Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach a patient with invasive breast cancer and DCIS s/p mastectomy and immediate reconstruction with a negative invasive margin, but a close DCIS margins?
I would observe such a patient. With a close DCIS margin post mastectomy, there is very little evidence of a benefit to PMRT. Subsequent local recurrence is well below 10% so I see no clear role for PMRT in such a case. Even if there was a close invasive margin unless there were other aggressive fac...
What is your preferred dose and fractionation schedule for a patient with a stage III non-small cell lung cancer, whose comorbidities preclude chemotherapy, but has good enough performance status to warrant an attempt at longer-term local control?
This is a very good question. I'd say the answer to this one is evolving! Typically the patients who cannot tolerate either sequential or concurrent chemotherapy for locally-advanced NSCLC are quite frail and/or have comorbidities that are significant. The results using radiation alone for Stage III...
What target expansions do you use when treating with 60 Gy in 15 fractions for the lung?
I skip the CTV and go straight to the PTV, which can be as tight as 5 mm and up to 10 mm if there are off-axis setup or CBCT imaging concerns. I don't use this fractionation with concurrent chemotherapy, and only do so when chemotherapy is omitted or delivered sequentially.
When offering palliative radiation for breast cancer, what dose/fractionation do you prefer and in what subset of patients do you believe derive the most benefit?
More recently after FAST-Forward, use 26 Gy in 5 for palliation as shorter and reasonable dose to palliate pain, bleeding, and drainage.
How do you manage a recurrent craniopharyngioma?
Complex answer—my personal view based on my Neurosurgery and SRS/RO experience:1. If the recurrence is a single large cyst—surgery (stereotactic aspiration combined with SRS to collapsed cyst immediately, have done the same day) or Intra-cavitary P32.2. If it's a small solid/micro-cystic recurrence—...
For patients with myxoid liposarcoma who needed upfront surgery and had an indication for PORT, would you consider dose reduction/hypofractionation of adjuvant radiation?
Great question. This touches on two distinct but related concepts: Dose Reduction for Myxoid Liposarcoma: The radiosensitivity of myxoid LPS is well established, and dose reduction has been studied, but almost exclusively in the preoperative setting. Prospective data support preoperative doses as lo...
How do you manage a nodal recurrence of an early stage glottic laryngeal cancer previously treated with definitive radiotherapy?
As a general rule, patients with post-RT recurrences that are resectable should undergo surgery rather than re-irradiation, unless surgery is expected to be associated with substantial risk or functional deficit (in which case the patient should be consulted about the risks of each modality). In the...
Is it necessary to treat one vertebral body above and below for palliation of spinal metastases?
No. The reasons to go one above & below were to avoid the dreaded miss from the dreaded days of bone scans, plain films & port films. That is much, much less likely these days with IGRT, CBCT, MRI (PET, etc.). We know treatment volume size correlates with toxicity. You can get some dysphagia/esophag...
How do you balance short-term efficacy against increased low-grade toxicity and quality-of-life considerations for higher single-fraction regimens in recurrent glioma patients?
When considering radiation options for recurrent glioma, in my mind, one size does not fit all. I consider several aspects of the specific patient’s clinical situation: Patient’s prior treatments: time interval, volume, location, and anatomic site, response to prior treatment, response duration from...
In a patient with gastroesophageal adenocarcinoma treated with neoadjuvant chemoimmunotherapy who had a good response but is unable to undergo surgery, how would you approach radiation therapy?
As the ARTDECO study did not show a difference in local control between 50.4 Gy and 61.6 Gy (given with carbo/taxol, but FOLFOX is also an option per PRODIGE5, depending on chemotherapy used as part of the initial chemo-IO), I would suggest 50.4 Gy.