Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you modify dosing and monitoring of Lu-177–PSMA therapy for patients with prior large-field RT involving substantial active marrow compared with patients who only had focal bone SBRT?
No, we do not modify dosing and monitoring of PSMA therapy with prior large-field RT. In the VISION trial, the vast majority of patients were heavily pre-treated, presumably many with pelvic radiation for definitive treatment or treatment for bCR prior to metastasis. Assuming that the patient had ap...
What is the role of radiotherapy in a newly diagnosed patient with parameningeal rhabdomyosarcoma w/ intracranial extension, a positive CSF but no extra-CNS metastases?
The question as to the role of RT in patients with parameningeal (PM) RMS with CNS leptomeningeal disease is complex and one lacking scientific evidence to support one’s answer. My response represents a historic viewpoint gained from hearing the discussions of the Intergroup Rhabdomyosarcoma Group (...
How does one interpret the LUMINA trial in the FLORENCE APBI ERA?
This is a common scenario. My practice is to discuss this with the patient. I discuss 5 fraction PBI or 5 fraction WBI depending on the scenario, as well as endocrine therapy and the differences in toxicity profiles. Given compliance rates of 50-60% with endocrine therapy long-term, many patients pr...
When proceeding with neoadjuvant CRT, what is your radiotherapy plan in a patient with distal esophageal adenocarcinoma and an avid AP window lymph node?
If it is not biopsied, but there is high suspicion of disease based on morphology and SUV, would treat to 50.4 in 28 if the surgeon is not removing, but can consider lower if they are. If with CTV/PTV expansion of primary, it remains discontiguous, it can be a separate field/isocenter.Of note, I typ...
How would you manage a patient treated with SBRT <1 year ago for a peripheral lung cancer who now has both mediastinal and local failure?
Presuming that the patient is inoperable due to the same reasons why the initial early stage disease was not managed surgically, given a peripherally placed primary, it likely can be retreated with SBRT, while minimizing chest wall and skin dose if at all possible. There shouldn't be an issue with r...
Despite the paucity of strong data showing benefit of chemotherapy + radiotherapy in patients with stage I-II high risk histology endometrial cancer, if you recommend treatment with both modalities, how do you determine treatment schedule?
For the purpose of this answer, I'll define high risk as serous, carcinosarcoma, undifferentiated, and dedifferentiated. Clear cell carcinoma can be considered and likely treated more by its molecular profile. As you indicate, there is little data to support the routine use of chemotherapy for FIGO ...
Would you consider boost radiation for focally positive margins after 50 Gy and surgery in undifferentiated pleomorphic sarcoma of chest wall?
I typically do not use a post-operative boost in patients with soft tissue sarcoma that have received preoperative radiation for a few reasons:(1) By the time surgery has happened and the patient has healed, it may be 2 months or more since completion of preoperative RT. If there is truly residual v...
Do you ever pause or delay radiation for an infection?
Infections can be frequent, especially in patients who are immune- compromised from prior chemotherapy or concurrent chemoradiation. I think the decision to hold treatment is site specific. I would not hold pelvic RT for a patient with a bladder infection as long as I was treating the infection and ...
What are the safest dose constraints for moderately hypofractionated prostate cancer?
At Penn, we have a protocol for 70 Gy/28 fractions using proton or photon therapy for low- and intermediate-risk patients. I initially designed it with a conedown as follows, but that is not always necessary/appropriate. CTV Initial = Prostate and proximal seminal vesicles to include at least 1 cm, ...
Given the long half-life of dexamethasone, what is an appropriate dose schedule?
After a discussion years ago with my fellowship-trained Neuro-oncologist friend (from Neurology track), I use dexamethasone only ever on a qam schedule. It doesn’t disrupt the sleep as much, there’s no waking for doses, the schedule is easy for patients and families to remember. In seven years of pr...