Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When treating stage IVB cervical cancer with both systemic chemotherapy and local pelvic radiation therapy, do you incorporate the use of bevacizumab as in GOG 240?
I generally favor starting with multi-agent systemic therapy (Carbo/Taxol/Avastin +/- Pembro) upfront to confirm that the patient is going to respond appropriately and not blossom with metastatic disease prior to making a decision of radiating the pelvis in oligometastatic cervical cancer, similar t...
Is there an SIB boost regimen for a dominant prostate lesion for 60 Gy/20 fx to the whole prostate?
There are no phase III data providing guidance on the "isotoxic" boost dose for a 20-fraction, hypofractionated prostate treatment similar to the experimental arm in FLAME (Kerkmeijer et al., PMID 33471548), but there are two prospective studies of which I am aware, DELINEATE and ARO2020-01, which d...
Would you treat someone following FLAME protocol for prostate cancer without fiducials if using daily CBCT?
The underlying concept within this very practical question is how we rely on on-board imaging for target localization. In my practice, in which I have high confidence in my GTV contouring accuracy and daily setup, I would feel very comfortable using CBCT instead of fiducials. My ideal process includ...
When do you choose motion management over free-breathing techniques for lung SBRT?
The take home message for everyone is that motion management, regardless of the method used, is necessary. All patients should undergo 4DCT imaging in order to construct a "motion map" to quantify tumor motion in all directions. You can never assume that tumors will move in a predictable pattern. Mo...
Is there a role for the addition of radiation to preoperative chemoimmunotherapy in NSCLC with limited N2 disease planned for surgery?
CheckMate 816 was a phase III randomized trial that demonstrated that adding nivolumab to platinum-based chemotherapy in the neoadjuvant setting improved pCR rates and event-free survival (Forde et al., PMID 35403841) and ultimately overall survival (NEJM 2025). The 5-year OS benefit was 10%, almost...
After R1 resection of a locally advanced, node-positive neuroendocrine tumor of the terminal ilium, would you offer adjuvant radiation therapy?
This is a very nuanced question, and I disagree with those suggesting radiation. The great majority of NETs occur at the terminal ileum and the great majority of these tumors are grade 1 or 2. If there was a positive margin it could take many years for that disease to manifest locally. I think radia...
At what PSA level do you offer early salvage radiotherapy?
For a patient with pT3 disease or positive margins, once the PSA is confirmed detectable, rising, and the patient is well-healed, it is appropriate to treat. Given the results from the now 7 adjuvant vs. salvage trials, delaying well past a PSA of 0.2 is associated with the need for more aggressive ...
How do you approach hemorrhagic brain metastases in melanoma?
This is a symptomatic brain metastasis from melanoma. Such patients had poor outcomes in the CheckMate 204 trial with dual IO therapy alone. Local control with RT therapy is advised. In our practice, we start with IO-therapy and radiation joins in whenever they are ready with the plan (as GKRS plan ...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
For NSCLC patients treated with neoadjuvant chemoimmunotherapy and surgery with ypN2 disease, what factors would cause you to recommend PORT?
This question is a tough one, and the multidisciplinary teams I work with are still trying to figure it out. This is mostly because only 13% (67/501) of randomized participants in the Lung ART study received neoadjuvant chemotherapy, and 0% received neoadjuvant chemoimmunotherapy; all had pN2 or ypN...