Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your planning approach for SBRT when the tumor abuts the great vessels such as aortic arch or SVC?
I think there are several reasonable approaches here. The first part is whether this is curative intent (early stage) vs non-curative but for local control (i.e. oligometastastic/oligoprogression). I lean towards being more aggressive in the curative intent setting while trying to be a little more c...
How would you treat a newly diagnosed hormone sensitive high risk prostate cancer with one small lung metastasis and no other evidence of metastatic disease per PSMA PET?
I think there is no solid answer to this. De-novo visceral metastases are very rare in mHSPC, and lung-only oligometastases on PSMA-PET are even more rare. Since lung metastases is expected to be visible on CT, this is undeniably a high-volume disease based on the CHAARTED criteria. Patients with vi...
How do you construct your target volumes for superior sulcus tumors?
This is one of my favorite topics, so I apologize in advance for my verbosity. Tumors invade: I worry that our RT fields, in general, are getting too tight (i.e., cancer often invades beyond what we can see on our imaging, and our CTV margins are often small). This is especially true for Pancoast tu...
What dose and fractionation would you recommend for treating the primary site of a patient with metastatic anal melanoma?
There is little data that defines the best approach to radiotherapy for the primary tumor in mucosal melanoma of the anal canal. In the context of metastases, a hypofractionated regimen seems most appropriate. Investigators from MDACC have published on a regimen of 30 Gy in 5 fractions given twice a...
In a patient with amyloidosis and abnormal liver function but child Pugh A, would you still proceed with SABR for a liver metastasis?
No great data regarding the impact of amyloidosis on liver tolerance, but if the patient was a CP Class A patient, I would feel comfortable offering SABR for a liver metastasis.
What criteria do you use for induction chemotherapy in advanced head and neck cancers?
We were advocates of IC for patients felt to be at higher risk for DM in oropharynx cancer. We believed these were patients with N2b-N3 disease. However, the recent PARADIGM and DeCIDE trials were negative for a survival advantage for IC, so personally my enthusiasm for IC for advanced oropharynx ca...
For ablative treatment of intrahepatic cholangiocarcinoma, what dose constraints do you recommend for the IVC when the tumor is adjacent to it?
The IVC is the lowest pressure vessel in the body, is thin walled, and not susceptible to pseudoaneurysm or atherosclerosis. According to the evidence and my experience, you can give way more than it takes to control any tumor to any vein. There has never been a venous complication related to radiat...
What factors affect your decision to offer adjuvant RT for thymoma s/p R0 resection?
First, I would review the pre-operation image to understand how extensive is the thymoma involved and then talk with the surgeon to find out where the high-risk area is. If the margin is negative and there is no trans-capsular invasion, I would not recommend post-OP RT. If there is a positive margin...
Would 45 Gy to the pelvis be sufficient for a locally advanced rectal cancer that has a complete metabolic response to TNT?
If you define the standard of care as what the vast majority of people do, the standard of care is to give 50.4 Gy in 28#, especially if nonoperative management is the goal. If surgery is part of the plan, we found that preoperative chemoradiation to 45 Gy followed by mesorectal excision resulted in...
Do you place asymptomatic patients being treated for brain metastasis with SRS on prophylactic steroids?
We do not use steroids routinely for asymptomatic patients being treated for brain metastases except if there is a concern based on anatomic location, volume, and/or presence of edema (e.g. adjacent to motor strip with significant edema, in or adjacent to brain stem, V12 brain receiving > or near 10...