Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When treating an intact whole breast with hypofractionated radiation, how do you approach boost dosing in the case of a close margin?
In the Plenary session of the 2012 San Antonio Breast Cancer Symposium, Dr. John Yarnold reviewed all of the updates of the UK START and Royal Marsden HFRT trials and discussed the fact that 40 Gy in 15 fractions had become the standard for the UK's National Institute for Health Care and Excellence ...
When is it necessary to boost the chest wall scar post-mastectomy?
Theres is no easy answer to this question, and utilization of scar boost varies across institutions based on preferences and interpretation of scant data. Notably, the original ASCO guideline on PMRT explicitly stated that there was insufficient data to say anything about using a scar boost (Recht, ...
In patients with breast cancer, do you use bolus when boosting a chest wall scar or flap with electrons?
In terms of evidence basis for use/non-use of bolus generally in the setting of post-mastectomy chestwall radiotherapy (not limited to electron boost, noting that the use of post-mastectomy boost at all is a topic worthy of debate), here's what I found when I explored the same question a few years a...
In patients receiving PMRT do you perform a boost if they have had reconstruction (tissue expanders,…)?
Ideally I think we should make treatment recommendations prioritizing the clinical features over the reconstructive approach. The benefit of the scar boost after mastectomy is unclear, and the target for the boost is also unclear, so I tend to reserve the boost for patients with multiple high risk f...
Would you radiate the thoracic duct for bilateral chylothorax in a hematologic malignancy with no discrete adenopathy?
We have done for adenopathy, which relieves obstruction and thus helps with drainage, but we don’t know how it would help in this situation.
How do you manage chest wall pain due to SBRT?
Chest wall pain is not an insignificant consequence of thoracic radiotherapy, especially after SBRT. Most of the data describing chest wall pain comes from the SBRT era. Older literature (breast and lung treatment) tends to focus mostly on rib fracture with chest wall pain but rarely differentiates ...
Would 45 Gy to the pelvis be sufficient for a locally advanced rectal cancer that has a complete metabolic response to TNT?
If you define the standard of care as what the vast majority of people do, the standard of care is to give 50.4 Gy in 28#, especially if nonoperative management is the goal. If surgery is part of the plan, we found that preoperative chemoradiation to 45 Gy followed by mesorectal excision resulted in...
Do you offer palliative whole liver radiation for patients with diffuse liver metastases?
Whole liver radiation is a very good palliative treatment for diffuse hepatic metastases causing pain or severe nausea/vomiting. I treat the whole liver plus a 1 cm margin to 7-8 Gy/1 fraction per the Phase II trial from Princess Margaret Hospital (Soliman et al., PMID 24062394). In this trial of 41...
What is the rationale for the recent change in the NCCN criteria for very high risk prostate cancer?
As the new Chair of NCCN's Prostate Cancer Guidelines, I am happy to answer this.The purpose of risk groups is not merely to be a prognostic divider, but to help guide treatment. Many systems have been developed that have greater prognostication than NCCN risk groups, such as STAR-CAP (which is supe...
How do you counsel a young man receiving EBRT as part of TNT for rectal cancer about risk of infertility?
I counsel male patients that, although the testes are outside the target dose volume, they will receive enough radiation that it could, at least temporarily, impair their ability to conceive. I offer to refer them for sperm banking prior to starting treatment.