Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Does your threshold for the duration of induction chemotherapy differ if opting for neoadjuvant SBRT vs chemoradiation in resectable pancreatic cancer?
No, most patients treated in the LaBahn/MCW pancreatic cancer program undergo treatment on a clinical trial. Outside of a trial, total neoadjuvant therapy typically starts with systemic therapy given for at least 2-4 months. While most patients are treated in the setting of a clinical trial, when pa...
Would you consider induction plus concurrent paclitaxel-RT to downstage a patient with initially unresectable cutaneous angiosarcoma, or do you reserve this approach for patients already deemed surgical candidates?
Induction paclitaxel is a standard approach and should be considered for all patients for whom medical comorbidity does not preclude its use. It is critical that the radiation oncologist evaluate the patient prior to chemotherapy so that the extent of disease can be appreciated prior to cytoreductio...
To what extent did device adherence play a role in the clinical endpoints with TRIDENT?
TTFields is a patient-directed therapy, and adherence directly affects how much treatment a patient actually receives. In TRIDENT’s post hoc analysis pooling both treatment arms, patients with at least 50% device usage, averaged over the first three months after TTFields initiation, had longer media...
In a patient with inflammatory triple-positive breast cancer who has a pCR to neoadjuvant chemotherapy, but has an incidentally found focus of intermediate-grade ER+/PR+/HER2- ILC in the mastectomy specimen, how would this impact your adjuvant radiation recommendations?
This finding would not have any impact on my recommendations, since her management needs to be guided by the inflammatory breast cancer. That means chest wall plus nodal irradiation tailored to the findings of axillary surgery. There are no data on whether we can decrease the dose in patients with a...
How do you approach SBRT liver constraints when the total liver volume is <700 cc?
We consider 3 different methods of thinking about liver constraints when evaluating a plan: 1) Sparing 700 cc's to < 15 Gy (for 3 fractions), and <17 Gy (for 5 fractions). 2) Liver mean dose constraints (as in RTOG 1112 for CP A cirrhosis, <14 Gy), and <15-16 Gy for non-cirrhotic patients depending ...
Do you treat synchronous bilateral breast cancers with RT simultaneously or sequentially?
We see a fair number of synchronous bilateral cases here. I am not aware of any compelling arguments or data for sequential treatment over simultaneous. Simultaneous is more efficient in terms of overall length of time, and allows for better coordination of the fields (but there is more time on the ...
Do you have a maximum size cutoff for lung SBRT in central NSCLC?
The bigger the tumor size, the lower the efficacy of SBRT. Typically, I wouldn’t treat lesion of size >7 cm for the following reasons: The local control is lower even with BED>100 Gy; There is high chance that the PTV overlaps with critical structures so toxicities could be high. There is high poss...
How do you approach the choice between 3-fx and 5-fx postop SRS for a resected brain metastasis for intermediate cavity volume?
Yes, decreasing the dose per fraction is a great way to increase normal tissue safety, with a small tradeoff of increasing a few more fractions. Increasing from 1 fraction to multiple fractions has enabled effective yet safe short-course radiation treatments. How few fractions we can do safely is de...
Would you recommend adding 4c of adjuvant nivolumab following SBRT to oligorecurrent NSCLC extrapolating from I-SABR results?
Extrapolating I-SABR results to oligo-recurrent NSCLC needs further investigation. Some preliminary prospective randomized studies have indicated that SBRT with concurrent IO may be beneficial for treatment-naive oligo-metastatic NSCLC or oligo-progressive disease after systemic therapy, including I...
Would you use radiation to treat a persistent VIN III lesion that involves the urethral meatus and has recurred multiple times despite ablation and resection?
I think that the "standard" answer would be to wait until the invasion is documented. Having said that, I would seriously consider a Cs-131 interstitial implant to the area, delivering a dose to total decay of 55 Gy. I have not done exactly this, but I have implanted VIN III adjacent to a positive r...