Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you consider downstaging neoadjuvant cemiplimab for borderline resectable CSCC in order to facilitate surgical resection?
The answer is yes, since the publications of the neoadjuvant cemiplimab study in the NEJM (Gross et al., PMID 36094839/). However, this is a change of standard of care, not yet vetted in the NCCN guidelines (Guideline SCC4), nor FDA approved for this indication. Thus, off label cemiplimab or pembrol...
How would you approach radiation therapy for indolent T-cell lymphoproliferative disorder of the gastrointestinal tract?
Indolent T-cell lymphoproliferative disorder of the GI tract was a provisional entity in the 4th edition of the WHO classification system. In the 5th edition, the disease has been renamed, "Indolent T-cell lymphoma of the GI tract" (Alaggio et al., PMID 35732829). The disease is rare, often mimickin...
Would you be willing to give definitive chemo-radiation and chemotherapy to a MSI-stable T2N0 low lying rectal cancer in a young healthy patient who wants to avoid surgery?
More likely to recommend total neoadjuvant therapy hoping for induction of complete clinical response. In our hands, on average, we are able to conserve the rectum in about 55% of treated patients with excellent rectal function and a regrowth rate of less than 10%. Local excision will not address th...
Are you routinely using neoadjuvant cemiplimab for cutaneous squamous cell carcinoma of any site?
No
Do you treat the optional radcomp posterior lymph node field for patients with breast cancer?
I usually treat if medial supraclavicular node is involved, high nodal disease (10 or more) burden in the axilla, inflammatory breast cancer, or any PET avid node in the posterior triangle prior to chemo.
How do you manage dry eye related to Pluvicto Lu-177?
This is a real but uncommon side effect of Pluvicto therapy. Per VISION, it will happen in maybe 3% of patients but almost never high grade. Interestingly, the absorbed dose for the lacrimal glands is 2.1 Gy/Gbq - which over 6 cycles full dose at 7.4 GBq/200 mCi per cycle means 92 Gy. There was a me...
How do you address the axilla in an incidentally found T1bNx invasive breast cancer with extensive DCIS on bilateral prophylactic mastectomy in BRCA-2 mutated woman?
I would send her for an axillary ultrasound and biopsy any suspicious lymph nodes. Following a mastectomy, it is challenging to do a sentinel lymph node biopsy so surgical evaluation of the axilla usually requires an ALND. If by imaging the axilla is negative, I would run her tumor characteristics t...
How do you approach a patient with prostate cancer with sclerotic/lytic lesions found on a CT scan but not seen on a bone scan or PET-PSMA?
This can be a tough situation, as sometimes healthy individuals can have sclerotic or lytic foci in various bones for reasons unrelated to any type of malignancy. The first thing I would try to do is compare the CT scans to any prior imaging if possible. If these lesions are completely unchanged fro...
Would you offer partial breast irradiation for women with G2 4cm DCIS with close margins of 1mm but a very large breast size?
Although size cut off is arbitrary, DCIS tumor size is one of the risk factors for IBTR. For large-volume DCIS like this case in question, what is not known is if a 1 to 1.5 cm CTV margin would capture all microscopic areas of disease or do we need to treat larger volumes. For that reason, I favor I...
How would you approach treatment of a patient with recurrent choroid plexus papilloma with intraventricular dissemination?
The management of choroid plexus tumors starts with diversion of the CSF flow, especially in this patient with a recurrence in the 4th ventricle. A gross tumor resection (GTR) is the most significant prognostic factor, but in this patient, it might not be feasible due to the dissemination in the lef...