Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What dose/fractionation would you use to treat an oligometastatic AP window lymph node?
Since the question mentioned "oligometastatic", I presume this is a lesion from an extrathoracic primary.For ultra-central and "ultra-ultra-central" (read: mediastinal) locations, if the intent is to be locally definitive, I would favor 60 Gy/15 fractions, strictly prioritizing OAR constraints -- in...
What is the appropriate workup and treatment for patients with SMART syndrome following radiation for brain tumors?
Stroke-like migraine attacks after radiation therapy (SMART) is a late presentation after treatment for a CNS malignancy (or brain radiation for another cause; e.g., prophylactic cranial radiation). It is one of many late effects of radiation therapy. Others may include vasculopathy, cognitive dysfu...
How would you approach treatment of a recurrent brainstem metastasis following prior SRS?
Recurrent brainstem metastasis can be quite catastrophic. In the upfront setting, I recommend treating to an adequate tumoricidal dose (unfortunately I've seen folks back off significantly in the brainstem and this can result in lower LC rates). Having said that, should a recurrence occur, I would n...
Would you recommend lymph node biopsy in a patient with SCC of the right ventral tongue (~1 cm) post excision with close margins and no noted adenopathy on imaging?
For patients with oral cavity cancers, a neck dissection is generally warranted. Hence, I would not recommend a node biopsy but rather refer the patient back to the surgeon to have a selective neck dissection performed. Since the patient underwent surgery of the primary lesion in the anterior tongue...
In an N+ rectal adenocarcinoma treated via PROSPECT with neoadjuvant FOLFOX with omission of CRT and no treatment response in the primary on pathology (ypN+), would you offer adjuvant chemotherapy or chemo-radiation?
Adjuvant FOLFOX was allowed in PROSPECT, and most patients received it. Presumably, patients with ypN+ disease were most likely to receive adjuvant FOLFOX. We do not (yet) have recurrence data broken down by ypN stage, but as the overall LR rate was less than 2%, I would not consider the lack of his...
What is your approach to adjuvant RT or chemoRT in LS-SCLC s/p lobectomy with N1 disease?
I am unaware of any data suggesting a benefit of adjuvant RT in this scenario assuming completely resected. In the absence of data, I would not recommend adjuvant RT in an N1 patient, rationale below. Adjuvant systemic therapy would be strongly recommended. My thought process to this is that SCLC ha...
For an early stage, estrogen receptor positive breast cancer in an elderly patient, would you recommend: hormonal therapy alone, radiation alone or both?
Based on the CALGB (and PRIME II, shorter follow up) data hormonal therapy without RT is a reasonable choice for many older patients given that there is no survival advantage to the addition of RT. Some patients who are in excellent health and want the maximum risk reduction, may be candidates for a...
Would you recommend observation for an early stage, low grade, ER+, pure tubular carcinoma of the breast after lumpectomy with negative margins for women younger than 65?
We have data in this subset of patients from BASO II. Essentially, the risk of 10-yr LRR was ~20% with nothing, 8% with endocrine tx or RT, and 2% with both. When I treat these patients, I give 40.05 Gy no boost. External beam APBI like IMPORT LOW seems quite reasonable. I would happily enroll these...
Are there extra precautions required for SBRT to a lesion that is proximal to an aortic aneurysm?
Instead of jumping to the SBRT issue, I would like to take the question as posed because I think there is a question of clinical appropriateness involved. If I were referred a patient with an aneurysm at high risk of rupture and who has a concurrent early stage lung cancer for which SBRT was being r...
Do you offer adjuvant durvalumab for stage I small cell lung cancer following SBRT or surgery?
Obviously, there are no direct data, and the standard is EP chemotherapy. The cure rate in this situation is still suboptimal, but the majority of patients are cured. Adding IO might improve survival, but will most certainly increase cost and toxicity. I would discuss with patients, and I often tell...