Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you treat an inoperable <5 cm NSCLC tumor involving the hilum with SBRT?
There is legitimate concern with the development of late toxicities such as bronchial stenosis and hemopytsis after SBRT for centrally located tumors. The recently updated data from RTOG 0813 confirms that even with early stage, node negative, centrally located tumors, there is an approximately 5% r...
Do you recommend re-excision of a unifocal positive anterior margin at skin after lumpectomy in a patient with otherwise low risk breast cancer features?
There are few data on how margin location affects outcome. A group from Dundee and Perth in Scotland reported that re-excision performed for an anterior margin of less than 1 mm found residual disease in only 4% of patients who had initial excision in the subcutaneous plane, compared to 24% of patie...
How do you treat Stage IIIC T4N3 NSCLC?
Probably need a bit more information since T4 is fairly heterogeneous, but it is absolutely treatable. If it involves both ipsilateral lobes, then SBRT to one isolated lesion and CRT for the rest is one approach. If T4 is involved in critical mediastinal organs, probably some induction therapy with ...
How do you approach the discussion about the potential risks of radiation therapy exposure and the development of secondary malignancies for patients with germline BRCA1/2 mutations?
It appears that the risk of secondary malignancies due to radiation exposure does not seem significantly enhanced in gBRCA-m carriers, unlike patients with Li-Fraumeni syndrome (for whom we would attempt to avoid radiation). The data on mBRCA-associated breast cancers would suggest that radiation is...
Do you use a liver dose constraint for right-sided breast cancer?
I don’t do it routinely as it is an infrequent significant issue clinically. In some cases, when tangent includes a significant bite of liver then try to adjust MLC following ALARA principle.
Have you encountered somnolence syndrome after whole brain radiotherapy?
Not specifically that I can recall. However, we should acknowledge that radiation oncologists might not be following our patients following whole brain RT with the optimal degree of diligence. Patients often have a limited life expectancy, are being followed and treated by other physicians. I suspec...
For post-operative radiation of resected high grade soft tissue sarcoma, how long of a delay do you tolerate before starting radiation?
The default/ideal answer is 4-6 weeks, but agreed that is often not feasible. In those circumstances, actively maximize wound healing efforts (plastic surgery, wound care service, lymphedema PT, etc) and start as soon as the surgeon feels it is safe to do so. But it does need to be safe, and ok by t...
Would you consider applying the principles of STAMPEDE with <5 oligometastatic non-regional lymph nodes from prostate cancer?
About 25% in STAMPEDE had low volume metastatic disease with no bone Mets, with most having a non-regional node in that category to qualify as low volume Mets.That being said, common iliac could be the primary drainage of prostate cancer based on SNLN studies and I would favor treating like node-pos...
How do you advise patients on cardiotoxicity when they are expected to receive a low mean heart dose and low cardiac substructure doses with their radiation plan?
I would say something along the lines of: "Radiation therapy is an effective tool for treating your cancer. However, whenever we give radiation therapy, there is always some incidental dose delivered to the adjacent normal tissues. We cannot make the dose zero to all of the normal tissues. Thus, we ...
Do you use an LAD constraint in the setting of BID thoracic radiation for SCLC?
The literature is convincing that an increasing dose to the heart (using whole-heart dosimetric parameters) is associated with an increased risk of adverse cardiac events and decreased survival. Recent and current investigations have attempted to correlate dose to specific cardiac substructures with...