Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What indicators have you found helpful in screening cases that would be appropriate for possible peer review in radiation oncology?
We have written a summary of this issue as it pertains to IMRT, but the concepts would apply to other aspects of external beam RT. Please see Moran et al, in Practical Radiation Oncology July–September, 2011 Volume 1, Issue 3, Pages 190–195. Table 2 in that document is a nice summary of what we cons...
What is the appropriate management of Stage 0 (testicular intratubular neoplasia) of the testicle?
For patients with ipsilateral TIN, usually one performs orchiectomy. This may be diagnosed as part of an infertility work up, as these patients often have primary infertility and atrophic testis. The issue of RT comes for patients with previous orchiectomy and then develop contralateral TIN. For the...
What is the best toxicity data to quote to patients for prostate IMRT vs nerve-sparing prostatectomy?
The surgery vs. RT question is a common one during a “2nd opinion†consultation with radiation oncology. More and more comparative data are being published regarding disease outcomes but many fewer exist regarding toxicity. I often hand out a copy of Sanda et al, NEJM 2008, which reports on qual...
Would you treat a patient with small cell lung cancer (limited to lung and mediastinum) but also with a malignant pleural effusion with upfront definitive thoracic chemoradiation?
I would treat such a case as EXTENSIVE DISEASE. That means chemotherapy with 4 cycles of Plat/Etop, and restage with PET. If the pleural disease has gone by imaging or/and pleural tap, I would add thoracic radiotherapy 30 gy/10 fractions and PCI 2.5 gy X ten. If the pleural space remains positive, I...
What is the most appropriate adjuvant treatment for a gross totally resected recurrent spinal meningioma that has not received prior radiation?
Our CNS radonc group discussed options of therapy in this scenario at our faculty QA meeting. In general, it was acknowledge that options of management would be case specific, and could vary given the rarity of these cases and the limited number of published institutional series. Overall, our group ...
What dose and fractionation do you use when you want an abbreviated course for incompletely resected squamous cell carcinoma of the pre-auricular area?
The answer to this depends on what you are targeting and in turn, the size of your target volume. If treating microscopic residual at the site of the primary (which was not larger than 2 cm), 35 Gy/5 fractions is the shortest course that is advocated by NCCN. For larger target volumes, consider 50-5...
Can chemotherapy be used instead of radiation therapy in a patient with extensive stage small cell lung cancer who presents with epidural spinal cord compression?
I think it would have to be done on a case-by-case basis, and the answer is likely "Not a good idea." Chemo can make SCLC shrink a lot, but you'd really have to monitor day by day with CAT scans. And it unlikely to take the pressure off the spinal cord arteries within hours to days, as is needed. Th...
When do you give treatment breaks for patients with NSCLC undergoing chemoradiation with serious toxicity?
I agree with @Dr. First Last's approach. I am very aggressive in not introducing treatment breaks during radiotherapy. One approach that I occasionally use to "make up" for dose issues when a break is inevitable is to accelerate at the end of treatment to make up for the break rather than to specifi...
How do you handle post-op, pre-radiation breast seromas and hematomas?
It depends on what I'm doing. If the patient is being treated to only the whole breast, like with the Canadian protocol, then I tend to do nothing. I just go ahead and treat. The hematoma usually won't resolve enough to change the volume over the three weeks. If I feel this patient needs a boost, th...
What is the best adjuvant treatment for resected NSCLC?
This is going to be a several part answer to a seemingly straightforward question. I’ll break this down into a few parts: 1) Which chemotherapy, 2) Targeted therapies in molecular subsets, 3) Anti-angiogenic agents, 4) The role of PORT (post-operative radiation therapy). 1. Which Chemotherapy: The s...