Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What references do you use for multi-parametric MRI delineation of the GTV in prostate cancer for prostate nodule?
In FLAME, the boost volume was the GTV on mpMRI as judged by the treating physician without any formal contouring guidelines (Kerkmeijer et al., PMID 33471548). There were differences in MRI protocols and physician judgement resulting in significant differences in tumor volumes between centers (van ...
Would you add ADT to EBRT for favorable intermediate risk patients with T1c prostate cancer by DRE and bilateral prostatic lobe involvement by MRI?
Let's break down the question: If the patient has favorable intermediate risk disease, but cT1c by DRE, then he must have either: Grade group 2 (Gleason 3+4), PSA <10, and percent positive cores <50%; or Grade group 1 (Gleason 3+3), PSA 10-20, and percent positive cores <50% For scenario 1: Havi...
In high or very high risk prostate cancer, do you utilize combined androgen blockade in patients receiving definitive RT?
Since I had initially posted this, the STAMPEDE investigators have released a new publication reporting the utility of intensified androgen axis blockade (abiraterone ± enzalutamide) in high-risk non-metastatic patients which included high-risk N0 (≈ 60%) and N1 patients (≈ 40%). For this combined p...
Would you consider 50 Gy in 20 fractions for a primary head and neck malignancy in an elderly patient with poor KPS?
Yes
Is it acceptable to do IFRT rather than whole posterior fossa boost for high risk medulloblastoma?
Based on dosimetric patterns of failure and early pilot studies of tumor bed boost from the University of Michigan and Memorial Sloan Kettering, respectively, the recently completed ACNS0331 clinical trial randomized patients with average risk medulloblastoma to whole posterior fossa or tumor bed bo...
How do approach palliation of local symptoms in the setting of metastatic vulvar cancer?
If patient's PS status doesn't allow definitive treatment, for local palliation, you can treat 4 Gy x 5 and then reassess in 2-4 weeks for further treatment.
How would you approach treatment for a glioblastoma from a radiation standpoint that was initially thought to be a metastases and therefore treated with multiple courses of SRS over the past few years?
It appears that the patient was empirically treated with multiple SRS courses; then, presumably, the patient must have undergone a biopsy/resection which disclosed the true nature of the problem (GBM). Therefore, the question is, what is the appropriate postop treatment for this patient? There are s...
Do you account for prostate shrinkage during XRT if ADT is started concurrently?
This is a common question since we reported the study results, and a valid one for sure. Stay tuned for an even larger meta-analysis of many more RCTs that further dives into the oncologic superiority of adjuvant compared to neoadjuvant ADT. However, to your question, what about toxicity?Here are my...
How do you counsel patients who will undergo external beam radiation regarding complications with breast implants from previous breast augmentation?
The best experience any individual can offer is likely anecdotal. There is one paper from the Mayo Clinic, which supports that most women are able to maintain an acceptable cosmetic outcome (about 2/3rd) and that with further intervention (i.e., capsulotomy) that number increased to 89%. The cosmesi...
Would you offer any degree of hypofractionation with concurrent chemotherapy for NSCLC?
I typically wouldn't, given limited data. CALGB 31102 (phase 1 trial) looked into this and found the maximal tolerated dose (MTD) to be at 60 Gy in 24 fractions (i.e., 2.5 Gy/fx). There's another phase 1 trial from Wisconsin which showed similar results (i.e., 2.5 Gy/fx). With these results in mind,...