Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage p16+ SCC of the oropharynx with bulky lymph nodes that are not responding as expected to standard chemoradiation?
During treatment: Confirm via daily CBCT that the nodes in question remain inside PTV_high. If there are notable changes in external contour or target contour, have dosimetry run a verification plan to confirm coverage. This is particularly necessary if there is enlargement of the node in question, ...
Can you treat the regional lymphatics when using a prone technique for treating the whole breast?
We had an institutional protocol in which patients were treated prone to the breast, axilla, and supraclavicular nodes. The breast was treated with tangents and a third field was added to treat the SCV nodes (as is done supine). Of note, the internal mammary nodes could not be included with prone po...
Is there a role for adjuvant RT in a pleomorphic dermal sarcoma after WLE?
Adjuvant radiotherapy (RT) should be considered for pleomorphic dermal sarcoma on a case-by-case basis. There is no clear data to support the use or omission of radiotherapy in this disease, but we base our clinical decision-making on three factors: Estimated local recurrence risk Morbidity of treat...
Would you recommend adjuvant radiation for an atypical fibroxanthoma of the scalp that is completed resected with +PNI and +LVI?
Atypical fibroxanthoma (AFX) is a rare cutaneous neoplasm. Diagnosis is often difficult, and may require the input of an expert soft tissue or dermatologic pathologist. I have seen many of these cases diagnosed elsewhere as AFX, and upon re-review, the diagnosis is changed to cutaneous squamous cell...
In a patient with biochemical recurrence after radical prostatectomy for pT2 disease and a high-risk Decipher genomic classifier, with a PSA of 0.7 ng/mL, is there a rationale for administering salvage radiation therapy to the prostate fossa?
Yes, salvage RT to the prostate fossa (+ ADT/ pelvic lymph nodes) would be considered the preferred option in this circumstance, in my opinion (see NCCN 2026.3). Despite the PSA being higher than is typical in 2026 and some risk factors for not responding to RT (e.g., margin-negative resection), it ...
What is the most appropriate dose-fractionation for an early stage, progressive cutaneous squamous cell carcinoma of the nose in an elderly/frail patient in the setting of the COVID-19 pandemic?
30 Gy/5 fractions or 40 Gy/10 fractions. I prefer 250 kvp. Increase dose by 10% with electrons and increase margins from 1 to 2 cm. Collimate on skin with a lead mask.
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...
Are there any contraindications to Pluvicto therapy you personally use, given that there are none directly provided by the manufacturer?
In this situation, it is helpful to review the eligibility and exclusion criteria from the VISION protocol directly. These can be found at NCT03511664 (Sartor et al., PMID 34161051). Many of these patients have been heavily pretreated, including prior taxane therapy, so my main concern is that they ...
Which imaging modality do you prefer when monitoring disease status for patients with prostate cancer undergoing 177-Lu PSMA treatment?
Imaging weeks or months later probably serves no useful purpose. What may be far more useful is SPECT for dosimetry imaging right after the first dose, to determine the absorbed dose in Gy to the tumors and the OAR. Then, if OAR doses permit, one may administer a higher dose of Pluvicto that may lea...
For LS-SCLC with radiographic CR after chemotherapy, is there a time point beyond which you do not offer radiation if there is a delay in initiation of radiation?
I don't think we really have any data guiding this scenario. We know that optimal benefit is achieved when definitive RT is given within the first 2 cycles of chemo. However, I don't think that chemo alone is adequate for total eradication of disease. If the patient is within 1-2 mos of completing c...