Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
Would you treat a patient who failed cryotherapy?
There is published data (small series), showing reasonable efficacy and good tolerence of salvage EBRT for cryotherapy failure and we have treated a few patients with this approach.
If a daily conebeam CT is done for prostate cancer treatments, do you subtract any treatment fractions to compensate for the daily imaging dose?
The radiation dose from daily imaging depends on techniques used. In most cases the dose of radiation is very low, relative to the dose delivered for treatment. Nonetheless, this dose is often delivered to non-targeted tissues and it is wise to minimize the dose and volume when feasible. From my phy...
What is your technique for CT and MRI fusion for external beam prostate planning?
We try to fuse prostate to prostate, knowing the limitations caused sometimes by bladder and rectal filling. Since the main advantage of MRI is to identify apex, base, and lateral edge, the fusion still helps in defining the prostate
How often should you re-plan interstitial brachytherapy for gynecologic malignancies?
Ideally one should scan before each fraction to ensure needle position and account for changes in critical organ anatomy. That being said, because of logistic constraints we do QA before each fraction to check for needle displacement and if measurements are off by 2 mm or more, then we do rescanning...