Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When do you consider re-irradiating patients with recurrent cervical cancer?
Because I have been seeing and treating a reasonable number of these cases for 35 years, I have some strong opinions on the matter. Although external beam re-irradiation in the setting of recurrent cervical cancer is fraught with great hazards and poor outcomes, interstitial re-irradiation has a hig...
Is there a role for stents for patients with a new diagnosis of metastatic upper rectal cancer with a near-obstructing primary?
I haven’t had much luck with stents - they hurt, they often migrate, and tumor growth or perforation is also a risk. My preferred approach is a diverting colostomy, then total neoadjuvant therapy, then resection with eventual ostomy takedown. (This assumes curative intent disease.) Of course, this d...
How do you manage persistent rectal bleeding in the setting of rectal adenocarcinoma in a treatment-naive patient?
For a locally advanced rectal adenocarcinoma in the era of TNT, treatment of the tumor with either chemoradiation or chemotherapy upfront is reasonable, and both choices are known to palliate colorectal cancers effectively. With more severe bleeding, we often consider starting with chemoradiation th...
When consolidating DLBCL with radiotherapy, do you treat all originally involved sites, or just initially bulky and partial responder sites?
When consolidating DLBCL with radiotherapy, several parameters must be taken into consideration. a) Is radiation therapy part of the treatment plan "on top" of full systemic treatment because of a certain risk situation due to not-optimal response of disease to systemic treatment (for example, FDG-a...
Would you consider adjuvant immunotherapy for a patient with high-risk Merkel cell carcinoma following definitive surgical resection and adjuvant radiation therapy?
Although there is no level 1 data supporting adjuvant RT in MCC, a relatively recent meta-analysis from an Italian group (Petrelli et al., PMID 31005218) showed that adjuvant RT is associated with a 75% reduction in local and locoregional relapses versus surgery alone, without a reduction in distant...
How would you treat a young breast cancer patient with limited nodal involvement and an isolated sternal oligometastasis at diagnosis?
Although there is limited data to support this approach, I have treated similar patients with "curative intent" with respect to the RT portion of their treatment. If the sternal oligomet is in close proximity to the ipsilateral IMNs, it can be included within the partial wide tangent fields for the ...
Can the results of Checkmate 577 be applied to patients who do not undergo surgery following chemoradiation because of a clinical complete response?
The standard approach for patients with locally advanced esophageal cancer would be to proceed with surgical resection after neoadjuvant chemoradiation, regardless of clinical response. And then, if surgical pathology confirms residual disease, to proceed with adjuvant nivolumab. If the clinical res...
How would you manage a recurrent pineoblastoma following prior CSI?
Recurrent pineoblastoma following prior CSI represents a challenging clinical scenario. As there is very little published data to guide optimal management, our approach is adopted from recurrent medulloblastoma. The prognosis for patients with recurrent medulloblastoma/PNET is poor, with 5-year OS <...
In light of the recently published Alliance A021501 trial, what is your approach to incorporating SBRT for the treatment of borderline resectable pancreatic cancer?
My approach is the same as it always has been. I have never used low-dose small volume "SBRT" for BRPC or LAPC because it does not make sense. Treating an infiltrating neurotropic tumor that spreads along arteries with millimeter margins on the gross tumor and leaving the regional lymph nodes untrea...
How do you approach treatment of an optic nerve sheath meningioma?
I typically do 50.4 in 28 fractions with a stereotactic technique. We use both co-planar and non-coplanar arcs. I keep the optics point max to 54 Gy. Several single institution series including: MacLean et al. IJROBP 2013, Bloch et al. (UCSF) JCNeuroSci 2012, Ratnayake et al. (Australia) JCNeuroSci ...