Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you treat an elderly patient (ECOG 0-1) with locally advanced rectal cancer and synchronous Merkel cell cancer of the extremity requiring adjuvant RT?
Interesting - the flurry of activity came several months after I treated the patient. The patient was not going to get further surgery for either. I choose to treat with definitive CRT (Xeloda) to 54 Gy w VMAT. I treated the Merkel Cell with 30/10 at the same time, presuming the patient would have a...
Do you change your monitoring strategy for a high risk prostate cancer after XRT if the initial PSAs have never been very high?
In general, a patient whose volume of cancer is out of proportion to their PSA makes me nervous. So, I'm much more worried about the patient with a PSA of 5 and multiple cores positive for high volumes of Grade Group 4-5 cancer than I am about the patient with a PSA of 5 and a single positive core s...
Would you offer re-irradiation for a patient with a left sided medial DIEP flap recurrence with a history of prior whole breast radiation 25 years ago?
With all favorable features, would suggest exploring the option of systemic treatment alone. If treating, may assess localized field rather than comprehensive RT.
When treating locally advanced cervical cancer with concurrent chemoRT, do you contour the presacral LNs to the bottom of S3 or you stop your contour at S2-S3?
We contour up until we start seeing pyriform muscle like contouring guidelines for gynecological cancer. We address the differences between prostate and gyne in this letter Musunuru et al., PMID 33610294
How do you approach adjuvant radiation treatment planning for R1/R2, node-negative NSCLC?
There are no guidelines for this. Dose: I would go to 54-60 Gy for positive margins (lower for focal, higher for diffuse)/microscopic disease and a bit higher for gross disease, 60-66 Gy (lower if there is not a "mass", higher if there is visible gross disease). If KPS supports, I would want to cons...
How would you approach an atypical teratoid/rhabdoid tumor (AT/RT) in an adult patient?
For adults, it depends on the metastatic disease status regarding dose to the craniospinal axis. A lot of the kids diagnosed with this tumor are under age three, so up front aggressive chemotherapy is usually their treatment paradigm until they are old enough to get radiation. For adults, though, we...
How would you treat a late hilar recurrence of biopsy-proven small cell lung cancer within the previously irradiated volume?
This has come up twice recently in my clinic. In both cases, were able to generate proton RT plans delivering 60 Gy that seemed reasonably safe. Both patients, unfortunately, developed progressive disease in other sites, perhaps highlighting that we should not take on too much risk when delivering l...
Do you recommend surveillance for secondary malignancies of the rectum and bladder after prostate XRT?
I think it's important to be sure that patients are up to date with screening for colorectal cancer before beginning a course of prostate XRT. I have had an occasional patient who was found to have a colorectal cancer on colonoscopy performed pre-treatment because they were out of compliance with sc...
How would you manage the axilla of a patient with a recurrent ipsilateral breast cancer treated with lumpectomy, sentinel node biopsy, and IORT?
Generally, I am unenthusiastic about reirradiation of breast cancer patients who've been treated with BCT. Even if one can avoid critical structures such as heart and lungs, brachial plexus, etc. Cosmesis is likely to be compromised, given sufficient length of follow-up. In this instance, presumably...
Does Oncotype score affect your decision to do regional nodal irradiation in a patient with early-stage breast cancer?
For ITC, would not change based on genomic testing and treat like node negative disease.