Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Is there a role for a post-operative boost in a patient with rectal cancer who has a positive margin after total neoadjuvant chemo and chemoradiation therapy?
As is usually the case with questions of this sort there is not just a yes or no answer. First, we rarely use a postop boost as if we have concerns about the circumferential margin on our initial evaluation, we set up the patient for intraoperative RT. IORT has big advantages in giving a very high l...
Do you recommend a waiting period to conceive after prostate radiation?
Yes, I typically advise that men and their partner use contraception for at least 3-4 months after the last fraction of radiotherapy based on the fact that the maturation cycle of sperm is estimated at approximately 2- 2.5 months. I typically counsel men prior to treatment that there is a chance (bu...
What constraints do you use for SBRT near the renal vessels?
The FASTRACK II protocol (NCT02613819) prescribes 42 Gy in 3 fractions and does not have dose constraints for renal hilum/vascular trunk. I used Timmerman's constraint of 19.5 Gy for 15 cc and got away with a handful of patients.This QUANTEC paper in the red journal has a good discussion and data on...
How do you approach the adjuvant treatment of glioblastoma following up-front laser interstitial thermal therapy (LITT)?
This is an emerging area with very limited information; there are no large prospective trials to adequately answer the question. The issues faced by a Radiation Oncologist include: 1. Interpretation of the post-op scan: what is the true GTV? This remains unclear; we include all enhancing abnormality...
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...
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...