Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Is it reasonable to use hypofractionation in early stage male breast cancer s/p lumpectomy?
Absolutely the same as what we do for women with breast cancer.
How do you approach dosing for post-op HNSCC nodal regions with ECE?
This is an area in which the communication between surgeon, pathologist, radiologist, and radiation oncologist is particularly helpful. While our surgeons try to submit nodes with descriptive identification of the nodal level they arise from, it still occasionally happens that we see a pathology rep...
How would you manage eccrine porocarcinoma of the great toe with positive superficial groin and pelvic lymph nodes s/p toe amputation and pelvic lymph node dissection?
Eccrine porocarcinoma (EPC) is an aggressive but rare skin malignancy, let alone one occurring at the great toe! A meta-analysis (Salih et al., PMID 28721214) of worldwide reports on EPC prior to 2016 offered a good overview of the disease’s natural history. It was noted that 31% had metastasis upon...
Is stage N2a alone an indication for PORT in oropharyngeal squamous cell carcinoma with no other adverse features?
The short answer is yes, based on it falling in a list of indications for post-op xrt, which includes lymph node size > 3cm. Further, if this were an oral cavity tumor, some would argue that any node positive patient should be treated adjuvantly (ie even N1, though interestingly many oral cavity can...
What dose-fractionation do you utilize when treating at-risk and elective lymph node levels in patients with HPV-positive oropharyngeal squamous cell carcinoma?
For HPV+ OPC getting definitive concurrent chemoRT, we have been treating the elective nodal levels to 30 Gy at 2 Gy per fraction in the past 5 years (Tsai et al., PMID 35050342). For those treated with definitive RT alone (or with cetuximab) or in the adjuvant setting, we did not reduce the dose in...
In which patients do you offer adjuvant radiation for porocarcinoma?
Porocarcinoma is a rare entity, and there are very limited data on optimal management. For this, and a small number of other very rare cutaneous carcinomas, I generally apply paradigms used in cutaneous squamous cell carcinoma. Positive margins that cannot be cleared, very deep invasion, desmoplasti...
Would you use fezolinetant for hot flashes for men on ADT?
I might consider it after trying the usual agents that will at least partially relieve symptoms in the majority of patients, such as low-dose megestrol or venlafaxine (there are others, but these are the ones with which I have had the most experience and success). Fezolinetant is expensive and requi...
How does treatment management change with a positive intramammary lymph node in the setting of a negative axilla, with the inclusion of these as N1 node in the AJCC 8th edition?
I don’t think anything would change for management as I would treat the same RT field and a med onc would follow the same principle of using genomic assay (or phenotype) to decide about systemic treatment.
When do you consider the addition of concurrent pembrolizumab to breast irradiation?
With the publication of KEYNOTE-522 (Schmid et al., PMID 32101663), we are seeing this scenario much more frequently as patients continue the pembrolizumab in the adjuvant setting.A post-hoc analysis of the timing of radiation in the KEYNOTE-522 trial was presented in abstract form at SABCS 2022, (P...
What PTV margins do you use for definitive prostate radiation?
I tend to follow the RTOG/NRG trials' guidelines for each clinical situation when deciding on margins from CTV to PTV (which use progressively tighter margins based on whether one is doing standard, moderate hypo-, or extreme hypo-fractionation): For conventional fractionation, RTOG 0924 states 0.5-...