Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you cover elective nodal regions in a patient with high-risk cutaneous SCC of the right medial forehead with clinically negative lymph nodes s/p WLE with graft?
This patient exhibits several adverse features that could warrant post-operative management. As a caveat, patient KPS and other factors may influence the decision point on if and what to treat. That said, the tumor size, thickness, and the presence of other high-risk features in aggregate (+PNI/LVSI...
What is the significance of grade in OPSCC?
Multiple groups have found an association between the impact of fractionation schedule on outcome and tumor differentiation using high quality prospective data (Eriksen et al., PMID 14751528, Bentzen et al., PMID 16110017, Lyhne et al., PMID 26255764). Well-diff and to a lesser extent moderate-diff ...
How would you manage a recurrent anaplastic supratentorial ependymoma in an adult?
There is no well-defined standard-of-care approach for previously irradiated, now recurrent ependymoma, in any setting, whether it is adult or pediatric, cranial or spinal, and supra vs. infratentorial. Unfortunately, the natural history at this stage is characterized by multiple relapses, each with...
What dose and setup would be recommended for isolated penile shaft metastasis from bladder cancer?
If this is isolated oligometastatic disease, I would treat it as if it were a skin cancer. If superficial and can be removed easily, this is a reasonable option. If not, then can consider a dose of 55 Gy in 20 fractions utilizing a direct electron field or orthovoltage if available. If the patient h...
How would you approach a locally advanced anorectal melanoma with local progression after 4 cycles of nivolumab and ipilimumab who is not a surgical candidate?
For non-operative management of anorectal melanoma, I most commonly use radiotherapy with a regimen of 30 Gy in 5 fractions delivered every other day vs twice weekly (Ballo et al., PMID 11958890; Kelly et al., PMID 21446049). The disease burden, in this case, sounds quite extensive in which case a...
Would you offer post op adjuvant radiation following keloid resection if it would result in a significant dose being delivered to the patient's thyroid gland?
This is less of a "medical" answer than one about patient values. As a specialty, we are remarkably conservative, especially when it comes to benign disease (see our reluctance to treat osteoarthritis, compared to other nations). Post-op treatment of keloids is essentially an aesthetic choice. We kn...
How would you manage EBER positive (non-keratinizing) SCCa of unknown primary in the head and neck?
CRT alone as long as neck disease is not multi-level, large, or in the lower neck. I would include bilateral nasopharynx, bilateral RP nodes, and node levels II-V bilaterally.
How do you explain fleeting, post-RT breast pain to patients, and what do you recommend as management?
It is common, underreported, and appears to be nerve related. I recommend assurance as intensity and frequency improve with time.
What radiation fractionation scheme would you use to palliate a patient with metastatic paratesticular leiomyosarcoma limited mainly to soft-tissue sites as well as the scrotum?
Same as other palliative treatments - 300 cGy X 10, 400 cGy X5...
What dose/fractionation scheme would you employ to palliate a metastatic colon cancer patient with several large painful anterior abdominal wall lesions?
Due to the prior surgery, there is almost always fixed bowel adherent to these scar/peritoneal recurrences. That is almost always the dose limiting OAR. The fractionation depends on the PS and life expectancy. From the description, the prognosis sounds poor so 20 Gy in 5, 30 Gy in 10, or 35 Gy in 14...