Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Is pre-treatment nodal ultrasound evaluation necessary if a patient undergoes upfront PET/CT for staging?
The answer to this question depends greatly on the local capabilities to conduct regional nodal ultrasound. If this can be done, then we find ultrasound to be very helpful. In today’s environment, it is difficult to obtain insurance approval for PET in the staging of node-positive breast cancer. Bey...
Would you consider modifying T&O fractionation during the COVID-19 pandemic?
We have been using 7gy x 4 instead of 5 fraction regimen in the past. A 2 fraction regimen showed lower local control in comparison to 4 fractions in the IAEA randomized trial.
When treating prostate cancer with moderate hypo-fractionation, what urethral dose constraints do you consider when boosting the dominate intraprostatic lesion?
At this point in time, I don't think there is a good answer to this question. The CHHiP trial, which led to the adoption of the 60 Gy in 3 Gy fraction schedule, did not have a dose constraint for the urethra. The FLAME trial, which demonstrated safety and efficacy for an SIB to a dominant intraprost...
Would you offer re-irradiation LDRT for someone with osteoarthritis or tendinitis if symptoms recur?
I have not personally offered a patient a third round of LDRT and do not know of any data that shows efficacy. However, I might offer a third round if a particular patient got adequate results with the first two and there was some separation in time (perhaps >1 year) since the last round.
Do you counsel patients differently about the risk of radiation induced malignancy when you are treating a proximal joint (hip) vs a distal joint (elbow) for benign conditions such as OA?
The mentality for this must change from radiation oncologist thinking to radiation medicine thinking. There have been no documented cases of malignancy from LDRT treatment of OA. Those who worry about the spine reference old studies giving 20 Gy in 5 fx with an open field pre-linac era. This is not ...
Can RT to non-bulky sites be omitted in an early stage (stage I or II) classical Hodgkin's lymphoma case with a CR by PET/CT?
Randomized studies have consistently demonstrated that combined modality therapy is superior to chemotherapy alone in regards to progression-free survival in early-stage Hodgkin lymphoma. The magnitude of the benefit varies across studies, but a relative risk reduction of ~50% can be expected which ...
How would you manage a pT2N1a invasive ductal carcinoma s/p lumpectomy and sentinel lymph node biopsy with ECE, and two mildly avid axillary lymph nodes on post-op PET/CT?
We often see mildly active lymph nodes on post-op PET/CT scans, so one important initial question is how long after the surgery the PET/CT was performed. Another question would be how many total lymph nodes were removed at the sentinel biopsy. If the scan was done ~6 weeks post-op and the patient ha...
Is it reasonable to treat a solitary plasmacytoma of the lung parenchyma with SBRT?
I have only treated one patient with solitary plasmacytoma of the lung over the past 15 years of doing lung SBRT. It is an extremely rare and unusual disease presentation for myeloma. Given the radiosensitivity of myeloma, I opted for 30 Gy in 5 fractions, which resulted in a completed response in t...
When planning spine SBRT, do you use volume dose limits to the spinal cord PRV, such as D0.35cc, in addition to maximum point dose?
An excellent recent paper from the MSK group on 3-fraction spinal SBRT (minimum dose of 27 Gy to PTV) was published last year, examining dosimetric predictors of radiation myelopathy. Of note, spinal cord delineation in this study was done using myelogram in 85% of cases, with 15% of cases utilizing...
What dose constraints do you use when treating ultra-central lung tumors with a hypofractionated/ultra-hypofractionated approach using 8-10 fractions?
Typically, ultra-central lung tumors mean that they abut/invade critical central structures such as the bronchial tree, tracheal, esophagus, major vessels, etc. For these critical structures, particularly for the esophagus, bronchial tree and tracheal, ablative dose could cause severe chronic toxici...