Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you treat a postoperative pT4a NX larynx who had TL without node dissection and no suspicious nodes on pre-surgical imaging, specifying nodal volume and dose levels?
Laryngeal T4a may consist of different entities with different LN involvement risks. If it involves the supraglottic larynx, it requires RT to levels II-IV bilaterally. If it is transglottic and extends to the subglottic larynx, include also level VI. If it is confined to the glottic larynx and the ...
How would you manage a patient with limited dural-based metastases?
Pachymeningeal (dural) metastases come in 3 varieties – distinguishing these entities is important therapeutically. Calvarial metastases with secondary pachymeningeal (dural) extension – these tumors can be thought of as bony metastases and can sometimes be monitored on systemic therapy if modest in...
How would you approach unresectable cutaneous angiosarcoma of the scalp?
Nearly the entire scalp can be reconstructed with a latissimus flap or ALT in this era. Anatomically unresectable disease is quite extensive. Clinical exam is critical upfront. While these start on the scalp, there is no barrier to spread to adjacent cutaneous areas. Look carefully at the ears and w...
How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?
These are often challenging questions/issues in our multimodality discussions. A couple of "general" principles/considerations. I would try, if at all possible to prove the presence of metastatic disease, however in the case of sub cm contralateral nodules, this is, as the question alludes to, not a...
Is there evidence to support the use of definitive CRT in patients with NSCLC in separate ipsilateral lobes and mediastinal lymph node involvement?
Challenging question. I am not aware of any level I evidence to answer this. In the absence of randomized data, I would allow common sense to prevail. Staging of this went from M1 to T4 from AJCC 6th edition to 7th edition mostly because these patients do better by survival then the traditional stag...
What is the risk of local recurrence in a high grade muscle invasive bladder cancer (MIBC) s/p incomplete TURBT treated with concurrent chemoradiation compared to a complete TURBT?
One source I’m aware of that could shed light on this specific question is a 2017 publication from MGH (Giacalone et al., PMID 28081860), reporting the outcomes of 475 patients with T2-4a N0 M0 bladder cancer treated with various protocols from 1986-2013. Not all patients had high-grade tumors, but ...
How would you manage a pre-menopausal woman with extranodal marginal zone lymphoma confined to the bladder wall?
Marginal Zone Lymphoma (MZL) when localized is curable in most instances with modest doses of RT (24-30 Gy), perhaps even less when the primary site is the orbit. It typically responds to rituximab but relapses occur in most cases. Therefore, definitive RT is the treatment of choice in the great maj...
For primary MZL of the breast, do you do whole breast to 24 Gy or ISRT?
Without knowledge of the age of this patient and whether the concern of carcinogenicity from half the normal dose of traditional whole breast radiation (which we obviously do all the time for breast cancer) is enough to warrant omission of curative intent therapy in what is otherwise described as a ...
Would you consider 5-fraction whole breast RT for a patient with multiple positive margins following lumpectomy for whom reexcision is not possible?
It’s not the whole-breast fractionation that matters, as 5 or 15 fractions are adequate doses for whole breast, but I would definitely add a boost equivalent to a dose of 16 Gy to the surgical bed.
How would you approach post-op radiation recommendations in patients who had neoadjuvant chemoimmunotherapy for HPV mediated OPSCC s/p TORS who have a complete pathologic response (pCR)?
Neoadjuvant immunotherapy for patients with TORS-eligible HPV-positive malignancies should not be done off study. KEYNOTE-689 did not include early-stage HPV+ oropharyngeal cancer patients, and as such, there is no prospective data to suggest a benefit to neoadjuvant immunotherapy in this patient po...