Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you include the supraclavicular basin in adjuvant radiation treatment fields if there were multiple positive axillary sentinel lymph nodes with ECE discovered at the time of resection of a proximal arm cutaneous SCC?
Short answer, I wouldn't. I'd do good restaging (PET vs contrasted CT or both) and ensure you're just dealing with microscopic residual or to guide boosting to gross disease dose if gross residual in axilla, and just treat your involved axilla and primary site if indicated. This is a patient who wou...
When (if ever) would you offer radiotherapy for renal cell carcinoma following nephrectomy?
There is no indication for any type of radiation after nephrectomy in resected RCC. Often a 'positive' renal vein margin is not a true positive, but rather an artifact of having a renal vein thrombus and this should be discuss with the Urologist and Pathologist and clarified in the report. Having sa...
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...
As consolidative thoracic radiation (cTRT) was prohibited on the seminal chemoimmunotherapy trials in ES-SCLC, how do you approach cTRT in practice?
There are two trials showing benefit for TRT for patients with ES-SCLC, one from Yugoslavia and one from the EORTC (though, the primary endpoint was not met). The Yugoslavian trial was not considered practice changing, while the EORTC study has made me consider adding TRT in certain patients, even w...
How would you approach a patient with recurrent grade 3 oligodendroglioma (MGMT-methylated, IDH mutant, 1p/19q co-deleted) 1 year after gross total resection and adjuvant chemotherapy and radiation?
There are multiple options to consider for the recurrence of grade 3 gliomas after prior chemotherapy or radiation. Regardless of whether or not the recurrence overlaps completely or partially with the prior treatment fields, options include systemic therapy (including IDH-targeted therapies for IDH...
Are there cases that should be referred to a center with a MR Linac for RT?
There likely are cases that would be best treated on an MR Linac, though I suspect they are relatively few and far between. The categories noted in the question stem are certainly considerations, however, I feel that only a subset of these patients would gain true advantages. MR Linac offers the pot...
Are there any indications to boost the axilla for women with locally advanced breast cancer who do not have clear gross residual/undissected axillary disease?
There is no indication for a boost in absence of undissected gross node for upfront surgery or residual node, which is not removed after neoadjuvant chemotherapy.
What surveillance do you recommend for a patient with locally advanced rectal adenocarcinoma who had a complete clinical response to total neoadjuvant therapy and declines to undergo surgery?
It is important to watch these patients closely since ~15-20% will have local regrowth/recurrence that are salvageable (Dossa et al Lancet 2017). The OPRA trial, recently presented at ASCO 2020, included 324 patients treated with TNT regimens and WW if complete response. Organ preservation rates wer...
What dose constraints do you use for hypofractionated radiotherapy for breast cancer undergoing regional nodal irradiation?
Long Answer: Currently, I offer hypofractioned RNI tx for patients only on clinical trials. The two trials that inform my treatment regimen/dose constraints are MA.39 and FABREC. As you are aware, MA.39 is a randomized trial for lumpectomy and mastectomy patients with limited nodal burden. When enro...
How would you alter your PTV margins for a lung SBRT target adjacent to the rib?
Overall, while I generally do not alter my margins substantially for an SBRT target adjacent to the rib, there are some circumstances in which I might make small/subtle changes. My driving thought process is that (in particular for stage I NSCLC) tumor control remains the most important factor, as c...