Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you recommend prophylactic cranial irradiation for ES-SCLC patients now that immunotherapy is included in the treatment schema?
I do not pursue PCI for most patients with extensive stage SCLC. We know the EORTC phase III study led by Ben Slotman (NEJM 2007) showed a decrease in the cumulative risk of brain metastases that translated into a survival benefit. One of the flaws of the study was the lack of baseline and regular M...
Are there particular subgroups of patients with glioblastoma who derive the most benefit from TTFields?
No validated subgroup has been identified. Patients with MGMT methylated tumors appear to gain most from treatment, but the EF-14 study was not powered to answer that question and patients with unmethylated tumors still saw a benefit. I recommend TTfields to all patients with newly diagnosed gliobla...
Would you offer PA nodal XRT in a patient with rising PSA and multiple PET positive nodes after previous prostate XRT treatment that is otherwise locally controlled?
This is a great question, and one that is being explored more and more, particularly for young, healthy patients with well-controlled primary disease. In addition, we are seeing more of these patients due to novel developments in imaging that can detect disease at much lower PSA values than before (...
What is the role for TTFields in patients who cannot undergo complete surgical resection for glioblastoma?
The EF14 trial included newly diagnosed glioblastoma patients who had gross total resections and those who had biopsies. Only 54% of patients had a GTR and 13% had biopsy. TTF plus temzolomide was associated with an increase in PFS and OS in all subgroups including extent of resection. So even if gr...
How do you decide on dose modification, interruption, or discontinuation of temozolomide in the concurrent and sequential settings?
With regard to an optimal maintenance regimen, there is no data to suggest that an alternate regimen is more effective than the standard 150-200mg/m2 days 1-5 in a 28 day cycle. However, there are some patients that cannot tolerate this regimen due to excessive/ poorly controlled chemotherapy-relate...
Following oral cavity radiotherapy, how do you advise patients on ongoing bisphosphonate therapy and the risk for osteonecrosis?
I asked the question, but since no one has responded, I will just comment that I have discontinued such therapy in one of my H&N patients for fear of increasing the odds of osteonecrosis occurring.
Would you offer RT to a patient who had a RP showing pT3b pN1 Gleason 9 prostate cancer with elevated post-op PSA?
If Axumin PET is negative for metastatic sites (prostatic Bed or Pelvic Nodes are excluded) Or even totally negative, I would treat.
How would you approach a symptomatic patient with with a history of whole brain RT with new bilateral MRI enhancing lesions within the optic nerves?
The differential would be optic neuritis from immunotherapy or leptomeningeal disease. Is there any visual deficit? It appears there is a lesion as described above rather than enhancement which would favor disease. One would need to know the disease status outside brain and if there is any other sus...
What is your surveillance imaging schedule following treatment of a pituitary adenoma?
Pituitary adenomas usually change little in size after either fractionated RT or SRS, and they progress slowly. Therefore, yearly imaging to look for increase in size is sufficient. For secretory pituitary adenomas, periodic (every 3 to 6 months) measurement of the level of the hyper secreted hormon...
How do you improve compliance with TTFields for patients who would like to discontinue therapy?
I think that TTF can be an incredibly empowering adjuvant treatment, that I agree should be encouraged as standard. Engaging a patient who might otherwise feel that they have lost control amongst a myriad of treatment hurdles, for which they have little control, can be frustrating. The data now sugg...