Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
If a patient has distal esophageal adenocarcinoma and a PET+ left supraclavicular lymph node, and nothing in between, would you cover the entire esophagus? Both supraclavicular fields?
My experience is anecdotal. I have often seen nodal spread from the paraaortic or GEJ nodes skip to the supraclavicular nodes with nothing in between. Since treatment of the entire esophagus would not be tolerated by most patients, I have elected to treat standard volumes and the involved SC nodal s...
Is REZUM (water vapor thermotherapy for BPH) safe after EBRT?
Although I am not aware of any studies evaluating the toxicity rates in patients undergoing REZUM after RT, I am aware of a few studies reporting the toxicity of TURP after RT. For example, Liu and colleagues conducted a retrospective review of the outcomes of 1,192 patients, 246 of whom underwent a...
How would you manage a large area of multiple, recurrent cutaneous squamous cell carcinomas of the scalp with ulcerations and non-healing areas despite cryotherapy, multiple Mohs procedures, and 5-FU?
Consider sending the patient to medical oncology for evaluation for cemiplimab. Large areas of the scalp can also be treated by making a 1 cm "cap" of bolus and utilizing VMAT to cover scalp soft tissues, with elective coverage of nodes and perineural pathways if indicated.
How have the results of the phase III RTOG 0631 trial impacted your use of spine SBRT?
NRG/RTOG and the investigators are commendable for completing this important trial and reporting the outcomes. The possible reasons for the negative results of the SBRT arm were discussed in the plenary session at ASTRO 2019 and in the Discussion section of the JAMA Oncol paper by the authors. This ...
Is Rad51D heterozygous mutation a contraindication to postmastectomy radiation?
BRCA1/2, PALPB2, CHEK2, and RAD50/51 mutations should not affect radiation therapy https://www.redjournal.org/article/S0360-3016(19)33530-8/fulltext
How do you boost a positive parametrial margin in endometrial cancer after TAH BSO?
For a patient with a positive margin, we would first want to image post-operatively to make sure there isn't any gross disease. MRI is most helpful for this. The goal for the dose would be to treat this region to about 60 Gy. We would initially treat the pelvis to 45 Gy with an integrated boost at t...
Is it ethical to still prescribe conventionally-fractionated treatments for breast cancer, prostate cancer, and osseous metastatic disease for patients that do not have contraindications to hypofractionation?
Wow - one of the most interesting questions on the platform.Zooming out: what’s the motivation behind asking this?Is it agenda-driven? An attempt to “finger wag”? Or confusion around why the zeitgeist hints that 1.8 Gy fractions are “unethical”?"Ethical" needs a contextual definition here. In genera...
What dose/fractionation scheme would you employ for treatment of a bone with impending fracture prior to surgical fixation?
There are several advantages to pre-op RT. For example, the target is much better defined pre-op, and normal tissue exposure can be minimized compared to post-op RT. However, treatment fields should be constructed to minimize the risk of RT-related post-op complications including delayed wound heali...
How do you approach a patient with inoperable urothelial carcinoma of the bladder with persistent non-muscle invasive disease despite intravesical BCG/IFN and intravesical chemotherapy?
T1 high grade urothelial carcinoma, with persistent disease after intra-vesicular therapy (e.g., BCG) is an aggressive disease and progression to invasive urothelial cancer is common. This entity tends to be multifocal / diffuse and transurethral resection (TURBT) alone is often inadequate as defini...
Are there any patient characteristics that make you change fractionation when treating per STAMPEDE?
I generally favor 55/20 for patients where I am treating just the prostate in the setting of non-oligometastatic disease, and not treating the other metastases. It is a relatively low dose and I can't think of a scenario where I would turn the dose down for any patient factors. 6 Gy x 6 is very reas...