Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How does a close DCIS margin factor into surgical and radiation decision making for Stage I invasive ductal carcinoma after breast conserving surgery?
Based on SSO and ASTRO guidelines for invasive tumor, no tumor at inked margin is considered negative by us for suitability for adjuvant RT. If there was calcification as part of the mammographic finding, then for close DCIS we would look at the specimen radiograph and also consider pre-RT mammogra...
How long would you stop standard GBM radiotherapy if the patient had a fall with minor head trauma?
I would do everything possible to minimize or ideally avoid treatment breaks, given no intracranial bleed. I would evaluate skin dose over the area of laceration and consider adapting the plan to meet skin constraints or lower dose to the suture if possible and not already low. If significant swelli...
In what situations do you recommend adjuvant radiotherapy for colon cancer?
It is appropriate to be cautious when considering the use of CXRT in patients with resected colon cancer. The main reason is that in the post-operative setting there is almost always fixed small bowel adherent to the tumor bed. For this reason, one may not be able to deliver a high enough dose to pr...
How do you manage a symptomatic primary breast tumor in a patient with metastatic disease?
It’s much harder to treat patients palliatively than to cure. The art of palliation generally requires weighing the acute and subacute toxicities of alternative treatments much more heavily and chronic toxicities less than we do for potentially curative care. It also requires assessing whether patie...
How do you approach management of a patient with intermediate risk prostate cancer treated upfront with HIFU and intermittent ADT who is later found to have rising PSA and biopsy-proven prostate-confined recurrence?
These are frustrating situations, and ones I am now seeing frequently as focal therapies have gained traction in the United States. The approach, needless to say, is highly individualized. Often, these glands are quite abnormal in MRI appearance, and there is a concern for fibrosis. My approach is h...
What is your approach to patients with locally recurrent prostate cancer following cryotherapy or HIFU?
Limited data has been published on this subject, however, the best results from a standpoint of disease control and side effect profile have been observed with salvage radiotherapy. In general, our practice has been to treat these patients with definitive radiation to doses of 70-74 Gy. For patients...
Which patients with locally advanced cervical cancer would you consider as candidates for moderately hypofractionated pelvic chemoradiation before brachytherapy?
At present, would not offer outside clinical trials, as data are limited, with some suggesting a higher risk of acute morbidity also. Doses of EBRT in these studies are also not similar, varying from 37.5 in 15, 40 in 16, 44 in 20, and 43.3 in 17.
How would you apply the results of CheckMate 204 in an asymptomatic patient with 10-20 metastatic brain lesions on dual immunotherapy for melanoma?
The results of CheckMate 204 showed that systemic therapy with both nivolumab and ipilimumab has clinically meaningful efficacy in patients with asymptomatic, untreated melanoma metastases to the brain. In this phase 2 study, however, only 22% of the patients had 3 or more lesions. Nevertheless, int...
Does pleural tenting adjacent to tumor impact your target volume for early stage NSCLC planned for SBRT?
Having reviewed the images in the cited paper, the question of how to define the target for tumors with proximity to the chest wall and that also show pleural tenting is one that my thoracic radiation oncology colleague will often discuss. The brief answer is that although tenting likely represents ...
If adjuvant radiation is indicated for a Merkel cell carcinoma of the upper extremity and hypofractionation is desired, what dosing regimens are recommended?
While more common cancers (breast, prostate, etc.) have well-designed clinical trials that demonstrate equivalence of hypofractionated radiotherapy and conventionally fractionated radiotherapy, similar types of studies are lacking in less common cancers like Merkel cell carcinoma. Part of the diffic...