Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your preferred setup/immobilization for patients with cutaneous malignancy of the toe involving the medial aspect of the digit?
I prefer surgery.
How do you manage early and symptomatic fibrosis in lung cancer patients after RT?
Fibrotic changes following lung radiotherapy are common, and I think the challenge here is determining whether the pulmonary symptoms are due to radiotherapy (pneumonitis) or exacerbation of underlying pathology.Initiating a patient on steroids is typically a several week commitment, with subsequent...
How do you manage leptomeningeal disease in relapsed rhabdomyosarcoma?
I recently had such a case and consulted with a well-known colleague who only specializes in pediatric oncology. The recommendation was to treat with 30Gy in 10 fractions with CSI, which I did. The patient is 5 months post this treatment and is disease-free in the CNS.
Would you treat extranodal extension WITHIN a matted nodal mass differently than at the surface in the postoperative setting for H&N cancer?
A matted nodes is a poor prognostic factor for both regional and metastatic disease. Our data https://www.ncbi.nlm.nih.gov/pubmed/25914344 shows a high risk of metastatic disease in HPV+ OPC, suggesting a need to intensify systemic therapy. This is supported by additional published data.
How do you approach adjuvant therapy for treatment of a high-grade astroblastoma?
Astroblastomas are rare and have historically not been assigned a grade by the WHO but there are plenty of cases where more malignant behavior has been observed. We now know that this is due to the fact that multiple types of tumors can have the characteristic astroblastoma pseudorosettes which have...
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...
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...