Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you treat a perineural IgG4-RD with persistent paresthesia?
Perineuritis is an uncommon manifestation of IgG4-related disease (IgG4-RD), but it does occur. In most cases, this is an incidental finding that is not associated with symptoms or nerve dysfunction. This is most often observed in branches of the trigeminal nerve (e.g., infraorbital nerve, frequentl...
In a patient with bilateral neck level II small cell carcinoma with no apparent primary after workup with plans to receive concurrent cisplatin/etoposide, what would be your treatment volumes?
Extrapulmonary small cell cancer, like its lung equivalent, is highly sensitive to chemotherapy but has a high rate of metastatic disease, which is the primary site of failure, with median DFS of about 6 months. If this patient achieves clinical CR after chemotherapy, I would forgo RT. I would consi...
Would a high Decipher score affect your recommendation regarding the addition of ADT to XRT in a favorable intermediate risk prostate patient?
The simple answer is YES.To walk through why...1. Trials like RTOG 9408 demonstrate that there is a metastasis and OS benefit in Intermediate Risk disease from the addition of short-term ADT to RT.2. Later work from many groups showed that intermediate risk is a very heterogeneous cohort. This shoul...
Would you favor radiation or immune modulating treatment like imiquimod to treat an uncomplicated basal cell carcinoma on the nose in an elderly patient for whom you'd like to avoid surgery?
If my patient was concerned about deformity, with 10 to 15 years of life remaining, unquestionably, I would recommend radiation.
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?
We do not have established thresholds for V12-V16 for fractionated SRS and adverse events especially limiting dose evaluation to the "normal" brain.We all need to remember, that the optimal models for estimating toxicity post-SRS include the target volume. YOUR TARGET IS YOUR TOXICITY. So first clin...
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.