Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How does urinary obstruction impact your choice of therapy for metastatic or locally advanced prostate cancer?
Bladder outlet obstruction due to locally advanced prostate cancer is typically due to bladder wall and ureteral orifice invasion and T4 disease. These patients can suffer from pain and urinary obstructive symptoms for long periods of time despite the use of ADT, ADT plus AR inhibition, or ADT plus ...
Are there any whole breast RT techniques or modifications to optimize cosmesis for patients who had prior breast augmentation?
There are various approaches one can take. If not suitable for APBI then one can do partial breast with tangent beam like IMPORT LOW which also decreases exposure of implant and can help reduce the probability of worsening of cosmetic outcome. The goal is to deliver as homogenous dose as possible wi...
How do you position patients in a prone belly board for reproducibility and optimal small bowel sparing for rectal cancer treatment?
The bowel either falls forward or it doesn't on the commercially available belly board device. I don't think that you can position patients differently to achieve better displacement of small bowel, but we have never studied this question. The patient's position is very reproducible day to day makin...
Are there situations in which neoadjuvant chemoimmunotherapy + surgery would be preferred over chemoradiation + consolidative immunotherapy for stage III lung cancer?
We are good at controlling tumors of one billion cells (1 cm size), less so for one trillion (10 cm). From a radiobiology point of view, when I see a resectable T4 tumor due to size over 7 cm, I usually ask my surgeons if they can please take it out. You suddenly get rid of half a trillion tumor cel...
What is the maximum electron energy you would consider using for a breast lumpectomy boost?
I don’t go higher than 12 MeV (normalized typically to 80-85%) and usually am more in the 9 MeV range nowadays if using pure electrons. I have moved to doing most lumpectomy boosts with photons as we can be pretty conformal and more homogeneous (although sometimes we end up treating more breast tiss...
Should IMPower010 results be extrapolated to superior sulcus tumors treated with chemoradiation and surgery?
No. Patients with superior sulcus NSCLC, for whom the standard of care is preoperative chemotherapy and radiation therapy followed by surgical resection, would all have been ineligible for IMpower010, which used chemotherapy +/- Atezolizumab in the purely adjuvant therapy setting. Therefore, the res...
What margin do you use when treating the prostate bed/fossa?
We use similar PTV margin of 5 mm. The only difference is in the definition, surgical bed CTV also includes ITV at the level of SV.
What dose constraints do you use when palliating pelvic structures in 5-10 fractions?
Very much depends on the total dose being delivered. If doing 20 in 5 or 30 in 10, I don't believe any structures in the pelvis are at risk for substantial toxicity, for acute or late. If going higher, then utilizing SBRT/VMAT constraints for the pelvis is reasonable. Can use @Dr. First Last' method...
What is your approach to CNS surveillance in resected superior sulcus tumors given high rates of intracranial metastasis in this population?
Despite the quantum improvement in complete surgical resection, pathologic complete remission, and overall survival rates in S9416/INT-0160 (the trial that established trimodality chemoradiation followed by surgery as the standard of care for superior sulcus NSCLC almost 2 decades ago), distant recu...
How do you approach a thoracic lymph node that is highly suspicious on CT and PET but negative on EBUS in patients with NSCLC?
Our institution is very privileged in having a very large, highly expert team of interventional pulmonologists. In the cases where we are conflicted over how to interpret imaging of concerning lymph nodes, and where we have had the chance for a deep dive at tumor board and accompanying expert radiol...