Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How should a contralateral breast cancer be treated when found during a prophylactic mastectomy?
Whenever a contralateral prophylactic mastectomy is planned, diagnostic imaging of that breast and nodal basin is recommended pre-operatively if not done within the last month or so. Any abnormality should be resolved diagnostically and treated accordingly. Even with this process, incidental cancers...
Would you consider adjuvant RT in an elderly patient with a T1N0 ER+ breast cancer who initially proceeds with endocrine therapy alone and is unable to tolerate it?
Given the low-risk nature of T1N0 luminal lesions among older patients (per the CALGB 9343 and Prime II trials), the conundrum of whether to pursue adjuvant endocrine therapy, radiotherapy (RT), or both after lumpectomy arises with some frequency. Patients who decline RT yet ultimately cannot tolera...
Would you offer bridging radiation before or after leukapheresis?
We believe the ideal time for bridging radiotherapy is after leukapheresis but before CAR T-cell infusion to avoid a negative impact on T-cell collection. However, the clinical situation has to be considered, and if a symptomatic presentation necessitates urgent treatment before leukapheresis, treat...
Would you use SBRT in patients with medically inoperable renal cell carcinoma?
Yes. Together with Drs. @Dr. First Last and Lee Ponsky from University Hospitals Seidman Cancer Center (UHSCC), we have published the first North American trial of SBRT for medically inoperable renal cell carcinoma. The attempt to escalate the dose from 24 Gy in 4 fxs to 48 Gy in 4 fxs was successfu...
When offering APBI, if a patient has invasive ductal carcinoma and DCIS, do they need to fill suitability criteria for both, or does the DCIS criteria only apply to pure DCIS?
In such cases, I use the criteria for invasive cancers. I only use DCIS criteria for pure DCIS.
Would you recommend removal of pec muscle for a positive microscopic deep margin post mastectomy?
Pec fascia and muscle involvement are independent risk factors for local relapse even with a negative margin. The situation is not common but for microscopic positive margin, have offered PMRT with an additional boost to the area of close margin (60-66 Gy and used pre-surgery imaging to identify the...
Do you routinely perform mammograms for women that underwent nipple-sparing mastectomy with reconstruction after a breast cancer diagnosis?
We don’t perform mammograms routinely for this subset unless clinically indicated.
What target volumes do you use for cavity SRS following surgical resection of brain metastases?
Update: Essentially, my answer is the same. I'd add that often the sx tract is covered with PTV and I might extend that if its close. But surgical tracts can be extensive. There's a nice paper by Byrne et al. out of MGH from the excellent Helen Shih's group. This is a good option to consider if you ...
When is it appropriate to use SBRT in treating lung metastases (oligomet, up to 3 mets etc.?)
Patients with lung metastases rarely die directly from their pulmonary disease. Rather, systemic disease progression is typically the obstacle. Therefore, I would judge that the most critical question is not "how" to treat but "when" to treat. With limited clinical trials to guide management, this r...
How do you define PTV margins for lung SBRT using breath hold technique?
Prior to even creating a PTV the decision of when to use/not use ABC is critical. Most medically inoperable lung patients don't handle ABC mediated breath-holds well, and would be better treated by abdominal compression and 4D CT ITV techniques. In our practice <10% of stage I NSCLC are treated with...