2 separ...
Do you alter definitive treatment recommendations for oropharynx p16+ cancers based on the new staging?
As you know, the new 8th Edition of the AJCC staging manual redefined prognostic staging for p16/HPV-positive tumors. It is important to note that p16/HPV is therefore not a PROGNOSTIC marker but rather a DIAGNOSTIC biomarker of a different disease entity entirely. The 8th Edition system is based of...
Does size influence your decision making for women with low or low-intermediate risk endometrial cancer after hysterectomy?
In otherwise low risk disease where I would favor observation, I do discuss pros and cons of adjuvant cuff brachytherapy if size greater than 2.5 cm or so.
When is adjuvant radiotherapy recommended for a high risk squamous cell carcinoma of the skin (non-H&N) if the tumor is resected with widely negative margins and there is no perineural invasion?
There is limited high quality evidence to guide management of "widely" excised cutaneous squamous cell carcinomas. There is an excellent prospective study reporting the outcomes of margin-negative excisions using techniques similar to Mohs surgery suggesting that there are several risk factors for l...
What fractionation would you recommend in a patient with recurrent early stage breast cancer who has had prior lumpectomy and IORT and refuses mastectomy?
While there is no standard of care, several options exist. It is important to delineate where recurrence is (true recurrence vs. elsewhere failure in breast). Also, IORT technique is important a low energy IORT (50 kv) has limited dose deposition beyond a few mm (5-6 Gy at 1 cm) and as such much of ...
What factors do you consider when electing to observe small brain metastases (vs treating with SRS)?
Since I see primarily brain metastases from lung cancer, my opinion will be confined to small cell and NSCLC brain metastases. For single or multiple small (and I am going to assume that they are asymptomatic) that are present at the diagnosis of small cell lung cancer, I think it is reasonable to ...
For patients with stage I NSCLC initially treated with SBRT, how do you best manage isolated regional nodal failure?
The 5-year loco-regional failure rate in RTOG 0236 was 38%, underscoring that there is considerable need for identifying a post-SBRT salvage strategy for these patients; there are only anecdotal reports in the literature as to how to best manage these patients. Our historic approach when the failure...