Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
How do you approach salvage of a local-only recrurrence of prostate cancer after definitive external beam radiation?
We continue to prefer "zero margin" whole gland "HDR-like" SBRT for this circumstance for prior external beam RT cases, *34 Gy/5 fx, though would exclude any patient that has preexisting grade 2 or higher toxicity from their original RT course (otherwise, no specific exclusions, if the metastatic w/...
How do you choose between ALND and RNI in the setting of LYMPHA or S-Lympha surgery?
The addition of microsurgical reconstruction with procedures such as LYMPHA, etc, has not necessarily changed the choice or clinical indications/scenarios for when ALND is done for a patient. However, I would say that if ALND is expected or planned for a patient, our breast surgical oncologists will...
What dose-fractionation and CTV margins do you typically employ for a CNS hemangiopericytoma?
I would discuss this at a multidisciplinary brain tumor board with my pathologists, neurosurgeons, neuro-oncologists, neuro-radiologists and would want to know the grade as well as extent of resection. Also, consider workup including spine imaging. In general, for grade 1 grossly resected hemangiope...