Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Should hippocampal-avoidance WBRT be the default option for WBRT?
I think this is a difficult question to answer as a lot depends on the particulars. Here's a list of some of those issues: Radiosurgery is very easily administered & frequently free of toxicity. Systemic agents are showing improved efficacy in the brain. Surveillance MR imaging = lower incidence of ...
Would you offer hippocampal sparing whole brain radiation for patients with brain metastases due to ES-SCLC?
Until we have built-in auto-segmentation, I find the RTOG contouring atlas very helpful for manual contouring of the hippocampus. I tend to use the lateral ventricle as my main landmark, and look for the circle of gray matter located medial to it. Once I've drawn a hippocampus, I'll look at it in th...
Do you constrain the dose to the oropharynx, parotids, or oral cavity when planning HA-WBRT?
On NRG CC001, there was no inter-arm difference in reported adverse events of oral mucositis (N=6 on conventional WBRT arm vs. N=4 on HA-WBRT arm), oral pain (N=3 on conventional WBRT arm vs. N=1 on HA-WBRT arm ), or dry mouth (N=19 on conventional WBRT arm vs. N=18 on HA-WBRT arm) (Brown et al., PM...
What are best practices for radiation oncology patient and staff precautions with the COVID-19 pandemic?
COVID Update 1/30/21 Wow, it's been almost a year. Here are some updates from our practices at University of Maryland. We have successfully treated both PUIs and COVID+ patients at all of our practices. We have yet to have a patient to staff (or staff to patient) transmission. We do not break patien...
Is a stereotactic/ thin-slice MRI of the brain absolutely necessary to determine eligibility for hippocampal sparing whole brain radiation therapy?
The small size of the hippocampal dentate gyrus (3-4cc) can render it difficult to delineate and conformally avoid if both the brain MRI and the treatment-planning CT simulation are not obtained with thin-slice axial images (not exceeding 1.5mm on the MRI, not exceeding 2.5mm on the treatment-planni...
Are there any volumetric constraints associated with toxicity in the dose range that is moderately above prescription (i.e. 30-35 Gy range), when planning hippocampal-sparing whole brain radiation?
This is an important question worth some discussion. As the question mentions, clinical trials of HA-WBRT have permitted a hot spot of 133% of the prescription dose of 30 Gy (or 40 Gy) to D2% of the whole-brain parenchyma as an acceptable protocol variation. Importantly, none of these trials have de...
What factors do you consider when selecting dose/fractionation for whole brain radiotherapy?
I assume this question is for brain metastases patients who are not eligible for hippocampal avoidance WBRT (ineligible criteria including but not limited to - mets 5 mm within either hippocampus, germ cell/small cell/lymphoma, leptomeningeal disease, etc.) - my default WBRT dose fractionation is 30...
Do you use either memantine or hippocampal sparing technique to preserve cognitive function when giving whole brain radiotherapy?
Dr. @Dr. First Last and I put together the response below:We use memantine and hippocampal sparing technique for all brain metastasis patients who are planning to receive WBRT. This is based off the recently published phase III trial NRG CC001 that found hippocampal avoidance WBRT plus memantine res...
When should you use single-fraction radiotherapy for spinal cord compression?
The SCORAD III trial is practice changing. But I do NOT plan to treat ALL patients with spinal cord compression with a single fraction of 8 Gy now. Here is why: SCORAD III is extremely important new study for the management of metastatic epidural spinal cord compression (MESCC) for patients with sho...
Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?
Though some clinicians have been exploring the idea of targeted therapy for EGFR mutant brain metastases, this has been done in the absence of strong evidence. Reasons for pushing this idea are that sometimes the lesions seem to respond, and this has been seen in some single arm studies and anecdota...