Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For a patient with intracranial mets for ES-SCLC who undergoes resection, do you routinely offer post-op SRS to the cavity, or do you proceed with WBRT?
While Whole Brain Radiation Therapy (WBRT) has been the standard, stereotactic radiosurgery (SRS) to the surgical cavity is increasingly being used to minimize neurocognitive decline. However, the issue is especially more nuanced for an ES-SCLC (we don't know whether the primary has been controlled ...
When proceeding with neoadjuvant CRT, what is your radiotherapy plan in a patient with distal esophageal adenocarcinoma and an avid AP window lymph node?
If it is not biopsied, but there is high suspicion of disease based on morphology and SUV, would treat to 50.4 in 28 if the surgeon is not removing, but can consider lower if they are. If with CTV/PTV expansion of primary, it remains discontiguous, it can be a separate field/isocenter.Of note, I typ...
What criteria are you using for retreatment with Pluvicto (Lu-177) in those who maintain a good performance status and appropriate lab work?
Mainly, whether or not they've exhausted standard options. At the time I'm answering this, Pluvicto is approved for castration-resistant metastatic disease, either pre- or post-taxane chemotherapy. If they have not had chemo, I usually recommend it. If they have, I get their medical oncologist to we...
Do you routinely contour spinal nerves as avoidance structures for spine SBRT/SRS cases other than those for the brachial and lumbosacral plexuses?
In my practice, I do not typically contour spinal nerves as OARs other than those for brachial and lumbrosacral plexuses. Radiculopathy can occur but it is usually well tolerated and self-limiting. In my experience, the rate of persistent radiculopathy is very low.
In a patient with rectal cancer, when would you consider brachytherapy monotherapy or brachytherapy boost after CRT?
For a patient with cT2N0 disease, the most appropriate use of brachytherapy would be sequential with pelvic radiotherapy, the bulk of data being with long-course CRT. Brachy can either be done prior to CRT or sequenced afterwards. We routinely use brachytherapy in appropriate candidates in our pract...
For patients starting Pluvicto, do you have patients stop their ARPI?
While the VISION trial allowed for concomitant use, it was only about half (53%) in the Lu-177-PSMA arm, and 2/3 (68%) of those on the standard of care arm - Garje et al., PMID 36693228. And the PSMAfore trial did not, as noted above by @Dr. First LastThe bigger question is, will you continue the AR...
How do you sequence Pluvicto vs docetaxel in a fit, chemotherapy-naïve patient with high-volume PSMA-avid mCRPC progressing on an ARPI?
I generally favor starting with docetaxel, though both are reasonable options. CCTG Study PR21 did not show a difference in radiographic progression-free survival between starting with docetaxel versus starting with Pluvicto in this setting. However, OS favored patients who started with docetaxel, a...
How do you counsel a young man receiving EBRT as part of TNT for rectal cancer about risk of infertility?
I counsel male patients that, although the testes are outside the target dose volume, they will receive enough radiation that it could, at least temporarily, impair their ability to conceive. I offer to refer them for sperm banking prior to starting treatment.
What mucosal surfaces do you commonly cover with HPV-positive squamous cell carcinoma of the head and neck of unknown primary?
This is an interesting question. Many radiation oncologists are eliminating the nasopharyngeal mucosa from the field when designing plans for “comprehensive mucosal irradiation” in cases of unknown primary head and neck cancers with HPV or p16 positive squamous histology. I am currently not comforta...
How would you treat synchronous high-risk prostate and rectal adenocarcinomas in an elderly man where the rectal cancer was resected secondary to obstruction (T3N0)?
Start with androgen deprivation. EBRT 45 to 50.4 Gy at 1.8 Gy per fraction to the pelvis. Boost prostate with brachytherapy if feasible or EBRT to somewhere around 80 Gy depending on the small bowel. Adjuvant chemo is unlikely to be tolerated.