Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you routinely offer IMRT to the entire pleural cavity in patients who undergo pleurectomy/local resection for mesothelioma without EPP?
I do not, and wouldn't recommend, routine IMRT to the entire pleural space in patients with mesothelioma s/p pleurectomy/decortication outside of a clinical trial. If we have learned anything from this disease, it is that "less" is often "more". About 15 years ago there was a surge of interest in ag...
When is it considered inappropriate to omit pathological mediastinal lymph node staging for non-small cell lung cancer?
This is a very good question often debated by thoracic radiation oncologists with their thoracic surgery colleagues and can get complicated. The best way to look at it, in my opinion, is to understand the sensitivity and specificity of FDG PET/CT to detect true mediastinal nodal disease. For example...
What is your approach to adjuvant radiotherapy for head and neck cancer after resection and reconstruction with a free tissue (muscle and bone) flap?
I work closely with our reconstructive surgeons to get their opinion on the health of the flap. In most cases, I am able to start radiation within the recommended 4-6 week window. There may be occasional cases where the flap has not been "taken" or the patient had to go back to the OR for a failed f...
What ratio of lumpectomy cavity volume to normal breast tissue do you consider reasonable for treating a patient with APBI?
In the Italian study, they used 50% prescription dose to 50% or less of breast volume outside PTV. I generally limit PTV volume to the total breast volume ratio of <25-30% to decide if PBI is an appropriate treatment, as dose constraints to the uninvolved breast get harder as PTV volume percentage o...
How do you manage thrombocytopenia when radiating the spleen?
Radiation oncologists are occasionally asked to see patients with symptomatic splenomegaly (early satiety, dyspnea, and pain) and evaluate for radiation therapy. Many such patients have non-functional bone marrow from diseases such as primary myelofibrosis. This leads to extramedullary hemoatopoiesi...
How do you interpret PSMA/PET with focal prostate activity after XRT currently on ADT with stable PSA?
The most concerning element of the case presented is that the patient’s PSA continues to be ≈ 5 while on ADT with presumably castrate levels of testosterone, which should be verified. The current PSA is one order of magnitude greater than would be expected from the effect of ADT alone possibly indic...
For patients with RCC or other radio-resistant histology with metastasis to long bones requiring surgical stabilization, what dose and volumes do you use for post-op RT?
Recent data from Sloan Kettering suggest that covering the entire hardware allows for better local control. I would stick with 30 Gy in 10 fx, if treating post-op. Can consider 1 or 5 fx, but since this is less for pain and more for local control, I would fractionate.
Would you electively treat any lymph node regions for small cell carcinoma of the pancreas?
In general, we model treatment for these patients on the regimens used for SCCa of the lung. The most important thing to establish is that non-operative management is the preferred approach due to the risk of distant metastases. In general, the value of elective nodal treatment is inversely proporti...
When treating a bulky squamous cell carcinoma of the anal canal, do you try to limit the dose to the external anal sphincter to any particular number to reduce the risk of chronic fecal incontinence?
No
What cardiac surveillance would you do for an asymptomatic male patient with a remote history of mantle field radiation for Hodgkin's lymphoma?
I would follow the long-term follow-up guidelines from COG based on heart dose - Children's Oncology Group (survivorshipguidelines.org)