Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you treat an in-field recurrence/marginal recurrence of NSCLC following previous definitive chemoradiation with salvage SBRT?
I would layer the answer to the patient. First question: Local control, yes or no. If yes, then when... to answer that discussion of systemic option and timing in multiD eval. If yes, then how... surgery, IR thermal ablation, radiation. If radiation then dose/technique... 50 Gy 5 fx, 50 Gy 10 fx, 50...
Do you stop consolidative durvalumab after one year as per the PACIFIC trial or continue if the patient is otherwise tolerating well?
The purpose of definitive therapy with chemoradiation followed by durvalumab is cure. The overall survival was significantly improved in those who received durvalumab for a year in the PACIFIC study. The follow up remains immature, but this data suggests that more patients with stage III lung cancer...
Is there evidence that radiotherapy to less than all sites of oligometastatic prostate cancer is beneficial?
The ORIOLE trial referenced above helps to answer this question. Within the SBRT arm (n=36), patients received PSMA PET, however, the treating rad oncs were blinded to the result and patients were "consolidated" based on conventional imaging. Treatment plans were then reviewed and compared to PSMA, ...
How would you treat an axillary presentation of a breast cancer in the absence of a breast primary?
In the era of MRI these have become rare as sensitivity of MRI is high. Our approach is to treat breast and RNI with no mastectomy as reported LR is low with this approach
What are the advantages/disadvantages of using static IMRT vs VMAT when treating breast cancer?
I think like most disease sites, you gain conformity and possibly more homogenous dose, while the low-dose bath increases. For PBI, I strongly prefer VMAT rather than mini-tangents with FIF (a type of IMRT). I have not found tangential inverse-planned RT to be beneficial in these cases. The VMAT pl...
What dose and fractionation would you use for a non-operable solitary fibrous tumor in the lumbar vertebra with definitive intent?
I remain unconvinced that protons offer better high-dose dosimetry (unless you believe in the shower/bath theory). Max dose will be less with fancy IGRT/IMRT (like 2 Gy a day Cyberknife). There might be no spinal cord, so you might be able to push the dose. I have no experience in such SBRT, but it ...
How would you manage a recurrent cervical cancer previously treated with vaginal cuff brachytherapy and has had a complete response to chemo-immunotherapy?
Ling et al., PMID 30600093 -The paper gives our philosophy in this scenario. The total dose is the function of dose to target and cumulative dose to rectum and bladder. To be able to give a higher dose with brachy, generally would favor around 30.6 Gy with EBRT and then limit the last 14.4 Gy to the...
How would you treat a p16+ squamous cell carcinoma confined in the recto-vaginal septum with no suspicious adenopathy on PET or MRI?
Early vaginal or anal cancer still has relatively high rates of lymph node involvement. In vaginal cancer, T1 lesions have lymph node involvement rates of 5 - 15%. In anal cancer, T1 lesions have a higher rate of 5 - 50%. If there are no mucosal changes then it is possible this is an in-transit LN f...
Would you recommend adjuvant radiation for a patient with head/neck merkel cell carcinoma following a pathologic complete response to neoadjuvant immunotherapy?
In CheckMate, after neoadjuvant IO and surgery, RT was recommended as part of care irrespective of response. Whether in patients with pCR, it added to the outcome is hard to say, as it was not randomized. We favor RT unless pre-IO disease was localized, small, and node negative.
How would you approach a patient with a carotid body tumor and metastasis to the cervical lymph node?
All such patients should be evaluated by a qualified otolaryngologist for removal of the primary tumor and the affected lymph nodes with a selective neck dissection. Surgery is considered the primary treatment for cure. For incomplete resections, adjuvant radiation therapy should be considered for i...