Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What fractionation would you recommend in a patient with recurrent early stage breast cancer who has had prior lumpectomy and IORT and refuses mastectomy?
While there is no standard of care, several options exist. It is important to delineate where recurrence is (true recurrence vs. elsewhere failure in breast). Also, IORT technique is important a low energy IORT (50 kv) has limited dose deposition beyond a few mm (5-6 Gy at 1 cm) and as such much of ...
What factors do you consider when electing to observe small brain metastases (vs treating with SRS)?
Since I see primarily brain metastases from lung cancer, my opinion will be confined to small cell and NSCLC brain metastases. For single or multiple small (and I am going to assume that they are asymptomatic) that are present at the diagnosis of small cell lung cancer, I think it is reasonable to ...
When would you recommend surgical debulking of pelvic or para-aortic lymph nodes in cervical cancer prior to definitive chemoradiation therapy?
We have not favored dissection and treated with SIB and sometimes added sequential boost ( EQ@ dose 58-66 Gy) based on sizemost current literature shows excellent regional control but high distant failure in these ptsfor bowel and duodenum ( two organs which could be limiting factor) we use v55 dose...
For patients with stage I NSCLC initially treated with SBRT, how do you best manage isolated regional nodal failure?
The 5-year loco-regional failure rate in RTOG 0236 was 38%, underscoring that there is considerable need for identifying a post-SBRT salvage strategy for these patients; there are only anecdotal reports in the literature as to how to best manage these patients. Our historic approach when the failure...
How would you approach oligometastatic (solitary) recurrence with previously resected pancreatic adenocarcinoma and adjuvant chemotherapy with a prolonged disease-free interval?
This is very different from colon cancer with a solitary recurrence after a long disease-free interval. In this case, before considering any local therapy, I would treat with a course of systemic therapy to establish favorable disease biology. The vast majority of patients with recurrent, oligometas...
At what field size would you consider splitting a palliative spine treatment into two different courses?
I usually don’t treat radiograph only. I usually ask for a detailed pain history and limit the size of RT to correlate with the pain and target MRI areas that are problematic (epidural, impending cord or fracture). I usually limit the sections if pt complains of pain involving many regions regions (...
What is your strategy for image surveillance for occult breast cancer after treatment?
As the are occult with all imaging including MRI there is no good strategy for imaging . Also risk of IBTR in modern era after RT in these patients is low and would just do routine annual mammogram for screening
When do you add an adjuvant bone-modifying agent in patients with history of localized breast cancer?
In my opinion this is controversial question. The meta-analysis performed by EBCTG 2016 of over 11,000 post-menopausal women, and over 6000 premenopausal women, clearly shows a benefit for the postmenopausal subset. The absolute overall survival improvement was 3.3% (p=0.002) for postmenopausal wome...
How would you approach treatment in recurrent, localized rectal mucinous adenocarcinoma?
Well-differentiated mucinous rectal adenocarcinoma is relatively treatment resistant. In general if there is an in-field local recurrence after prior radiation (ie: is not a marginal miss), then that is very good evidence that it is radiation resistant. There are many studies now showing that re-irr...
What dose do you try to keep the contralateral breast when treating a PMRT inflammatory breast cancer that is extending across midline?
You follow the principal of ALARA as it is more important to control aggressive IBC and you need to treat volume required adequately.