Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you offer liver SBRT without fiducial placement?
When we first started doing liver SBRT cases in the early Paleolithic 2000s (refs), we never used fiducials and just managed by using the nearest liver surface contour (or diaphragm if using a breath hold technique) and/or any other intrahepatic anatomy that was distinguishable once we added CBCT. I...
In your practice, what is your goal dose for boosting positive PA nodes in either the adjuvant or definitive treatment for cervical cancer?
The dose of RT is based on the risk of tumor recurrence tempered by normal tissue constraints. In general, known or suspected gross nodal disease is treated to 60 Gy; higher doses of 62-66 Gy may be used for large nodes that are not immediately adjacent to the duodenum, particularly if a portion of ...
Which patients with relapsed/refractory NHL are appropriate for pre-CAR-T bridging radiation therapy?
Before answering this important question, I think that we, as Radiation Oncologists, should give serious consideration to moving past the terminology of "bridging radiation therapy" and instead refer to it as "pre-CAR-T infusion radiation therapy." Bridging therapy was initially an apt name; we were...
How do you best communicate SBRT planning directives, specifically in regard to how "hot" the plan should be?
This is where common language becomes uncommonly important. There are two languages one can speak re: doses in external beam radiation therapy. In language one, the 100% line always equals the MD's prescribed gray* dose. In language two, the 100% equals the maximum gray dose in the plan. Most of my ...
How would you approach oligoprogression of metastatic prostate cancer with a large met in the humeral head?
The role of radiotherapy for oligometastases is developing, with many studies underway. The best prospective data yet is for castration-sensitive oligometastatic prostate cancer, but there are several retrospective studies looking at the role of SABR for oligoprogressive CRPC. Two worth looking at a...
When treating a soft tissue sarcoma close to humeral head, what humeral head dose constraint should be used?
This is a fantastic question particularly in light of your absolutely correct assessment that the literature is silent on this issue. And osteonecrosis of the humeral head and humeral fractures have certainly been reported (e.g. Rossleigh et al (1986) Cancer); this coupled with a potential arthritis...
What planning and dose constraints are you using for 5-fraction hypofractionated FRST for vestibular schwannoma?
When using fractionated SRS (fSRT) of 25 Gy in 5 fractions for vestibular schwannomas, I use only 2 constraints: the brain stem and the cochlea, if the patient has serviceable hearing. In this case, the only OAR needed is the brain stem, 23 Gy <0.5 cc. I don't worry about the trigeminal nerve as it ...
What is your target volume for a recurrent low-grade meningioma previously treated with surgical resection alone?
This is a great practical question. What I have done is to fuse the original MRI, the pre-op recurrence scan and the post-op recurrence scan so that the clinical target volume can be all the meningeal surfaces that were ever in contact with the meningioma (initially or at progression). I don't usual...
Are there dosimetric scenarios where using a FFF beam would be beneficial in a non-modulated beam, like AP/PA or 3D conformal?
Except for less treatment time, the rest would all be less advantageous with FFF, as it takes more time to plan, and the dose is less uniform when using it for 3D conformal RT.
Is there evidence to support bladder preservation therapy in node positive bladder cancer?
Although there aren’t randomized data suggesting the superiority of trimodality therapy (TMT) over any other treatment for N+ bladder cancer, I think most feel that it is the standard of care as alluded to in the question. Broadly speaking, patients and providers have two options: radical therapy or...