Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When utilizing hypofractionated radiotherapy in the post mastectomy setting, are the nodal regions dose painted to a different dose or the same dose as the chest wall/reconstructed breast?
Our usual dose to the reconstructed breast/chest wall is 45 Gy in 18 fractions, requiring at least 95% of the PTV to receive 100% of the prescribed dose. The prescribed dose to internal mammary nodes (when treated) is the same, with a slightly lower acceptable dose (95% of the PTV receiving 95% of t...
Is there any situation where hypofractionation of post-mastectomy radiation (CW and regional nodes) is absolutely contraindicated?
While not absolute given some phase 2 data, I am not currently offering hypofractionated PMRT to patients with reconstruction, as I am awaiting results of the Alliance trial. I do offer hypofractionated PMRT to patients who are not undergoing reconstruction. However, I am cautious in patients with c...
What are your top takeaways in Breast Cancer from ASCO 2025?
My Top 3 takeaways in Breast Cancer from ASCO 2025 ASCENT-04: Sacituzumab Govitecan Plus Pembrolizumab as a New First-Line Standard for Metastatic PD-L1-Positive Triple Negative Breast Cancer (TNBC): The treatment landscape for metastatic TNBC continues to evolve rapidly. At ASCO 2025, presentation ...
How would you manage a pT2N1a invasive ductal carcinoma s/p lumpectomy and sentinel lymph node biopsy with ECE, and two mildly avid axillary lymph nodes on post-op PET/CT?
We often see mildly active lymph nodes on post-op PET/CT scans, so one important initial question is how long after the surgery the PET/CT was performed. Another question would be how many total lymph nodes were removed at the sentinel biopsy. If the scan was done ~6 weeks post-op and the patient ha...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Do you offer low-dose radiation therapy for osteoarthritis of the spine?
DEGRO has published guidelines on this very topic, so I would respectfully disagree with a comment arguing a lack of data. Of course, if one is looking for level 1 data on irradiating benign diseases in general, there may be little to satisfy.That being said, there's no level 1 data espousing the be...
What are your top takeaways in GU Cancers from ESMO 2025?
KEYNOTE-905: These impressive results change the management paradigm of patients with MIBC who are surgical candidates but are not cisplatin-eligible. Over time, it may be that EVP perioperative therapy becomes the standard of care for all patients with MIBC with plans to proceed with cystectomy. I...
Would you omit radiation for an elderly woman with bilateral breast cancers (both early-stage disease and ER+/PR+/HER2 negative) who otherwise meets the criteria for endocrine therapy alone?
Yes. If the patient meets omission criteria on each side individually, then I offer omission to the patient overall as part of shared decision-making, although it is conceivable that the absolute benefit of radiation is doubled in this scenario. As usual, this assumes the patient will be compliant w...
What are your top takeaways in Head & Neck Cancers from ASCO 2025?
The phase 3 KEYNOTE-689 and the phase 3 NIVOPOSTOP. A key distinction is that KEYNOTE-689 incorporated both neoadjuvant and adjuvant immunotherapy, while NIVOPOSTOP restricted immunotherapy to the adjuvant phase and specifically targeted patients with high-risk features (+ margins and ECS) post-surg...
Are any centers routinely using 55 Gy in 20 fractions with chemotherapy for definitive treatment of head and neck cancer following presentation of the HYPNO study?
I would not consider 55 Gy in 20 fractions a standard approach. The comparator arm was not standard practice in the US (66 Gy in 33 fractions with 5 weekly cycles of cisplatin at 35 mg/m2). Both the total RT dose (66 Gy < 70 Gy) and the total cisplatin dose (cumulative dose 175 mg/m2, less than the ...