Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you use minimum cutoff values for any PFTs below which you would not offer conventionally fractionated chemoradiation or SBRT for NSCLC?
We have historically not used a cut-off lower-limit for FEV1 or DLCO when selecting patients for SBRT for stage I NSCLC. This is supported by both our own (PMID 19487961) and the Indiana University (PMID 18394819) series in which patients were divided into quartiles by baseline PFT's. In both series...
How important is a severely diminished diffusion capacity in determining whether to offer a lung cancer patient radiotherapy?
Conventionally, Pulmonary function tests (PFTs) are considered essential before considering thoracic surgery and by extension this rule has applied to definitive radiation. This is because baseline pulmonary function (PF) can predict the risk of pulmonary complications after thoracotomy, and patient...
What is a safe and effective dose and fractionation for palliating head and neck cancer?
I agree with aggressive treatment in patients with a good performance status. For those with a poor PS or with multiple comorbidities, we've used the QUAD SHOT regimen- 14Gy over 4 fractions in 2 days, repeated every 4 weeks up to a dose of 42Gy/12 fractions, if tolerated. This fractionation gives a...
For a patient with T3N1M0 esophageal adenocarcinoma, who suffered esophageal perforation necessitating metallic stent placement, would you favor a neoadjuvant chemoradiation or perioperative chemotherapy approach?
In situations of esophageal perforation, the main concern will be the dissemination of disease particularly in the thoracic cavity, i.e. pleura. Therefore, I favor a systemic therapy approach upfront. Should the patient have a good response to systemic therapy, then chemoradiation could be considere...
In a patient with a mid-esophageal squamous cell carcinoma with tracheal invasion confirmed on bronchoscopy, would you treat with definitive chemo-radiation with curative intent?
I generally start with chemotherapy alone in these patients, usually carbo/taxol for 2-3 months, and then re-evaluate with PET, bronchoscopy, and endoscopy to determine if there is still evidence of transmural invasion into the trachea. Often, if the tumor responds, the tracheal invasion is no longe...
What type of local consolidation therapy, if any, would you offer to a patient with thymoma and pleural metastasis with complete metabolic response after chemotherapy?
A lot of caveats depend on patient age/performance status/comorbidities, the path and extent of initial disease. Thymoma (depending on path), even with pleural disease, can be quite indolent, and in most cases, you aren't losing much by observing off therapy or on maintenance systemic therapy. Retro...
Is it appropriate to use moderate hypofractionation for the treatment of patients with high-risk prostate cancer?
At Fox Chase, we conducted a phase III randomized prospective clinical trial comparing conventionally fractionated IMRT with moderately hypofractionated IMRT from 2002-2008, for men with intermediate and high risk prostate cancer. Men were randomized to 76 Gy in 38 fractions or 70.2 Gy in 26 fractio...
For a breast cancer patient treated with a mastectomy who has clear indications for post-mastectomy radiation therapy, what do you consider to be the longest acceptable delay prior to initiating PMRT following surgery?
The longest I've ever waited is 6 months, and that was in a young patient with T4b N3b M0 disease that progressed on weekly taxol and then experienced a complete pathologic response to FAC. I felt that this patient had a substantial risk of local-regional recurrence and that even if the benefit of r...
How would you sequence treatment (chemo and chemoRT) for a patient with a very symptomatic locally advanced rectal adenocarcinoma, MSS, with involved pelvic nodes and a mass abutting the sphincter, with no distant disease on CT but marked elevation in CEA above 300?
A pretreatment CEA level above 300 ng/mL is far beyond the typical range seen in stage II–III disease and warrants aggressive investigation. PET/CT should be strongly considered in this case to exclude occult distant disease, as it can change management in 8–11% of patients and is specifically recom...
How would you treat a subcutaneous metastatic atypical carcinoid tumor?
If it is solitary, one can excise it also for local control.