Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you recommend chemoradiation to the pelvis for a patient with squamous cell carcinoma of the anus metastatic to the liver who has had a complete response to chemotherapy in the pelvis and a liver resection?
The patient is very fortunate. Oligometastases in anal cancer is not a well-studied phenomenon. I do think that this patient is at risk of recurrence in the pelvis, which could be very symptomatic. For this reason, I would suggest radiation therapy. And probably at doses used in the early days of tr...
When treating locally advanced breast cancer preoperatively that is progressing on neoadjuvant chemotherapy, to what doses do you treat the gross disease, breast, and regional nodes?
I typically treat 50 Gy to large fields including the entire breast and regional nodes and take any gross disease to 60-66 Gy. I also discuss with my medical oncologist the possibility of concurrent xeloda as well.
When treating prone breast how do you recommend contouring the breast?
I typically follow the atlas guidelines but will "cheat" laterally and/or posteriorly in some cases. For example, if the heart would be in the field and the tumor is not posterior, I may not come all the way to the pectoralis posteriorly; or, if treating all the way to the latissimus results in too ...
How would you manage a patient with high risk prostate cancer with rising PSA after RP who has oligometastatic bone disease in the pelvis?
For now, the standard of care is systemic treatment of which the type is sometimes driven by extent of bony disease.
Which radiation modality for definitive prostate cancer has the lowest risk of erectile dysfunction?
This is a great question. Historically, we have considered brachytherapy to be superior, with the caveat that I am not aware of any randomized data to support this. What is interesting is the ProtecT trial showed almost no difference in erectile dysfunction at 6 years between the Radical Radiotherap...
Can post-lumpectomy radiation be omitted for ER/PR(+) low-volume (2 mm) low-int DCIS, with > 2 mm margins in a post-menopausal patient who will be taking tamoxifen?
This is an individualized decision weighing the benefits and potential toxicity. We know from many prospective trials that none of the clinical features mentioned sufficiently put the recurrence risk low enough (often defined as <10%) to omit radiation. However, radiation also likely will not have a...
What dose and volume would you treat in a patient with diffuse large B-cell lymphoma confined to the stomach after complete response to R-CHOP?
In a patient with stage IE gastric DLBCL in a complete response (Deauville 1-3) after R-CHOP, I would consolidate with 30 Gy of RT. The volume would depend upon the size of the original tumor and how defined the original disease was on PET-CT and upper endoscopy. In a patient with a smaller lesion i...
For ES-SCLC with a distant cCR and local cPR after systemic therapy sustained for at least 1 year, how would you approach consolidative thoracic RT?
The CREST trial by Slotman referenced enrolled patients with the findings above after 4-6 cycles of chemotherapy, and required patients initiate radiation therapy within 6 weeks. If this patient truly has not progressed 1 year after chemotherapy, I am not clear on what the additional benefit of radi...
What is the role for RNI in a postmenopausal female with clinically N+, hormone receptor positive breast cancer s/p lumpectomy and ALND with low volume nodal disease (e.g., 1/12 nodes positive)?
When thinking about low volume nodal disease in cN+ patients, I tend to think about MA20 which included patients undergoing an ALND and 85% had 1-3 LN involved. I will offer these patients adjuvant RT to the breast and RNI (SCV/axilla with consideration of IM nodes based on dosimetry) based on the i...
If a patient with low metastatic burden has bulky retroperitoneal adenopathy without osseous metastasis, would you recommend prostatic radiation?
We could debate whether "bulky" retroperitoneal adenopathy is a truly low volume metastatic disease, but technically it would fit the definition used in the STAMPEDE Trial. In addition, patients presenting with nodal metastatic disease may have a more indolent course than those presenting de novo wi...