Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage a middle thoracic esophageal squamous cell carcinoma (tumor is 25-30 cm from carina) with a positive supra-clavicular lymph node?
For Proximal/Mid Thoracic ESCA, supraclavicular node is considered a regional node, and therefore part of the AJCC N1-N3 staging system, and should be managed with locoregional treatment, using preoperative or definitive chemoradiation, to 50-50.4 Gy in 2.0/1.8 Gy per fraction. The node could be tre...
Do you recommend adjuvant ADT instead of neoadjuvant ADT with prostate RT?
If ADT and RT are synergistic rather than additive, then the sequencing of therapies should matter. Neoadjuvant: ADT has been shown to reduce proliferation and cell cycling (increase radioresistance) and decrease hypoxia (increase radiosensitivity). However, tumor hypoxia is not a major driver of ou...
What dose/fractionation do you like to use for palliation of bulky LAD from CLL/SLL?
I have treated patients with bulky mass(es) - mostly parotids of recent. Bulky mass(es) -> I like either 400cGy x1 but most use 200cGy x2 (mostly used by me) -> (Electrons for structures like the parotid, but photons for deeper stuff.) For example, when I treated a few parotids glands, they were swo...
What clinical parameters determine when you treat a large HCC lesion with ablative radiation vs Y-90?
Based on 3 negative randomized trials that have compared Y-90 to relatively inactive targeted therapy (Sorafenib), Y-90 has no evidence-based role in the treatment of HCC. In fact, systemic therapies have improved and 3 regimens have shown a survival benefit for locally advanced and metastatic HCC. ...
How do you manage intramedullary spinal cord metastases in the presence of previous radiotherapy?
This is an unusual presentation but can be treated when approached correctly and provide important palliative effect especially in good performance patients. First and foremost, a neurosurgical evaluation including the possibility of a cordotomy should be undertaken. Should the patient be deemed a n...
Do you consider the undissected ipsilateral level IV neck a high or low risk nodal station after selective neck dissection of levels I-III revealed positive node(s)?
Our general philosophy for the postoperative neck is 3 dose levels: 60 - tumor bed (+ margin), 57 - operative bed, 54 - undissected neck. These doses are based on treatment in 30 fractions. Naturally, though, there is the proverbial art versus science. In post op the tumor bed is virtual, often base...
Does the use of A+AVD versus ABVD affect your decision for consolidation RT for bulky Hodgkin lymphoma?
A+AVD is an acceptable regimen for advanced HL based on results from the ECHELON-1 study (Ansell et al., PMID 35830649) showing an improvement in both PFS (82% vs 75% at 6 years) and OS (94% vs 89%) compared with ABVD. Radiation therapy was not incorporated into this study.In advanced HL, regardless...
Do you use a comprehensive volumetric, rather than numeric, cutoff in consideration of SRS vs WBRT for brain metastases?
I think there is quite a bit to unpack from this question. First, I would contend that there is a whole world between SRS & WBRT. There are even active multi-institutional randomized studies being performed to better define this world. Many institutions, including mine, have largely shifted away fro...
What cochlear dose constraint (if any) would you use when treating an acoustic neuroma without serviceable hearing on that side?
I don't think it's necessary to spare the cochlea when treating an acoustic neuroma in a patient who has no serviceable hearing left on the same side of the neuroma. Even if the patient has residual hearing, radiation treatment is likely to lead to complete hearing loss. However, when hearing preser...
For a patient post-prostatectomy with a high PSA (>1), a negative MRI pelvis, and a negative PSMA PET scan, do you pursue any other imaging?
The sensitivity of PSMA scan for PSA above 1 is about 75-90%. I would proceed with salvage RT plus ADT like we did in the era when PSMA was not available.