Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What dose do you typically use when retreating locally aggressive and recurrent SCCs of the scalp (with no regional or distant mets)?
Not much great data to support this contention, but my general practice is EQD2 of 70-80 Gy in a continuous course using shrinking field technique, depending on prior radiotherapy and tolerance of nearby organs at risk. For gross disease, concurrent systemic therapy may be worthwhile in patients tha...
When performing IMRT treatment planning for head and neck cancer, how do you instruct your dosimetrists to manage the optimization process for targets that are very close to the skin surface (or with PTVs that extend into air), yet the skin itself is not at risk?
We use method #2 described - creating a faux bolus in the planning system without changing the 3mm PTV expansion on CTV. If in the re-calculation process the dose is not adequate to gross disease under the skin or at the anterior commisure, physical bolus may be applied. In reality, we rarely use ph...
Do you recommend altered fractionation when using cetuximab with head and neck RT?
The 5-year update of the randomized study of RT vs RT and cetuximab for HN cancer added additional factors related to better outcome in patients receiving cetuximab (in addition to the findings that only oropharyngeal cancer benefited, published previously in the NEJM paper). The additional factors ...
What is the rate of dementia following whole brain radiotherapy in patients with brain metastases who survive for over a year?
To answer this question we need to have a common understanding of "dementia." I think that those of us who follow patients long-term after WBRT all agree that there are cognitive changes that develop. From the placebo arm of RTOG 0614 we know that at 6 months 65% of patients experienced cognitive dy...
Do you treat the surrounding erythema for cutaneous squamous or basal cell carcinoma?
Target delineation for cutaneous carcinomas often relies on physical examination, rather than imaging. Appreciation of the subtle signs of skin cancers is therefore important. Dermatologic surgical guidelines suggest using erythema around cutaneous SCCs as a part of the gross disease. For this reaso...
For patients with advanced-stage NSCLC being treated with concurrent chemoRT who miss treatment days secondary to acute toxicities, do you add on fractions at the end of treatment to compensate for repopulation, as is done in head and neck cancers?
It's a priority that patients undergoing definitive chemoradiation of any sort, especially inoperable NSCLC, not miss a fraction of RT. I encourage the continuation of RT in the setting of neutropenia, thrombocytopenia, and significant esophagitis, as long as reasonable and safe. Often the significa...
When would you use concurrent cetuximab with radiation for a patient with H&N cancer who is not a good candidate for concurrent chemotherapy?
Additional data has been added since I have addressed this question in 2015: the role of concurrent cet-RT in HNC patients who cannot receive chemotherapy. The large majority of these patients are elderly with heavy smoking/drinking history, and typically have non-HPV related Sqcca associated with p...
Is there a role for radiation therapy after chemotherapy for localized anaplastic large cell lymphoma?
Hard to answer this question as posed. ALCL when localized is primarily confined to skin. Treatment of choice in this circumstance is RT alone, generally 40 gy in conventional fractions. ALCL not primarily in the skin is a systemic disease best rx'd with chemo, rarely localized. For the latter, I wo...
What is the best management of a lacrimal gland MALToma?
Ocular MALT can occur in the conjunctiva, lacrimal gland or retroorbital tissue. Although chlamydia can cause this, treatment with antibiotics without documenting infection has not been reported to have a significant response rate. Even in patients who test positive for DNA, I have seen mixed respon...
Are there situations in which hypofractionated breast RT is acceptable after neoadjuvant chemotherapy and lumpectomy?
In my practice, I routinely offer hypofractionated whole breast radiation plus a boost (40 Gy/15 fractions plus 10-14 Gy in 5-7 fractions, as per START B) to any patient 40 and older who has received neoadjuvant chemotherapy and lumpectomy, provided my target is the breast only or breast plus low ax...