Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you sequence Pluvicto vs docetaxel in a fit, chemotherapy-naïve patient with high-volume PSMA-avid mCRPC progressing on an ARPI?
I generally favor starting with docetaxel, though both are reasonable options. CCTG Study PR21 did not show a difference in radiographic progression-free survival between starting with docetaxel versus starting with Pluvicto in this setting. However, OS favored patients who started with docetaxel, a...
How do you approach hormone replacement therapy for premenopausal patients following pelvic radiation therapy?
Most patients who undergo pelvic radiation will become menopausal. Physiologically, the outcome is similar to surgical menopause because sufficient doses of radiation result in complete loss of ovarian function. In contrast, after natural menopause, the ovaries continue some types of endocrine funct...
Is there anything you use for patients with anticipatory nausea who has failed Ativan and Zyprexa?
I know of no data, but I would consider hypnosis, mediation and mindfulness, cognitive behavioral therapy, acupuncture, and medical marijuana as possible options for anticipatory nausea refractory to lorezapam and Zyprexa. Hypnosis, mindfulness, and cognitive behavioral therapy are in a sense are re...
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
How are the long term results of RTOG 9802 being incorporated into practice in the treatment of "high risk" low grade gliomas?
Answer was written along with Cleveland Clinic resident, Ehsan Balagamwala, MDThe decision to treat low grade gliomas (LGG) can be very challenging. At our institution, we typically utilize the EORTC risk factors to stratify our patients. EORTC high risk is defined as having 3 or more of the followi...
Would you give PMRT to a young woman with a T1-2 breast cancer with a micromet on SLNB?
No great data as far as I know. In general, I treat micromets as ~pN0. @Dr. First Last and colleagues reported on LRR rates and prognostic factors for failure in pN0 patients treated with mastectomy to identify subsets of node-negative patients with sufficiently high risk of LRR who might benefit fr...
What dose constraint, if any, do you use for the diaphragm when treating liver or lung tumors with SBRT?
I treated a HCC patient with a subdiaphragmatic tumor with SBRT 54 Gy in 3 fractions. He developed right posterior chest wall pain that radiated to his right shoulder. On autopsy, he was found to have a path CR in his tumor and necrosis of the adjacent diaphragm muscle. The chest wall appeared gross...
How are you approaching patients with early-stage NSCLC who progress on neoadjuvant chemo-immunotherapy and are no longer surgical candidates?
This is a good question, and we are seeing it too often these days. This question cites progression as the reason for not proceeding to surgery after neoadjuvant chemo-IO. We are also seeing patient refusal and ineligibility (i.e. N3 disease that didn't respond) as reasons. I think it's very importa...
Are there any patients with newly diagnosed GBM in whom you would adopt Early-Start TTFields based on the TRIDENT study?
The authors of EF-32/TRIDENT should be commended for performing this impressive randomized trial of an already FDA-approved therapeutic in GBM maintenance, asking the question of whether an earlier start of TTF, during chemoradiation, improves overall survival. This is also a big ask of the therapeu...
What surrogate(s) do you use to determine toxicity/safety for a SRS plan with numerous metastases?
Before we turn to surrogates let us look at the information that a plan carries and has valuable implications on the quality of the work being done.First we record and report coverage, selectivity, conformity and gradient indices for every patient and every lesion.Second we plan in a consistent mann...