Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What SBRT dose and constraints would you use for a primary endobronchial NSCLC that is too thick for brachytherapy?
It really depends on the size and location of the lesion with respect to the proximal bronchial tree and other mediastinal structures (such as the esophagus). SBRT, as commonly understood (e.g., 50 Gy in 5 fractions), strikes me as risky in most such scenarios. Something more like 60 Gy in 15 fracti...
Should we be stopping new starts of patients who can be triaged for 2-3 months like prostate cancers on ADT when significant community spread of COVID-19 is detectable in our area?
I would for those patients requiring ADT, which is the way I interpreted the question. I want to elaborate more because @Dr. First Last brought up other scenarios we should consider and he brings some more good points: Many patients could get active surveillance for a period of time before ADT is co...
How do the results of the phase 2 TREASURE trial for consolidative RT for ES-SCLC impact your practice?
Thoracic radiotherapy is defined not only by dose, but critically by treatment volume. The TREASURE protocol permitted large CTV expansions, discretionary irradiation of clinically uninvolved nodal regions, and substantial additional PTV margins. Elective nodal irradiation is not part of contemporar...
How would you manage RT for a locally advanced squamous cell carcinoma of the anal canal in a >90-year old if chemotherapy is not recommended?
For any elderly patient, a discussion of goals of care in the context of symptoms is warranted. In the chance this is a small asymptomatic cancer in a patient with limited life expectancy, no therapy may be reasonable. However, this does not seem to be the case for your patient.If the patient is dee...
Do you recommend prostate RT for patients with metastatic (M1) disease?
My short answer to this provocative question is “no, I don’t offer men with M1 disease local radiation unless there’s a palliative need.” Treating the primary in the asymptomatic M1 scenario, whether with RT or with surgery, is a major commitment of time, resources, and risk to the patient. The leve...
What would be your radiotherapy plan for an overall stage IIA, low-lying, MMRd rectal adenocarcinoma to try to avoid APR?
For an MMRd rectal cancer, I would use immunotherapy! Very promising data from MSKCC suggesting upwards of 100% clinical complete response with dostarlimab alone, without the need for RT!
Would you consider neoadjuvant immunotherapy followed by radiation for a patient with locally advanced basal cell carcinoma?
This is a relatively data-free area, so there's no “right” answer.I think the first question to ask is whether this basal cell carcinoma (BCC) is amenable to curative intent radiotherapy (assuming surgery is not possible). If so, any adjunctive drug therapies are of secondary relevance.For locally a...
Should we consider radiation therapy for patients with N2 EGFRm NSCLC who will receive osimertinib, though RT was excluded on ADAURA?
For an EGFR-mutant N2 disease, we favor adjuvant chemotherapy (OS benefit) and/or adjuvant TKI based on ADAURA trial (DFS survival). The only prospective data regarding the use of adjuvant radiotherapy comes from a phase III trial, Lung Adjuvant Radiotherapy Trial (Lung-ART), where patients were ran...
Do you recommend chemoradiation following neoadjuvant FOLFIRINOX for resectable pancreatic cancer?
Tough question, with lots of evolution in this area in the past few years. The data would suggest that for borderline resectable pancreatic cancer, there is a benefit in terms of OS from preoperative treatment. For unresectable disease, the small chance of conversion into resectability is worth the ...
Would you consider a patient with DLBCL to have CNS involvement if no brain lesion is seen on imaging, CSF flow cytometry is negative, but PCR is positive for MYD88 and KMT2D mutations?
Cerebrospinal fluid (CSF) is an ultrafiltrate of plasma contained within the ventricles of the brain and the subarachnoid spaces of the cranium and spine. It is possible that cfDNA fragments containing MYD88 and KMT2D mutations may have found their way into the CSF and thereby detected by PCR techni...