Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach the use of parathyroid hormone-related protein analog drugs in the setting of prior external beam radiation?
The concerns about prior external beam radiation are due to the independent increased risk of osteosarcoma associated with external beam radiation. The boxed warning associated with the PTH anabolic drugs WARNS that patients with prior radiation should not receive PTH anabolic drugs. (Note this is n...
How would you approach SCC of unknown primary, p16-, EBV-, metastatic to a large 5.5 cm level 2 neck node, if you suspect a cutaneous origin after clinical workup?
Surgery and postop RT to the ipsilateral parotid and neck
How would you treat a stage III lung cancer with N2 disease and a small synchronous contralateral lung primary?
Given that the patient has synchronous primary NSCLC's, I would treat each definitively. There is minimal data regarding this exact scenario but a couple of options are possible. One could include the contralateral lesion in the RT fields when treating with chemo/RT and durva. Alternatively, one cou...
For a patient with locally advanced lung cancer and mediastinal but not hilar involvement, would you electively treat the ipsilateral hilum?
As Dr. @Dr. First Last eludes, the lymphatic drainage pattern justifies buzzing the hilar basin. It's unclear if we need to prescribe a full (60 Gy) or microscopic dose (45-50 Gy). The hilar region often receives an incidental microscopic dose anyway due to dose spillage from the 60 Gy targets. But,...
What dose do you recommend for an oligometastatic bone metastasis involving the glenoid?
For a bone lesion close to a ball and socket joint, I tend to use 35 Gy in 5 fractions in order to decrease the risk of damage to the cartilage. I usually expand 5 mm from GTV to generate a CTV with trimming of the portions that go beyond the bone if no extraosseous extension. I also expand a 2-3 mm...
How would you approach an HPV+ retroperitoneal mass s/p resection involving the psoas/ureter, with uterus/cervix negative for any cancer?
When the PET and EUA are negative, I have treated HPV positive unknown primary with post-op or definitive chemo RT based on location. There is limited published data on HPV positive groin or pelvic nodes with occult primary. The last one I treated for unresectable RP mass had good response locally b...
What is the role of SBRT in recurrent oligometastatic ovarian cancer?
Ovarian granulosa cell tumor are not as chemo sensitive and respond more to local treatment and have long disease free interval and longer time to recur. Surgery where feasible and if not local treatment with fractionated IMRT or SBRT is reasonable based on location and extent of disease to prolong ...
Would you recommend ALND or sentinel node re-mapping in a patient with recurrent breast cancer of the areola complex who had previous nipple-sparing mastectomy and SLNB and no previous radiation?
The extent of axillary surgery in general, and also in the setting of locally recurrent disease with a clinically-negative axilla, has lessened over time, largely to try to mitigate arm morbidity. In the past, if a patient had a prior SLNB at the time of the original diagnosis, it was not uncommon t...
What target volumes and expansions would you use for neoadjuvant chemoradiotherapy to a large thymoma with the goal of shrinking the tumor to aid resectability?
Achieving an R0 resection is an important prognostic factor in thymoma. If there is concern that an R0 resection may not be realized, typically due to the proximity of the disease to the great vessels, then neoadjuvant therapy is often recommended.At our institution, we universally recommend neoadju...
What is your approach to definitive radiation for p16+, cT2N1M0 (AJCC 8th ed) base of tongue SCC?
If there are multiple ipsilateral LNs, then I recommend CCRT with cisplatin. 70 Gy in 35 fractions via IMRT/VMAT. If only a single LN, I would likely recommend the same (especially if a large LN) if the patient could tolerate it, though RT alone is reasonable. If RT alone, then I typically accelerat...