Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach liver SBRT in patients with hepatocellular carcinoma who aren't candidates for surgery or other interventional procedures when the overall liver volume is small making it difficult to achieve liver constraints?
These are tough situations. I have used proton and photons for HCC. In the situation you described, I would generally favor IMPT due to improved low dose distribution and keeping the parenchyma not treated to a minimum while still giving an ablative dose more comfortably. Although the mean liver dos...
What neoadjuvant approach is best for an adenocarcinoma of the GE junction (arising in Barrett's) with a large hiatal hernia?
I haven't found any publication or clinical trial regarding this very incidental finding. However, I had the opportunity of discussing in tumor board a similar case. I suggested to consider surgical management of the hiatal hernia first, and shortly after recovering, proceed with chemotherapy and ra...
If a patient diagnosed with seminoma after orchiectomy has margin positive disease noted in the spermatic cord and no overt metastasis on imaging and normal tumor markers, how should this patient be staged?
I believe that the staging would be pT3cN0M0S0 in this case. Margin-positive disease suggests continuous rather than discontinuous spermatic cord invasion. In case this was felt to be discontinuous, NCCN v1.2024 now has a note on staging such patients as pT3 (high-risk stage I) and not as M1 (stage ...
Do you prefer to treat patients prone (on a belly board) or supine when treating rectal cancers?
If the goal is reducing small bowel dose, one should use a belly board and treat in prone position. There was a systematic review in the Green Journal regarding this. It's also beneficial when treating with IMRT, as seen in this publication.
How would you manage an epidural spinal metastasis causing cord compression from rhabdomyosarcoma?
Leptomeningeal spread of rhabdomyosarcoma could result from the dissemination of tumor cells in the CSF by direct extension or by malignant cells growing along blood vessels or nerve sheaths. I would first get a total spine and a brain MRI to assess where there is gross disease present in other part...
Would you recommend adjuvant radiation for a large dedifferentiated anterior abdominal wall liposarcoma?
When I have the opportunity to evaluate such a patient before treatment begins, I strongly favor pre-operative radiation with conventional fractionation and margins. If meeting the patient after surgery, it depends a great deal on how the closure was accomplished: reconstructed abdominal wall, prima...
How do you approach an out of field intracranial recurrence for a GBM?
Any patient with recurrent GBM should have multidisciplinary evaluation for indivdualized clinical decision. For patients with out of field recurrence, I would still consider clinical trials as the first option. Off trial, multiple factors should be taken into consideration, including, age, KPS, ne...
When treating keloids with electrons post-operatively, what margin do you use when making your electron field cut out?
Usually about 1 cm around the scar on each side to account for penumbra which is 10% of energy of electron (6 mm for 6 mev electron) and small set up uncertainty.
If an anatomical defect forms due to rapid disease response from pelvic radiation for large gynecological tumors, is it safe to proceed with a further radiotherapy boost?
I would proceed with brachytherapy as planned. For a fistula, if symptomatic, would consider diversion - bilateral nephrostomy or diversion colostomy as needed. Brachytherapy would treat the involved bladder or rectal wall to a therapeutic dose without any needles in the tissue, thereby avoiding any...
Given POP-RT trial, do you cover elective nodes in high risk prostate cancer?
Ah, to treat nodes or not for prostate cancer -- an area that everyone loves to debate. The recent, fascinating POP-RT trial does shed some important light on this topic, but it's important to keep the trial's patient population in mind when deciding whom to apply it to. Also, the trial is not witho...