Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What are your top takeaways in GU Cancers from ASCO 2025?
Here are the top 3 prostate cancer studies: AMPLITUDE. LBA5006: Attard and colleagues show that the PARP inhibitor niraparib plus abiraterone/prednisone delayed rPFS in men with mHSPC (HR 0.63, p = 0.0001), meaning this is the first ARPI/PARPI successful combination in this hormone-sensitive HRRm se...
What dose-volume constraint should be used for the normal brain parenchyma in a patient receiving 5-fraction SBRT?
This is tough, because most of the literature is based upon single fraction SRS for 1-3 lesions. There are no one criteria for brain doses for multi-session treatments as stated above. Tumor coverage is most paramount, and I agree with the need to respect the adjacent structure doses and to optimize...
What is your preferred dose and fractionation for muscle invasive bladder cancer and how do you decide between them?
I'm using 5,500 cGy in 20 fractions since the Lancet Oncology meta-analysis. If I treat nodes, treat 4,400 cGy in the same 20 fractions. Seems like the mild-moderate toxicity might be higher than with 180-200 cGy/day regimen. The paper referenced above only assessed Grade 3 or higher toxicity. But t...
What is your approach to the adjuvant treatment of early-stage mixed-histology endometrial cancer with a significant clear-cell component?
Clear cell carcinomas are under-represented in most clinical trials and hence, clear evidence-based recommendations are difficult to make. Even a small percentage of clear cell is sufficient to label these as “high grade”. The recently published ASTRO guidelines mention that chemotherapy may not ben...
How do you apply hyperfractionated RT in the dose painting IMRT era in head and neck cancers?
I prefer to use the DAHANCA approach (Overgaard J et al, Lancet Oncol 2010) of providing 6 fractions weekly, 2 Gy per fraction, with a second fraction on a Fri (at 6 hours apart). This is an accelerated course delivering 72 Gy to the primary PTV over 6 weeks. Compared with other fractionated regimen...
In a patient with a history of prior BCS+RT for early stage breast cancer who is now s/p repeat lumpectomy for a low risk in-breast recurrence, what dose/fractionation regimens are appropriate for reirradiation?
PBI using IMRT to 1.5 Gy BID to 45 Gy like phase 2 RTOG.If declines, can do once a day conventional fractionation to 45-50.4 Gy.
What CTV expansions do you use for NSCLC with conventional chemoradiation and do you do different expansions based on specific histologies?
We do 5 mm for all chemoRT cases and do not alter based on histology.
Is there an age that is too young for prostate irradiation?
Great question, and quite relevant, given that over 10% of newly diagnosed prostate cancers occur in men 55 years of age or younger. Although I consider a patient's "biological" age (lifestyle, performance status, etc) more than his chronological when deciding the UPPER age limit for radiation, it i...
What are your preferred strategies to manage mild to moderate rectal ulceration causing tenesmus and discomfort after chemoradiation for rectal adenocarcinoma?
Radiation-induced proctitis or tenesmus -- important to determine if the cause is external or internal to anal verge. Also important to rule out rectal fissures as this typically requires a different approach (Analpram cream and high fiber diet, +/- GI evaluation). If the cause is internal to anal v...
As PARTIQoL was a negative study, what is the current role for proton therapy in the management of prostate cancer patients?
Thank you for the comprehensive answer Dr. @Dr. First Last! It is interesting you talk about integral dose - that almost rarely comes up from the patient in my experience. They have read and have been told that it IS less toxic (not that it may be). They are told that protons are better and the auth...