Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you consider adding abiraterone or docetaxel in patients with high risk prostate cancer whose PSA does not become undetectable after ADT and radiotherapy with castrate level testosterone?
There are three concepts here at its core: Does adding abi or doce to ADT/RT in high-risk PCa improve outcomes in unselected patients? Does a detectable PSA while on ADT impact prognosis? Does intensifying therapy in patients with a detectable PSA while on ADT improve outcomes in this subset? Here a...
How do you define PSA progression after salvage or adjuvant prostate fossa radiotherapy?
This is an excellent question which in part mixes tradition, clinical practice, and the conduct of clinical trials both on-going and in the past. Fundamentally, from a clinical stand-point the definition of PSA failure should help manage the patient and improve outcome (prolong life, decrease harm s...
When should the dissected axilla (levels I-II) be included when delivering RNI?
Please see my posting on November 2022 for more details on this subject. To summarize, most of the dissected axilla lies within breast/chest wall tangents, so it is routinely irradiated when RT is used. The upper part of Level 2 is usually outside the tangents and lateral to what is traditionally de...
How do you approach patients with severe mucositis receiving chemo-radiation for head and neck cancer with regards to empiric antifungal or antiviral treatment?
Severe mucositis remains a problem for patients receiving chemoradiotherapy for locally advanced head and neck cancers. While neutropenia can occur in some patients, it is not as frequently seen when compared to those who undergo bone marrow transplants, meaning that our patients do not commonly dev...
Based on the recent guidelines, should prostate SBRT dose be no higher than 3625 cGy in 5 fractions?
We have delivered prostate SBRT in high volume using 3,800 cGy/4 fx since 2006. The UCSF group has also used this schedule in a large number of patients for a similar time frame. For over a decade prior to that, the exact same dose regimen was used with HDR brachytherapy and published as "safe and e...
How do you approach treatment for a patient with an isolated perineal/pubic recurrence of penile SCC s/p definitive surgery?
This would be a case where multidisciplinary input would be very valuable including input from surgery, medical oncology, and radiology. An MRI may also be helpful to help better define the local extent of disease for the multidisciplinary evaluation, and I would try to get a PET/CT to aid in the as...
Do you restrict the dose rate during treatment delivery to a pacemaker in addition to limiting the Dmax?
Delivering a high dose rate implies that the pacemaker would be exposed to the machine's direct output. High-dose-rate exposure to a pacemaker could lead to an instantaneous malfunction and, even if temporary, should be avoided. Please err on the safe side.
Would you treat a patient for heterotopic ossification prophylaxis if >72 hours after surgery?
RT is very effective in reducing heterotopic ossification that can happen after surgery/trauma to the hips. We have always been taught to do either before 24 or less before surgery or within 72 hours after surgery. The rationale is that RT prevents HO by the inhibition of osteoprogenitor cells proli...
How do you manage bladder spasms during pelvic radiotherapy?
My approach would depend on the disease under treatment, specific symptoms, concurrent therapies, and whether or not the patient has a prostate. The first thing I would do, if you have not already done it, is obtain a urine sample to rule out infection. Let's assume that was done and there is no inf...
In locally advanced rectal cancer treated with total neoadjuvant therapy, do you adjust boost volumes to only include post-chemo gross disease/nodes plus a margin?
The answer to this question is that there is usually no risk reduction advantage to making the boost volume smaller for the last 5.4Gy. it may be better to make the boost volumes larger than a uniform expansion on the GTV.There is no definitive guide to boost volumes in rectal cancer. We published o...