Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you check surface dose when treating post-mastectomy patients with radiation?
We have stopped using bolus except for T4b disease, dermal involvement, or extensive LVSI, pathologic dermal involvement, or positive margins. In cases where we use bolus check with in vivo dosimetry and aim for 90% or above dose. Another situation where a bolus may be used is in a very thin chest w...
In the wake of the COVID-19 pandemic, are there any hypofractionated regimens (without concurrent chemotherapy) that could be utilized for head /neck cancer in a post operative setting?
A very recent paper by Eric Hall and David Brenner’s group (Shuryak et al., Int J Radiation Oncol Biol Phys 2019) is titled “optimized hypofractionation can markedly improve tumor control and decrease late effects for head and neck cancer”. Using a recently improved model, they concluded that an opt...
What are the current official guidelines regarding managing patients during COVID-19?
Here are some guidelines and FAQ from professional societies: NCCN: https://www.nccn.org/covid-19/default.aspx ASTRO FAQ: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/COVID-19-FAQs ASCO Coronavirus Resources: https://www.asco.org/asco-coronavirus-information
How well does a negative non-contrast MRI of the brain exclude metastasis in a patient with squamous cell carcinoma of the lung?
I don't think the question has enough information to give a good answer. For example, if it was a T3, N2 NSCLC, or a small cell, then "yes" I'd repeat the MRI with contrast. On the other hand, if it was a T1, N0 NSCLC, then "no", I wouldn't. In other words, if I thought there was a real risk of havi...
How would you approach adjuvant therapy for a fully resected vulvar carcinoma with a single positive lymph node?
There is not a simple answer to this question. In most cases, omitting adjuvant therapy is appropriate, but in certain cases, adjuvant radiation therapy + chemotherapy is advised, even in the presence of only a single positive lymph node. It has been over 30 years since Homesley and co-workers’ 1986...
What is the role for chemoimmunotherapy in the up front setting in non-metastatic head & neck cancer outside of clinical trials?
Phase III studies of immunotherapy concurrent with chemo-RT vs chemo-RT alone, JAVELIN Head and Neck 100 and KEYNOTE-412, didn’t demonstrate a survival benefit of the immuno-containing regimens (while post hoc analyses suggested that PD-L1 positive patients may have benefited). These studies did not...
How would you approach reirradiation in a patient with a history of whole-breast RT many years ago, now with a small intermediate-grade DCIS s/p lumpectomy with an elevated DCISionRT?
I would favor PBI with 40 in 15 or 45 in 30 (BID) with VMAT/IMRT.
What high dose rectal constraints do you use when using a hypofractionated prostate regimen?
Of course the answer is different depending on which hypofractionated regimen that you use.If you are using the CHHiP regimen (60 Gy in 20 fractions) the trial investigators have updated their recommended constraints based on the observed toxicities in the trial.In a preproof online they have provid...
Would you consider definitive chemoradiation for small cell lung cancer that would otherwise be limited stage but has a solitary brain metastasis at presentation?
At the risk of sounding old-fashioned, a brain metastasis in a small cell lung cancer patient still makes them extensive, that is, stage IV. The standard of care for stage IV/extensive stage small cell lung cancer is systemic therapy and immunotherapy followed by immunotherapy consolidation, with ra...
Do you need renal biopsy before SBRT for RCC suspicious cancer?
Yes. The teaching is usually that ≈ 20% of small renal masses (<4 cm) are benign, and this rate goes down as size increases (Thompson et al., PMID 19286217). Features such as contrast enhancement, tumor location, and sex can help to improve the malignant risk potential of these lesions, but no combi...