Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For cisplatin ineligible patients with locally advanced head and neck cancer, would you consider RT + immunotherapy rather than RT + cetuximab?
No. While the cited GORTEC trial showed pembrolizumab was no worse than cetuximab, the results from HN004 showed a significant reduction in PFS in the durvalumab arm. This plus emerging data from the lab of @Dr. First Last (Darragh et al., PMID 36385142) showing that elective nodal radiation signifi...
Would you offer radiation to a patient with extensive vulvar dysplasia not amenable to surgical resection and previously resected micro-invasive vulvar cancer in the setting of immunosuppression for solid organ transplant?
I have never done RT for dysplasia alone in the absence of invasive disease so would avoid it and try other means and keep on close follow up.
How would you approach the primary treatment of a rapidly growing uterine carcinosarcoma with local extension through the anterior abdominal wall?
This patient needs multimodal therapy - surgical resection is a mainstay of treatment followed by adjuvant therapy (most likely chemotherapy +/- vaginal brachytherapy). In terms of chemotherapy agents - up front adjuvant treatment is usually carboplatin/paclitaxel or ifosfamide/paclitaxel. I would p...
What treatment would you recommend to a patient with a locally recurrent sarcoma of the retrohepatic IVC (reconstruction of IVC with PTFE graft) resected over 2 years ago?
I would want to know histology, grade, and size. Most caval tumors are leiomyosarcoma. Local recurrence is rare for retroperitoneal LMS. But it can happen, especially as here with an untreated positive margin. If resectable, I would recommend surgery and RT to standard STS doses. The standard timi...
Is it preferred to use VMAT or dynamic conformal arcs for coplanar lung SBRT?
I don't know that there is a preference. It's just different ways of getting dose to tumor. One is basically forward planned, one is inverse planned. There is an additional charge to do inverse planning. Just as an example, the original CyberKnife plans were always NOT inverse planned and they are ...
How do you approach treatment of a grade 4 IDH-mutant astrocytoma, a diagnosis now distinct from glioblastoma according to the 2021 WHO Classification for CNS Tumors?
This is an excellent question. The short answer is that until we have more data on this new entity, I would treat an IDH mutant (mt) grade 4 astrocytoma as I would have prior to the 2021 WHO revision, that is to say, with concurrent chemoradiation therapy and adjuvant Temodar for 6 cycles (or a clin...
For a postmenopausal patient with a pT2N0 breast cancer s/p BCS+SNB who qualifies for MA20, how do you decide between RNI, high tangents, and standard whole breast RT?
TL;DR: "This patient would have fit Z11 criteria - if they had positive nodes. Patients did very well with tangents/high tangents. For N0 patients that would have been otherwise eligible for Z11, I would treat with standard whole breast RT." The absolute reduction in isolated LRR in MA.20 was 5% at ...
What treatment would you recommend for a patient with recurrent oligometastatic abdominal leiomyosarcoma, with two liver lesions?
I would ask for needle ablation. Leiomyosarcoma is unusual among cancers in that serial oligometastatic recurrence is not uncommon. These people can be managed with serial destructive therapy - resection, needle ablation, or radiosurgery. I have met people with LMS who have had many resections and a...
Would you offer adjuvant therapy of any kind to a patient with synchronous primary lung cancers if all early stage and curatively treated?
Personally, I would not. However, this assumes that we are convinced that these are distinct early stage lung cancers. I would advocate for NGS testing of each tumor to ensure these are not actually sites of metastases. If truly distinct early stage cancers, then would treat with surgery/radiation a...
How would you approach a T3N1M0 mid rectal cancer that is MMR deficient?
About 2.7% of rectal adenocarcinoma are mismatch repair deficient (dMMR) (Papke Jr. et al., PMID 36322852) and locally advanced dMMR rectal cancers have a great response to immunotherapy. Six months of single agent Dostarlimab led to 100% complete clinical response in the phase 2 study including 14 ...