Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you use neoadjuvant TKI or neoadjuvant radiation for a large chest wall sarcoma with an NTRK fusion on NGS?
Although there is no data to support the "neoadjuvant" use of NTRK inhibitors in NTRK-fused sarcomas, the rapidity of response to this approach is amazing. There is also a school of thought that the use of NTRK inhibitors in NTRK-fused sarcomas affords a durable response. My experience is different....
Is there any role for radiation in the treatment of stage II nasopharyngeal DLBCL involving bilateral nasopharynx and unilateral cervical nodal involvement but without bony or nerve involvement?
The role of RT in the rx of stage II DLBCL, either nodal or extranodal in type, remains controversial with NCCN guidelines allowing for either approach. There is agreement that initial therapy should be systemic, typically R-CHOP at present. For patients achieving CR (PET-negative), we routinely use...
Can I treat breast nodal volumes with hypofractionation?
Yes. Published randomized trials have treated/reported 2,000 patients with doses of >2 Gy in hypofractionation vs standard fractionation trials with treatment to the axilla. Trials include Start A/B (513 patients), the old trial by Ragaz et al., PMID 15657341 (318 patients, hypox 37.5 Gy in 15 fx), ...
How do you treat anal margin tumors?
Yes that is the standard of care for anal margin tumors. Even if there is a positive margin it is reasonable to consider following well and moderately differentiated tumors without lymphovascular space invasion closely and using definitive treatment as a salvage. These tumors rarely progress rapidly...
If technically feasible, would you consider SBRT for locally recurrent ampullary carcinoma in an inoperable radiation naive patient?
No. A stereotactic technique cannot improve outcome when the duodenum cannot be avoided. As in every ampullary cancer I have ever treated, you are limited to palliative doses by the tolerance of the mucosa. Larger doses per fraction only serve to narrow the therapeutic index and use up tolerance bas...
How do you sequence HDR brachytherapy boost and external beam RT for prostate cancer?
The typical sequence for our combination IMRT/HDR patients is IMRT first followed by the HDR boost about a week later. HDR is much more forgiving (substantially less GU toxicity) so the gap between IMRT and HDR is less than when we did seed boosts. However, our first clinical trials in the late 1990...
How to you sequence HDR brachytherapy for definitive prostate cancer treatment?
This is a great question, for which there are several options. I think a lot of it comes down to your department capabilities, trade-offs, what you and your team are comfortable with, etc. When starting the prostate HDR brachytherapy program at MGH, I spoke to many different centers that had it up ...
What brachytherapy dose/fractionation should be used for small cell carinoma of the cervix?
I treat a small cell carcinoma of the cervix the same as a squamous cell or adenocarcinoma as far as the RT portion of treatment. I would give 45 Gy pelvic RT (I would treat PA if involved or if there are positive pelvic nodes). I would give SIB to positive nodes to 55 Gy (2.2 Gy/fx) in the pelvis a...
Are pancreatic fiducials necessary when delivering dose escalated radiation therapy for inoperable pancreatic cancer and using cone beam CT for IGRT?
Some form of precise respiratory motion management is necessary to cover the GTV optimally. Deep inspiration breath hold or end expiratory gating are preferred. Both require a metallic fiducial for set up. We do not recommend trying to set up to soft tissue. We often use the metallic endobiliary ste...
What systemic therapy would you offer to a patient with metastatic EGFR exon 19 deleted NSCLC to the brain with isolated CNS progression while on osimertinib 80 mg and progressed through WBRT?
If this is isolated CNS progression, the answer will depend on the number of metastatic sites. This is worth a conversation with your radiation oncologist. If there are 1-5 sites progressing within the CNS, it may be reasonable to consider treating these with SRS (even if patients have had prior who...