Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you apply an ipsilateral lung constraint for conventionally fractionated lung RT?
To my knowledge, there is limited data in the setting of lung cancer that informs ipsilateral lung constraints, outside of mesothelioma protocols. One study by Ramella et al., PMID 19619955 described an ipsilateral V20 of 52% and V30 of 39% as predictive of grade 2 or higher pneumonitis for patients...
Would you offer chemoRT to a colon cancer case with a resected polyp with positive margins if the patient wishes to avoid surgery?
“Wishes to avoid surgery” is different than refusing surgery. Subtle difference perhaps, but I feel like with proper counseling and persuasion, it is possible to “adjust” a wish. A hard refusal is a different matter. But be it wish or refusal, I would not irradiate. Think of how much normal tissue y...
In patients with active IBD and rectal cancer, do you take any precautions before starting TNT?
First, I would be sure that the patient really needs TNT. If a patient has active inflammatory bowel disease, they will not tolerate TNT very well. If a patient has inactive IBD, there is not likely to be much added morbidity. I would be very hesitant to use TNT if someone has really active IBD. The...
How would you approach an adjuvant prostate cancer case if small bowel falls into the prostate bed?
I try to keep most of it less than 54 and use 56 Gy max point dose for my small bowel constraint. I keep shaving off of the PTV to achieve that. Treating with a full bladder should get most of the bowel out of the field so you can at least treat the bladder neck and the anastomosis which are the reg...
Do you use minimum cutoff values for any PFTs below which you would not offer conventionally fractionated chemoradiation or SBRT for NSCLC?
We have historically not used a cut-off lower-limit for FEV1 or DLCO when selecting patients for SBRT for stage I NSCLC. This is supported by both our own (PMID 19487961) and the Indiana University (PMID 18394819) series in which patients were divided into quartiles by baseline PFT's. In both series...
How would you manage BCC to the left cheek after only half of a radiation course was completed three months ago and non-operative management is preferred?
An assessment of three domains is going to help the patient and physicians in this case: Patient related factors: A medical emergency that lasts three months implies a lot-- so what is the performance status of the patient now and what is the prognosis; because an ECOG 3-4+ patient with new onset mu...
Under what circumstances, if any, would you wait on initiating a TKI for metastatic recurrence of a Stage III NSCLC which occurred while on consolidative durvalumab to minimize pneumonitis risk?
Hepatotoxicity is of greater concern with ALK/ROS1 inhibitors. ALK inhibitors such as crizotinib or alectinib in combination with anti-PD1/PD-L1 agents led to higher than expected rates of hepatic and/or dermatologic AEs (Spigel et al., PMID 29518553; Kim et al., PMID 35875467). The field has learne...
How do you manage a supraclavicular only recurrence in NSCLC previously treated with chemoradiation for Stage III disease?
If the patient is otherwise fit and wishes to pursue aggressive therapy, I would consider definitive dose radiation therapy either as consolidation after systemic therapy, or concurrent with systemic therapy.While any recurrence of lung cancer is often a harbinger of systemic progression, a minority...
Would you offer a palliative or more aggressive course of radiation therapy for a symptomatic isolated supraclavicular recurrence of a squamous cell carcinoma of the esophagus?
Such early disease progression suggests there was likely occult involvement of the supraclavicular lymph node at the time of initial diagnosis. My decisions on management would hinge upon the extent of initial CRT field.If the supraclavicular lymph node was in field, I would favor a systemic treatme...
Given RADICALS-HD, are you completing 24 mo vs 6 mo of ADT with XRT following RP?
Initial: We know 2 years of ADT works. Adding to the classic RTOG 9601, RADICALS-HD demonstrated an improvement in the primary and clinically-relevant endpoint of MFS.Who should be offered 2 years is a more nuanced question. I rely heavily on the PSA to guide as I am influenced by the significant in...