Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach the treatment of synchronous primary pancreatic and base of tongue cancers?
There are probably many possible pathways here although none of them are ideal. If the patient has a BRCA 1/2 or PALB2 mutation, or even if not, they could start with Gemcitabine + cisplatin for the pancreas cancer which might have some activity against the base of tongue cancer. If there is a respo...
What dose constraints do you apply to the LAD for lung SBRT?
This is a great question and one that does not yet have a clear answer from SBRT toxicity outcomes data. Practically, I think we start with contouring the nearby coronaries (which is not such an easy task to broadly implement from a workflow standpoint!) and evaluating the low to moderate isodose li...
How would you manage a low risk patient with a negative fusion prostate lesion by biopsy but MRI shows apparent advanced disease?
Assuming that the patient has NCCN low-risk features and MRI findings of EPE (which is the most common situation), I would think about this situation in two different subcategories: (1) active surveillance (AS) is still under consideration, and (2) the patient has decided he would like to proceed wi...
In a patient with isolated inguinal nodal recurrence one year after a margin negative anal excision for Grade 1, T1 SCCA of the anus, would you include the anal canal/rectum as part of salvage chemoradiation therapy?
Absolutely yes- the risk is lower for T1 8-10 percent but it is possible. Given the failure should include the entire anal canal and RNI to at least 45 /25 and can SIB gross node to 50 plus depending on size. Anecdotally I had one case like this , resected small T1, node failure where only the ingui...
What is the earliest time to check PSA after prostatectomy?
The half-life of PSA in the circulation is about 3 days, so there is no point checking PSA within the first 15 days (5 half-lives) as any detectable PSA at that point may just represent residual PSA that has yet to be cleared. Most surgeons I have worked with generally wait 4-6 weeks, which should b...
Would you recommend upfront radiosurgery for trigeminal neuralgia caused by AVM abutment at the entry root zone?
Radiosurgery (SRS) at high doses to the dorsal nerve root entry zone is an effective treatment modality for primary or idiopathic trigeminal neuralgia (TN), but is significantly less efficacious when utilized for secondary trigeminal neuralgia, as caused by tumors, plaques, AVMs, etc. There are case...
What is your approach to postoperative radiation for intraductal carcinoma of the parotid?
I would consult a pathologist specializing in head and neck cancer. Low grade intraductal ca is similar histologically and clinically to intraductal ca in-situ of the breast, with myoepithelial markers and ductal differentiation, and requires surgery alone. On the other hand, high grade ductal carci...
How would you approach a patient with acute development of radiation changes around the target while undergoing a course of lung SBRT?
The answer to this question is dependent on the dose/fractionation of lung SBRT being employed. For example, at our institution, we preferentially use single fractions for peripheral lesions and for fractionated central dose schedules such as 50 Gy in 5 fractions, we do not gap the treatments but tr...
How would you treat a patient with oligometastatic disease to the lung for whom SBRT/SABR is not feasible?
I am not sure what this means exactly, as far as not technically feasible. Very old machine? Lack of dosi/physics support? If you can do VMAT with image guidance at your machine, you can probably do SBRT/SRS. You just need to have physics do their thing. In America, we use a billing definition to c...
How do you treat a rectoprostatic fistula after prostate SBRT?
This is a difficult problem to manage, regardless of whether it occurs after SBRT or any other type of prostate radiation. It will require close cooperation between multiple specialists. Early involvement of a gastroenterologist and a colorectal surgeon is imperative as this is likely to require a d...