Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you sequence SRS for brain metastases for a patient receiving dual immunotherapies?
To be honest the strategy in this regard at our center has been haphazard at best. I have not seen any adverse effects that could be clearly related to concurrence of combination dual immunotherapy therapy and GK SRS.My colleague Marc Ernstoff reported results of the Checkmate study which clearly po...
Would you include any elective nodal stations for cases of T3/T4 node-negative NSCLC staged by PET/CT in which a patient cannot undergo nodal sampling?
In short, my answer is “noâ€. I do not target elective lymph nodes for NSCLC patients receiving definitive RT. There are now a few RCTs for locally advanced NSCLC indicating that elective nodal irradiation can be omitted from concurrent chemoradiotherapy (Yuan et al [PMID 17551299], Nestle et al ...
Would you initiate radiation before chemotherapy for the treatment of early stage breast cancer?
The data doesn’t suggest difference in outcome based on sequence but by convention chemo is done before RT. That being said, if for logistical reasons it helps to do RT before chemo then I would do RT before chemo
How would you treat an early-stage gastric adenocarcinoma in a patient who is medically inoperable and not fit enough for chemotherapy?
In my n=1 experience, I treated a medically inoperable patient with a T1N0M0 gastric body adenocarcinoma with "definitive" RT with mild Xeloda. I had the gastroenterologist place clips around the tumor. I treated the whole empty stomach and lymphatics to 45Gy and the gross disease to 54Gy. The patie...
How do you define close and negative margins for soft tissue sarcoma?
The paper by Gundel et al, “Analysis of margin classification systems for assessing the risk of local recurrence after soft tissue sarcoma resectionâ€, J Clin Oncol, 2018 provides useful data regarding the predictive power of different margin classification systems for extremity and truncal soft ...
How do you manage unresctable thoracic esophageal cancer invading the trachea?
I treat these cancers with chemoradiation therapy. That is, I don't forego treatment for fear of creating a fistula where there wasn't one before. Stabilization of the airway is important and should be established before starting treatment and reassessed throughout. If there is a pre-existing fistul...
What dose fractionation schedule do you use to treat head and neck cancer in a patient with Fanconi's Anemia?
If p16 positive oropharynx, 1.2 Gy bid to 64.8 Gy. Otherwise 74.4. Probably no chemo.
What is the best test to determine HPV status for SCC?
The short answer is, p16. It is a better marker of HPV-driven disease than HPV-FISH is. HPV-FISH expression can be lost during oncogenesis, and some data shows the test is more error-prone than p16 immunohistochemistry. In addition, p16 status may better capture oncogenesis from all HPV-subtypes, wh...
What constraints do you use for the normal brain when treating large CNS tumors with standard fractionation?
With photon therapy, we use guidance (not absolute), using the following principles, when using 1.8 to 2 Gy per fraction: Lenses max dose 7-10Gy Optic Chiasm and optic nerves max dose < 60Gy without chemotherapy and 56Gy with chemotherapy. Retina max dose < 50Gy without chemotherapy and 45Gy...
Do you routinely use PRVs for CNS planning?
We do not use PRVs specifically for primary CNS planning or for brain mets treated with Gamma Knife. We have PRV constraints for Spine SRS specifically for the spine.