Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When do you consider and how do you implement spatially fractionated (GRID) radiation therapy?
Typically GRID should be considered for patients with massive or recurrent tumors who had underwent previous radiation. Published clinical results employing GRID therapy have most commonly focused on its use in the palliative setting. Some centers use it in definitive bulky head and neck treatments ...
Do you recommend MRI pelvis/prostate in a patient with biochemical recurrence after XRT and negative axumin PET scan?
This is a difficult question to answer as the context is very important. If this is a younger patient with fast doubling time that warrants aggressive treatment, the answer will be different than in an older patient with a slow doubling time. The patient's particulars (co-morbid conditions, prior tr...
Do you electively treat the ipsilateral hilum in patients with peripheral limited stage small cell lung cancer who have negative pathological sampling of mediastinal and hilar nodes by EBUS and no FDG-avid nodes on PET?
These patients by your description essentially have stage I SCLC. They may be candidates for lobectomy followed by adjuvant chemo (or chemo followed by lobectomy, if surgical candidates).Similarly while there are a range of acceptable approaches to these patients if they are not/marginal surgical ca...
Would an unfavorable molecular subtype cause you to proceed with ALNDx after a positive SLNBx?
I dont think we have data to suggest ALND is required in unfavorable subtypes with positive SLN if meeting up front criteria of Z011/AMAROS. Roughly 15% of Z011 were ER- and 300 of the roughly 1400 in AMAROS did not receive endocrine therapy so likely there were some unfavorable in these studies. W...
For rectal adenocarcinoma initially staged as T2N0 and treated with upfront surgical resection, but pathologically upstaged to pT3N0 without high risk features, how do you approach adjuvant therapy?
It is not uncommon for a rectal cancer which was initially felt to be T1-2 and node negative to be revealed to be more advanced stage after surgery. To know what to do in these settings, we have to go “old school” and revisit trials reported in the 1990s, combined with lessons learned in the 2000s.S...
How would you treat an upper extremity high grade neuroendocrine carcinoma s/p 6 cycles of cisplatin and etoposide followed by resection ypT0 ypN1?
I would be suspicious. I recently treated a patient with the same diagnosis who was diagnosed with cutaneous small cell carcinoma on an inguinal node excision, recurred during adjuvant chemo with inguinal, external iliac, and common iliac adenopathy. Path was reviewed and diagnosis changed to Merkel...
What length of ADT do you recommend in a patient with a very low risk prostate cancer who otherwise has a PSA >20?
I would start by confirming that I feel comfortable with their biopsy results:1) ensuring that there appears to be adequate sampling of the prostate on biopsy,2) obtaining an MRI to make sure there is not a concerning appearing lesion that was not sampled (for instance, anterior disease),3) would al...
For a patient with HER2+ breast cancer with progressive but asymptomatic disease in the brain, would you hold off on WBRT to do a trial of tucatinib, or proceed with WBRT then tucatinib?
The trial allowed both treated and untreated brain mets, and showed response rate and improved survival. If the patient is not a candidate for SRS, it’s reasonable to watch brain lesions with serial MRIs.
How would you plan adjuvant radiation for a N+ breast cancer in a patient who had received prior lung SBRT near the treatment field?
I have had cases with SBRT and started off with CT planning for the breast; I have used DIBH. I then fuse previous dose plan to current plant. For these cases, I have not always used VMAT. If this is lung SBRT, typically OAR constraints are not drastically affected for breast RT with respect to ipsi...
How do you manage a supratentorial anaplastic ependymoma in an adult?
Unfortunately, given the rarity of this tumor, we'll never know for sure. However, I do treat those patients similar to high grade gliomas in adults. Having said that, in high grade gliomas, I use smaller margins 0.5-1 cm (GTV --> CTV) and I think it would be appropriate in this setting as well. A b...