Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
To obtain insurance approval for DIBH when treating left breast cancers, are there particular dose constraints to sites that you employ?
I am surprised insurance companies are still restricting the use of DIBH for left side breast cancer and need some metrics to support it. Mean dose to heart is low with DIBH as it helps to restrict scatter and transmission from conformal heart block and knowing each Gy to the heart matters, DIBH is ...
How would you manage a T2N0 anal squamous cell carcinoma in a patient with a history of FAP s/p remote proctocolectomy with J pouch creation?
This is a rare situation. The more common would be an adenocarcinoma developing in residual rectal mucosa after proctocolectomy for ulcerative colitis or FAP. If disease is locally advanced in those cases, and therefore an indication for radiotherapy, I’ve favored pre-op total neoadjuvant therapy se...
When would you recommend observation and withhold adjuvant RT in resected esthesioneuroblastoma?
I can’t think of an instance unless was an extremely early lesion with negative margins in an elderly, infirm patient. I haven’t seen it in over 40 years. Short answer, almost never.
How do you manage locally advanced adenocarcinoma of the base of tongue?
This is typically a surgical disease being minor-salivary gland, followed by adjuvant radiation therapy as needed. These do not normally respond to radiation therapy alone well at all. The question is what if the patient cannot tolerate or refuses surgical resection?
Do you counsel patients with an ileostomy about significant diarrhea when treating the pelvis with radiotherapy?
For patients with an ileostomy, they should be told that they are expecting to have an ileostomy output of approximately 1 to 1.5 L per day immediately after recovery from surgery. However, the output may decrease over time.If a large amount of small bowel is in the pelvic radiation field and/or the...
What concurrent dose/fractionation regimen do you prefer when treating large cell neuroendocrine tumor of the lung?
This is an interesting problem. Assuming the pathologist reports this as "large cell neuroendocrine", essentially this is a non-small cell lung carcinoma and we treat as such recognising the significant concern for brain metastasis. We do not do PCI for these patients and a pre-treatment MRI brain i...
How would you treat an adenoid cystic carcinoma (well-diff, +extensive PNI) of the vulva s/p excision with positive margins?
Rare case! I have only treated one case, and as Dr. @Dr. First Last wrote, I have extrapolated from head and neck. Such tumors are rarely associated with lymph nodes. They mainly recur locally or distally following nerve routes. In our case, the patient had a 3 cm adenoid cystic carcinoma of the rig...
Would you administer pelvic radiation therapy to a post-menopausal patient with locally advanced carcinosarcoma with high risk features s/p TAH/BSO with a vesico-urethral fistula that would be in the radiation therapy field?
Although the role of adjuvant RT in uterine carcinosarcoma is unclear, it does appear that local control is enhanced. So my answer depends on "how high risk is high risk?". The question suggests that the risk of local recurrence is quite high ("locally advanced" is the descriptor), so I do think it ...
Do you electively cover any nodal volumes for superior sulcus tumors?
No. I grew up with the Fletcher textbook and the Lindberg frequency diagrams in head and neck. The logical extension to lung was assumed. My middle name is Thomas, and I am a doubter. For practical reasons at the dawn of CT treatment planning and dose escalation (pre-VMAT), including supraclavicular...
What dose-fractionation and clinical target volume do you use when treating tenosynovial giant cell tumor (TGCT), historically known as pigmented villonodular synovitis (PVNS), of the knee?
4500 cGy at 180cGy/fx.