Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Should TNF inhibitors be held in patients undergoing radiation therapy?
We do not hold TNF inhibitors when needed for patients undergoing radiation therapy.
For gyn cancers receiving chemoradiation, how high can you boost grossly positive nodes with SIB if not near bowel?
I typically will give a simultaneous integrated boost (SIB) of 60 Gy in 30 fractions to the pelvic and para-aortic nodal CTV, which is the PET positive GTV plus a 3 mm margin. If possible I will boost the GTV of larger gross nodes (>1 cm) to 66 Gy (2.2 Gy/fx) with no margin, if constraints can be me...
What is the role of radiotherapy in cutaneous pseudolymphoma?
I generally like the term "Cutaneous B-cell lymphoid hyperplasia" to describe this entity which is characterized by a reactive B-cell proliferation within the dermis developing in response to an adverse stimulus (medication, insect bite, etc.). Sometimes the antigenic stimulus can't be identified. ...
Is it appropriate to dose de-escalate in low risk HPV+ SCC of the oropharynx outside of a clinical trial setting?
I am going to write specifically on de-escalating HPV-OPSCC in the adjuvant setting first, important caveats for adjuvant de-escalation, and then about the general philosophy on de-escalation in clinical trials.Concerning adjuvant treatment, after careful consent, we are de-escalating patients with ...
What dose constraint, if any, do you use for the diaphragm when treating liver or lung tumors with SBRT?
I treated a HCC patient with a subdiaphragmatic tumor with SBRT 54 Gy in 3 fractions. He developed right posterior chest wall pain that radiated to his right shoulder. On autopsy, he was found to have a path CR in his tumor and necrosis of the adjacent diaphragm muscle. The chest wall appeared gross...
Would you consider omission of PORT for node+ NSCLC with a positive margin in the setting of a high tumor PD-L1 score and plans for immunotherapy?
For gross positive margins (R2), no, adjuvant chemoRT followed by consolidation immunotherapy. For R1, SOC would still say PORT and adjuvant systemic therapy. But let's try to tease it out in a more nuanced way from available data. First PD-L1 high is certainly a check in the plus column for a clini...
How do you approach treatment volumes and dosing around post-operative neck dissection scars in patients with head and neck SCCs?
The traditionally accepted target volume for post op RT is the "surgical bed" - meaning all the areas where the knife has been! This volume is generally treated to 60 Gy in 30 fx for SCC + additional boost for close/positive margins and/or ECE. One could consider lowering the dose to 56-57 Gy for a ...
What proton dose regimen would you use for locally recurrent esophageal cancer previously treated with chemoRT?
Like @Dr. First Last, I would also somewhat challenge the premise of the question. Typically, the dose-limiting structure for re-irradiating esophageal cancer is the esophagus itself, so protons do not offer an inherent advantage in this case. Protons may still be reasonable to reduce lung or heart ...
Would you include the entire op bed (including flap) within the radiation field in a patient requiring a V-Y advancement flap for closure following a radical vulvectomy?
It depends on one's assessment of the risk of recurrence in the region of the flap. It sounds like the positive margin is pretty significant and situated at the vaginal introitus. Most likely, the area of the flap is at risk, but this assessment should be individualized. Assuming that the flap is he...
Is it necessary to treat one vertebral body above and below for palliation of spinal metastases?
No. The reasons to go one above & below were to avoid the dreaded miss from the dreaded days of bone scans, plain films & port films. That is much, much less likely these days with IGRT, CBCT, MRI (PET, etc.). We know treatment volume size correlates with toxicity. You can get some dysphagia/esophag...