Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your treatment approach to patients with extremity sarcoma with multiple positive regional nodes?
We generally include lymph nodes > 3 cm or multiple lymph nodes in the first echelon area if within a reasonable distance to the primary in the preoperative volume. For first echelon nodes at greater distances from the primary site without in transit involvement, we would separate out the primary CT...
How do you approach local therapy for oligoprogression of metastatic NSCLC?
Tsai et al. presented data from the CURB trial at ASTRO 2021. This showed a significant improvement in median PFS (44 vs 9 weeks) for NSCLC patients with oligoprogression (unlimited mets at presentation and 5 or less mets on progression) randomized to SBRT vs best supportive care. Interestingly, the...
Is there a volume limit above which you might not offer standard chemoradiation for a patient with a GBM?
I think this requires more information to answer. I presume the question is if there is a GBM that is of a certain size for which I may not offer standard chemoRT. There may be situations for which I may not offer standard 60 Gy in 30 fx IMRT and consider hypofx RT including older patients or patien...
How do you treat the seminal vesicles when using moderate hypofractionation for prostate cancer?
The question refers to moderate hypofractionation and I will begin by defining moderate hypofractionation. In my book moderate hypofractionation involves daily fractions of 2.4-4 Gy/day as opposed to 1.8-2 Gy/day which remains the norm in the United States. There are several prospective reports of m...
Is there a benefit to metastatic & primary site RT in RMS w/ persistent marrow disease?
While I agree with the response by Dr Ermoian, I believe the case is more complicated than simply irradiating the gross disease at the primary site. Overall survival and Progression Free Survival for Stage 4, Group IV RMS has not changed substantially over the past almost 5 decades, despite many suc...
What is your approach to a patient with an advanced stage diffuse large B-cell lymphoma treated with chemotherapy alone (with a PET CR) who then develops an isolated CNS relapse?
This is a challenging albeit relatively rare situation. First, I would make sure to complete systemic workup, including MRI of brain/spine, CSF cytology, and PET/CT. I would not consider radiosurgery even for a single brain lesion, as this is ultimately a more diffuse disease process. If patient has...
Do you ever offer repeat radiation for hepatobiliary cancers in cases of local recurrence after definitive external beam or SBRT?
I do offer repeat radiation for hepatobiliary cancer after definitive external beam or SBRT. The dose and fractionation really depends on the size of the recurrence, the status of the patient's liver disease e.g. Child Pugh status (CP), and its location in proximity to critical structures.If the les...
What fractionation do you use for consolidative chest RT in extensive stage SCLC?
3 Gy x 10 is arguably the standard of care.For patients with good performance status, and who do not have extensive disease outside of the thorax (which is clearly a judgment call), we consider 2.5 Gy x 20 with a 2 week break. This is a well-tolerated schedule with respect to esophagitis. For those ...
When treating two primary early stage lung cancers with SBRT, do you treat both at the same time or stage your treatment?
A completely non-clinical but nevertheless "real world" thought:If you deal with Evicore, the insurance pre-auth gatekeepers for many private insurances in the U.S. (BCBS e.g.), and they "catch wind" that you're not going to treat such a patient's lesions synchronously, it's highly likely they will ...
How does the finding of incidental proximal seminal vesicle invasion on mpMRI alter your recommendation for brachytherapy in a patient with prostate cancer who was initially a candidate?
An additional thought........... Regarding this question as well we need to be cautious about the word "incidental". Normally an "incidental" finding would be characterized as a patient who was undergoing a CT scan of the abdomen and pelvis for the workup of a high grade prostate cancer, for instanc...