Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What duration androgen deprivation do you recommend with salvage pelvic radiotherapy for pelvic node relapse after prostatectomy?
6 months ADT, 2 years ADT, 2 years ADT + abiraterone/prednisone seems reasonable depending on the circumstances. For example, early pelvic node recurrence for pT3b Gleason 4+5 would be a higher risk than a very late recurrence of pT2 Gleason 3+3.
How would you utilize brachytherapy boost in addition to EBRT for HPV-dependent invasive squamous cell carcinoma present as a large pelvic side wall mass, presumed to be of cervix primary, albeit the negative biopsies of the cervix?
I have had one P16+ SCC of Unknown Primary that presented as a solitary pelvic sidewall mass/node, no FDG avidity outside of that region, who had a full gynecological evaluation. First things first, ensure a thorough anorectal evaluation to rule out an anal primary. I would treat with a focus on uni...
Can post op RT be omitted in a surgically repaired pathological fracture site in multiple myeloma if the patient will receive systemic therapy?
For extremities (e.g., the femur), if the pain is largely from structural instability, which resolves after surgical stabilization, then proceeding with systemic therapy without post-op RT would be very reasonable. On the other hand, if the patient is having persistent pain after surgery from the os...
When do you recommend RT versus stenting for SVC syndrome in patients who cannot receive systemic therapy?
The option to stent upfront should always be considered before starting palliative treatment for SVC syndrome. Especially since it can offer reliable relief in a more timely manner. More importantly, it can at times avoid premature death in those in whom XRT might not work. However, it's critical to...
How do you explain progression free survival to patients?
This is a really, really important question. I'd argue we often greatly undervalue the importance of communication with our patients and the impact the quality of our communication has on what they understand about their illness. I remember once having a long conversation with a patient where I outl...
How would you manage p16+ SCC of the oropharynx with bulky lymph nodes that are not responding as expected to standard chemoradiation?
During treatment: Confirm via daily CBCT that the nodes in question remain inside PTV_high. If there are notable changes in external contour or target contour, have dosimetry run a verification plan to confirm coverage. This is particularly necessary if there is enlargement of the node in question, ...
Can you treat the regional lymphatics when using a prone technique for treating the whole breast?
We had an institutional protocol in which patients were treated prone to the breast, axilla, and supraclavicular nodes. The breast was treated with tangents and a third field was added to treat the SCV nodes (as is done supine). Of note, the internal mammary nodes could not be included with prone po...
Would you recommend adjuvant radiation for an atypical fibroxanthoma of the scalp that is completed resected with +PNI and +LVI?
Atypical fibroxanthoma (AFX) is a rare cutaneous neoplasm. Diagnosis is often difficult, and may require the input of an expert soft tissue or dermatologic pathologist. I have seen many of these cases diagnosed elsewhere as AFX, and upon re-review, the diagnosis is changed to cutaneous squamous cell...
What is the most appropriate dose-fractionation for an early stage, progressive cutaneous squamous cell carcinoma of the nose in an elderly/frail patient in the setting of the COVID-19 pandemic?
30 Gy/5 fractions or 40 Gy/10 fractions. I prefer 250 kvp. Increase dose by 10% with electrons and increase margins from 1 to 2 cm. Collimate on skin with a lead mask.
Which imaging modality do you prefer when monitoring disease status for patients with prostate cancer undergoing 177-Lu PSMA treatment?
Imaging weeks or months later probably serves no useful purpose. What may be far more useful is SPECT for dosimetry imaging right after the first dose, to determine the absorbed dose in Gy to the tumors and the OAR. Then, if OAR doses permit, one may administer a higher dose of Pluvicto that may lea...