Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For primary CNS lymphoma, when do you refer for whole brain radiation therapy (WBRT)?
When data are limited, consensus guidelines tend to rely on the personal clinical experiences of the guideline committee members. That may explain the NCCN guidelines. Recently, remarkable progress has been noted in the treatment of CNS lymphoma with drugs alone. Ibrutinib is particularly effective ...
What is the rationale for the recent change in the NCCN criteria for very high risk prostate cancer?
As the new Chair of NCCN's Prostate Cancer Guidelines, I am happy to answer this.The purpose of risk groups is not merely to be a prognostic divider, but to help guide treatment. Many systems have been developed that have greater prognostication than NCCN risk groups, such as STAR-CAP (which is supe...
Are you comfortable combining relugolix with enzalutamide or abiraterone?
I usually avoid these combinations. The challenge is that relugolix is not superior to other ADT methods in terms of efficacy (at least based on available data) but there are safety issues with considering these combinations. All three of these medications are substrates for similar enzymatic metabo...
When do you recommend post-operative radiation therapy for extracranial chondrosarcoma?
When an en bloc resection with negative surgical margins is not achieved. Typically, this means tumors of the axial rather than appendicular skeleton, as margins are typically wide in the latter. There is "oncolore" that chondrosarcomas are radioresistant tumors. This is likely true at lower pallia...
Do you offer APBI for patients with invasive disease if there is high grade DCIS present in the lumpectomy specimen?
In these situations, I am still comfortable offering PBI to patients. DCIS is seen with invasive disease in a fair number of cases so this comes up frequently and as long as other criteria are met, I view this as appropriate for PBI.
When do you recommend postoperative radiation therapy for a ureter carcinoma?
The role of postoperative radiotherapy for ureteral cancers (and, by extension/association renal pelvis cancers) is controversial. Patients who might stand the most to benefit from adjuvant radiotherapy are those with locally advanced disease; unfortunately, these patients have a high risk of distan...
What is your radiation approach/details for regionally involved prostate cancer (N1)?
For intact cases, I usually attempt to deliver a single-phase plan with multiple dose levels in 28 fractions as detailed below:Elective Pelvic LN volume (CTVn1): 50.4 Gy/28 fx. In cases of N1 disease, I would usually include the common iliacs. When the GTVn is near the cranial field edge, I usually ...
How do you approach patients with stage III unresectable, combined histology NSCLC/SCLC?
For stage III lung cancer with mixed NSCLC and small-cell lung cancer, we treat patients with concurrent chemotherapy (cisplatin/etoposide every three weeks) and definitive radiotherapy (60-66 Gy in 30 fractions, QD), followed by adjuvant immunotherapy (durvalumab). The rationales are as follows: Ra...
When you do recommend conventional fractionation over moderate hypofractionation for prostate cancer?
I am routinely using 2.5-3 Gy in patients with low, intermediate, and some high risk patients so I guess I am an early adopter (or a cavalier nutjob). The exclusion criteria from the two published non-inferiority trials of moderate hypofractionation that are relevant to this question are quoted more...
Would you consider neoadjuvant immunotherapy prior to radiation for a locally advanced skin squamous cell carcinoma?
While the definitive trials are yet outstanding and enrollment in NRG HN0014 (NCT06568172) should be encouraged where it is open, the present indications for using cemiplimab should follow its principal indication, unresectable cutaneous squamous cell cancer, a minority of cases at 5%. Practically s...