Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When is the earliest you would consider starting radiation after total laryngectomy?
I’ll first try to answer the question of a suitable time interval between radical surgery and the initiation of post-operative radiotherapy (PORT) for advanced H&N cancer in 3 ways: For those who only want treatment “guidelines”: NCCN states explicitly that the preferred interval between resection a...
What is the appropriate dose for palliation of bulky prostate cancer?
As always with palliation, the devil is in the details. How bad is the disease, what is the patient's performance status,... Having said that; very little literature is out there, but one prospective study explored doses from 30-39Gy in 3Gy fractions and found good palliation and low toxicity. There...
Would you recommend adjuvant radiation therapy to the locoregional lymph node basins for Merkel cell carcinoma (MCC) with a solitary macroscopically positive lymph node (LN) without ECE after lymph node dissection?
As always the need to prophylacticaly treat possible residual nodal disease is influenced by many factors. Histology a key factor. Merkle cell is usually one step ahead of treatment. In this case I would definitely treat the nodes at risk. I would also treat widely around the resected primary skin s...
What is your approach to adjuvant treatment to the tumor bed and/or regional lymph nodes for an early stage Merkel cell carcinoma status-post WLE and sentinel lymph node biopsy?
Merkel cell carcinoma is almost always beyond what you think are the safe margins of resection. Regardless of the completeness of wide local excision I generally extend the postoperative field two or 3 cm beyond the theoretically clear margin, obviously staying off of critical structures such as the...
What is the radiation volume for M+ pure germinoma with brain only extra-ventricular mets and negative CSF/spine imaging?
In general, I wouldn't recommend chemo for M+ Germinoma kids because it does not favorably improve the therapeutic ratio based on the findings from GCT96 (NCT00293358).Independent of chemo, 24 Gy CSI with a boost to 36-40Gy is sufficient for cure. With chemo, 21 Gy CSI & an involved field boost to 3...
Would you ever consider SRS or WBRT in an asymptomatic pregnant patient with multiple brain metastases?
I agree with @Dr. First Last that radiation can be deferred in an asymptomatic patient and should be considered. However, brain progressive brain metastases can be neurologically debilitating and radiation may need to be considered for a patient that is not delivering soon. The patient will need to ...
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.
Is it reasonable to offer APBI in an obese patients with large breasts and N1mi disease?
Most published data with micromets and no nodal RT (most are small series) show a risk of regional recurrence is very low and varies from 0 to 5%. For that reason, micromets would not be contraindications to APBI because if the same patient has a mastectomy done, we would not offer any RT for node.
What cumulative dose constraints would you use for the normal liver when repeating SBRT for liver metastases with a longer time interval (i.e. 2-3 years)?
I will assess cumulative dose within the normal liver with retreatment but if the interval is 2-3 years, I think there has been enough repair in a non cirrhotic liver that one could consider it nearly de novo treatment. There has been very little literature directly examining the impact of re-irradi...
Would you treat a patient with evidence of prostate cancer who refuses biopsy?
No. I cannot think of a situation where I would treat localized prostate cancer with radiotherapy without biopsy confirmation.In the scenario provided above (PSA>15, PI-RADS 5), we cannot be positive the patient even has cancer. A meta-analysis (Barkovich et al., PMID 30807218) found PI-RADS 5 repre...