Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you utilize EUS to determine the nodal radiation fields in esophageal adenocarcinoma?
Assuming that the primary lesion is PET avid, I would not hold up therapy for EUS. If the patient clearly needs to be treated for locally advanced disease, the only question is whether the fields need to be modified. EUS is better than CT (or PET CT) in determining the precise T-stage, especially fo...
Does p16 negative status of anal squamous cell carcinomas affect your treatment approach?
While data are clear that being P16 negative is a poor prognostic sign, we do not have any data on how to alter treatment for these patients. Therefore, I do not change management based on P16 status.
When do you offer hyperbaric oxygen therapy to a pediatric brain tumor patient with radiation injury/necrosis?
I really think it depends as much on the clinical setting as it does the imaging appearance. If you have a case where you are on the early end of the timeline for a CNS RN event (i.e. 3-4 mo post-RT) and the patient is high risk (due to location dose, re-RT, concurrent chemo, etc), then it's worth c...
How would you approach a patient with advanced stage DLBCL with a single-site of residual FDG-avid disease after completion of R-CHOP in the frontline setting?
First would be to assess the residual activity level (e.g. PS 4 or 5), as sometimes a short-interval PET may show improvement. If concern is for residual disease in setting of PET showing partial response, I would consider biopsy of the residual site prior to making any changes in therapy. Once a d...
How would you approach therapy for a young, fit patient with alveolar rhabdomyosarcoma involving the anterior nasal vault/sinuses in the absence of available clinical trials?
The patient should be risk stratified (as per the Intergroup Rhabdomyosarcoma Study Group classifications) and treated with multimodality therapy, including chemotherapy and likely definitive radiotherapy, depending on the specific location. Surgery is also a consideration, but these are generally c...
Would you offer adjuvant chemotherapy for a large, high-grade radiation-induced malignant peripheral nerve sheath tumor following R1 resection?
I assume a post op scan shows no gross disease. Technically this is not "adjuvant" since there is known microscopic residual disease. In a young patient with good PS and organ function, it's reasonable to discuss risks and benefits of systemic chemotherapy (Doxorubicin + Ifosfamide) now vs. close f/...
Would you consider APBI in a primary breast adenoid cystic carcinoma?
I would be reluctant based on local spread pattern.
What is the management of residual bulky (~ 2cm) internal mammary lymph node metastasis from breast cancer after neoadjuvant chemotherapy?
This is relatively uncommon in our practice. However, if there is residual bulky IM adenopathy after chemotherapy, my first question would be whether or not there might be another systemic agent to consider trying before the patient goes to surgery. I would lean toward this approach when feasible. H...
What CTV margins do you use for indolent advanced stage lymphoma treated with palliative radiation alone?
If palliation for advanced indolent lymphoma, I use 2 Gy x 2 to gross disease with CTV of 0-1 cm. My goal is to palliate the clinically symptomatic disease and nothing more. Dose has virtually no side effects for most sites, and retreatment is possible in adjacent or same sites if needed.
How would you manage a positive deep margin in the setting of mastectomy and expander placement?
With these cases, I first discuss with the patient's surgeon if there is any role for re-excision. If not, then I look at whether it is prepectoral or subpectroal. With a subpectoral implant/expander, the at risk margin is in front of the implant/expander; while with a prepectoral implant/expander, ...