Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do the results and approval based on ADAURA trial suggest a role for adjuvant osimertinib in patients with stage IIIB-C, EGFR mutant patients treated with concurrent chemoradiation?
ADAURA trial was not designed to address this issue. But that being said, we need to remember few things before considering "maintenance durvalumab" in patients with EGFR-mutant lung cancer, following chemo-radiation: 1. EGFR-mutant NSCLC patients may not derive any clinical benefit from single-agen...
In a patient with metastatic breast cancer who has progressed on multiple medications and has now developed multiple brain metastases, what is your radiotherapy plan if the patient is taking sacituzumab govitecan?
The limited published data have not shown increased complications with SRS along with sacituzumab, unlike increased necrosis seen with HER2/neu antibody conjugate. Khatri et al., PMID 41026418
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...
In light of the pending overall survival data and reported declines in quality of life associated with the PSMAddition trial, how do you envision incorporating Pluvicto into the management of mHSPC?
The PSMAddition trial was a phase III trial of [177Lu]Lu-PSMA-617 (i.e., Pluvicto) combined with androgen deprivation therapy (ADT) plus an androgen receptor pathway inhibitor (ARPI) in patients with PSMA-positive metastatic hormone-sensitive prostate cancer (mHSPC). This trial randomized men with u...
How would you apply the results of CheckMate 204 in an asymptomatic patient with 10-20 metastatic brain lesions on dual immunotherapy for melanoma?
The results of CheckMate 204 showed that systemic therapy with both nivolumab and ipilimumab has clinically meaningful efficacy in patients with asymptomatic, untreated melanoma metastases to the brain. In this phase 2 study, however, only 22% of the patients had 3 or more lesions. Nevertheless, int...
What would your approach be for a locally advanced head and neck cancer diagnosed concurrently with a mid-esophageal cancer?
In the handful of similar cases that I have seen, I have worked with medical oncology to tease out a concurrent chemotherapy regimen. What we have often ended up doing is treating the head and neck cancer as normal (to 70 Gy) and the esophagus cancer to a relatively standard dose (usually to 50 Gy t...
For a patient s/p laryngectomy with positive margins, would you start radiotherapy 6 weeks s/p surgery if there is a delay in concurrent chemotherapy?
The question is a bit challenging without understanding the reason why the patient is suited for XRT but not chemo. My best guesses would be a concurrent infection or PS issues, possibly due to deconditioning after a hard surgery.However, part of the decision would involve when it is anticipated tha...
In p16-positive oropharyngeal squamous cell carcinoma, when induction therapy is considered before definitive chemoradiation, how do you choose between a traditional TPF regimen and carboplatin/paclitaxel/pembrolizumab?
Sequential therapy, as defined by induction chemotherapy followed by chemoradiation, is generally reserved for patients at high risk for recurrent or metastatic disease. The published randomized data offers no improvement in survival with TPF followed by CRT versus CRT. Thus, such an approach can be...
In mCRPC patients who had an initial response to Pluvicto but progress within 12 months, where do you position PSMA radioligand retreatment relative to other next-line systemic options in your sequencing strategy?
After Lu-PSMA therapy, we may consider taxane chemotherapy, Ra-223, ARPI, or clinical trials in addition to Lu-PSMA retreatment. Retreatment may be more heavily considered in patients with prior deep response to Lu-PSMA, high avidity on a repeat PSMA PET, and/or limited candidacy for other treatment...
Would you omit RNI in a patient with locally advanced TNBC with N1 disease who has an ALND and is found to have a pCR in the nodes?
This is the topic of the NRG B-51 randomized clinical trial which recently closed to new patient accrual. Until we have data from this trial, my default will be to prefer RNI in my triple negative patients known to have nodal involvement at the time of diagnosis, even if they experience a nodal pCR....