Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you still routinely offer post-op radiation after bone fixation?
I'm a little nervous about the phrasing of the question as it implies that there is an ongoing evolution in practice here. I don't think there is. To emphasize, PORT is--and remains--the standard of care following orthopedic stabilization of bony metastases: Alcorn et al., PMID 38788923Now, it is fa...
Does the presence of cribiform histology at biopsy in prostate cancer affect your management in an otherwise intermediate-risk prostate cancer?
There have been no trials on this specific question, so there is room for debate and more science (hoping our recent grant submission in this area gets funded...). Here is my current thinking. This is for generally healthy patients with long life expectancy (≥10 years, but especially if ≥15 years). ...
How would you approach early stage NSCLC in a patient who is not an ideal surgical candidate and has pulmonary AVMs?
The standard volumes and flows of PFTs do not assess regional differences in what is perfused and ventilated. V/Q scans do, but their most common use for pulmonary embolism is their most common role. This serves to identify gas exchange near the primary as well as where the AVM’s reside. Target the ...
What urgent palliative radiation regimen would you use for a nonmetastatic patient with a large ulcerated breast mass in whom you are hoping to treat with subsequent comprehensive radiation?
What makes this situation urgent? Every non-inflammatory breast cancer patient with a large, ulcerated mass that I can think have has been in a patient who has neglected her breast cancer, as in multiple years. I don't know the role of comprehensive radiotherapy (elective nodal?) in the palliative s...
How do you treat a focal pericardial metastasis?
In the era of oligometastatic disease, I understand the question. But an isolated event found at the pericardium is a stretch of concept. The issues of both the target and its physiological motion, and the presumably late cardiac injury, balance a choice of what’s best for the patient. How likely is...
In patients with advanced endometrial cancer who you plan to treat with chemotherapy + immunotherapy (per GY018 or RUBY), how and when do you utilize adjuvant EBRT and/or brachytherapy?
Reading the question at face value - does advanced endometrial cancer mean stage IVB? III/IVA? If IVB, there is not routinely a role of 'adjuvant' EBRT or BT.Given the discussion of adjuvant therapy, I presume the question is asking for the small fraction of RUBY and GY-018 patients who were stage I...
What are your dose constraints for SBRT pancreas (absolute and relative) when treating with 5 fractions?
We contour duodenum, other small bowel, and stomach separately and for each allow V33 < 1cc and max 0.035 cc < 36-38 Gy. We will sometimes also add a 3mm PRV for these organs (if close) and try to keep this v35 < 1-2 cc. Of note, some protocols allow for higher dose to these structures...but on prot...
Do you use a chest wall constraint when treating large lung cancers with 8 or 10 fraction SBRT?
There are a few studies that report that the volume receiving 30 Gy correlates to toxicity, and the Kavanaugh paper provides a "rule of thumb" - if 30cc of chest wall receives 30 Gy or more, then there is a 30% risk of severe chest wall toxicity. Dr. Videtic at Cleveland Clinic reports this, as well...
In an elderly patient with limited transportation issues, is there a hypofractionated regimen you have found acceptable for a localized squamous cell carcinomas of the eyelid?
I am fortunate to work with a “XRT for skin cancer” guru, Dr. W.H. Morrison, and sought his counsel to answer this question, as largely with the conversion of skin cancers from a radiation-treatable disease to a surgical disease with the advances in Mohs surgery and oculoplastics, at MDA we rarely s...
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...