Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In what situations would you recommend adjuvant radiation therapy for patients with locally advanced and/or recurrent basal cell carcinoma that receive vismodegib followed by surgery?
Adjuvant radiation therapy should be considered for locally advanced basal cell carcinomas when surgical margins are positive, or when there is perineural invasion, particularly in high-risk anatomical locations such as the face. This recommendation is endorsed by both the NCCN and the American Acad...
How would you approach the radiation treatment of multiple recurrent lentigo maligna on the sole of the foot in an active patient not desiring further surgery?
While surgery remains the gold standard in the management of lentigo maligna (LM), radiotherapy has been used for decades as an alternative, particularly in those patients with surgical comorbidities or where surgery may result in poor functional or cosmetic outcomes. Additionally, radiotherapy is o...
Would you give lung SBRT to a patient with bullous pemphigoid on the chest and torso?
If this patient has a clinically relevant lung cancer (which, by the clinical description, it sounds like it is felt they do) then I would feel comfortable treating them with SBRT. The very focal nature of SBRT makes this a very different scenario than large-field radiation. There is minimal data ov...
Do you offer SBRT Liver for patients with low platelets?
The highest predictor for the development of HCC is cirrhosis, and with cirrhosis invariably comes portal HTN and low platelets. Almost all of our primary HCC patients have some degree of thrombocytopenia, many below 100,000. As such, we have treated them all without difficulty or complication. We w...
Does pre-chemotherapy extent of nodal involvement impact your decision to offer adjuvant radiation in cN1, ypN0 triple-negative breast cancer?
There are few data on this subject. The group at the Netherlands Cancer Institute in Amsterdam created what they called the "MARI" approach for such patients (Koolen et al., PMID 28524246). In brief, they performed an axillary ultrasound and marked the largest suspicious node with a radioactive seed...
How do you sequence chemotherapy with radiotherapy for advanced endometrial cancer?
Unfortunately, we don’t even know for sure if we need RT for stage III disease.GOG 258 showed early concurrent chemo RT is no better than chemotherapy alone (delaying chemo increased distant mets, which probably negated locoregional control benefit of RT). For this reason, chemotherapy has become st...
How do you manage PSA progression while a patient is on Xofigo or Pluvicto?
The tl;drPSA is very much an imperfect tool for these patients. The data show that PSA may initially increase over multiple cycles before decreasing, though this is a minority of patients. Most patients whose PSA increases early have resistant disease, and you should investigate further with imaging...
Would you treat a male breast cancer patient with post-mastectomy radiotherapy for a single positive sentinel lymph node and a low Oncotype?
In the setting of a mastectomy with a positive SLN and no ALND, I tend to extrapolate from AMAROS. While Z0011 had no mastectomy and AMAROS limited mastectomy patients, I am comfortable extrapolating axillary management to mastectomy setting.In this case, I would offer PMRT to chest wall and regiona...
Would you offer adjuvant chemotherapy or radiation to a resected MSS T3N0 high-rectal lesion with low anterior resection without pre-op therapy?
For patients with T3N0 upper rectal cancer with no significant risk factors (R0, CRM clear, no EMVI) who undergo high quality TME surgery as suggested by an intact TME pathologic specimen, the 5-year risk of pelvic recurrence without the delivery of adjuvant radiotherapy is < 5%. I do not recommend ...
Should high risk prostate cancer patients be placed on more potent ADT (abiraterone or enzalutamide) in the upfront setting with definitive RT instead of the standard LHRH agonist?
With STAMPEDE suggesting improvement with the addition of abiraterone in very high risk N0 patients, this is certainly becoming a consideration. Duke is completing a trial of concurrent abiraterone/STADT/definitive radiation for intermediate and lower high risk prostate cancer. Results forthcoming. ...