Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you sequence hypofractionated radiation and systemic therapy for patients with unresectable cholangiocarcinoma?
I have generally cared for patients analogously to that done in the initial NRG GI001 or ABC07 trial designs with the use of initial systemic therapy for 3-6 months followed by consolidative RT targeting a BED > 80.5, assuming a/b ratio of 10 Gy. Tao et al., PMID 26503201 In my practice, it’s most c...
What is current practice for sparing a tissue strip in extremity radiation?
So far as I am aware, RTOG 0630 is the only source for a "skin strip" constraint, and as @Dr. First Last mentions, the protocol does not fully specify how this was defined. ("No more than 50% of a longitudinal stripe of skin and subcutaneous tissue of an extremity should receive 2000 cGy. This strip...
How do you treat elective neck regions in a patient with a second primary HN cancer and prior neck dissection and radiation?
Almost all re-irradiation trials and retrospective series have targeted the gross disease alone, without electively treating nodal basins. Even with this limited target volume, grade 4 toxicity is 20-30%, and treatment related deaths occur in 5-10% of patients. Locoregional control is only about 50%...
In what situations would you place a prophylactic trach prior to radiation for head and neck cancers?
In my practice, the decision on a prophylactic trach is made in a multidisciplinary setting in close coordination with my ENT colleagues. Generally speaking, we will consider placing a trach prior to treatment if there is a high concern for potential airway deterioration during radiotherapy. Clinica...
How would you manage a high grade primary mediastinal leiomyosarcoma status-post excision with negative margins?
There are scant data describing the role of adjuvant radiotherapy for mediastinal soft tissue sarcomas. The principles of managing sarcomas in other sites support post-operative radiotherapy following removal of a high grade lesion from a restricted anatomic space such as the mediastinum despite app...
How do you manage refractory radiation cystitis status post pelvic EBRT/BT?
Thankfully chronic radiation cystitis and specifically radiation-induced hemorrhagic cystitis is relatively rare (2-8%) [1]. However, it can be a chronic and debilitating complication after pelvic radiotherapy. In managing these patients, first, I make sure to rule out another cause of cystitis – in...
Would you offer PMRT to a perimenopausal female with a single positive LN with microscopic ENE who has otherwise low risk features?
In this case, I would discuss the role of PMRT given her nodal involvement with microscopic ENE and being perimenopausal, despite having other low risk features. I would counsel the patient that the data suggests reductions in LRR with improvements in DFS, and DDFS though no clear survival advantage...
When using hypofractionated whole breast radiotherapy with a simultaneous integrated boost to the lumpectomy cavity, what IGRT strategy do you use?
My preference is CBCT daily and matched to clips/cavity. Our practice also does SGRT for all patients (tattoo-less clinic); however, that is not routinely reimbursed. If treating like RTOG 1005 (48/40 in 15 Fx) and approved for IMRT, will get approved for IGRT.
Would you consider whole breast re-irradiation in a patient with a second/recurrent breast cancer and prior history of breast radiation therapy many years ago, if the tumor characteristics are not amenable to partial breast re-irradiation?
A second lumpectomy after recurrence post-lumpectomy/RT in itself makes it amenable to APBI, i.e., the pathology or clinical factors do not matter after a 2nd lumpectomy. Since the early literature (from UPMC) to more recent prospective trials (RTOG 1014), the CTV is the lump cavity, regardless of o...
When is the ideal time in the disease course to offer radiotherapy for Dupuytren's disease for the most optimal outcomes?
Radiotherapy is most effective when fibroblasts are actively proliferating, i.e., during the cellular or proliferative phase of the disease, when there is a palpable, progressive nodule or cord but no fixed contracture.Prospective German trials show that treating during this biologically active peri...