Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
How do you approach a patient with a solitary brain metastasis from small cell lung cancer s/p resection with otherwise limited thoracic disease?
This is rather an uncommon situation but can happen if a patient presents with a synchronous solitary brain metastasis (with or w/o symptom) and undergoes craniotomy and resection only to find out that it is small cell lung cancer. Additional information is needed on the volume of intra-thoracic dis...
How would you treat a patient with newly diagnosed ALK+ Stage IIIB non-small cell lung cancer (NSCLC)?
Stage IIIB encompasses T3-4N2 and T1-2N3, so I will assume that we are not going to consider a neo-adjuvant approach. Standard treatment for stage IIIB ALK+ NSCLC would be definitive concurrent chemo/RT given with curative intent. Reasonable chemo regimens would be weekly carboplatin plus paclitaxel...
Does being on maintenance pembrolizumab change how you manage patients with partial metabolic response on PET/CT 3 months after chemoradiation for cervical cancer?
No, a good percentage of patients will not have a complete response by 3 months. Six months seems to be a reasonable cutoff. Persistent disease at 3 months does not seem to be a worse prognostic factor than completion at 6 months. At the 3-month mark, I would not manage differently. At 6 months, I w...
Do you recommend treatment of the entire extent of the hardware and/or bone when treating a bone metastasis that has received pre-irradiation surgical stabilization?
In the era where imaging like MRI, CT scan, or PETCT is routinely performed, we have not been chasing entire hardware and only treating image based disease with a generous margin. I would not worry about microscopic disease along the entire hardware when the goal and endpoint is palliation.
In what situation would you obtain an MRI before adjuvant or salvage RT to the prostate bed?
In my response, I will assume that the your treatment planning is CT based, as would be the case in most centers, including mine. In the adjuvant setting, I do not get MRIs, since by definition the PSA is undetectable and I do not feel that an MRI will give you useful information beyond what you wou...
Do you have a size criteria when treating lung oligometastases with SBRT?
A lesion 3-5 mm is difficult to characterize on PET, low yield for a biopsy, and non-specific, even if it developed in interval scans. Multiple 3-5 mm lesions could also be from an infectious/inflammatory condition. If the lesions are likely from cancer (i.e. new lesions with rising tumor markers, o...