Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your response to the question, "Is this terminal?"
Thanks for this question, it's really important. This question comes up in two distinct scenarios: when a person is first diagnosed and when a person is nearing the end of her life. Let's talk about them in sequence. 1). At diagnosis: When a person is first diagnosed, this question is part of "getti...
How do you decide between stereotactic arrhythmia radiation (STAR) and repeat catheter ablation in patients with refractory ventricular tachycardia who have already failed one prior ablation?
This is a great question and something that the ongoing RADIATE-VT trial is working to answer (NCT05765175). In this phase III RCT trial, recurrent VT patients who have had at least one prior catheter ablation, are considered to be candidates for a repeat catheter ablation by their electrophysiologi...
What hypofractionated regimens would you consider for postoperative SCC of the hand with a positive margin?
I have started to use 50 Gy in 20 fractions in all patients with a recent retrospective analysis from Australia for cutaneous squamous and basal cell cancers that has been used for head and neck patients, another sun-exposed site with cosmetic concerns. This type of question is hard to answer as man...
How would you approach adding ADT to salvage radiation therapy for a biochemically recurrent prostate cancer patient with very high Decipher but non-luminal B on PAM50?
Yes, especially if PSA is more than 0.5 ng/mL.
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
If a patient has a history of lumpectomy and adjuvant radiation, and then develops an in-breast recurrence s/p mastectomy with breast only disease and no nodal disease, would you re-irradiate the chest wall?
Typically not. Now, if the breast lesion is very large or has a positive margin, or was stuck to the muscle, I would consider re-RT. In the adjuvant setting, PMRT is beneficial, but the therapeutic ratio is not that large. Remember some of the older studies (and studies w/o chemotherapy) did not dem...
How do you manage a nodal recurrence of an early stage glottic laryngeal cancer previously treated with definitive radiotherapy?
As a general rule, patients with post-RT recurrences that are resectable should undergo surgery rather than re-irradiation, unless surgery is expected to be associated with substantial risk or functional deficit (in which case the patient should be consulted about the risks of each modality). In the...
Would you consider delaying tarlatamab initiation in a patient with ES SCLC who recently completed RT for CNS disease, given the concern for immune effector cell-associated neurotoxicity syndrome (ICANS)?
I would not delay beyond what we already do for other systemic treatments. We tend to wait at least a week or more after whole brain RT and systemic therapy of any nature. I do not think this is any different.
When planning spine SBRT, do you use volume dose limits to the spinal cord PRV, such as D0.35cc, in addition to maximum point dose?
An excellent recent paper from the MSK group on 3-fraction spinal SBRT (minimum dose of 27 Gy to PTV) was published last year, examining dosimetric predictors of radiation myelopathy. Of note, spinal cord delineation in this study was done using myelogram in 85% of cases, with 15% of cases utilizing...
Would you consider once weekly radiation with a simultaneous integrated boost for a patient with node negative breast cancer with a positive margin for whom reexcision is not an option?
If the patient is advised on data and risk, it's not unreasonable. Another alternative is once weekly whole breast and then add a 6th-week boost.