Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...
What is your approach to women with breast cancer who opts for a staged approach with up-front lumpectomy and SLN biopsy (pN-) when there are indications for adjuvant radiation therapy but she plans for a later mastectomy (=>6 months)?
That is not a common approach I have seen, and I would question the rationale of putting a patient through two surgeries when one can be done and forgo RT. If pN0, it would depend on what significant delay is, and I would extensively counsel the patient on recurrence risk should they end up forgoing...
What is the rationale for the recent change in the NCCN criteria for very high risk prostate cancer?
As the new Chair of NCCN's Prostate Cancer Guidelines, I am happy to answer this.The purpose of risk groups is not merely to be a prognostic divider, but to help guide treatment. Many systems have been developed that have greater prognostication than NCCN risk groups, such as STAR-CAP (which is supe...
Do you typically recommend placement of a rectal spacer prior to definitive radiotherapy, regardless of dose/fractionation?
In my opinion, the potential and role of rectal spacing in minimizing toxicity is not debated. The concern about spacing relates to risks of the procedure and its associated additional cost to treatment may be greater than the potential improvement in toxicity for the patient. As we continue to show...
Do TTFields work synergistically with SRS for patients with brain metastases?
In terms of the synergy of TTFields with radiation, we have little direct data for confirmatory validation of this interaction. However, there are some limited data that suggest that there is synergy between TTFields and several other therapeutic modalities, including chemotherapy and radiotherapy...
Can I treat breast nodal volumes with hypofractionation?
Yes. Published randomized trials have treated/reported 2,000 patients with doses of >2 Gy in hypofractionation vs standard fractionation trials with treatment to the axilla. Trials include Start A/B (513 patients), the old trial by Ragaz et al., PMID 15657341 (318 patients, hypox 37.5 Gy in 15 fx), ...
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...
How do molecular and clinical factors guide personalized selection of HSRT dose fractionation regimens with bevacizumab in recurrent high-grade gliomas?
Multivariate analysis identifying HSRT dose fractionation, tumor grade, IDH mutation, and 1p/19q codeletion as significant predictors of progression-free survival (PFS) in recurrent high-grade glioma strongly supports a shift toward biomarker-driven stratification in future trials. These findings un...
Would you consider neoadjuvant immunotherapy prior to radiation for a locally advanced skin squamous cell carcinoma?
While the definitive trials are yet outstanding and enrollment in NRG HN0014 (NCT06568172) should be encouraged where it is open, the present indications for using cemiplimab should follow its principal indication, unresectable cutaneous squamous cell cancer, a minority of cases at 5%. Practically s...
What dose and fractionation do you use in the setting of head and neck reirradiation?
We have traditionally treated recurrent HNC with full standard fractionated RT concurrent with chemo. In recent years we have transitioned to SBRT, typically 40 Gy in 5 fractions. The use of SBRT is more convenient; current data suggest that both methods achieve similar tumor control rates and simil...