Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In a patient with very high risk prostate cancer opting for prostatectomy, when, if ever, do you recommend neoadjuvant ADT?
I generally do not offer ADT with or without a potent ARSI prior to RP even in high risk disease. While small single arm studies have shown that a few such men can achieve a pathologic CR and that path CR/MRD is associated with better outcomes after RP, for most patients, this approach has no clear ...
Would you consider utilizing pembrolizumab/enfortumab as a bladder preservation approach in patients with MIBC?
Yes, I think that this is a viable approach. Data from perioperative trials, including KN-905 and EV-304, suggest very high rates of pathologic complete responses in almost two-thirds of all patients at the time of radical cystectomy. Many of these patients may not need radical cystectomy for an opt...
Would you ever consider treating a patient with locally advanced NSCLC with SBRT to the primary tumor plus conventional mediastinal chemoradiation?
I have used the technique when the primary is far away, and conventional techniques would give a large PTV on the primary due to respiratory motion. Options in that case would include breath hold, abdominal compression, or phase gating for all 30 fractions of a conventional plan, or treating the med...
Is pre-treatment nodal ultrasound evaluation necessary if a patient undergoes upfront PET/CT for staging?
The answer to this question depends greatly on the local capabilities to conduct regional nodal ultrasound. If this can be done, then we find ultrasound to be very helpful. In today’s environment, it is difficult to obtain insurance approval for PET in the staging of node-positive breast cancer. Bey...
How does SUPREMO alter your recommendations for PMRT?
There has been a very long debate as to which, if any, patients having upfront mastectomy and axillary surgery who are found to have 1-3 positive axillary nodes (pN1) benefit from post-mastectomy radiation therapy (PMRT). I gave my thoughts in this forum on the implications of the "SUPREMO" trial fo...
In a patient with high-risk cutaneous squamous cell carcinoma of the face with extracapsular extension after ipsilateral neck dissection and rapid contralateral cervical nodal recurrence, what is the optimal management?
In various published series, around half of patients fail to achieve a complete response to cemiplimab. From the clinical details, the current active area of disease appears to be the contralateral neck with no distant disease. Curative treatment is preferred. C-POST trial established surgery + adju...
What is your radiotherapy plan for stage IVA (cT4) cervical SCC with the tumor completely obliterating the bladder trigone?
I would follow the same schedule. After concurrent chemo RT, I would use HDR brachy with a hybrid applicator to achieve a D90 of 85 Gy or above to the HR-CTV and avoid any hotspot in the bladder wall. Part of the bladder wall in the trigone area receives a therapeutic dose.
How do you differentiate between drug-induced ILD vs radiation pneumonitis in a patient receiving adjuvant T-DXd and adjuvant radiation therapy who develops new pulmonary abnormalities on surveillance imaging?
There are different ways to differentiate between T-DXd-induced ILD and radiation pneumonitis. Radiation pneumonitis is typically confined to the radiation field and has sharp geometric borders, but T-DXd-induced ILD presents with a cryptogenic organizing pneumonia pattern and patchy consolidations ...
Should the use of a brachytherapy boost affect the duration or use of ADT in intermediate or high risk prostate cancer?
We traditionally think of 4-6 mo ADT for intermediate risk, and 18-36 mo ADT for high risk men treated with EBRT (whether dose escalated or not). For high risk men in our practice, I have usually recommended 28 mo (from RTOG 9202) ADT as a standard. I do think it is fair to consider a course <28 mo ...
What would be the targets and dosing for a patient with p16+ unilateral neck disease and a small basaloid SCC of the BOT found after diagnostic tonsillectomy and BOT resection?
While detailed, often these questions are not detailed enough, and so I try to generalize and read between the lines to think what the specific question might be. The nuances are: Is the question p16+/basaloid SCC different from HPV+? The short answer is no. What is a diagnostic tonsillectomy and BO...