Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach a patient with indolent, small-volume, but slowly progressive lung mets from sarcoma?
If small volume without active extrapulmonary disease and amenable to addressing all lesions with SABR, surgery, or a combination of both, I would target all lesions with local therapy. If the above conditions are met, these can often be monitored closely with q3-6 month CT surveillance in the prese...
How would you treat an isolated para-aortic recurrence while receiving adjuvant pembrolizumab after definitive chemoradiation for cervical cancer?
If the patient has failed while on pembro, I would favor holding/stopping IO and plan for definitive chemo-RT to the para-aortic region with SIB boost with weekly cisplatin.
Under what circumstances would you start steroids for a patient with a new brain tumor prior to biopsy or resection?
Agree. As a corollary, if lymphoma is suspected, do NOT use steroids before diagnostic confirmation unless there are severe symptoms or significant mass effect. If steroids are unavoidable, diagnostic confirmation should be pursued within days due to the lymphotoxic effects of steroids decreasing di...
How do you apply the concept of a lumpectomy bed boost in the setting of oncoplastic surgery?
This is a very common and often frustrating issue in patients I absolutely feel the need to boost (younger, larger tumors, high grade). I now consistently request my surgeons place a 3D tissue marker (brand name Biozorb) which preserves the location of the lumpectomy despite oncoplastic reconstruct...
How would you approach a patient that did not have preoperative axillary imaging and was found to have macromets on sentinel node biopsy, and on radiation planning scan has abnormal appearing nodes?
Prominent node on planning CT is common after SNLN. However, in this situation based on the pathology, would favor sonogram and biopsy, and if positive, dissection followed by RT. The probability that the node is additional macromets is high based on the pathology.
What is the current role for genetic profile testing (e.g. DecisionDx-SCC) in the treatment paradigm for cutaneous malignancies?
This is a very cool test that has a lot of potential to help us make decisions in practice (full disclosure, I advise Castle and get research support from them, but am not directly compensated by them). The data published thus far shows that it is prognostic to predict nodal or distant mets. However...
How do you treat non-spine bone oligometastases?
Get the MRI. It is proven to reduce inter-observer variability in contouring (Raman et al., PMID 29748100). More philosophically, sometimes you'll see something more, sometimes you won't. But the only way to know is to check. And if this treatment is worth doing, it's worth doing accurately -- espe...
How would you manage a completely excised true anal margin squamous cell carcinoma, with anal canal uninvolved, with positive inguinal nodes that were not managed surgically?
Chemo RT to anal margin, anal canal, inguinal and pelvic nodes to 45 Gy/25 fx. Boost positive inguinal nodes to 55.8-59.4 at 1.8 Gy/fx. PET at 3 months. Resect whatever is left (hopefully nothing).
How would you manage a patient less than 40 years old with an incidentally found LGG, IDH mutated, 1p19q intact, s/p STR?
Update: On August 6, 2024, the FDA approved Vorasidenib for IDH-mutant low-grade gliomas based on findings from the INDIGO trial. This decision highlights the FDA's incompetence and lack of scientific integrity, clearly demonstrating that the agency prioritizes pharmaceutical companies' interests ov...
Would you recommend radiation for an unresectable chest wall recurrence after two prior courses of radiation?
The answer depends on multiple factors: 1) How extensive is the present disease 2)Is there evidence of distant mets 3) What was the prior dose of RT and when 3) What types of systemic therapy have been used, what was the response and when 4) What is the patient's overall condition 5) Does the skin s...