Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you irradiate the breast of a patient with an unknown primary malignancy manifesting as bulky axillary adenopathy and non-specific poorly differentiated carcinoma histology?
Incidences of occult breast primary has reduced with the advent of MRI imaging. If the IHC of the node doesn’t support breast primary (GATA 3 or mammoglobin are breast specific markers), then I would not treat the breast.
How do you manage patients with pancreatic adenocarcinoma who progress during neoadjuvant FOLFIRINOX, such that borderline resectable disease is now unresectable but still localized?
Great question; this area is rapidly evolving. I hope some of the ViewRay crowd will see this and chime in. We give ablative doses of radiation (~100Gy BED). That results in survival that is similar to surgery in patients like this (inoperable in an aggressive surgery practice at MSKCC, MSS in prepa...
Would you consider prostate SBRT in a patient with focal extracapsular extension?
Most of the time, the concern for ECE is based on MRI findings. Some of the time the concern for ECE is based on broad capsular contact or irregularity of the capsule. Previous studies have demonstrated that the distance of actual microscopic ECE is 5 mm or less. So suspected ECE or early ECE is inc...
What rates of hemorrhage do you quote to patients receiving SRS/fSRT to intact brain metastases?
I have not had very many patients develop a hemorrhage into a brain metastasis treated with SRS. And those that have hemorrhaged probably had a tendency to do that with their initial presentation with brain metastases. And these hemorrhagic brain metastases have a higher incidence of symptomatic pre...
What CTV expansion volumes would you recommend for a large, unresectable, symptomatic desmoid tumor of the neck?
I would be generous. 2 cm. I’m heavily influenced by "don’t miss and don’t underdose". I appreciate the risk of collateral damage and follow my patients indefinitely, now up to 42 years.😳 I’m acutely aware of the major complications I’ve caused and the recurrences I might have prevented. A difficult...
How do you approach subsequent WBRT following prior brainstem SRS/fSRT?
So I’m assuming this patient who now needs WBRT after SRS for brainstem mets needs it because of elsewhere recurrence. Frankly, I don’t really have a WBRT constraint and ideally, the SRS was over 6 months ago but if the patient needs WBRT I would proceed. I would discuss the potential risk of radion...
Do you have a goal isodose line coverage for skin in the setting of post mastectomy RT with expanders in place?
I don't have a separate goal for skin dose per se in these cases; I primarily look at coverage. In terms of skin dose for these case, I only worry when there are features concerning for skin recurrence and when using higher energy photons.
Is postoperative radiotherapy indicated for a primary parotid gland melanoma?
Yes. I suspect that it would be a nodal met from an unknown primary. Surgery and postop RT.
How would you treat a bulky axillary squamous cell carcinoma of unknown primary in an elderly person?
70 Gy/ 35 fractions over 30-35 treatment days. Electively treat remainder of the axilla and supraclav to 56 Gy at 1.6 Gy per fraction SIB.
What dose of consolidative EBRT do you use after IORT for breast?
I look at these as two types of cases: 1. Planned IORT as boost: ex. younger patient with features warranting a boost who may be having oncoplastic surgery. I will post-operatively give 40.05/15 to the whole. 2. Planned IORT as monotherapy with high risk pathology: if positive margins, I discuss re-...