Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is the maximum dose that you would give to residual unresectable gross disease in the axilla in the setting of recurrent breast cancer s/p ALND?
The FAST-Forward boost trial will be informative here, and I would recommend reading the protocol, because one can consider using the standard arm now, which is 40 Gy to the breast (and nodes, when RNI is indicated), and a 48 Gy boost, all in 15 fractions. This dose is recognizable as the breast boo...
Would you add whole-pelvis radiation as MDT (metastasis-directed therapy) in a patient with 1 pelvic node and 2 osseous metastatic sites for castrate-resistant prostate cancer?
This patient would not fit the PEACE V-STORM eligibility criteria, since the trial excluded patients with distant metastases and did not include patients who were castrate resistant, so I do not think you can extrapolate the results to this patient. One could argue that what you propose to do (SBRT ...
When planning spine SBRT, do you use volume dose limits to the spinal cord PRV, such as D0.35cc, in addition to maximum point dose?
An excellent recent paper from the MSK group on 3-fraction spinal SBRT (minimum dose of 27 Gy to PTV) was published last year, examining dosimetric predictors of radiation myelopathy. Of note, spinal cord delineation in this study was done using myelogram in 85% of cases, with 15% of cases utilizing...
How do you manage a seminal vesicle recurrence after prostate brachytherapy?
Finding more of these in the PSMA era. Have managed a few patients with SBRT +/- ADT adjusting dose based on overlapping OAR if needed.
How would you counsel a patient concerned about receiving IMRT rather than IMPT for oropharyngeal cancer?
I would tell the patient there is absolutely no concern at all with IMRT, and it is a very well-established SOC. I am personally unclear about the OS benefit with IMPT, as it was pointed out, unexpected. It is unusual to see no difference in PFS and no tox difference, and yet there is an OS differen...
How would you approach management of a large, fungating squamous cell carcinoma of the auricle if surgical management is not desired by the patient?
For a tumor this size and with cartilage invasion, I would recommend starting with induction cemiplimab to best response (generally 4-6 cycles), followed by consolidative RT, generally electrons. Prior to starting the immunotherapy, I would stage the neck with a contrast CT scan, as tumors of this s...
Are there any online or publicly available pelvic floor physical therapy resources you regularly use or offer to patients?
PFPT is a great adjunct to many treatment regimens for pelvic conditions, such as urge or stress incontinence, dyspareunia, and pelvic pain. While supervised PFPT is outstanding, many women cannot maintain regular follow-up sessions, especially if they have to travel. I direct my patients to YouTube...
In light of the recent results of FAST-Forward, particularly the 5-year results of the nodal substudy, would you consider offering ultra-hypofractionation for WBI + RNI?
While I think that the data on moderate hypofractionation is mature enough (40 Gy in 15 fractions or 4256 in 16 fractions) to consider moderate hypofractionation in many patients undergoing regional nodal radiation or PMRT, I personally am not yet comfortable routinely offering Fast Forward to this ...
Do you treat regional nodes for SLN-determined node negative patients with early stage breast cancer in a medial location?
High grade. Triple neg.
Do you recommend an additional procedure for melanomas if there is tumor within 1-2mm of the margin?
Yes, for most invasive melanomas. For melanoma in situ, I often measure the distance between the tumor and the margin and add that information to the dermatopathology report. In certain anatomical locations (near eye, nose, ears, digits, genitals) or certain clinical situations, 2mm of clear margin ...