Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you recommend additional nodal boost in patients with suspicious internal mammary nodes that respond completely after neoadjuvant chemotherapy?
Our standard practice is to boost undissected regional nodes (IMC, ICV, SCV) that completely respond radiographically, an additional 10 Gy after regional nodal irradiation, and boost those that persist on imaging after chemotherapy 16 Gy. If the radiographic complete response was associated with sig...
How would you approach adjuvant RT for porocarcinoma of the face?
The reported outcomes after surgery in the published literature are all over the place. With some saying surgery alone is adequate and others reporting that these have a high incidence of local, in-transit, and regional recurrence. I tend to treat these with Merkel cell carcinoma volumes.
Would you treat an enlarging metastasis of the brainstem/upper cervical spinal cord with SRS in the setting of widespread disease and prior WBRT?
From what I understand, this is a patient with extensive-stage SCLC and widespread intracranial disease (>40 brain metastases), previously treated with WBRT (presumably 30 Gy in 10 fractions?), now presenting with a symptomatic (~2–3 cm) enlarging lesion at the brainstem/upper cervical spinal cord j...
What are indications for adjuvant radiation for well differentiated non-intestinal adenocarcinoma of the nasal cavity?
I would irradiate all except a well defined T1N0 resected en bloc with negative margins.
How would you palliate a large, symptomatic vaginal melanoma recurrence with limited small pelvic lymph node metastases?
Palliation. Treat problems that are symptomatic. No expensive systemic work up. Pall RT to the pelvis if it’s symptomatic. 30 Gy/10 fractions, 25 Gy/5 fractions, or 20 Gy/2 fractions with a 1 week inter-fraction interval. Apologize for the lengthy response.
Would you omit radiation to the R0 tonsil tumor bed after TORS for p16+ tonsillar SCC when delivering adjuvant radiation to the neck due to + lymph nodes found intraoperatively?
No This is a strategy being advocated particularly from centers that are strongly surgery driven. There has been at least one publication, but the data so far is with small retrospective sample sizes. There is a certain historic irony, as when postoperative radiation was initially advocated in the 1...
Do you require both biopsy of the primary in addition to nodes in your practice for HNC?
While it is ideal to get biopsy from a putative primary and putative nodes, I do not think that it is needed. In cases with a known mucosal H+N primary and several PET avid nodes, I would almost never request biopsy and just treat those as gross disease. The more challenging situation is when you ha...
In stage 4 hilar cholangiocarcinoma, after stenting the biliary tree is there value in radiating the hilar area in addition to systemic therapy so as to maintain patency of the biliary system for a longer period of time or do you depend on the systemic therapy and the stenting alone?
In the setting of metastatic hilar cholangiocarcinoma, biliary patency is one issue but the greater issue is colonization of the biliary tree with gut flora that leads to repeated bouts of cholangitis, and progressive biliary sclerosis that happens regardless of the use of radiation. These patients ...
How would you treat node positive prostate cancer with only a single peri-rectal node on PSMA PET but no other nodal basins involved?
I have encountered this situation more commonly in patients who have failed after radical prostatectomy and extensive pelvic lymph node dissection rather than in newly diagnosed patients. However, in the PSMA PET era, I believe we are seeing more patients with perirectal nodal involvement, so I have...
Would you withhold whole brain radiation therapy for pts with brain metastases from NSCLC unsuitable for resection or stereotactic radiotherapy?
The QUARTZ trial, published earlier this month, was a phase III non-inferiority trial with a primary endpoint of quality-adjusted life-days and pragmatic inclusion criteria. Patients with NSCLC who were unable to undergo SRS or resection were randomized to supportive care (OSC) with or without WBRT ...