Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach management of a large, fungating squamous cell carcinoma of the auricle if surgical management is not desired by the patient?
For a tumor this size and with cartilage invasion, I would recommend starting with induction cemiplimab to best response (generally 4-6 cycles), followed by consolidative RT, generally electrons. Prior to starting the immunotherapy, I would stage the neck with a contrast CT scan, as tumors of this s...
How would you manage the side effects/toxicities (e.g., pain, swelling, erythema) of adjuvant EBRT to the ear for cutaneous SCC?
I have had a few patients experience acute pain in the ear canal, probably from inflammation, wet desquamation, and bacterial overgrowth. Ciprodex Otic drops x 7-10 days have been helpful.
What is the preferred neoadjuvant/adjuvant chemotherapy regimen for HPV-associated nasopharyngeal cancer?
Let me give more context: Had an interesting conversation with a med onc colleague regarding neoadjuvant or adjuvant gem/cis for HPV-associated NPC. I personally make a distinction between EBV-associated NPC and HPV-associated NPC. My interpretation of the data is that the benefit is only/mainly for...
In p16-positive oropharyngeal squamous cell carcinoma, when induction therapy is considered before definitive chemoradiation, how do you choose between a traditional TPF regimen and carboplatin/paclitaxel/pembrolizumab?
Sequential therapy, as defined by induction chemotherapy followed by chemoradiation, is generally reserved for patients at high risk for recurrent or metastatic disease. The published randomized data offers no improvement in survival with TPF followed by CRT versus CRT. Thus, such an approach can be...
For unresectable-appearing BRAF V600E papillary thyroid cancer involving the trachea and carotid artery, is neoadjuvant targeted therapy a viable path to surgery, or is definitive radiation the better option?
If the tumor is considered unresectable due to carotid encasement, as is likely in this case, then neoadjuvant targeted therapies should not be considered. Multikinase inhibitors (i.e., lenvatinib) or targeted therapies (dabrafenib and trametinib) will not produce great enough responses to make the ...
What dose-fractionation scheme and esophageal constraints should be used to treat an ultra-central, medically inoperable, stage I NSCLC abutting the esophagus?
For lesions abutting the esophagus, SBRT with BED >100 Gy should NOT be used due to high risk for ulceration and even fistula. Instead of SBRT, more fractionated radiotherapy with BED <84 Gy should be considered (60 Gy in 15 FX is still too high for the esophagus). In addition to maximal point dose,...
Would you continue serial PSMA PET scans after 2 negative scans for patients with a persistently rising PSA post-RT?
Some context would probably be helpful for this. E.g., PSA >2 is different for a patient post-prostatectomy vs. post-radiotherapy. But, in general, if clinical suspicion of cancer recurrence/progression is high, and PSMA PET is negative, one can consider the following options: There may not be a ca...
How do you decide the right time to transition to hospice?
Talking about hospice is one of the hardest jobs we have. It's hard because we don't like doing it, because we often don't know how to do it well, and because we angst about doing it too early or too late. It's an important thing to think about. I actually think perhaps the most important factor in ...
How do you treat dermal metastases in the setting of prior breast irradiation?
There is no fixed approach. Based on effect and volume of prior RT, interval since last treatment, extent of dermal mets with or without surgical excision, and intent of care. One can do conventional fraction RT with or without hyperthermia, based on availability and gross or microscopic disease.
Should ultra-short course RT be standard for elderly or poor performance status patients with glioblastoma?
The recent phase III randomized trial published by Roa et al. examining the efficacy of short course radiotherapy in elderly and/or frail patients with newly diagnosed GBM builds upon his previous work finding equivalent outcomes in elderly patients (age > 60 years) receiving 60 Gy in 30 fractions ...