Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your preferred radiotherapy regimen for palliative treatment of cutaneous T cell lymphoma?
Cutaneous T-cell lymphomas (CTCLs) comprise numerous distinct entities in the WHO classification of hematologic malignancies. The most common CTCL is mycosis fungoides (MF) followed by primary cutaneous anaplastic large cell lymphoma. As with most hematologic malignancies, both diseases are particul...
What is the biggest mistake people make when starting a linac SRS program?
We teach a course on SBRT and Radiosurgery so I get to talk to many people starting SBRT and radiosurgery programs. I will offer one common programmatic error and highlight some common treatment planning errors. Although some will disagree, a common programmatic error is thinking that you can do it ...
For patients between 40-49 years old who undergo lumpectomy, how do you choose between offering PBI per the updated PBI guidelines or boosting based on boost guidelines?
I think this is an informed discussion that includes data on the pros/cons of each approach. One challenge is that when patients hear about a 5 fx PBI approach, it's harder to rationalize 15 fx WBI (I use SIB for my boosts). You can consider PBI for low-risk patients in this age group but I also cou...
In women with locally advanced HER2+ breast cancer who have had a complete response to neoadjuvant chemotherapy, what factors impact your decision to offer PMRT?
Currently, the use of PMRT should be based on pre treatment staging. If pretreatment staging is stage III, I would recommend RT. If pretreatment nodal staging is IIB would favor observation but would also consider for B51 study randomizing between RT vs observation.
What dose/fractionation would you use to treat an oligometastatic AP window lymph node?
Since the question mentioned "oligometastatic", I presume this is a lesion from an extrathoracic primary.For ultra-central and "ultra-ultra-central" (read: mediastinal) locations, if the intent is to be locally definitive, I would favor 60 Gy/15 fractions, strictly prioritizing OAR constraints -- in...
What is the appropriate workup and treatment for patients with SMART syndrome following radiation for brain tumors?
Stroke-like migraine attacks after radiation therapy (SMART) is a late presentation after treatment for a CNS malignancy (or brain radiation for another cause; e.g., prophylactic cranial radiation). It is one of many late effects of radiation therapy. Others may include vasculopathy, cognitive dysfu...
How would you approach treatment of a recurrent brainstem metastasis following prior SRS?
Recurrent brainstem metastasis can be quite catastrophic. In the upfront setting, I recommend treating to an adequate tumoricidal dose (unfortunately I've seen folks back off significantly in the brainstem and this can result in lower LC rates). Having said that, should a recurrence occur, I would n...
Would you recommend lymph node biopsy in a patient with SCC of the right ventral tongue (~1 cm) post excision with close margins and no noted adenopathy on imaging?
For patients with oral cavity cancers, a neck dissection is generally warranted. Hence, I would not recommend a node biopsy but rather refer the patient back to the surgeon to have a selective neck dissection performed. Since the patient underwent surgery of the primary lesion in the anterior tongue...
In an N+ rectal adenocarcinoma treated via PROSPECT with neoadjuvant FOLFOX with omission of CRT and no treatment response in the primary on pathology (ypN+), would you offer adjuvant chemotherapy or chemo-radiation?
Adjuvant FOLFOX was allowed in PROSPECT, and most patients received it. Presumably, patients with ypN+ disease were most likely to receive adjuvant FOLFOX. We do not (yet) have recurrence data broken down by ypN stage, but as the overall LR rate was less than 2%, I would not consider the lack of his...
What is your approach to adjuvant RT or chemoRT in LS-SCLC s/p lobectomy with N1 disease?
I am unaware of any data suggesting a benefit of adjuvant RT in this scenario assuming completely resected. In the absence of data, I would not recommend adjuvant RT in an N1 patient, rationale below. Adjuvant systemic therapy would be strongly recommended. My thought process to this is that SCLC ha...