Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you sequence I-131 and external beam radiation therapy after thyroidectomy for locally advanced thyroid cancer?
I've not had an occasion wherein I sequence a radiopharmaceutical and XRT for thyroid cancer, as a planned event. Again, different indications for different therapeutics here. The radioisotope is designed to address I-avid, minimal volume disease while XRT is designed to treat macroscopic, generally...
How would you treat a prostate cancer with malignant priapism due to direct tumor extension?
Carefully! No seriously, this is a case where MRI imaging and the utilization of complete androgen blockade can make a big difference. Also coordination with urology. I've treated one patient in this circumstance, and luckily for him, he did get symptomatic relief with LHRH antagonist (which I would...
Would you consider lymph node basin radiation in a patient with upper extremity Merkel cell carcinoma with one positive SLN but with no other positive lymph nodes found on axillary dissection?
Yes. My preference would have been to obtain a PET, excise the positive node, and irradiate the axilla to reduce the risk of arm edema.
How do you account for only a partial fraction of radiation being delivered due to machine malfunction?
For conventional fractionation, I have typically disregarded this partial dose and repeated that fraction at full dose unless it was >75%. For SBRT, in one case, half the dose was delivered in one arc. and the next day once the problem was fixed the patient received the second arc to complete that f...
What are your top takeaways from ASCO GU 2022?
My top abstracts and questions that arise from them: 1) ARASENS with darolutamide in high volume de novo mHSPC showing an OS benefit with darolutamide over ADT/docetaxel. Will this pertain only to high volume/risk patients who are chemo-fit and de novo which seemed to comprise the vast majority of ...
How do you treat a low grade mucoepidermoid carcinoma with unkown primary site?
A misnomer. Low grade MECs don’t metastasize so, if it does, it’s not low grade regardless of the histology. Neck dissection plus postop RT and include the potential primary site if feasible.
How do you manage lengthy unplanned breaks during radiation therapy for breast cancer?
Dr. @Dr. First Last et al published a consensus guide for responding to unanticipated delays in treatment for multiple cancer sites (PMID 30999000). For breast, the recommendation is to add 2Gy lumpectomy boost for each week of missed treatment, up to 66Gy. I found this advice helpful when we had a ...
What is your approach to patients with T4 NSCLC due to several ipsilateral lung nodules in different lobes?
Needs a multi-disciplinary discussion for evaluation of the possibility of local management of all of these lesions. Thoracic surgery should weigh in on both medical fitness for surgery and the extent of resection that would be required to clear all lesions. The patient should have recent PFTs and p...
How do you manage near-field recurrence of a soft tissue sarcoma that was previously treated with pre-op RT?
First, try to figure out what is really going on here. Local control rates for preop RT and resection--assuming both of those were done well--should be ~90%. So this situation should be unusual. Was a satellite lesion missed during initial diagnosis? Were volumes delineated correctly, including T2 F...
When is postmastectomy radiation therapy indicated for a de-novo occurrence of cancer in the chest wall after mastectomy without prior malignancy, such as in a patient who had prophylactic mastectomy?
This is such a rare occurrence and I may have done this a few times. I have usually limited to CW only if SNLN is done as part of surgery and is negative. That being said, feel local excision alone with adjuvant systemic treatment as indicated may be an option.