Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How long after initiation of steroids do you typically recommend waiting prior to delivering radiation therapy for spinal cord compression?
This is an interesting question. Because the role of steroids in spinal cord compression has evolved over the last few years (less daily high dose use 96mg or greater), its overall role in MSCC is under scrutiny. Unless, there is a soft tissue mass causing the ESCC, or, where steroids are needed for...
Would you continue treatment of a rectal metastasis in a patient who is found to have radiographic evidence of contained rectal perforation during the treatment?
Good clinical question. In my experience, I have treated quite a few of both rectal and anal cancer cases, but not one from a metastatic nature that I can recall. But, in any event, my clinical instincts/experienced would push me to ask the following questions: Is this a change in his my daily/weekl...
How do you manage patients with history of multiple perianal condylomas who develop focal high grade squamous intraepithelial lesions in the anal margin?
In the absence of invasive disease, surgical resection is always the treatment of choice for in-situ disease. If the recommendation is APR, it should be well documented. If the patient refuses the surgical option, then radiation can be offered with very careful documentation. The reason for that is ...
What factors determine the choice of treatment in the management of intermediate (BCLC stage B) hepatocellular carcinoma?
For Stage B disease, the major factors that I use to determine treatment (we discuss all such cases at our institutional multidisciplinary liver tumor board) are performance status, Child Pugh score/liver function, and the extent of disease. If patients have PS 0-2 and are CPA/B7, these patients may...
Would you alter your treatment plan of the neck for oropharynx cancer after an excisional biopsy/violation of the neck?
I would base my decision on pathology. 1. Evidence of ECE or soft tissue invasion: cover the scar and tissue plane there-under to full dose. In this scenario I wire scar and place bolus with 2cm margin around at time of sim. Cover soft tissue leading up to scar to mimic dissection plane. Cover any ...
In castrate-resistant metastatic prostate cancer, how do you decide whether to offer radionuclide therapy versus external beam radiation therapy to select sites?
Since Xofigo improves survival in these patients in comparison to EBRT, if they meet trial criteria, I favor xofigo, as that would help with skeletal related events and improve survival. One other factor to consider is patients should not be on Zytiga. Concurrent Zytiga and xofigo in clinical trial ...
How would you approach SRS for a multiply hemorrhagic unresectable brainstem cavernous malformation?
If a patient has a hemorrhagic or symptomatic brainstem cavernous malformation (CM) that is unresectable, SRS may be the only option. I try to go as high of a dose as I can while respecting dose tolerance to the uninvolved brainstem. Depending on that, my typical dose would be 16 Gy. Retrospective s...
Do you consider dermal invasion an indication for PMRT in the absence of other risk factors?
Did the patient have neoadjuvant chemotherapy between diagnosis and surgery? If yes, than I would treat based on upfront clinical staging. If over 60 and no reconstruction would consider 40 Gy/15 fx to chest wall and nodes otherwise 50/25 fx or Alliance Trial if interested. If no neoadjuvant che...
How would you manage a male with a prior history of localized prostate cancer s/p radiation to prostate only (two years ago), who now presents with a T1N0 squamous cell carcinoma of the anus?
There is data where t1 no anal cancer was treated with RT alone with a localized field. There was low risk of recurrence of the outside treatment volume and that would be my approach to avoid overlap and given the chance of sphincter preservation. Also, I have not used it but data also shows good ef...
Is cardiac sparing whole lung IMRT acceptable for Wilms Tumor?
I think we have enough dosimetry and clinical data to use cardiac sparing imrt off trial. We will be testing this modality further in future Wilms tumor clinical trials in COG. I routinely use this technique and know many others who do so too. John Kalapurakal