Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you consider the undissected ipsilateral level IV neck a high or low risk nodal station after selective neck dissection of levels I-III revealed positive node(s)?
Our general philosophy for the postoperative neck is 3 dose levels: 60 - tumor bed (+ margin), 57 - operative bed, 54 - undissected neck. These doses are based on treatment in 30 fractions. Naturally, though, there is the proverbial art versus science. In post op the tumor bed is virtual, often base...
Does the use of A+AVD versus ABVD affect your decision for consolidation RT for bulky Hodgkin lymphoma?
A+AVD is an acceptable regimen for advanced HL based on results from the ECHELON-1 study (Ansell et al., PMID 35830649) showing an improvement in both PFS (82% vs 75% at 6 years) and OS (94% vs 89%) compared with ABVD. Radiation therapy was not incorporated into this study.In advanced HL, regardless...
Do you use a comprehensive volumetric, rather than numeric, cutoff in consideration of SRS vs WBRT for brain metastases?
I think there is quite a bit to unpack from this question. First, I would contend that there is a whole world between SRS & WBRT. There are even active multi-institutional randomized studies being performed to better define this world. Many institutions, including mine, have largely shifted away fro...
What cochlear dose constraint (if any) would you use when treating an acoustic neuroma without serviceable hearing on that side?
I don't think it's necessary to spare the cochlea when treating an acoustic neuroma in a patient who has no serviceable hearing left on the same side of the neuroma. Even if the patient has residual hearing, radiation treatment is likely to lead to complete hearing loss. However, when hearing preser...
For a patient post-prostatectomy with a high PSA (>1), a negative MRI pelvis, and a negative PSMA PET scan, do you pursue any other imaging?
The sensitivity of PSMA scan for PSA above 1 is about 75-90%. I would proceed with salvage RT plus ADT like we did in the era when PSMA was not available.
How would you manage a patient with a high-risk asymptomatic bone metastasis with a driver mutation?
It seems that the unexpected outcome of a survival benefit was likely due to the prevention of fractures that likely led to hospitalization then death. This was a phase II study and OS was a secondary outcome, but it does make sense. Complicating metastatic cancer with a femur fracture leading to ho...
How do you manage a patient who presents with a tracheoesophageal fistula from a lung or esophageal primary that is non-metastatic?
My experience with this has typically been with primary esophageal cancer presenting with TEF. It's obviously a challenging and individualized situation requiring multidisciplinary input and extensive clinical assessment and discussion. I generally recommend induction chemotherapy since the ideal sc...
How would you approach a patient with vitreoretinal lymphoma without CNS or systemic involvement?
The optimal treatment approach for primary intraocular lymphoma is debated. This is a rare disease with only small retrospective series guiding therapy. There is no clear superior treatment approach in the literature. In clinical practice, younger patients are often treated initially with high-dose ...
When using Quad Shot regimen for palliation of unresectable head and neck cancers, would you treat concurrently with chemotherapy?
No. If palliative RT, I usually don’t recommend concomitant chemo.
In asymptomatic patients with castrate resistant prostate cancer who have failed chemotherapy and have progressive PSMA-avid vertebral body metastases, when do you prescribe lutetium 177 (Pluvicto) vs prophylactic spinal radiation?
It's rarely either/or. I would say that pretty much any patient like the one described in the question should be getting Pluvicto as it has a demonstrated OS benefit. But sometimes the patient may also need more immediate palliation with EBRT before Pluvicto can get up and running. The main issue he...