Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you treat a patient with Gleason 8 or 9 prostate cancer, pretreatment PSA 15-24, with retroperitoneal adenopathy?
I would offer a similar approach to that described nicely by @Dr. First Last and @Dr. First Last: definitive RT+ADT+abiraterone, with SIB to the grossly positive nodes. My caveats and additions are: I start with a frank discussion with the patient re: evidence for various scenarios and general prog...
Would patients receiving targeted therapies be eligible for TTFields for brain metastases?
It is unknown whether NSCLC brain patients receiving targeted therapies should also receive TTFields. The most common patients would be those harboring EGFR mutations or ALK rearrangement. This would need to be studied and should not be presumed to be safe, as other unforeseen toxicities have occurr...
How would you manage a patient with non-mutated oligometastatic NSCLC with a brain met who underwent resection of the brain met, had 4 cycles chemoIO, and had resection of the primary lung CA with pCR and now is NED?
This is a great question, and this scenario does come up occasionally within our Thoracic Tumor Boards. What makes this scenario more complicated is the integration of immune checkpoint inhibitors into standard practice. However, this question has been addressed in the pre-immunotherapy era with num...
What is your preferred approach for managing oligoprogressive NSCLC during second-line or later systemic therapy if patient is otherwise responding well at other sites of disease?
I would offer metastasis-directed therapy with SBRT or if necessary based on site, hypofractionated (8-15 fractions) RT to oligoprogressive disease in this setting which we now have Phase 2 randomized data to support due to the nice work of Dr. @Dr. First Last and her team in the CURB trial. Patient...
What adjuvant treatment would you give to a locally advanced esophageal adenocarcinoma status post neoadjuvant FLOT s/p resection with positive margins?
For an R1 resection, considerations would include re-resection if feasible or chemoradiation. I would not favor chemotherapy unless there was evidence of a really convincing response from FLOT. I assume MSI testing was done.
In a patient with esophageal cancer with lymph node involvement, would you consider treating with definitive chemo-radiation if they have a single area of retroperitoneal metastasis?
If a patient has non-regional retroperitoneal adenopathy without other distant metastasis (i.e., below the level of the celiac axis), that patient has M1 disease, and upfront definitive chemoRT would no longer be the standard of care (systemic therapy alone would be). However, I would then consider ...
What constraints do you use for a non-weight bearing bone when treating a patient with sarcoma?
The only long bone that is truly not weight bearing is the fibula. (This is why ENTs can harvest fibula for mandible reconstruction and not reconstruct the fibula.) All other long bones are weight bearing under at least some circumstances. Femur and tibia are obviously WB with ambulation. However, t...
Given that ESOPEC did not mandate PET staging, are the conclusions of the study still applicable for patients who are staged with PET?
I believe the study results are still applicable to patients who are staged with PET.ESOPEC supplementary data show that 7 patients (all in the pre-op CRT group) had M1 disease at diagnosis, which was discovered due to PET staging. The total number of patients in each study arm with M1 disease prior...
How do you approach an early stage breast cancer patient s/p BCS in which ECE is found on a positive sentinel node?
These are cases that we are facing more commonly and my thought is the answer shouldn't change whether this is BCS or mastectomy (though less data in this setting).I will discuss with the patient the limitations of Z011 and AMAROS with respect to ENE. With focal microscopic ECE, I will often proceed...
What is the role of adjuvant radiation in R0 node positive resected pancreatic adenocarcinoma in light of the recently presented RTOG 0848 abstract?
There are three options here in my practice. 1) Treat, 2) don't treat, and 3) "watch and wait, then ablate" (for a local recurrence). In general, I treat patients with CXRT who have positive margins (IMRT 45 Gy/25# to regional volume with SIB of 62.5 Gy to the margin. If it is an R2 resection (which...