Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do we reconcile what appears to be a more aggressive surgical resection for DCIS than for invasive disease?
The guidelines panels did an outstanding job in generating both the DCIS and the invasive cancer margins guidelines. It needs to be recognized, however, that despite the sophisticated meta-analysis upon which the recommendations are based, the studies in the meta-analysis had limitations. Appropriat...
What is the recommended initial treatment for spinal cord compression due to non-Hodgkin lymphoma (e.g. diffuse large B-cell lymphoma)?
The answer depends greatly on clinical circumstances, such as stage of disease, degree of neurological impairment, prior treatment if any, etc. First, I would argue there is seldom a role for surgical intervention ( other then biopsy to establish diagnosis) since lymphomas are uniquely radiosensitiv...
Do you offer ultra-hypofractionated 5-fraction RT regimens for DCIS s/p lumpectomy?
The premise of this question attempts to "split" DCIS from early-stage invasive disease. When we live in an eternal present-tense, we naturally repeat the mistakes of the past. Again, as for modest hypofractionation, we are not going to see a "separate" clinical trial for pure DCIS in this space. In...
What regimen/constraints do you use for moderately hypofractionated salvage / post-prostatectomy radiation?
Current NCCN guidelines continue to recommend prescribed doses for adjuvant/salvage post-prostatectomy RT of between 64 and 72 Gy using standard fractionation. These regimens are known to be safe and effective. However, substantial non-randomized outcomes data from numerous institutions, including o...
For unresectable typical carcinoid, what is the appropriate radiation regimen?
I've treated a handful of these patients with SBRT, and we published a small case series, but to be honest, I'm not sure what to conclude about the efficacy. Historically it's difficult to draw any conclusions about the response of carcinoid tumors to radiation, whether it be fractionated or SBRT. T...
What are your top takeaways in Supportive Care from ASTRO 2024?
Keynote session: The Science of Bite-sized Well-being During Uncertain Times: Evidence, Practice and Resources to Share; Bryan Sexton, PhD This was a very interesting session, which could benefit not only attendees, but also members of our staff, and could lead to improved outcomes through a decreas...
How would you work up a patient with prostate cancer with bone scan suspicious for metastatic disease and a negative PSMA PET/CT?
While some bone metastases are 99mTc-positive and PSMA-negative, this circumstance is quite rare (< 2%). Based on this alone, in cases like this, I typically conclude that the patient is clinically M0. However, I do consider 3 other factors: the prevalence of bone metastases within the patient’s par...
For a patient with ENKTL nasal type (nose/sinus involvement) who has hepatic toxicity with pegasparaginase but a CR after 2 cycles of chemotherapy with a plan for "sandwich" radiotherapy - what, if any, chemotherapy would you resume after completion of radiation?
This is an interesting situation as there is not much data. The cure rate is high for early-stage disease after chemoradiation, even with VIPD and no asparaginase regimens (see de Pádua Covas Lage et al., PMID 36446856). Nature reviews which show in Table 2 survival curves similar for asparaginase r...
Would you consider treating a patient with prostate cancer and biopsy-proven involved inguinal nodes with radiation to the prostate/pelvis/groin?
Would favor starting with ADT plus ASRI and base subsequent treatment in 3 to 6 months based on responses ranging from prostate-only RT (like STAMPEDE for nonregional node) or definitive RT to primary and node.
Would you consider PMRT in patients with clinically node negative breast cancer found to have micrometastatic nodal disease after neoadjuvant chemotherapy?
Post neoadjuvant chemotherapy with residual disease in axilla reflects an incomplete response to chemo. The use of terms like micromets or ITC in this setting could be misleading, as these terms have been validated in patients who have upfront SNLN without any neoadjuvant chemotherapy. The NSABP Stu...