Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In patients who have residual bladder tumors after maximal TURBT, would you boost the GTV above typical doses, 55 Gy/20 fractions or 64 Gy/32 fractions, assuming you can meet constraint?
In the British study, (55/20 + MMC), these patients were encouraged but not required to undergo complete TURBT; ~45% in each arm of the study did not get a complete TURBT. No boost was given to those who did not get a complete TURBT. As this is the only RCT (for some reason, the RTOG never did an RT...
Are patients with MIBC and bladder neck involvement good candidates for bladder preservation with chemoradiation after maximal, but not complete, TURBT?
Both BCON and BC2001 suggest that a complete TURBT may not be essential for bladder preservation. Incomplete TURBT is a surrogate for a higher stage and predicts poorer outcomes irrespective of the modality used for treatment.Elumalai et al., PMID 36517194
How would you treat an elderly, frail patient with a bulky penile SCC with bilateral inguinal nodes?
These are challenging cases. Conventional wisdom is that patients with bulky nodes are considered rarely curable without surgery: However, this has not been my experience. Nevertheless, to achieve a durable outcome, including cure, our practice has been to use combined chemotherapy and radiation the...
Would you offer liver SBRT without fiducial placement?
When we first started doing liver SBRT cases in the early Paleolithic 2000s (refs), we never used fiducials and just managed by using the nearest liver surface contour (or diaphragm if using a breath hold technique) and/or any other intrahepatic anatomy that was distinguishable once we added CBCT. I...
Which patients with relapsed/refractory NHL are appropriate for pre-CAR-T bridging radiation therapy?
Before answering this important question, I think that we, as Radiation Oncologists, should give serious consideration to moving past the terminology of "bridging radiation therapy" and instead refer to it as "pre-CAR-T infusion radiation therapy." Bridging therapy was initially an apt name; we were...
How do you best communicate SBRT planning directives, specifically in regard to how "hot" the plan should be?
This is where common language becomes uncommonly important. There are two languages one can speak re: doses in external beam radiation therapy. In language one, the 100% line always equals the MD's prescribed gray* dose. In language two, the 100% equals the maximum gray dose in the plan. Most of my ...
How would you approach oligoprogression of metastatic prostate cancer with a large met in the humeral head?
The role of radiotherapy for oligometastases is developing, with many studies underway. The best prospective data yet is for castration-sensitive oligometastatic prostate cancer, but there are several retrospective studies looking at the role of SABR for oligoprogressive CRPC. Two worth looking at a...
When treating a soft tissue sarcoma close to humeral head, what humeral head dose constraint should be used?
This is a fantastic question particularly in light of your absolutely correct assessment that the literature is silent on this issue. And osteonecrosis of the humeral head and humeral fractures have certainly been reported (e.g. Rossleigh et al (1986) Cancer); this coupled with a potential arthritis...
What is your target volume for a recurrent low-grade meningioma previously treated with surgical resection alone?
This is a great practical question. What I have done is to fuse the original MRI, the pre-op recurrence scan and the post-op recurrence scan so that the clinical target volume can be all the meningeal surfaces that were ever in contact with the meningioma (initially or at progression). I don't usual...
Is there evidence to support bladder preservation therapy in node positive bladder cancer?
Although there aren’t randomized data suggesting the superiority of trimodality therapy (TMT) over any other treatment for N+ bladder cancer, I think most feel that it is the standard of care as alluded to in the question. Broadly speaking, patients and providers have two options: radical therapy or...