Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Under what circumstances would brachytherapy be preferred over electron therapy for treating skin cancers?
For small (<2 cm) nonmelanoma skin cancers, I would say that brachytherapy is preferred for these reasons: Better cosmesis - 90-95% report excellent, which is better than electron series, particularly at the edge. Better for curved surfaces like the nose b/c applicator is flush on the skin with no ...
Does lymphovascular invasion trump POLE mutation in early-stage uterine cancer adjuvant therapy decisions?
In the current ESGO guidelines, stage I and II POLE types are always low risk, irrespective of substantial LVSI, with a predicted risk of recurrence being less than 10 percent, and favoring observation. That being said, in practice, I do offer brachytherapy, as I feel it is a low morbidity procedure...
What tissue tolerance constraints do you use for the esophagus, spinal cord, and heart for reirradiation of a NSCLC mediastinal lymph node failure?
I opted to write a response to this question, but honestly the answer is elusive to me. With respect to SBRT: for spinal cord, I rely on Dr. Sahgal’s work (he has several papers on this topic); for other organs, there are less data.For conventionally fractionated radiation, most are familiar with th...
Is there any evidence that demonstrates an increase in rectal or bladder toxicity with protons for prostate cancer compared to IMRT?
This is a great and controversial question. I recently contributed to a review that tried to summarize the current studies to date looking at this question. As you know, there are no completed phase 3 trials comparing protons to photons in this space, and we eagerly await results from the PARTIQoL t...
How do you approach a patient with cN0 breast cancer who has high risk features but did not have a sentinel node biopsy?
For T1 and T2 disease, I usually treat levels 1 and 2 in tangent beams.
Would you offer focal prostate boost per FLAME protocol for GTV defined by PET alone without MRI?
I think there are two questions here: Can you use PSMA PET to define the boost target? Yes (with a little bit of caution). There have been several reports on the safety/feasibility of PSMA-based focal boost. Note, though, that FLAME was based on MRI, and we can expect that the PET-defined lesion may...
When do you add chemotherapy to post operative RT for vulvar carcinoma?
We add for node positive disease treated with adjuvant RT especially if it is macromets (either after SNLN or INLND). Gill et al., PMID 25868965
When would a completion inguinofemoral node dissection followed by adjuvant RT (+/- chemo) be favored over definitive RT (+/- chemo) for SLN+ vulvar cancer?
The interim analysis of the GROINSS-V II trial showed a recurrence in 12.2% (10/82) of patients treated with radiation in the setting of positive sentinel lymph node biopsy for vulvar cancer. On subset analysis the risk of nodal recurrence was 2.2% for micrometastases (< or = 2 mm) and 20% for macro...
Is re-excision of residual disease ever itself an indication for PMRT?
This situation seems rather strange, but clearly the original surgery was inadequate, and re-excision still doesn't add up to optimal cancer surgery. Given these concerns, PMRT seems like a good idea. The fact that this is a right-sided lesion is helpful in avoiding cardiac RT in this young woman. T...
How do you manage a soft tissue sarcoma arising from neurofibromas (NF1)?
Great question! Sarcoma (STS) arising in the setting of NF1 can be challenging.I usually recommend for preop XRT, image-guided RT for STS should be 50 Gy in 2 Gy/fx:GTV = MRI T1 plus contrast imagesCTV for Intermediate-to-High Grade Tumors ≥ 8 cm: CTV = GTV and suspicious edema (defined by MRI T2 im...