Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach the discussion about the potential risks of radiation therapy exposure and the development of secondary malignancies for patients with germline BRCA1/2 mutations?
It appears that the risk of secondary malignancies due to radiation exposure does not seem significantly enhanced in gBRCA-m carriers, unlike patients with Li-Fraumeni syndrome (for whom we would attempt to avoid radiation). The data on mBRCA-associated breast cancers would suggest that radiation is...
Do you use a liver dose constraint for right-sided breast cancer?
I don’t do it routinely as it is an infrequent significant issue clinically. In some cases, when tangent includes a significant bite of liver then try to adjust MLC following ALARA principle.
Have you encountered somnolence syndrome after whole brain radiotherapy?
Not specifically that I can recall. However, we should acknowledge that radiation oncologists might not be following our patients following whole brain RT with the optimal degree of diligence. Patients often have a limited life expectancy, are being followed and treated by other physicians. I suspec...
For post-operative radiation of resected high grade soft tissue sarcoma, how long of a delay do you tolerate before starting radiation?
The default/ideal answer is 4-6 weeks, but agreed that is often not feasible. In those circumstances, actively maximize wound healing efforts (plastic surgery, wound care service, lymphedema PT, etc) and start as soon as the surgeon feels it is safe to do so. But it does need to be safe, and ok by t...
Would you consider applying the principles of STAMPEDE with <5 oligometastatic non-regional lymph nodes from prostate cancer?
About 25% in STAMPEDE had low volume metastatic disease with no bone Mets, with most having a non-regional node in that category to qualify as low volume Mets.That being said, common iliac could be the primary drainage of prostate cancer based on SNLN studies and I would favor treating like node-pos...
How do you advise patients on cardiotoxicity when they are expected to receive a low mean heart dose and low cardiac substructure doses with their radiation plan?
I would say something along the lines of: "Radiation therapy is an effective tool for treating your cancer. However, whenever we give radiation therapy, there is always some incidental dose delivered to the adjacent normal tissues. We cannot make the dose zero to all of the normal tissues. Thus, we ...
Do you use an LAD constraint in the setting of BID thoracic radiation for SCLC?
The literature is convincing that an increasing dose to the heart (using whole-heart dosimetric parameters) is associated with an increased risk of adverse cardiac events and decreased survival. Recent and current investigations have attempted to correlate dose to specific cardiac substructures with...
How would you treat an unresectable epithelioid angiosarcoma invading the cavernous sinus, wrapping around the carotid artery?
Stage with PET and MRI. If any concern for intradural spread, complete spine imaging and consider LP to r/o LMD. Start with neoadjuvant taxane-based chemotherapy, potentially in a doublet (e.g., gem/tax). Then definitive CRT with concurrent taxol and conventional fractionation to 70 Gy, while respec...
How do you manage symptomatic fat necrosis following adjuvant breast radiotherapy?
If the diagnosis of fat necrosis is not in doubt (i.e., recurrence has been ruled out) and is not getting better: You can start with NSAIDS, warm compresses, a supportive bra, and massage therapy. Then, I'd consider steroids, though evidence is limited, Prednisone 20 mg for a week or so. Some peopl...
What do you do for patients who require radiation for breast cancer (either post-lumpectomy or post-mastectomy) but who have a pacemaker on the ipsilateral side?
A pacemaker is always a challenge when located in or nearby a radiation field. Typically, I would prefer to treat patients as I would normally treat them so as not to compromise care. However, that may require moving the pacemaker to the contralateral side. When treatment is ready to start, protoc...