Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In a patient with borderline resectable pancreatic adenocarcinoma s/p 10 cycles FOLFOX and aborted Whipple due to locally advanced disease, do you recommend dose escalation beyond 54 Gy?
Yes, there is no contraindication to giving an ablative dose after exploration. 54 Gray is a palliative dose, which has not improved overall survival based on the LAP07 trial. While it's fair to say that we do not know the definition of definitive or ablative in LAPC, we have published OS results ve...
What is the maximum dose that you would give to residual unresectable gross disease in the axilla in the setting of recurrent breast cancer s/p ALND?
The FAST-Forward boost trial will be informative here, and I would recommend reading the protocol, because one can consider using the standard arm now, which is 40 Gy to the breast (and nodes, when RNI is indicated), and a 48 Gy boost, all in 15 fractions. This dose is recognizable as the breast boo...
Would you treat a mastectomy scar that went into the high axilla with a radiation boost?
I was taught to always use a scar boost when giving prophylactic chest-wall irradiation. That was based on the observation that local recurrences often appeared adjacent to the mastectomy scar before they developed elsewhere in the chest wall. However, the value of giving this extra dose (like the u...
In light of recent updates on neoadjuvant enfortumab vedotin plus pembrolizumab for muscle-invasive bladder cancer showing benefit, how should a trimodality bladder-preservation strategy be contextualized?
The treatment of muscle-invasive bladder cancer. has evolved quickly. Neoadjuvant EVP is absolutely the standard of care in all patients who can receive it. The clinical trials (EV-303/304) used cystectomy as the bladder-directed therapy, and this is the standard of care. Having said that, many pati...
Do you routinely offer post-operative radiotherapy for resected retroperitoneal sarcomas?
I do not routinely offer post-operative RT for resected RP sarcomas. Our approach is to offer pre-op. If pre-op is not given, regardless of R0/1 resection, we do not offer post-op. In these case, we will follow with surveillance scans and if recurrence is noted consider pre-op followed by surgical r...
In mCRPC patients who had an initial response to Pluvicto but progress within 12 months, where do you position PSMA radioligand retreatment relative to other next-line systemic options in your sequencing strategy?
After Lu-PSMA therapy, we may consider taxane chemotherapy, Ra-223, ARPI, or clinical trials in addition to Lu-PSMA retreatment. Retreatment may be more heavily considered in patients with prior deep response to Lu-PSMA, high avidity on a repeat PSMA PET, and/or limited candidacy for other treatment...
When do you start adjuvant radiation with areas of delayed wound healing after reduction mammoplasty?
Great question. I have cared for many patients with delayed healing post-lumpectomy (e.g., from infection, wound failure, etc.), and that experience is likely pertinent to the mammoplasty setting. Once the wound is open, it is going to take many weeks/months to “fully” heal, and it is not practical...
Does receipt of chemoimmunotherapy for LS-SCLC impact your recommendation for PCI?
Historic data showed that the addition of PCI for patients with limited-stage small cell lung cancer showing response after chemoradiotherapy improves overall survival and decreases brain failure rates by about 50%. Recently, the addition of consolidation immunotherapy after concurrent chemoradiothe...
What first-line therapeutic regimen do you consider most appropriate for metastatic clear cell renal carcinoma presenting with brain metastasis and vasogenic edema?
For patients presenting with brain metastases, I always do local therapy, usually SBRT, before systemic therapy. I am nervous about starting immune-based therapy or a TKI in patients with uncontrolled CNS metastases. There are small series using TKIs such as cabozantinib in this setting, but since S...
In patients with esophageal or GEJ cancer who start with FLOT but receive only 1 or 2 cycles due to intolerance, would you switch to neoadjuvant chemoradiation (i.e., CROSS) or proceed to surgery?
In the randomized ESOPEC trial, 87% of patients assigned to FLOT completed all four planned preoperative cycles. However, this question reflects a common real-world scenario where treatment-limiting toxicity prevents completion of perioperative chemotherapy.In this setting, switching to neoadjuvant ...