Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Can you/do you use an androgen receptor blocker alone in patients with metastatic hormone-sensitive prostate cancer who cannot tolerate GnRH-directed therapy?
Anti-androgen monotherapy for hormone-sensitive (M0 or M1) prostate cancer is not currently supported by FDA approvals or NCCN/AUA guidelines. Two recent studies that have explored enzalutamide monotherapy in patients with M0 and/or M1 hormone-sensitive prostate cancer are shown below. Enzalutamide ...
What is your approach to high-grade neuroendocrine tumor of the stomach?
I had a recent patient with this clinical picture with disease limited to the stomach. We chose a tri-modality approach. I delivered 45 Gy in 20 Fx with chemotherapy for small cell and treated the FDG avid disease in the stomach with a margin. The MDC recommendation was for surgery. They underwent s...
How do you approach ADT and pelvic lymph node radiation in the salvage setting for patients with a PSA <0.5 ng/mL?
This is an important and timely question.As I have previously written on this forum, I highly recommend those interested in first reading https://www.ncbi.nlm.nih.gov/pubmed/30238901, which outlines those who should and shouldnt receive ADT with salvage RT. In general, those with PSA <0.5 should rec...
When is postoperative radiation indicated after enucleation of an ocular melanoma?
Difficult question to answer because a rare situation with limited data. Drawing on data from the Collaborative Ocular Melanoma Study (COMS), orbital recurrence after enucleation is uncommon. From COMS Report 11 of patients enucleated for large uveal melanomas, the likelihood of orbital recurrence w...
After completing SRS for brain mets, how long should the medical oncologist wait before starting chemotherapy?
I usually don't ask the medical oncologist to wait to deliver chemotherapy after SRS for brain mets. When delivering whole brain radiotherapy, there is some breakdown of the "blood-brain barrier" and this may account for the increased toxicity we see when chemotherapy is delivered during whole brain...
How would you manage the axilla in a patient with Merkel cell carcinoma of the left forearm with clinically negative, axillary sentinel node positive disease?
I would irradiate the axilla with 50 Gy in 25 fractions. I would not recommend completion lymphadenectomy, regardless of number of sentinel lymph nodes involved with carcinoma, or extranodal extension of carcinoma. A randomized controlled trial has demonstrated that 50 Gy in 25 fractions targeting c...
What is the appropriate role for radiation therapy in patients with HCC or intrahepatic cholangiocarcinoma who are transplant candidates?
Most HCC and cholangiocarcinoma patients who are transplant candidates are often also SBRT candidates. We have used SBRT to bridge patients to transplant. These patients often have had prior liver directed therapies such as MWA, RFA or TACE. There are no randomized trials comparing different liver d...
How do you manage early stage breast cancer patients with suspicious internal mammary nodes on imaging?
In patients with a suspicious IMN, who are getting BCT, I would: a. Include the IMN chain in the target volume and give it the same dose as the breast is getting. b. Boost the IMN suspicious area to a dose that would reasonably sterilize that node. In the era of 2 Gy per fraction, that typically wou...
What dose constraints would you use if reirradiating the prostate using SBRT?
This is a difficult question to answer in this forum due to the limited availability of prospective data on which to define optimal OAR tolerance. The answer would depend on the dose, fractionation, treatment volume (GTV vs. whole gland), and technique which would be employed (CK vs. IMRT/VMAT). The...
Do you use the re-radiation schedule 39Gy in 26 fx BID for a rectal patient who initially received 25 Gy in 5 fractions and then has pelvic recurrence?
We have retreated rectal cancer patients with pelvic reRT (using protons) with doses as high as 39-45 Gy BID after both conventional fractionation and 25 Gy/5fx. In patients with prolonged interval since the original RT, no other sites of disease, good ECOG, and no good systemic/surgical options, th...