Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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?
These patients can have good outcomes with definitive chemoRT. PET and MRI brain for staging. Shave hair and have derm examine for any satellite lesions. Induction taxane-based chemo. Then chemoRT with concurrent taxol. CTV volume is controversial but needs to be generous. At a minimum, 3-5 cm in sk...
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 ...
When using FAST Forward, how important is it for the treatment to be delivered Monday through Friday in one week as opposed to spanning a weekend?
Presumably unimportant. From the protocol: "13. TREATMENT SCHEDULING AND GAPSTreatment can start on any day of the week.A gap of up to 3 days is acceptable in the event of machine service or breakdown. This is preferable to transferring the patient to a machine on which daily verification imaging is...
How do you manage an unresectable high-grade glioma of the distal cord/cauda equina?
Doses may vary by institution. Our typically practice is to cover the gross disease to 54 to 50.4 Gy in 1.8’s for conus/cauda and then approximately two vertebral bodies above and below to 50.4-45 Gy (for instance if the superior extent is in true cord, then it’s typically prescribed to 45 Gy with p...
Do you recommend adjustment of lung dose constraints in the setting of stage III lung cancer treated with definitive concurrent chemoradiation followed by planned consolidation immunotherapy?
No, the normal tissue constraints have not changed now that adjuvant durvalumab is the new standard of care. Of course we should always be trying to make our normal tissue dose constraints as low as possible, without underdosing the target. And we should probably assume that all patients are going t...