Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your approach to brain reirradiation in the setting of recurrent/progressive gliomas?
A lot of factors need to be considered prior to offering brain reRT in such a setting, most importantly- interval since the 1st course of RT, patient's ECOG and neurologic function, age, perceived life expectancy, size of the lesion, location of the lesion, WHO grade of glioma, patient's expectation...
What adjuvant treatment approach would you recommend for a patient with early-stage MSI-high gastric cancer who received neoadjuvant ipilimumab (×2) and nivolumab (×6) per the NEONIPIGA regimen, followed by R0 resection with no pathologic response?
I would favor FOLFOX x6 as per classic. This scenario raises the question: Was this truly MSI-H? I would confirm MSI status with next-gen sequencing. I would have expected a response if MSIH on ngs with concomitant high TMB. Our institutional practice has been to review all MSI-H IHC cases done outs...
Do you consider tertiary grade pattern, LVI or PNI on prostatectomy specimens as adverse features to recommend EBRT and ADT for patients with unfavorable intermediate prostate CA after prostatectomy with undetectable PSA?
No, I don’t think there is any current available evidence to define a benefit for ADT in the post-operative setting for patients with an undetectable PSA. The two major trials which define a benefit for ADT in this setting, RTOG 9601 and GETUG AFU-16 had a lower limit of a PSA of 0.2 at treatment in...
What is the value of resection in high risk (but small or early stage) skin cancers at the medial canthus?
The value of resection of a high risk small or early stage skin cancer at the medial canthus is potential assurance of complete removal of the skin cancer by confirmation of negative margins. Depending on the extent of disease and surgical approach, this may or may not be straightforward. There are ...
How do you simulate and treat a prostate cancer patient with a persistently full rectum?
Simulation should lead to reproducible and desirable treatment positioning of the patient and their anatomical orientation. For prostate cancer, the state of bladder and rectal filling need to be considered. I think that a "comfortably" full bladder is widely used for simulation and treatment, but r...
If adjuvant radiation is indicated for a Merkel cell carcinoma of the upper extremity and hypofractionation is desired, what dosing regimens are recommended?
While more common cancers (breast, prostate, etc.) have well-designed clinical trials that demonstrate equivalence of hypofractionated radiotherapy and conventionally fractionated radiotherapy, similar types of studies are lacking in less common cancers like Merkel cell carcinoma. Part of the diffic...
What is your approach to adjuvant radiation for anorectal mucosal melanoma s/p wide local excision?
Primary anorectal melanomas are very rare, thus there are no large randomized trials to guide their care. As with any melanoma, surgery is the mainstay treatment. Oncologic surgery often entails APR leading to permanent colostomy thus local excision is sometimes preferred.Following excision, adjuvan...
How do you manage vaginal necrosis after pelvic radiation?
This is a broad topic that doesn't lend itself to a short answer format; however, I will offer a few thoughts. The first thing, of course, is to keep it from happening through judicious RT technique. Vaginal necrosis is most likely due to brachytherapy administration rather than external beam RT, an...
When is radiation indicated in the treatment of perianal paget's disease?
Extramammary Pagets disease is essentially adenocarcinoma in-situ and typically managed surgically. I would not treat with radiation unless it is invasive. If it is invasive and inoperable or if it would require APR, radiation is an excellent option. I treat them like SCCa of the anal canal, except ...
How would you treat a late local recurrence of extramammary Paget's disease of the vulva, not amenable to resection?
If the patient does not have any invasive disease, or underlying malignancy or nodes, then I would consider treating this with radiation, specifically superficial brachytherapy. At our institution, we routinely treat similar patients with large perineal, inguinal EMPD patients with 3D custom printed...