Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your preferred fractionation scheme for spine SBRT for radioresistant histologies?
As long as it's safe, and I can meet the OAR constraints, I escalate the GTV (but not the entire VB) to 20-24 Gy in 1 fx, 28 Gy in 2 fxs, 30-33 Gy in 3 fxs, 35-40 Gy in 5 fxs. While more work has been published in escalation with single fraction, I find that it's easier to safely escalate those to 4...
If a patient has multiple PET-avid level 3, supraclavicular, or IMN nodes that are small and would have been considered negative by size criteria with traditional imaging, that are no longer positive on PET after chemotherapy, would you try to boost these nodes?
I'd certainly cover the initially involved nodal regions, treating typically to 50 Gy and then, if they were small initially and became PET negative after chemo, stop there. The only time I'd consider boosting if there was preserved glucose avidity following chemo. Obviously respect for normal tissu...
Do you still offer adjuvant chemotherapy and chemoradiation for NSCLC after neoadjuvant chemoimmunotherapy?
In the pre-neoadjuvant era, the options for patients who had R1 (positive margin) or R2 (gross residual disease) were: re-resection followed by adjuvant chemo; sequential adjuvant chemo followed by radiation; or concurrent chemoradiation. There is retrospective data suggesting a survival benefit fro...
What is the recommended adjuvant dose for neuroendocrine cancer in the head and neck?
I assume it's a high grade NEC (small cell or LCNEC) and in that case, I'd treat to 50 Gy in the adjuvant setting with a tumor bed boost (for ECE) to 60 Gy. The volume would be dependent on the location of the primary and the nodal stage.
Is post-mastectomy chest wall radiotherapy indicated for DCIS with very close (<1 mm) or positive margins?
As with most clinical situations with limited data, individualized decision-making is key. Based on small series, I do not generally offer RT post mastectomy for DCIS if it is close. If it is clearly involved after reviewing with the pathologist, I would discuss with the surgeon and patient taking i...
Would you offer PMRT to a pre-menopausal patient with early stage breast cancer, favorable biology, and an axillary dissection showing pN1a disease?
The role of PMRT in this situation remains controversial with factors considered including age/menopausal status, number of nodes, presence of ECE, receptor status, neoadjuvant chemo use, etc.If the patient received neoadjuvant therapy and ypN1, I would offer PMRT.If no neoadjuvant therapy, I often ...
Do you recommend CDK4/6 inhibitor, radiotherapy, or both following surgery for a pathologic fracture from HR+ breast cancer?
The goal of therapy is to help control pain and enhance healing. Post-op RT is routine with the most common dose used by us being 20 Gy in 5. It’s reasonable to do with concurrent CDK4/6 inhibitor.https://www.ncbi.nlm.nih.gov/pubmed/31360799
How would you plan a post-op, distal rectal adenocarcinoma s/p neo-adjuvant chemotherapy and APR with minimal treatment response?
The PROSPECT trial evaluated the omission of radiotherapy from preoperative management for cases that presented with a disease that could be resected with a sphincter-sparing TME. In addition, if the disease responded poorly to preoperative FOLFOX, then patients on that arm were required to receive ...
What radiation treatments would you offer an older man with unfavorable intermediate-risk prostate cancer, with comorbid conditions, if you don't feel he is a good candidate for full-course radiation therapy with ADT?
What is the point of treatment at all if an elderly patient has significant comorbid conditions? I would first consider the likelihood that they would even live 5 to 10 years and fully discuss the side effects of all treatments. There is nothing wrong with watching these patients and not making deci...
Would you offer salvage prostate reirradiation with a rising PSA but negative biopsies?
Quick answer is No. I would NOT give re-irradiation with a negative prostate biopsy. Salvage RT (SBRT or brachy) can have toxicity, sometimes severe. There must be a good justification to give it and a negative biopsy to me is a contraindication assuming the biopsy was performed correctly.