Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Considering the surgical margins used in TORS, is it necessary to cover the entire tongue base with an elective dose in IMRT of cT1-3 HPV+ squamous cell carcinoma grossly involving one side of the base of tongue?
Frankly, I see no point in doing TORS if a patient is likely to require postop RT unless you believe that you can safely treat neck only (which includes unavoidably part of the ipsilateral oropharynx to irradiate the RP nodes). And I do not (but have been wrong before). Particularly HPV positive non...
What systemic therapy would you recommend for a patient with metastatic triple negative breast cancer (HER2 1+) who has progression of brain mets after WBRT and while receiving first line chemotherapy?
There is early evidence of untreated intracranial metastasis activity (overall response rate 73%; 11/15 patients) with trastuzumab deruxtecan (T-DXd) in patients with HER2+ breast cancer (1), but such data are not yet available for HER2-low breast cancer. Therefore, I would advocate a standard appro...
Do you escalate the dose in adjuvant pancreatic cancer radiation therapy similar to how many are treating locally advanced disease with dose escalation?
A few points to consider about this modern perspective on adjuvant CXRT for pancreatic cancer are: A positive margin is one of the least controversial indications for adjuvant CXRT in pancreatic cancer. If you get a case to treat, you don't want dose to be the reason for failure. 50.4 Gy has been th...
In a young patient with recurrent low-grade glioma s/p gross total resection, is there any role for further observation instead of radiation and chemotherapy?
As simple as this question seems to be on the surface, it is actually a very difficult clinical scenario to opine with certainty, primarily because of a lack of data. So, let us address this with each option in mind, weighing the pros and cons: Observation: We do know that in resected patients, radi...
What ipsilateral lung constraints if any do you utilize for SBRT and or hypofractionated RT in the lungs?
Following up to this question, I wanted to see if there are any new thoughts on this. I think most rad oncs who I have asked, do not really utilize an ipsilateral lung constraint for SBRT or hypofractionated 60/15 style plans. I was wondering if this might be related to old school rules of thumb, li...
How would you treat a patient with p16 (-) neck lymph node metastasis of an unknown primary, considering their history of prior supraclavicular and chest wall irradiation?
The management of SCCUP is complex and individualized and I would argue that the mitigation of risk is most important in a patient who may be considered for reRT. I would probably favor neck dissection and search for primary with biopsies and at least ipsi tonsillectomy (esp if the LN is in level 2)...
For unresectable radiation induced angiosarcoma, what dose and fractionation would you use?
45 Gy at 1 Gy TID with 10 cm margins, boost to 60 Gy with same fractionation with 5 cm margins. If still incompletely resectable, 75 Gy. Outcomes have been published by NPM.
What volumes would you treat and what dose constraints do you use for breast and lymphatic re-irradiation?
H&N cancer brachial plexus re-irradiation data, “Among patients with a Dmax greater than vs less than 106 Gy, the 1-year cumulative incidence of brachial plexopathy (BPP) was 42% vs 4% P = 0.005. V80 > 1cc (1-yr cumulative incidence BPP 34% vs 4% P = 0.03) and V90 > 0.3cc (32% vs 4%, P = 0.046) asso...
Would you offer postmastectomy re-irradiation in a patient with locally advanced, ER-/Her2+ disease with pathologic complete response after neoadjuvant chemo?
Our threshold for PMRT for reradiation is high because the therapeutic ratio changes. Stage III her2 neu positive non inflammatory breast cancer treated with dual her2neu therapy with pCR would avoid RT.
Does a negative neck dissection adequately cover the treatment of the neck for a patient that clearly needs PORT for an oral tongue cancer?
I do not feel comfortable omitting RT to the neck in cases of oral tongue cancer. The lymphatic drainage of the oral tongue is complex. The textbook on Head and Neck Cancer by Million and Cassisi (2nd ed., Figure 16-31) has a nice representation of the crossing lymphatics of the oral tongue. From th...