Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you treat inguinal lymph nodes for rectal cancers involving the anal canal?
One of my residents recently told me that I should treat the inguinal nodes for low lying rectal cancers based on recommendations on the MedNet. I realized this is an old post, but I would like to add a nice reference that really convinced me that there is probably minimal benefit to treating inguin...
Should the use of a brachytherapy boost affect the duration or use of ADT in intermediate or high risk prostate cancer?
We traditionally think of 4-6 mo ADT for intermediate risk, and 18-36 mo ADT for high risk men treated with EBRT (whether dose escalated or not). For high risk men in our practice, I have usually recommended 28 mo (from RTOG 9202) ADT as a standard. I do think it is fair to consider a course <28 mo ...
What prostate cancer patient population would benefit from a brachytherapy boost after EBRT without the use of ADT?
The paper referenced in the question for better or worse is the best evidence we have regarding the benefit we can expect from a brachy boost, the benefit we can expect from the addition of ADT to EBRT, and if you were to compare EBRT+ADT vs EBRT+brachy. It shows that adding ADT has an OS benefit co...
For a patient with a rising PSA after prostatectomy with seminal vesicles being negative for disease at surgery, do you ever treat the prostate bed and seminal vesicle bed with different doses in an SIB plan?
Conclusion: The short answer is no, I do not utilize de-escalation to the SV bed, and I treat the entire operative bed to 64-66.6Gy. Below is a rationale and some linked resources, if helpful: A. Dose: The recently published RTOG 0534 allowed a range of doses (64.8Gy-70.2 Gy); however, since the ini...
Do you offer liver SBRT for metastatic colorectal cancer after local recurrence following previous treatments such as radiofrequency ablation (RFA), radioembolization, and chemoembolization?
I do offer liver SBRT for local recurrence after other liver directed therapies. With regard to RFA, there have been a number of single institution retrospective studies suggesting that RFA has a higher recurrence rate than SBRT for lesions larger than 2-3 cm (Jackson et al., IJROBP 2018; Franzese e...
Do you advise patients to hold DMARDs for conditions such as psoriasis or rheumatoid arthritis while actively undergoing radiation treatment?
Data in this setting is limited. I have usually not held DMARDs with RT unless treating with concurrent chemo RT or treating a site (pelvis) where myelosuppression caused by RT would further suppression immunity especially with biologics and methotrexate.
How do you approach anti-seizure medication management when it was started by another team for a seizure-naive patient before/after craniotomy for a tumor?
I would refer you to Dr. @Dr. First Last's answer to a similar question (https://www.themednet.org/question/15031) which beautifully summarizes data and guidelines. I usually counsel patients that everyone regardless of their medical history has a certain risk of seizure under physical stressors, th...
How do you decide between internal versus external decompression of malignant obstruction of the ureter (MUO)?
The decision between ureteral stenting and percutaneous nephrostomy placement is, by definition, an interdisciplinary one with my urologic oncology colleagues. If a ureteral stent is feasible, that typically is my preference as patients typically prefer this approach. Ultimately, the impact of local...
How should the outcomes and QOL results of the ProtecT Trial be interpreted?
The trial is a masterpiece. Quality assurance on the treatments, complete follow-up, careful cause-of-death ascertainment, pristine and long term quality of life data.My conclusions:1. The vast majority of men with low-risk and low-intermediate risk disease do not benefit from immediate treatment. I...
Do you include the prostate when treating bladder cancer?
Dr. @Dr. First Last is correct, in the North American trials prostate has been included in the lower dose CTV on grounds that urethral and prostatic stroma can both be involved and to recapitulate surgical treatment where the prostate would be removed with the cystoprostatectomy. A study in PRO last...