Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you determine whether to treat a young adult with stage IA Hodgkin Lymphoma with the adult or pediatric treatment paradigm?
There is a long history of pediatric protocols for HL differing somewhat from the adult ones, but not much biologic rationale to support this, as the disease in young adults is biologically the same as in pediatric patients. Side effects of RX may of course differ, particularly with regards to RT an...
How do you balance target coverage with tolerances of the ipsilateral eye structures and the risk of vision loss in advanced head and neck cancers?
My personal approach is to always recommend induction systemic therapy for T4b unresectable disease with orbital invasion. If it is at all resectable (T4a), I agree with offering curative surgery (including enucleation) upfront or induction if that is a surgeon preference, then post-op chemoRT or RT...
How do you manage intracranial metastases from gestational trophoblastic neoplasia?
High risk gestational trophoblastic neoplasia with brain metastases is rare, and treatment has evolved over the past few decades and centered on multi-agent chemotherapy. The most well-cited regimen is EP-EMA (etoposide, 150 mg/m; cisplatin, 75 mg/m, intravenous, day 1; etoposide, 100 mg/m; methotre...
For T2-T3 N+ rectal patients with large (2+ cm) bilateral sidewall nodes outside the TME volume, should you extend elective nodal volumes anteriorly to include external iliacs?
No, I would not routinely extend elective nodal volumes anteriorly to include external iliac nodes in a patient with T2-3 N+ disease and large bilateral sidewall nodes outside the TME volume. Lymphatic (and venous) drainage of low and mid rectal cancers includes internal iliac (pelvic sidewall) and ...
Would you offer radiation therapy to the prostate in addition to up to 1-3 osseous metastases in a patient with newly castrate-resistant oligometastatic prostate cancer, with no prior treatment to the prostate?
I would not treat the prostate except for palliation of local symptoms. There is no proven benefit of local RT for castrate-resistant prostate cancer.
Should patients about to start radiation be required to have COVID-19 testing, if resources are available?
We are also pre-testing all procedural cases using PCR, but are doing symptom/question screening for all outpatients, not allowing visitors outside of special situations, and maintaining social distancing in the hospital (decreasing areas for patients to sit) so they are forced to remain apart. The ...
Would you consider short course RT for rectal cancer in the post-op setting given COVID-19?
I would not use short course in the postoperative setting. Virtually all of the data on short course are preoperative, where most of the irradiated bowel is removed surgically. The patient would get over the acute reaction from short course postoperatively, but I have major concerns about late effec...
Would you recommend PMRT for a patient with a right breast mastectomy with closest margin less than 0.1cm?
I would consider this if there were other high risk factors like T2 disease, high grade or LVSI. In absence of these factors, favor systemic treatment alone. Here is one reference.
Do you contour the renal hilum/vascular trunk and renal cortex as separate structures when doing SBRT near the kidney?
This is an excellent question in radiotherapy dosimetry that has long been overlooked. In classical radiobiology, a typical organ-at-risk (OAR) can be considered as exhibiting either parallel or series patterns based on the spatial arrangement of its functional subunits (FSUs) (Withers HR et al. IJR...
How would you approach a resectable and isolated ''in-field'' local recurrence of head and neck cancer detected mid-way through adjuvant radiation?
It's highly unlikely to be resectable. If you really believe there is a local recurrence during treatment, which I’ve seen less than 5-6 times per year, accelerate, add chemo if you haven’t; and if that doesn’t work, consider hospice. Surgery is not the answer.