Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you use a 4D CT to account for hepatocellular carcinoma tumor motion?
If your IGRT solution is KV imaging, then implanted fiducals are very important for multiple reasons. However, to take full advantage of having them in place, I recommend using an inspiration breath hold technique as well using the Varian RPM system or gating belt that comes with the True Beam. This...
How do you manage patients with low-lying rectal adenocarcinoma who refuse surgery?
There is no simple answer to this question. There is a long history of patients being treated primarily with radiation therapy, but the interest has been much greater in the past few years with the publication of the Brazilian and other data. First, a word of caution regarding this paper in that the...
How does a close DCIS margin factor into surgical and radiation decision making for Stage I invasive ductal carcinoma after breast conserving surgery?
Based on SSO and ASTRO guidelines for invasive tumor, no tumor at inked margin is considered negative by us for suitability for adjuvant RT. If there was calcification as part of the mammographic finding, then for close DCIS we would look at the specimen radiograph and also consider pre-RT mammogra...
Should a lumpectomy cavity boost be given to cN0 patients who receive neo-adjuvant chemotherapy and have a path CR, if planning to complete hypofractionated whole breast radiation?
Once you have recommended post-lumpectomy radiation (and today there are no data to support omission of whole breast after pCR), this question of boost is- are the potential residual cells that you are trying to eradicate more radiosenstive so eradicated by lower dose? There are truly no data on thi...
Are special precautions necessary for esophageal cancer with tracheal invasion prior to chemoradiation?
In addition to the standard staging workup for esophageal cancers including EGD/EUS and cross sectional imaging with CT and PET scan, modern guidelines also suggest evaluation of tracheal anatomy with bronchoscopy. It has been our institutional practice to consider this procedure in any patient with...
Is there evidence to support routine use of adjuvant chemotherapy for resected rectal cancer treated with pre-operative chemoradiation?
We settled this question in 1985 with the GITSG study showing chemo, or radiation were better than observation and the combination had the best survival (GITSG, NEJM 312,1465, 1985). Whether you administer radiation or systemic therapy before or after surgery is irrelevant but all three modalities h...
What is the preferred dose and fractionation scheme for patients with pituitary macroadenomas?
Radiation treatment approach for pituitary adenomas is dependent on several factors. This includes whether it is secretory or nonsecretory, and proximity to optic nerves/chiasm. Surgical resection should always be considered as the first approach (with the exception of prolactinomas, which should be...
When does a rising PSA after prostatectomy indicate growth just of normal prostate?
The concept of residual prostate tissue after prostatectomy has been around since the advent of the PSA. The idea that BPH could exist within this residual tissue has been suggested for nearly the same amount of time. Very little data exists regarding this concept. It has been demonstrated that resi...
Do you boost residual lung disease after chemotherapy after whole lung irradiation for patients with Ewings, Rhabdomyosarcoma or Wilms?
A patient who did not undergone a resection for the gross residual pulmonary metastatic disease in either Ewings or RMS may receive a boost at the completion of the whole lung portion of their radiotherapy. It is infrequent that this occurs at our institution as our bias is to resect the gross resid...
For extremity rhabdomyosarcomas (hand) with positive epitrochlear and axillary lymph nodes, do you treat the lymph nodes or just the primary?
Treatment of extremity RMS (either hand or foot) requires either resection or radiation for local treatment, in the setting of effective systemic therapy. There are good data in the literature showing that the primary tumor can be effectively irradiated, while retaining function and form so to avoid...