Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach image-guidance and creation of ITV/PTV margins for rib SBRT?
Delineation of rib lesions indeed can be difficult on planning CT. First step is to determine if patient's clinical symptoms correlate with the target area - I have encountered situations wherein collateral history (whether referring doc, or trainee) can bias treatment intent before meeting the pati...
Would you omit radiation in ER/PR negative DCIS patients who are otherwise low risk?
I have usually favored RT in this setting.
What is your preferred PMRT dose/fractionation for patients with implant reconstruction?
I stated in a post in July 2022, that I switched to using hypofractionation for patients with both autologous and implant-based reconstructions after the FABREC trial closed, which we participated in. The results of FABREC presented at ASTRO showed no significant difference between the hypofractiona...
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
This would be an unusual presentation for marginal zone lymphoma (MALT lymphoma) and not one I've actually encountered. In a large series from MSKCC, "soft tissue/bone" comprised 2% of cases treated with radiation therapy (IJROBP 2015;92:130). Case series from Princess Margaret (Cancer 2010;116:3815...
How would you treat a patient with retroperitoneal lymphadenopathy that has been biopsy proven metastatic seminoma, who is not a candidate for orchiectomy, RPLND, or systemic therapy?
Very unusual case, but primary seminomas can be found in sites other than the testes. Of non-testicular primary sites, the mediastinum is probably the most well-known but other sites including the retroperitoneum have been described in the literature. Various theories for how these develop include l...
How would you approach a patient with malignant spindle cell neoplasm of the scalp excised with a focally positive deep margin?
Although I agree that a re-excision would be helpful for margin clearance, it is probably unlikely that more tissue (which may be negative for Ca) would help delineate the pathology. An immunosuppressed transplant patient most likely has a cutaneous SCCa (with spindle cell features) and our surgeons...
Is there a threshold platelet count for which you would consider holding RT?
It depends on what site. For head and neck and thoracic malignancies contribution to marrow dose is minimal and myelosuppression is normal nadir effect of chemo so we dont hold RT for low platelets. For pelvic malignancies I usually use threshold of 50K for holding RT and 100K for holding concurrent...
How would you treat an endobronchial NSCLC abutting a hiatal hernia in a patient who is medically inoperable?
Rates of G5 toxicity (hemorrhage primarily) with even 8 fraction SBRT from the HILUS trial are unacceptably high. The hiatal hernia adds another layer of complexity and the increased risk for tox with stereotactic approaches. If the patient can get chemo, I’d favor concurrent conventionally fraction...
In light of the recently published LAP07 trial, what is the role of radiation in unresectable pancreatic cancer?
The recent publication of LAP07 is welcome, as the results have been known since the data were presented at ASCO 2013, and my impression is that the results have already led to a reduction in the use of radiation for locally advanced pancreatic cancer. This may be appropriate, but the results need t...
How would you treat a stage I peripheral <3cm extranodal marginal zone lymphoma of the lung? Is SBRT appropriate? If so, what dose would you use?
Marginal zone lymphoma of the lung is a very uncommon variant of MZL but appears to have the same favorable outlook as MZL in other locations. Standard dose for localized MZL is 24-30 gy (2gy per fraction) with lower doses generally used in the eye with local control exceeding 90%. Investigations ar...