Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you recommend PMRT using a hypofractionated course to the chest wall and nodes?
With recent publication of Chinese data with median follow-up of 5 years showing no difference in any end point, we routinely offer hypofractionation to patients 65 and above with non inflammatory breast ca and no immediate reconstruction. For patients who have reconstruction done or planned, we enr...
Under what circumstances would you treat prostate cancer without a biopsy?
I largely agree with Dr. @Dr. First Last's comments as well as a prior post on this site in which anecdotes are cited of situations which falsely appeared suggestive of prostate cancer. As contemporary guidelines recommend treatment only in patients with localized prostate cancer with > 5-10 year li...
What is your approach to patients with unresectable, node-negative perihilar cholangiocarcinoma who have undergone biliary stenting and have no evidence of distant disease?
For perihilar cholangiocarcinoma that has been deemed unresectable by hepatobiliary surgeons, a good consideration is to have the patient evaluated for liver transplantation. The Mayo Clinic protocol allows tumor mass of <3cm, no nodal disease, and vascular involvement is allowed. Depending on the f...
How do you time re-staging studies and adjuvant durvalumab for stage III NSCLC treated with definitive cCRT?
In the PACIFIC study, 713 patients who received at least 2 cycles of platinum-based chemotherapy with radiation (CRT) and did not develop disease progression were randomly assigned in a 2:1 manner to receive durvalumab at 10 mg/kg every 2 weeks up to 12 months or placebo. Randomization took place be...
For patients with inoperable stage III NSCLC who are unable to receive or refuse definitive chemoradiation, how do you decide among radiation alone, pembrolizumab alone, or radiation followed by either pembrolizumab or durvalumab?
So, this is a challenging question – actually two questions – 1) unable, 2) refuse. With respect to unable, this typically would (I assume, and in my practice) refer to patients whose functional status is sufficiently poor to prevent one from giving chemotherapy along with radiation. Note that esse...
How do you monitor response for stage III NSCLC patients receiving consolidation immunotherapy?
Generally, the first imaging post chemoradiation (CRT) would have been performed about 6-8 weeks following completion, and this has changed as we start durvalumab within 42 days following CRT. I perform a baseline CT chest prior to starting durvalumab. I proceed to monitor with CT chest about every ...
Do you do a CT simulation for post op heterotopic ossification prophylaxis?
Yes, we treat a fair amount of HO cases at our institution in NJ, and in most cases, at least that I know of, we have always obtained CTs for planning. Honestly, because the anatomy is so straightforward in the hip area to be treated, just plain 2D imaging will suffice. In the old school way, we use...
How do you approach the use of whole brain radiotherapy in a patient who has previously received 2 or more courses of SRS to overlapping sites?
In light of lack of evidence otherwise, I am hesitant to modify my treatment dose or field in a patient who received SRS and received SRS again to the same site for failure, that now needs WBRT for recurrent local or distant brain disease. What is clear is that when doing so, there is anecdotally a ...
Can a second course of SRS be used to treat a brain met that initially responded to SRS and then progressed?
One should use caution in interpreting imaging as a definitive sign of progression, as sometimes radiation necrosis can mimic those findings. if asymptomatic, the patient can be considered for close observation with imaging and if symptomatic, one should consider a surgical option also.
What is the consensus on the size of the expansion from the gross tumor volume (CTV) to the clinical target volume (PTV) in treating intact supraglottic squamous cell carcinoma with radiotherapy?
The modern approach for head and neck cancer, based on international guidelines, has been CTV high dose (70 Gy) = GTV + 5 mm expansion (respecting anatomic boundaries and structures not at risk). Some centers in the past and present have also had an intermediate volume where an additional 5mm is add...