Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you ever consider treating a patient with locally advanced NSCLC with SBRT to the primary tumor plus conventional mediastinal chemoradiation?
I have used the technique when the primary is far away, and conventional techniques would give a large PTV on the primary due to respiratory motion. Options in that case would include breath hold, abdominal compression, or phase gating for all 30 fractions of a conventional plan, or treating the med...
In a patient with borderline resectable pancreatic adenocarcinoma s/p 10 cycles FOLFOX and aborted Whipple due to locally advanced disease, do you recommend dose escalation beyond 54 Gy?
Yes, there is no contraindication to giving an ablative dose after exploration. 54 Gray is a palliative dose, which has not improved overall survival based on the LAP07 trial. While it's fair to say that we do not know the definition of definitive or ablative in LAPC, we have published OS results ve...
Do you recommend treating pre-chemo volumes to full prescription dose for locally advanced nasopharyngeal cancer following induction chemotherapy?
I think it is reasonable if the purpose of the chemo was to shrink the primary away from OARs like the optic chiasm. Obviously, as @Dr. First Last says, if the tumor was exophytic, you don't need to treat the air. However, I would still include in my high dose CTV the pre-chemo routes of spread, e.g...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
For locally advanced breast cancer, to what dose do you treat undissected clinically positive level III axilla, SCV or IM nodes?
At MD Anderson Cancer Center, we systematically stage the regional nodes using ultrasound. We biopsy suspicious nodes with FNA at the time of ultrasound. Given this systematic approach to staging, we have a large experience treating patients with biopsy-confirmed infraclavicular, supraclavicular, an...
For patients with locally advanced EBV-associated nasopharyngeal carcinoma treated with induction gem/cis, what concurrent chemo regimen and scheduling do you typically use during radiotherapy?
Cis/gem induction is based on the paper by Zhang et al., PMID 31150573. They used 100 mg/m² every 3 weeks of cis concurrent. ~ 40% received 3 cycles, 50% 2, and 10% 1. As many have in our concurrent scenarios for HN CA, our medical oncologists prefer the weekly 40 mg/m². There remains no clear 2nd l...
What role do you see for functional imaging in selecting patients with HPV-associated oropharyngeal cancer for radiation dose de-escalation?
This study, led by Dr. @Dr. First Last, is unique in using F-MISO PET to select patients for a notably aggressive de-escalation plan, to a 30 Gy total dose for responding patients. We need to wait for long-term results before accepting it in the clinic, notwithstanding that F-MISO is not widely avai...
Can SpaceOAR be inserted a second time?
I had the same thing happen and placed a second SpaceOAR without difficulty. I also have a few cases where the patient had a local recurrence, and a second rectal spacer (after prior radiation with a rectal spacer) was used without difficulty. Please be aware that placement of a rectal spacer after ...
Which types of pancreatic cancer patients should we consider sending to a center that offers EUS-guided Radiofrequency Ablation (RFA) therapy?
EUS-guided ablation for appropriately selected mucinous pancreatic cysts and, to some degree, neuroendocrine tumors is becoming increasingly standardized with multiple reviews on the subject. (Rodger et al., Techniques and Innovations in Gastrointestinal Endoscopy 2024, Moyer & Canakis, PMID 3879629...
Would you offer empiric lung SBRT for two growing FDG-avid lung lesions in a patient with severe COPD on oxygen?
This is a good question! The short answer is yes, most likely. Many patients are too high-risk to receive biopsies; this is decided by surgery/pulm/IR. Unless the patient has contraindications to RT or something like severe IPF (where treatment may be worse than the disease), I would likely offer th...