Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you dose or sequence therapy to overcome radioresistance from oligometastatic disease from RCC?
RAPPORT (NCT02855203) [Siva et al., PMID 34953600] was a phase I/II trial which used a combination of RT and pembrolizumab. RT was given with SBRT (20 Gy/1# prescribed to the 80% isodose line) or conventional radiotherapy (30 Gy/10#) when the treatment volume was in close proximity to a dose-limitin...
In a patient with high-risk cutaneous squamous cell carcinoma of the face with extracapsular extension after ipsilateral neck dissection and rapid contralateral cervical nodal recurrence, what is the optimal management?
In various published series, around half of patients fail to achieve a complete response to cemiplimab. From the clinical details, the current active area of disease appears to be the contralateral neck with no distant disease. Curative treatment is preferred. C-POST trial established surgery + adju...
How would you sequence treatment (chemo and chemoRT) for a patient with a very symptomatic locally advanced rectal adenocarcinoma, MSS, with involved pelvic nodes and a mass abutting the sphincter, with no distant disease on CT but marked elevation in CEA above 300?
A pretreatment CEA level above 300 ng/mL is far beyond the typical range seen in stage II–III disease and warrants aggressive investigation. PET/CT should be strongly considered in this case to exclude occult distant disease, as it can change management in 8–11% of patients and is specifically recom...
How do you sequence radiation and capecitabine in breast cancer patients receiving adjuvant capecitabine for residual disease after neoadjuvant chemotherapy?
According to personal communication with Dr. Masakazu Toi (June 13, 2017), the corresponding author of the CREATE-X NEJM publication, radiotherapy was administered prior to capecitabine in the majority of cases on this study. It is worth noting that in CALGB 49907, a randomized trial comparing capec...
How do you approach the discussion of omission vs. inclusion of adjuvant radiation in patients with low to intermediate-grade DCIS?
There are several factors when evaluating patients with low/intermediate grade DCIS and the role of RT: Estrogen negative. While rare, I almost always recommend RT. Willingness to take endocrine therapy. More and more patients are concerned about taking endocrine therapy and I discuss RT in these pa...
How do you follow patients after SBRT for NSCLC?
When we started our lung SBRT practice almost 13 years ago, the follow up schedule was based on trying to measure the benefits and impact of the therapy in a fairly structured fashion so that we could develop expertise in understanding outcomes, radiographic changes, patient experience, and treatmen...
Given COVID-19, is there a good hypofractionated regimen for postmastectomy radiation for locally advanced breast cancer?
In light of COVID-19, we offer 2.66 x 16 PMRT with comprehensive RNI. This regimen is under study in ALLIANCE A221505, commonly known as RT-CHARM. Primary endpoint is reconstruction complications at 2 years. We discuss with reconstructed patients (most all will take if offered). Routinely given to u...
In patients with unresectable, liver-limited neuroendocrine tumors (NETs), what clinical or radiographic criteria guide your decision to prioritize systemic therapy over locoregional approaches?
The first question is always if it is truly unresectable... What is considered unresectable by some might be considered resectable by others, so I always recommend getting an opinion from an HPB surgeon with substantial experience in treating patients with NETs (whether that is done in person or at ...
In what circumstances would you recommend adjuvant radiation for a keratocanthoma with SCC after resection?
KA by itself (in the absence of SCC) is at the interface of benign and malignant. In a pure KA, if margins are negative, no further RT is needed. If there is SCC mixed, as can happen even with BCCs, the adjuvant RT indication rules pertaining to SCC prevail.
When would you offer neoadjuvant immunotherapy prior to Mohs surgery in a locally advanced squamous cell carcinoma for which clearance may require enucleation?
I would flip this question around and answer that radiotherapy is often a terrific option around the eyes, and it should always be considered in this area, especially when a radical surgical procedure is being entertained. Between en face therapy with a shield (superficial, electrons) and IMRT/VMAT,...