Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When treating inguinal lymph nodes in the setting of pelvic RT, what is your preferred setup in order to minimize dose to the penis?
I have tried a variety of different setups but have found that building a scrotal shelf works the best. The patient is set up supine in the frog leg position using your immobilization method of choice. I then use a custom moldable headrest and place it against the perineum to serve as a shelf for th...
Under what circumstances would you consider omitting radiation in patients with early stage, unfavorable (bulky) Hodgkin Lymphoma?
We should first acknowledge that combined modality therapy improves progression-free survival in early-stage HL compared with chemotherapy alone. Stated more succinctly- if you give combined modality therapy, there is a lower risk of relapse; if you give chemotherapy alone, there is a higher risk of...
How do you manage spinal cord compression in a new suspected neuroblastoma diagnosis?
While there is evidence that chemotherapy, surgery, and radiation can all be effective for some patients,1 there are no definitive studies or data that prove the best approach for all patients. A 2017 systematic review concluded that the “currently available literature remains suboptimal as a guide ...
What treatment volumes and dose do you use for postoperative soft tissue sarcoma of the scalp with negative margins?
While there is institutional variation in practice, our standard has been to extend extremity/trunk paradigms to the head and neck region, including the scalp. For negative margins for a scalp sarcoma, we typically use margins of 3-3.5 cm for CTV for the first course and then 1.5-2 cm CTV for the co...
How do you counsel patients on imaging findings after liver SBRT for HCC, particularly with regard to expectations on timing to tumor resolution?
My experience has been that the more successful the treatment, the sooner the patients want the good news. In reality, a well-designed and executed SBRT treatment to an ablative dose should result in 85 to 95% tumor control (mostly size independent) at 2 years with very little local progression afte...
How do you approach a patient with locally advanced head and neck cancer requiring chemoradiation that needs extensive dental work from an oral surgeon, but because of insurance and social issues cannot feasibly get the teeth removed?
Treat them. Teeth won’t kill them, the cancer will.
How long of a delay are you willing to accept for vaginal cuff brachytherapy either as primary therapy or as boost?
The absolute benefit of vaginal cuff HDR boost is small and 6 months delay would negate any such benefit.
How do we reconcile what appears to be a more aggressive surgical resection for DCIS than for invasive disease?
The guidelines panels did an outstanding job in generating both the DCIS and the invasive cancer margins guidelines. It needs to be recognized, however, that despite the sophisticated meta-analysis upon which the recommendations are based, the studies in the meta-analysis had limitations. Appropriat...
Do you offer adjuvant radiation therapy for a breast cancer patient with dermatomyositis?
This is an exceptionally important question for clinicians. I'm a little biased as I run an autoimmune Myositis Clinic, but here are my two cents: Paraneoplastic dermatomyositis (DM) is a fairly common occurrence (roughly about 15% of all DM cases, but up to 30-40% in some subtypes, such as adult pa...
What is the role of adjuvant radiation in R0 node positive resected pancreatic adenocarcinoma in light of the recently presented RTOG 0848 abstract?
There are three options here in my practice. 1) Treat, 2) don't treat, and 3) "watch and wait, then ablate" (for a local recurrence). In general, I treat patients with CXRT who have positive margins (IMRT 45 Gy/25# to regional volume with SIB of 62.5 Gy to the margin. If it is an R2 resection (which...