Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When treating prostate cancer with moderate hypo-fractionation, what urethral dose constraints do you consider when boosting the dominate intraprostatic lesion?
At this point in time, I don't think there is a good answer to this question. The CHHiP trial, which led to the adoption of the 60 Gy in 3 Gy fraction schedule, did not have a dose constraint for the urethra. The FLAME trial, which demonstrated safety and efficacy for an SIB to a dominant intraprost...
Is it reasonable to treat a solitary plasmacytoma of the lung parenchyma with SBRT?
I have only treated one patient with solitary plasmacytoma of the lung over the past 15 years of doing lung SBRT. It is an extremely rare and unusual disease presentation for myeloma. Given the radiosensitivity of myeloma, I opted for 30 Gy in 5 fractions, which resulted in a completed response in t...
What dose constraints do you use when treating ultra-central lung tumors with a hypofractionated/ultra-hypofractionated approach using 8-10 fractions?
Typically, ultra-central lung tumors mean that they abut/invade critical central structures such as the bronchial tree, tracheal, esophagus, major vessels, etc. For these critical structures, particularly for the esophagus, bronchial tree and tracheal, ablative dose could cause severe chronic toxici...
How do you approach a patient with indolent, small-volume, but slowly progressive lung mets from sarcoma?
If small volume without active extrapulmonary disease and amenable to addressing all lesions with SABR, surgery, or a combination of both, I would target all lesions with local therapy. If the above conditions are met, these can often be monitored closely with q3-6 month CT surveillance in the prese...
How would you treat an isolated para-aortic recurrence while receiving adjuvant pembrolizumab after definitive chemoradiation for cervical cancer?
If the patient has failed while on pembro, I would favor holding/stopping IO and plan for definitive chemo-RT to the para-aortic region with SIB boost with weekly cisplatin.
How would you approach a patient that did not have preoperative axillary imaging and was found to have macromets on sentinel node biopsy, and on radiation planning scan has abnormal appearing nodes?
Prominent node on planning CT is common after SNLN. However, in this situation based on the pathology, would favor sonogram and biopsy, and if positive, dissection followed by RT. The probability that the node is additional macromets is high based on the pathology.
How would you manage a completely excised true anal margin squamous cell carcinoma, with anal canal uninvolved, with positive inguinal nodes that were not managed surgically?
Chemo RT to anal margin, anal canal, inguinal and pelvic nodes to 45 Gy/25 fx. Boost positive inguinal nodes to 55.8-59.4 at 1.8 Gy/fx. PET at 3 months. Resect whatever is left (hopefully nothing).
Would you recommend radiation for an unresectable chest wall recurrence after two prior courses of radiation?
The answer depends on multiple factors: 1) How extensive is the present disease 2)Is there evidence of distant mets 3) What was the prior dose of RT and when 3) What types of systemic therapy have been used, what was the response and when 4) What is the patient's overall condition 5) Does the skin s...
Do you offer consolidative thoracic radiation for oligometastatic NSCLC following upfront immunotherapy?
Yes, I do offer consolidation in patients with oligometastatic lung cancer after immunotherapy. Like @Dr. First Last, often these patients are referred to me at "oligoprogression," when one lesion progresses (often the primary or largest site), but most minor lesions appear to be under control. The ...
Would you favor post op radiation therapy for soft tissue sarcoma if a positive margin were still expected despite pre-op radiation?
The key question here is whether you are dealing with tumor ON the plexus, expected to result in a microscopically positive (R1) margin, or tumor IN the plexus, expected to result in gross residual disease (R2). If tumor is ON the plexus, a planned R1 margin on a critical structure, with addition o...