Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When should the dissected axilla (levels I-II) be included when delivering RNI?
Please see my posting on November 2022 for more details on this subject. To summarize, most of the dissected axilla lies within breast/chest wall tangents, so it is routinely irradiated when RT is used. The upper part of Level 2 is usually outside the tangents and lateral to what is traditionally de...
Are there any radiation dosimetric considerations for patients with lung cancer that have had a TAVR?
No, the new valve solves a mechanical problem. It will have some metal in it, so it would be visible whether it is a mechanical or biosynthetic type. I'd suggest not having a direct beam hit it, as that is the area of the coronary arteries' origins, and avoid dose spillage to reduce late toxicity. T...
When would you offer single fraction adjuvant partial breast irradiation instead of a 5-10 fraction course for early stage breast cancer?
We have not offered a single fraction, and our standard is 26 to 30 in 5 fractions. Data on a single fraction is not enough to support this recommendation for now.
What is your radiation approach to metastatic pancreatic tail adenocarcinoma s/p gem/abraxane and FOLFIRI now with an oligo-progressive LUL lung metastasis?
I certainly would favor metastasis-directed therapy with SBRT, given the PFS benefit observed in EXTEND, and I think the case for utilization in the oligoprogressive state is even stronger pan-tumor compared to consolidative treatment. I'd treat 50-55 Gy/5 fractions or could consider fractionating o...
What is your protocol for type of surveillance imaging (CT/MRI/PET) and frequency of follow-up after SBRT to a bone metastasis?
I typically have approached decisions regarding surveillance based on the site (i.e., spinal vs. non-spinal bone metastasis), indication for SBRT (i.e., definitive or post-operative, particularly in spinal metastasis patients who required initial debulking), and primary site (i.e., radiosensitive, s...
What is your treatment approach for patients with base of skull glomus jugalare tumors (paraganglioma)?
Depending on the patient's performance status, size of tumor, and location within the skull base, I may opt for radiosurgery upfront or simply external beam radiotherapy. For radiosurgery, typically my dose is 16 Gy and for external beam may range from 45 to 50.4 Gy.
In a patient with esophageal cancer with lymph node involvement, would you consider treating with definitive chemo-radiation if they have a single area of retroperitoneal metastasis?
If a patient has non-regional retroperitoneal adenopathy without other distant metastasis (i.e., below the level of the celiac axis), that patient has M1 disease, and upfront definitive chemoRT would no longer be the standard of care (systemic therapy alone would be). However, I would then consider ...
What is your preferred fSRS dose/fractionation for large brain metastases?
For large intact brain metastases, my preferred fSRS dose/fractionation would be 27 Gy in 3 daily fractions. There are retrospective studies showing 1-yr local control rates of 91% using 27 Gy in 3 daily fractions vs 77% using single fraction SRS for large intact brain metastases > 2 cm (Minniti et ...
How do you treat unresectable pancreatic adenocarcinoma invading into the duodenum?
No, 54Gy did not improve survival in the LAP-07 trial, so it is definitively not a definitive dose. I would give 75Gy in 25 fx (100Gy BED) with capectabine. We have published how we do this in multiple papers, but essentially a 5mm duodenal PRV is carved out of the PTV75 so that there is a gradient...
When treating adenocarinoma of the pancreas to 75 Gy in 25 fractions, what dose constraints do you use for small bowel, large bowel, and stomach?
Planning Volumes Definition Doses by Fractionation Scheme 15-Fraction 25-Fraction Microscopic Extension PTV CTV + 5mm (CTV = GTV + 1cm + CA, SMA, +/- porta hepatis, +/- splenic hilum basins) 37.5Gy/15 45Gy/25 High Dose PTV GTV + 5mm margin excluding GI PRV expan...