Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For a rectal cancer with questionable T3 or questionable N+ by MRI, can short course radiation be given followed by surgery and the pathology still be interpreted to guide adjuvant chemotherapy?
This is a somewhat common scenario. In these situations, I have strongly favored short course RT followed by immediate surgery such that there is not a sufficient time interval between RT and surgery to allow any significant pathologic response. I think you can be confident in that the pathology aft...
How would you treat an elderly patient with T1 glottic laryngeal cancer who refuses 28 fractions?
I would suggest using 52 Gy in 16 fractions. This is NCCN-supported for T1 glottic lesions and has a long track record of success and tolerability (Gowda et al., PMID 12972304). I have used this regimen exclusively with VMAT. That said, it predates IMRT and 3-D conformal is very reasonable. I would ...
What were the historical radiation fields and dose for treatment of benign tonsillitis?
The majority of patients treated under this indication were children in the late 1940s, 1950s and early 1960s. The prevailing thought at the time was that the irradiation of the tonsils and adenoids would help clear acute and chronic inflammation, and "atrophize" the resultant hyper-plastic lymphoid...
How do you manage grade 3 enterocolitis from 5FU mitomycin and pelvic radiotherapy?
With infection ruled out and CT showing diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field, presumably, it is due to the 5FU/mitomycin. In the few cases I have had, it generally heals 2-3 weeks after counts nadir. Besides supportive care (Imodium, Lomotil, Gas-X, ti...
How does a diffusely positive PSMA in the prostate affect treatment planning in a patient with MRI and biopsy showing only one area of disease?
There are three parts to my answer: First, mild to moderate PSMA uptake can be seen in benign conditions, including BPH and prostatitis (e.g., reviewed by Satapathy et al., PMID 32755196). Second, I don't see how the discrepancy between PSMA PET and MRI/biopsy would affect radiation treatment planni...
How would you manage a non-surgical poorly differentiated neuroendocrine tumor of unknown primary with a bulky nodal conglomerate causing pain?
This is a question that could have many reasonable answers. Depending on PS, site, symptoms, and overall onc plan - many standard palliative regimens could be deployed, including more aggressive palliative if this were the only (known) site of disease and more durable local control is intended. Also...
Would you cover elective nodal regions in a patient with high-risk cutaneous SCC of the right medial forehead with clinically negative lymph nodes s/p WLE with graft?
This patient exhibits several adverse features that could warrant post-operative management. As a caveat, patient KPS and other factors may influence the decision point on if and what to treat. That said, the tumor size, thickness, and the presence of other high-risk features in aggregate (+PNI/LVSI...
What is the significance of grade in OPSCC?
Multiple groups have found an association between the impact of fractionation schedule on outcome and tumor differentiation using high quality prospective data (Eriksen et al., PMID 14751528, Bentzen et al., PMID 16110017, Lyhne et al., PMID 26255764). Well-diff and to a lesser extent moderate-diff ...
How would you manage a recurrent anaplastic supratentorial ependymoma in an adult?
There is no well-defined standard-of-care approach for previously irradiated, now recurrent ependymoma, in any setting, whether it is adult or pediatric, cranial or spinal, and supra vs. infratentorial. Unfortunately, the natural history at this stage is characterized by multiple relapses, each with...
What dose and setup would be recommended for isolated penile shaft metastasis from bladder cancer?
If this is isolated oligometastatic disease, I would treat it as if it were a skin cancer. If superficial and can be removed easily, this is a reasonable option. If not, then can consider a dose of 55 Gy in 20 fractions utilizing a direct electron field or orthovoltage if available. If the patient h...