Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you work up a patient with prostate cancer with bone scan suspicious for metastatic disease and a negative PSMA PET/CT?
While some bone metastases are 99mTc-positive and PSMA-negative, this circumstance is quite rare (< 2%). Based on this alone, in cases like this, I typically conclude that the patient is clinically M0. However, I do consider 3 other factors: the prevalence of bone metastases within the patient’s par...
For a patient with ENKTL nasal type (nose/sinus involvement) who has hepatic toxicity with pegasparaginase but a CR after 2 cycles of chemotherapy with a plan for "sandwich" radiotherapy - what, if any, chemotherapy would you resume after completion of radiation?
This is an interesting situation as there is not much data. The cure rate is high for early-stage disease after chemoradiation, even with VIPD and no asparaginase regimens (see de Pádua Covas Lage et al., PMID 36446856). Nature reviews which show in Table 2 survival curves similar for asparaginase r...
Would you consider treating a patient with prostate cancer and biopsy-proven involved inguinal nodes with radiation to the prostate/pelvis/groin?
Would favor starting with ADT plus ASRI and base subsequent treatment in 3 to 6 months based on responses ranging from prostate-only RT (like STAMPEDE for nonregional node) or definitive RT to primary and node.
Would you consider PMRT in patients with clinically node negative breast cancer found to have micrometastatic nodal disease after neoadjuvant chemotherapy?
Post neoadjuvant chemotherapy with residual disease in axilla reflects an incomplete response to chemo. The use of terms like micromets or ITC in this setting could be misleading, as these terms have been validated in patients who have upfront SNLN without any neoadjuvant chemotherapy. The NSABP Stu...
How do you deal with a discordant MRI prostate after a systematic biopsy?
This is a good question and something that we are coming across more often.A few assumptions that I am making with reference to your question: When you state “discordant” MRI prostate after biopsy, I am assuming that you mean that the biopsy demonstrated something like Gleason 3+3 or maybe nothing a...
How do you contour your elective obturator lymph node volume?
I favor stopping once the obturator vessel exits the pelvis and is lateral to internus muscle like NRG gyn atlas. Feel the extending contour below that exposes more rectum. We highlighted the differences between prostate and gyn atlas in this letter to the editor: Musunuru et al., International Jour...
What clinicopathologic features do you consider when deciding whether or not to use a PMRT scar boost?
We've discontinued all routine use of PMRT scar boost We offer chest wall boost only for R1/R2 margin, T4 disease (whether inflammatory or just skin involvement), and in the re-irradiation setting with an at risk or positive margin (repeat chest wall radiation for isolated chest wall recurrences wit...
When offering palliative radiation for spinal cord compression, do you ever "open up the field" if there is evidence of leptomeningeal disease on MRI?
Considering the urgency of the situation and the poor prognosis associated with LMD, my approach is to treat the area causing cord compression. I would treat the offending area of the spine, often using a "one vert body above and below" margin on the gross disease causing the symptoms that I intend ...
How would you approach a patient over the age of 40 with a sub-totally resected frontal oligodendroglioma, WHO Grade II, 1p/19q co-deleted, IDH mutant, with imaging concerning for second site in the pontomedullary junction?
The pontomedullary junction is not usually amenable to a biopsy (unless the lesion is exophytic); as such, there are 2 possibilities: a) the second lesion is related to the one that has undergone subtotal resection, or b) the lesion is of a different nature. Statistically, it is more likely to be a ...
How would you manage a very large diffuse skull base meningioma involving the olfactory groove, bilateral cavernous sinuses, and abutting optic chiasm that is not amenable to surgical resection?
Skull base meningiomas are the ones that are commonly referred to Radiation Oncology departments as they are difficult to treat surgically, especially when they involve cranial nerves compartments as is the case in this patient. Given the number of OARs at risk for this patient, if the meningioma wa...