Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When proceeding with neoadjuvant CRT, what is your radiotherapy plan in a patient with distal esophageal adenocarcinoma and an avid AP window lymph node?
If it is not biopsied, but there is high suspicion of disease based on morphology and SUV, would treat to 50.4 in 28 if the surgeon is not removing, but can consider lower if they are. If with CTV/PTV expansion of primary, it remains discontiguous, it can be a separate field/isocenter.Of note, I typ...
What total dose do you use for a close and positive breast cancer margin that cannot be re-excised?
Based on consensus guidelines, there is no such thing as a close margin as HR for recurrence did not change based on margin width. That was the reason for group to conclude that no tumor at inked margin is a negative margin (except for pure DCIS or those who had neoadjuvant chemo).If we give a boost...
Would you consider radiating an unresectable intimal sarcoma if it involved the valves of the great vessels?
First, I would quickly confirm that the patient is truly unresectable. I've seen complex cases deemed unresectable and therefore palliative at very fine institutions that were subsequently treated definitively after a second opinion at a center of peak surgical expertise. It is worth recognizing tha...
How would you manage a patient treated with SBRT <1 year ago for a peripheral lung cancer who now has both mediastinal and local failure?
Presuming that the patient is inoperable due to the same reasons why the initial early stage disease was not managed surgically, given a peripherally placed primary, it likely can be retreated with SBRT, while minimizing chest wall and skin dose if at all possible. There shouldn't be an issue with r...
Despite the paucity of strong data showing benefit of chemotherapy + radiotherapy in patients with stage I-II high risk histology endometrial cancer, if you recommend treatment with both modalities, how do you determine treatment schedule?
For the purpose of this answer, I'll define high risk as serous, carcinosarcoma, undifferentiated, and dedifferentiated. Clear cell carcinoma can be considered and likely treated more by its molecular profile. As you indicate, there is little data to support the routine use of chemotherapy for FIGO ...
Would you consider boost radiation for focally positive margins after 50 Gy and surgery in undifferentiated pleomorphic sarcoma of chest wall?
I typically do not use a post-operative boost in patients with soft tissue sarcoma that have received preoperative radiation for a few reasons:(1) By the time surgery has happened and the patient has healed, it may be 2 months or more since completion of preoperative RT. If there is truly residual v...
Do you ever pause or delay radiation for an infection?
Infections can be frequent, especially in patients who are immune- compromised from prior chemotherapy or concurrent chemoradiation. I think the decision to hold treatment is site specific. I would not hold pelvic RT for a patient with a bladder infection as long as I was treating the infection and ...
What are the safest dose constraints for moderately hypofractionated prostate cancer?
At Penn, we have a protocol for 70 Gy/28 fractions using proton or photon therapy for low- and intermediate-risk patients. I initially designed it with a conedown as follows, but that is not always necessary/appropriate. CTV Initial = Prostate and proximal seminal vesicles to include at least 1 cm, ...
How do you counsel eligible patients on lung cancer screening who are hesitant because of the cancer risk from CT scans?
This is simple. The risk of lung cancer in patients who have smoked for >20 years is orders of magnitude higher than the theoretical risk of medical X-ray-induced cancers from low-dose CT (LDCT) screening. A typical LDCT scan exposes patients to approximately 1.5 mSv of radiation, equivalent to abou...
In the setting of recurrent breast cancer after breast radiation, who receives a mastectomy and is found to have positive axillary nodes, under what circumstances would you give radiation to the chest wall and nodes vs the nodes only?
There is no absolute answer, and it is a function of time to recurrence, previous volume of RT, and potential benefit of RT (based on extent and location of recurrence and phenotype of disease). The threshold to treat is higher than upfront setting for sure. Treatment can vary from none to comprehen...