Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In a locoregionally advanced breast cancer with multiple positive surgical margins, how safe is it to wait for a re-excision vs treating upfront with comprehensive RT if surgery cannot be done the short term due to the COVID outbreak?
Agreed, higher radiation dose will not replace negative margins. Obtaining negative margins is ideal. If the patient is a systemic therapy candidate, I would agree with @Dr. First Last and proceed with systemic therapy and then re-excision.
Should we consider radiation therapy for patients with N2 EGFRm NSCLC who will receive osimertinib, though RT was excluded on ADAURA?
For an EGFR-mutant N2 disease, we favor adjuvant chemotherapy (OS benefit) and/or adjuvant TKI based on ADAURA trial (DFS survival). The only prospective data regarding the use of adjuvant radiotherapy comes from a phase III trial, Lung Adjuvant Radiotherapy Trial (Lung-ART), where patients were ran...
Have treatment recommendations changed for Stage I endometrial Cancer based upon PORTEC 4 results?
PORTEC-4a will almost certainly change recommendations for adjuvant treatment in high-intermediate risk stage I patients with endometrial cancer, and in at least 2 different ways, in my opinion. By following the molecular profiling guidelines, nearly half of these patients will avoid adjuvant treatm...
How do you determine dose for prostate SBRT?
The Stanford experience published by King et al was an important one describing a prospective experience of SBRT at dose levels of 35-36.25 Gy, and these dose levels were used based upon prior single institution retrospective reports from community practice settings where a good deal of experience ...
Is it necessary to use double contrast MRI for treatment planning of brain SRS?
"Necessary" is perhaps too restrictive a term, but speaking anecdotally, at Barrow Neurological Institute (BNI) we, for essentially the past 20 years, routinely obtain thin cut (1mm) SPGR double-dose gadolinium MRI to plan radiosurgery for patients with brain metastasis. In support of this, a recent...
What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?
This really boils down to two issues: CTP score and size of the lesion. For patients who are CTPA with a lesion <3 cm, RFA/MWA or SBRT are good options although there is some data from the University of Michigan (Wahl et al., JCO 2014) that lesions > 2 cm are better served with SBRT. For solitary le...
In a patient with rectal cancer, when would you consider brachytherapy monotherapy or brachytherapy boost after CRT?
For a patient with cT2N0 disease, the most appropriate use of brachytherapy would be sequential with pelvic radiotherapy, the bulk of data being with long-course CRT. Brachy can either be done prior to CRT or sequenced afterwards. We routinely use brachytherapy in appropriate candidates in our pract...
How would you approach a radiation-induced angiosarcoma of the breast after mastectomy with negative margins?
Based on this research we tend to offer RT for high grade or tumor more than 5 cm or RT induced; there is no good prospective data. Based on UF series, we offer accelerated hyperfractionation 1.5 BID to 45 to 50 Gy, treating only chest wall.
Does non-urothelial histology impact your approach to chemoradiotherapy for muscle-invasive bladder cancer?
There is no randomized data available in this regard to guide us through non-urothelial histologies for MIBC. However, certain points that are worth considering in their management are: For small cell or neuroendocrine tumors, cisplatin/etoposide or ifosfamide/doxorubicin-based systemic therapy in ...
When do you consider re-irradiating patients with recurrent cervical cancer?
Because I have been seeing and treating a reasonable number of these cases for 35 years, I have some strong opinions on the matter. Although external beam re-irradiation in the setting of recurrent cervical cancer is fraught with great hazards and poor outcomes, interstitial re-irradiation has a hig...