Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is the maximum V20 on ipsilateral lung that can be safely accepted for 3 or 4-field breast plans?
We routinely treat the IM nodes so my comments reflect this practice: 1. I shoot for a mean ipsilateral lung V20 below 35%. This is achievable in most, though not all, plans. 2. The biggest driver of ipsilateral lung V20 is the amount of lung in the SCV field. 3. While it is tempting to raise the ma...
Is there any data to support the use of hormone therapy with RT in the adjuvant post-prostatectomy setting?
Unfortunately, randomized data remains limited. Although pT3/N1 pts were included in RTOG 8531 (www.ncbi.nlm.nih.gov/pubmed/15817329), the majority of the pts included in this trial were treated with definitive radiation. At ASTRO 2011, Shipley et al reported the results of RTOG 9601 (www.redjournal...
What is your criteria for a prophylactic PEG tube in patients initiating head and neck radiotherapy?
We do not routinely insert prophylactic tubes to patients receiving bilateral neck RT concurrent with chemo, unless they are malnourished to start with. The outcome is a need to insert feeding tubes to 25-33% of these pts due to sig wt loss during chemo-RT. Thus, most pts do not need PEG. continuing...
What is a safe and efficacious fractionation to use when re-irradiating a recurrent GBM?
I am a fan of 6x5 to the T1post and 5x5 to the local FLAIR; this is extrapolating from MSK experience of 6x5 to the post-op cavity for resected brain mets.
What's the safest way to hypofractionate treatment for prostate cancer?
The longest published data is on 2.5 Gy to 70 Gy from the Cleveland Clinic.That being said, the three randomized trials which have been presented or published (Italian , MDA, And FCCC (published recently in JCO)) have not shown any superiority of hypofractionation over conventional fractionation. Ra...
Which patients with intermediate and high risk prostate cancer should not receive androgen deprivation therapy?
Based on randomized trials that didn't exclude patients with cardiac risk factors, an overall survival benefit has been observed for intermediate and high risk localized prostate cancer. Review of RTOG studies has not detected an increase in cardiovascular events. That said, appropriate management o...
Do you decrease the duration of hormones in a man with high risk prostate cancer and cardiac risk factors?
I do consider a shorter course of ADT in the setting of a patient with significant cardiac disease, but usually only after speaking with the patient's cardiologist to first determine if there may be other mitigating risk factors that are more readily modifiable. If the patient is older than 75 or ha...
For patients with high risk prostate cancer, is there data to support prostatectomy, as opposed to upfront RT?
In 2010, MSKCC published a study in JCO which suggested surgery was better than 81 Gy IMRT for high risk prostate cancer. The study had many limitations including selection bias of higher stage patients. in the RT group, there was only short term androgen ablation, lack of salvage or delayed salvage...
How should I interpret a Gleason 7 prostate cancer (4+3 or 3+4) with tertiary grade 5?
The scoring system adopted by 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma specified that in a prostate biopsy, the two numbers should be the primary pattern and the highest grade (not the second most common type as was done...
What is your institution's active surveillance protocol?
The topic of active surveillance continues to evolve in light of the PIVOT trial and rapid adoption of mpMRI for initial staging. The 2014 NCCN guidelines summarize commonly used approaches, does not yet advocate for mpMRI, but declares an urgent need for more research. Meanwhile, the 2014 NICE Guid...