Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you talk to patients with intermediate-risk prostate cancer deciding between LDR brachytherapy (monotherapy) vs HDR mono vs SBRT vs EBRT, in terms of the comparative side effect profile of each approach?
It’s hard to add much to Dr. @Dr. First Last's excellent evidence-based answer, but I’ll elaborate on the counseling aspect from my perspective. Introduction: I start by acknowledging how difficult it is to weigh several totally foreign options and acknowledge the gravity of the decision. My patient...
Can the results of Checkmate 577 be applied to patients who do not undergo surgery following chemoradiation because of a clinical complete response?
The standard approach for patients with locally advanced esophageal cancer would be to proceed with surgical resection after neoadjuvant chemoradiation, regardless of clinical response. And then, if surgical pathology confirms residual disease, to proceed with adjuvant nivolumab. If the clinical res...
How would you manage a recurrent pineoblastoma following prior CSI?
Recurrent pineoblastoma following prior CSI represents a challenging clinical scenario. As there is very little published data to guide optimal management, our approach is adopted from recurrent medulloblastoma. The prognosis for patients with recurrent medulloblastoma/PNET is poor, with 5-year OS <...
In light of the recently published Alliance A021501 trial, what is your approach to incorporating SBRT for the treatment of borderline resectable pancreatic cancer?
My approach is the same as it always has been. I have never used low-dose small volume "SBRT" for BRPC or LAPC because it does not make sense. Treating an infiltrating neurotropic tumor that spreads along arteries with millimeter margins on the gross tumor and leaving the regional lymph nodes untrea...
How do you approach treatment of an optic nerve sheath meningioma?
I typically do 50.4 in 28 fractions with a stereotactic technique. We use both co-planar and non-coplanar arcs. I keep the optics point max to 54 Gy. Several single institution series including: MacLean et al. IJROBP 2013, Bloch et al. (UCSF) JCNeuroSci 2012, Ratnayake et al. (Australia) JCNeuroSci ...
Do you modify dosing and monitoring of Lu-177–PSMA therapy for patients with prior large-field RT involving substantial active marrow compared with patients who only had focal bone SBRT?
No, we do not modify dosing and monitoring of PSMA therapy with prior large-field RT. In the VISION trial, the vast majority of patients were heavily pre-treated, presumably many with pelvic radiation for definitive treatment or treatment for bCR prior to metastasis. Assuming that the patient had ap...
What is your preferred dose and fractionation schedule for a patient with a stage III non-small cell lung cancer, whose comorbidities preclude chemotherapy, but has good enough performance status to warrant an attempt at longer-term local control?
This is a very good question. I'd say the answer to this one is evolving! Typically the patients who cannot tolerate either sequential or concurrent chemotherapy for locally-advanced NSCLC are quite frail and/or have comorbidities that are significant. The results using radiation alone for Stage III...
What is the role of radiotherapy in a newly diagnosed patient with parameningeal rhabdomyosarcoma w/ intracranial extension, a positive CSF but no extra-CNS metastases?
The question as to the role of RT in patients with parameningeal (PM) RMS with CNS leptomeningeal disease is complex and one lacking scientific evidence to support one’s answer. My response represents a historic viewpoint gained from hearing the discussions of the Intergroup Rhabdomyosarcoma Group (...
How would you manage an isolated nodal recurrence of breast cancer in a patient with a prior history of mantle-field radiation?
The clinical details of the patient's "initial" radiation-associated breast cancer and what adjuvant treatment(s) she received after her mastectomy and reconstruction would be helpful here, both in determining the risk of the nodal recurrence she has now experienced and what additional therapies she...
How does one interpret the LUMINA trial in the FLORENCE APBI ERA?
This is a common scenario. My practice is to discuss this with the patient. I discuss 5 fraction PBI or 5 fraction WBI depending on the scenario, as well as endocrine therapy and the differences in toxicity profiles. Given compliance rates of 50-60% with endocrine therapy long-term, many patients pr...