Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you consider elective neck nodal irradiation for a large >5 cm head and neck extramedullary solitary plasmacytoma arising from the nasal cavity?
A plasmocytoma in the nasal cavity may bear a higher risk for nodal involvement if it involves Waldeyer's ring or nasopharynx.Adding ENI to the neck will certainly increase the risk of toxicity and only lead to a modest benefit in terms of isolated regional recurrence. I would thus not perform elect...
For SRS, do you prefer fixed kV imaging (e.g. ExacTrac) or cone-beam CT?
In our practice (at U Rochester), we have the ExacTrac system which captures orthogonal X-rays for each couch rotation, using 2 imaging sources on the floor and 2 imaging detectors on the ceiling (in a criss-cross orientation). So, you never get typical AP and lateral films (which I have become accu...
Do you hold palbociclib (or another CDK4/6 inhibitor) in a patient with metastatic HR+ breast cancer while receiving palliative radiation?
Currently there are no large studies on combining radiation therapy with palbociclib. Many of the patients with hormone receptor positive metastatic breast cancer have bony metastases and often need radiation for palliation. There is a small study showing that combination of radiation and palbocicli...
What is the optimal sequencing for SBRT boosts in prostate cancer?
I prefer to follow the schedule used on the PROMETHEUS trial (prospective, phase 2) and have had good results. Wegener et al., PMID 38302321 This protocol delivered an upfront 2-fraction SBRT boost with each fraction given 1 week apart. The EBRT component (46 Gy in 23 fractions) was then delivered 2...
In patients undergoing pre-operative chemoradiation for rectal adenocarcinoma with clinically positive pelvic sidewall nodes that may not be surgically accessible, do you boost these nodes above 50.4 Gy?
I use IMRT with a simultaneous integrated boost to 62.5Gy or 70Gy to lateral pelvic, non-TME nodes that are greater than 5 mm on MRI. I use 70Gy when I can spare the sciatic nerve and the ureter, otherwise 62.5Gy /25 fx (the low pelvis receives 50Gy). I always asked the surgeons if they plan to remo...
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...