Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your standard dose for total skin irradiation in a mycosis fungoides patient?
Our standard has been to do the low-dose 12 Gy TSE regimen as it still has good overall response rates with low toxicity.https://www.ncbi.nlm.nih.gov/pubmed/25476993https://www.ncbi.nlm.nih.gov/pubmed/28843374I asked @Dr. First Last to weigh in on this and he agrees that 12 Gy is the standard.
Do you do recommend further mediastinal staging for patients with SCLC or inoperable NSCLC with N1 disease on PET?
I would usually request an EBUS. PET is really outstanding for staging of all lung cancer, but sensitivities in the 90+%, but it will occasionally miss the small nodes of the mediastinum. In SCLC, with a N1 node "with high SUV" the pretest probability of having an N2 node is quite high, so it would ...
How do you manage gastroesophageal junction cancer after resection with a positive circumferential surgical margin when no neoadjuvant treatment has been given?
Fortunately this is not a common occurrence in my practice. However, prior to the wide acceptance of preoperative RT/chemo for esophageal cancer it was more common. I don't think the data base is very good for answering the question, but I have usually treated these patients with essentially the sam...
How would you manage a small to medium sized but unresectable nodal recurrence within the original treatment volume for a head and neck squamous cell carcinoma?
There are a lot of points to consider before you can make this decision: what is the time interval from prior RT? what dose was received to this node from prior RT? what are the critical organs at risk if you were to treat this node? why is this node considered unresectable? how large is the nodal ...
What is your preferred imaging modality for evaluating brain necrosis versus tumor progression after SRS?
My preferred modality is to get cerebral blood volume or perfusion with MRI. It is easy to obtain and adds 5 min to scanning time. Elevated CBV is more consistent with tumor recurrence and diminished CBV is more consistent with radiation necrosis. We have done less brain PET with FDG because inflamm...
What morphologic criteria do you use to call prostate cancer N1 on imaging?
Good question. By old CT standards from the 90s that include not only prostate but NSCLC as well, the criteria for positive LNs was a short axis LN diameter of 1cm or greater. Some have used CT with MRI imaging and lowered to as low as 5-7 mm, too.Source: The diagnostic accuracy of CT and MRI in the...
Can a lumpectomy boost be omitted in a cN0 triple negative breast cancer that has a complete response after neoadjuvant chemotherapy?
At present we don't omit boost for triple negative even after pCR We do participate in the study of exceptional responder to chemo where goal is to see if surgery can be omitted ( pts get adjuvant RT to breast plus boost without surgery)
Do you treat facial and peri-parotid nodes in locally advanced nasal cavity/nasal vestibule cancer?
Yes, I cover those nodal areas for vast majority of cases. Only exception might be if lesion is posteriorly located.
When would you cover the pre- and/or post-auricular nodal basins electively in the post-op setting for tumor involving the parotid gland?
The facial nodes are rarely involved and treating them significantly increases morbidity. I typically treat levels 1b, 2, and 3 for most parotid glad tumors. I do cover them for high grade (grade 3) carcinomas and any squamous cell carcinoma metastatic to parotid nodes.
Can you spare radiation to the neck on a lateralized supraglottic cancer with cN0 neck clinically and neg nodes on PET?
I would not advise it. Supraglottis has high risk of bilateral lymph node drainage, even if clinically and radiologically node negative. Not aware of any data to support sparing the neck. You can treat to a lower dose, but must treat bilateral levels 2-4.