Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What dose and fractionation do you utilize for node positive HCC?
First thing to point out is that the evidence for an oligometastatic state for HCC is limited. In general, however, I would still recommend definitive RT for limited hilar or infradiaphragmatic nodal spread. The 2 approaches are: 5 fraction SBRT with dose reduction based on the mean liver dose and ...
How would you treat a young patient with an EGFR 19 deletion and a locally advanced lung mass who had a brain metastasis that was resected?
The technically correct, textbook answer would be 1st line EGFR therapy for metastatic NSCLC, which would be osimertinib + carboplatin/pemetrexed (FLAURA2) or amivantamab/lazertinib (MARIPOSA). However, given the unique circumstances here, I would treat this patient slightly differently.I've written...
Would you consider radiating an unresectable intimal sarcoma if it involved the valves of the great vessels?
First, I would quickly confirm that the patient is truly unresectable. I've seen complex cases deemed unresectable and therefore palliative at very fine institutions that were subsequently treated definitively after a second opinion at a center of peak surgical expertise. It is worth recognizing tha...
In ES-SCLC presenting with limited asymptomatic brain metastases and treated upfront with systemic therapy alone (carbo/etop/atezo), how would you approach the brain if MRI shows PR after a few cycles?
In our practice, we would typically watch such a patient on systemic therapy. However, we would stress the need for vigilant monitoring and likely administration of RT (SRS ideally) at the carbo/etop/atezo transition to atezo monotherapy, given the poor intracranial efficacy of the maintenance syste...
Would you offer local radiotherapy to prostate in a patient with small cell neuroendocrine carcinoma who had a complete response to chemotherapy?
Thank you for this great question. Yes, I would strongly consider radiation therapy to the prostate and pelvic LNs for small cell carcinoma of the prostate. Small cell carcinomas of the prostate are rare and comprise <1% of all prostate cancers and are known to be more aggressive. They are often unr...
How would you approach a patient with vitreoretinal lymphoma without CNS or systemic involvement?
The optimal treatment approach for primary intraocular lymphoma is debated. This is a rare disease with only small retrospective series guiding therapy. There is no clear superior treatment approach in the literature. In clinical practice, younger patients are often treated initially with high-dose ...
If adjuvant radiation is offered to an elderly patient with H&N SCC s/p Mohs surgery who is planned for multi-stage reconstruction of the defect with plastic surgery, when should adjuvant radiation be started?
Tumor control comes first. If the surgical defect is such that reconstruction is required, it is even more imperative to focus on the above principle, as a recurrence would almost certainly risk ruining the entire collective effort. Vascular flaps could be safely performed post-RT in most cases by s...
Would you recommend adjuvant radiation therapy to the locoregional lymph node basins for Merkel cell carcinoma (MCC) s/p WLE with negative margins and isolated tumor cells in 1 of 3 right inguinal sentinel lymph nodes?
Yes, this is not an easy disease to cure in the node-positive setting. So, the question can be framed: do isolated tumor cells constitute a benign finding, frank malignancy, or a space in between? I don't have an answer to that, and perhaps given the rarity of the entity, that answer will remain rec...
How is your approach to a patient referred for radiotherapy for keloids with a history of Beals syndrome?
Although of theoretical concern, I am not aware of any contraindication to RT (treatment philosophy similar to Ehlers-Danlos syndrome).
Does pleural tenting adjacent to tumor impact your target volume for early stage NSCLC planned for SBRT?
Having reviewed the images in the cited paper, the question of how to define the target for tumors with proximity to the chest wall and that also show pleural tenting is one that my thoracic radiation oncology colleague will often discuss. The brief answer is that although tenting likely represents ...