Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your approach to brain reirradiation in the setting of recurrent/progressive gliomas?
A lot of factors need to be considered prior to offering brain reRT in such a setting, most importantly- interval since the 1st course of RT, patient's ECOG and neurologic function, age, perceived life expectancy, size of the lesion, location of the lesion, WHO grade of glioma, patient's expectation...
What adjuvant treatment approach would you recommend for a patient with early-stage MSI-high gastric cancer who received neoadjuvant ipilimumab (×2) and nivolumab (×6) per the NEONIPIGA regimen, followed by R0 resection with no pathologic response?
I would favor FOLFOX x6 as per classic. This scenario raises the question: Was this truly MSI-H? I would confirm MSI status with next-gen sequencing. I would have expected a response if MSIH on ngs with concomitant high TMB. Our institutional practice has been to review all MSI-H IHC cases done outs...
Do you consider tertiary grade pattern, LVI or PNI on prostatectomy specimens as adverse features to recommend EBRT and ADT for patients with unfavorable intermediate prostate CA after prostatectomy with undetectable PSA?
No, I don’t think there is any current available evidence to define a benefit for ADT in the post-operative setting for patients with an undetectable PSA. The two major trials which define a benefit for ADT in this setting, RTOG 9601 and GETUG AFU-16 had a lower limit of a PSA of 0.2 at treatment in...
When in the treatment of OA do you think it is optimal to offer LDRT?
Evidence reality check: Two well-conducted sham-controlled RCTs (hand and knee OA) were negative for clinically meaningful benefit at their primary endpoints. (Minten et al., PMID 30231990, Mahler et al., PMID 30366945). ArthroRad (multicenter randomized, single-blinded) compared standard-dose vs ve...
What is the value of resection in high risk (but small or early stage) skin cancers at the medial canthus?
The value of resection of a high risk small or early stage skin cancer at the medial canthus is potential assurance of complete removal of the skin cancer by confirmation of negative margins. Depending on the extent of disease and surgical approach, this may or may not be straightforward. There are ...
When do you treat heterotopic ossification with radiation pre-operatively?
Can pre-op radiation be delivered more than 24 hours before surgery?No — this is not recommended and is generally ineffective.Why timing matters (biologic rationale):HO formation is driven by pluripotent mesenchymal progenitor cells that are recruited and activated by: Initial trauma Surgical manipu...
How do you simulate and treat a prostate cancer patient with a persistently full rectum?
Simulation should lead to reproducible and desirable treatment positioning of the patient and their anatomical orientation. For prostate cancer, the state of bladder and rectal filling need to be considered. I think that a "comfortably" full bladder is widely used for simulation and treatment, but r...
How do you counsel patients on imaging findings after liver SBRT for HCC, particularly with regard to expectations on timing to tumor resolution?
My experience has been that the more successful the treatment, the sooner the patients want the good news. In reality, a well-designed and executed SBRT treatment to an ablative dose should result in 85 to 95% tumor control (mostly size independent) at 2 years with very little local progression afte...
If adjuvant radiation is indicated for a Merkel cell carcinoma of the upper extremity and hypofractionation is desired, what dosing regimens are recommended?
While more common cancers (breast, prostate, etc.) have well-designed clinical trials that demonstrate equivalence of hypofractionated radiotherapy and conventionally fractionated radiotherapy, similar types of studies are lacking in less common cancers like Merkel cell carcinoma. Part of the diffic...
What is your approach to adjuvant radiation for anorectal mucosal melanoma s/p wide local excision?
Primary anorectal melanomas are very rare, thus there are no large randomized trials to guide their care. As with any melanoma, surgery is the mainstay treatment. Oncologic surgery often entails APR leading to permanent colostomy thus local excision is sometimes preferred.Following excision, adjuvan...