Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you consider delaying tarlatamab initiation in a patient with ES SCLC who recently completed RT for CNS disease, given the concern for immune effector cell-associated neurotoxicity syndrome (ICANS)?
I would not delay beyond what we already do for other systemic treatments. We tend to wait at least a week or more after whole brain RT and systemic therapy of any nature. I do not think this is any different.
What anal squamous cell carcinoma patients, if any, do you take to 59.4 Gy?
I will not usually treat a patient to over 54- 55.8 Gy. The rate of sphincter dysfunction increases sharply at about this dose level and there is no compelling evidence that higher doses are of benefit. However, for very extensive tumors, sphincter function may be severely compromised at presentatio...
In a patient with very advanced head and neck cancer treated with induction chemotherapy and then definitive radiation do you recommend adding concurrent chemotherapy with the radiation?
Sequential chemotherapy does not provide a survival benefit over definitive chemoradiation. [1], [2], [3]. Hence, reasons to consider induction chemotherapy are for local control of disease and to delay the onset of distant metastases. Additionally, there are concerns for increased toxicity and dela...
How old was the most elderly patient you have successfully treated with definitive radiation or chemoradiation for advanced oropharyngeal cancer?
The timing of this question could not be more fitting, since I am currently treating a 97 y.o. gentleman with radiation therapy for his HPV-associated oropharyngeal cancer. Upon his simulation, my therapist and nursing staff gave me a hard time for even offering the patient any cancer treatment. Lit...
What pulmonary dose constraints do you use for patients undergoing lung SBRT for metachronous or recurrent disease after definitive chemoradiation?
Re-irradiation for lung tumor is an area of growing interest. Most of the data is based on retrospective series from single institutions so we don't have a standard to go by. The most important issue is patient selection. The largest risk is pneunonitis. Reported rates from MDACC, MSKCC and Louisvil...
How would you manage a middle thoracic esophageal squamous cell carcinoma (tumor is 25-30 cm from carina) with a positive supra-clavicular lymph node?
For Proximal/Mid Thoracic ESCA, supraclavicular node is considered a regional node, and therefore part of the AJCC N1-N3 staging system, and should be managed with locoregional treatment, using preoperative or definitive chemoradiation, to 50-50.4 Gy in 2.0/1.8 Gy per fraction. The node could be tre...
Do you recommend adjuvant ADT instead of neoadjuvant ADT with prostate RT?
If ADT and RT are synergistic rather than additive, then the sequencing of therapies should matter. Neoadjuvant: ADT has been shown to reduce proliferation and cell cycling (increase radioresistance) and decrease hypoxia (increase radiosensitivity). However, tumor hypoxia is not a major driver of ou...
What dose/fractionation do you like to use for palliation of bulky LAD from CLL/SLL?
I have treated patients with bulky mass(es) - mostly parotids of recent. Bulky mass(es) -> I like either 400cGy x1 but most use 200cGy x2 (mostly used by me) -> (Electrons for structures like the parotid, but photons for deeper stuff.) For example, when I treated a few parotids glands, they were swo...
What clinical parameters determine when you treat a large HCC lesion with ablative radiation vs Y-90?
Based on 3 negative randomized trials that have compared Y-90 to relatively inactive targeted therapy (Sorafenib), Y-90 has no evidence-based role in the treatment of HCC. In fact, systemic therapies have improved and 3 regimens have shown a survival benefit for locally advanced and metastatic HCC. ...
How do you manage intramedullary spinal cord metastases in the presence of previous radiotherapy?
This is an unusual presentation but can be treated when approached correctly and provide important palliative effect especially in good performance patients. First and foremost, a neurosurgical evaluation including the possibility of a cordotomy should be undertaken. Should the patient be deemed a n...