Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach a patient with metastatic Merkel cell carcinoma to the axillary/supraclavicular lymph nodes of unknown primary?
It's important to note that the first step is to thoroughly stage the patient - PET/CT (additional imaging as warranted) and a skin survey. For a patient with a nodal-only disease, I would approach this as a potentially curative case. While it's possible that the risk of distant metastatic disease i...
Would you offer re-irradiation after prostate SBRT for recurrence in prostate and lymph node?
We assume the patient has been fully re-staged. For consideration of possible re-irradiation to the prostate itself, the area of concern in the prostate should be biopsied. One may also give consideration of biopsy to the lymph node if feasible, especially if it's equivocal on imaging. Of course, w...
Do you offer partial breast irradiation to women with tumors infiltrating the dermis (not epidermis) who otherwise fall in the "suitable" ASTRO category?
All the randomized trials in APBI suggested that it is more beneficial for low-risk patients, i.e., the SUITABLE in the ASTRO guidelines or very simply the T1No ER+, >50 years old. With a dermal infiltration, it could be an area not receiving the full dose and the patient is not a low risk anymore. ...
Are there any preferred chemotherapy regimens for Stage IV NUT carcinoma?
We have a current stage IV NUT carcinoma patient. With permission, I am paraphrasing my discussions with Drs. Christopher French and Dr. Geoffrey Shapiro from Dana Farber Cancer Institute. There is no "standard" first-line chemotherapy regimen. However, in fit patients, the current recommendation a...
In what cases do you rely on fiducials for alignment prior to SBRT?
I have used them primarily for small liver mets that are not easily seen on Cone Beam CT without contrast. I typically place at least 3 around the lesion for alignment.
In a very young woman who is s/p mastectomy for a small, high grade, Her2 positive breast cancer, with a micromet in a sentinel node, would you favor completion axillary dissection or PMRT or close surveillance?
These are relatively common cases. The IBCSG 23-01 study does not support ALND in patients with micrometastases (Galimberti et al., PMID 30196031) though <10% underwent mastectomy so the majority of patients likely received RT to part of the axilla with whole-breast irradiation.In patients presentin...
Would you omit a lumpectomy boost in a younger patient (<50 y) with a primary tumor that is otherwise favorable?
This is certainly an evolving area, but I do routinely offer boost solely based on younger age (< 50 or < 40) in patients with otherwise favorable features (ex. T1N0 ER+/PR+/HER2-).
Granted adequate target coverage, do you constrain dose to sub-volumes of the heart when treating locally advanced lung cancer?
This is a very important question that recent data is beginning to shed light on. It’s difficult to address cardiac sub-structures without first talking about mean heart dose, its evolution, and the relationship with baseline cardiac risk. While MHD certainly has its limitations, there is a utility ...
Given risks to ADT, do you use it for cytoreduction in low risk and favorable intermediate risk patients prior to brachytherapy or SBRT?
ADT for purely cytoreduction has increasingly fallen out of favor with variable guidelines discouraging the use of ADT solely for this purpose. This is in part because low-risk men should be offered active surveillance now, and unfavorable intermediate and high-risk men generally should be offered A...
Is the skin dose adequate when treating a patient prone for breast cancer?
Good Question! This is how you can approach the issue in any patient position: The skin is not a target in whole breast radiation planning. When contouring breast tissue, typically 5 mm from skin surface is eliminated/deleted when creating this structure. Plan your whole breast treatment after creat...