Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach an elderly patient with early stage breast cancer with micropapillary histology?
Not a lot of literature but this review (https://www.ncbi.nlm.nih.gov/pubmed/29228910) evaluated invasive micropapillary cancers finding higher rates of LRR.For elderly patients, I would offer hypofractionated whole breast irradiation. Would consider APBI, but would not be my primary recommendation....
What are your dose constraints for treating axillary nodal basin in melanoma with 30Gy/5fx?
The original paper treated with AP-PA fields, and the dose to isocenter was 3-6% lower than the prescription dose. Grade 1, 2, and 3 toxicity (edema) were limited - 21%, 19%, and 1%, respectively. Thus, this remains a standard treatment approach, and our directive is as follows:"27 Gy to cover targe...
Should upfront neck dissection in head and neck squamous cell carcinoma obviate the need for chemo in a T1N2 oropharyngeal cancer with no ECE?
While I do not advocate a neck dissection to avoid chemotherapy, when these patients come to our institution already having a ND performed, if there is no ENE and the primary tumor is small, I think RT alone is reasonable.
How do you manage pneumonitis in patients with Stage III NSCLC receiving durvalumab?
Pneumonitis is a concern following chemoradiation (CRT) alone, and the addition of durvalumab leads to increased caution. Patients on the durvalumab arm in the PACIFIC trial, had some increase in pulmonary adverse events. Any-grade cough (35.4%) and pneumonitis or radiation pneumonitis (33.9%) were ...
Does consolidation durvalumab increase the risk of pneumonitis in Stage III NSCLC?
Given the heterogeneity of pneumonitis presentation, the presence of pre-checkpoint inhibitor chest/mediastinal irradiation (by definition in this trial), and the other risk factors often seen in this population (COPD/emphysema, current/past smoking history), it is a real challenge to decipher pulmo...
What is the best treatment regimen for a fungating SCCa of the scrotum arising from untreated genital warts invading the groin and base of the penis with bilateral inguinal nodes?
This is a case where I would like to see the patient and the imaging before giving you my opinion. Management in this situation will take a multidisciplinary approach with med onc, urology, and possibly a colorectal surgeon being involved in addition to rad onc. I don’t think there is a single best ...
What RT dose do you recommend for carcinoma in situ of the glottic larynx?
I use 2.25 Gy/fx per the Yamazaki randomized trial (PMID: 16169681), 56.25 Gy to 63 Gy depending on lesion bulk. Sometimes the laryngeal biopsy may not have been deep enough to detect invasion or only a portion of a larger lesion was biopsied, leaving the possibility of invasion remaining. We discus...
When do you consider total neoadjuvant therapy (chemotherapy and chemoradiation) for rectal cancer?
My practice, and that of my group, has moved more towards a TNT model for stage II and III patients, though I think we are all looking for the PROSPECT data to be finalized. NCCN has adopted TNT as a possible consideration, and other groups are considering this more and more (Cercek et al, Jama Onco...
How does the presence of lymphangitic spread in a single lobe impact your management strategy for locally advanced NSCLC?
in my anecdote of n=1 I included the entire lobe as CTV/ITV - chemoRT 60/30 followed by durva. Provided lung constraints are met I would suggest to include entire lobe as is at risk
Would you electively treat the neck for a completely resected parotid carcinoma ex pleomorphic adenoma with negative lymph node sampling?
Yes, unless there’s a reason not to. For that matter, if it’s a high grade carcinoma and you know you’re going to add postop RT, don’t do the neck dissection and irradiate the neck. It is as effective.