Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Based on the recent guidelines, should prostate SBRT dose be no higher than 3625 cGy in 5 fractions?
We have delivered prostate SBRT in high volume using 3,800 cGy/4 fx since 2006. The UCSF group has also used this schedule in a large number of patients for a similar time frame. For over a decade prior to that, the exact same dose regimen was used with HDR brachytherapy and published as "safe and e...
Do you consider induction immunotherapy or chemoIO prior to chemoradiation for locally advanced PDL-1> 50% NSCLC if normal tissue constraints are not met?
If normal tissue constraints can't be met, or significantly higher chance of distant metastatic disease due to extensive local/regional disease, I would consider induction chemo/IO for patients with negative EGFR, ALK mutation and PD-1>1% before definitive chemo/RT in inoperable stage III NSCLC. Thi...
How do you manage early stage I uterine serous carcinoma?
The management of these patients remains controversial. The data are conflicting and treatment choices tend to be based more on impressions than solid data. Most clinicians advocate chemotherapy although randomized trials have not clearly shown benefit for this subset. For stage IA, we typically tre...
Would you offer a third course of palliative radiation after two courses of 8 Gy in 1 fx?
Hip pain can mean different things - is it the ilium, ischium, acetabulum, femur, or L-spine causing the pain?If it is the exact same bone as previously treated, a third fraction of 8 Gy can generally be safely given over the course of 4 years, especially if pain relief each time has lasted ~2 years...
What is the best approach in a patient with a single brain metastasis in the setting of progressing systemic disease?
There is no single "best approach" for a single brain metastasis, even in the setting of progressing systemic disease. First, ask if it is obvious that a single lesion is a brain metastasis. The patient needs to be made aware that the diagnostic error rate can be as high as 15%. If unsure, then tiss...
Has the recent SBRT vs HDR monotherapy analysis changed your use of HDR monotherapy for intermediate-risk prostate cancer?
With excellent outcomes with SBRT in this group (PACE-B), the additional advantage of brachy is limited. The predominant use of HDR brachy is either as a boost for high-risk or as salvage after previous EBRT.
How would you manage a small posterior vaginal defect noted at the time of cervical brachytherapy?
If it is from a disease, I would continue brachy as planned and address the defect based on response and healing. If unrelated to disease, I would have it sutured and continue brachy as planned.
Do you recommend re-excision of a unifocal positive anterior margin at skin after lumpectomy in a patient with otherwise low risk breast cancer features?
There are few data on how margin location affects outcome. A group from Dundee and Perth in Scotland reported that re-excision performed for an anterior margin of less than 1 mm found residual disease in only 4% of patients who had initial excision in the subcutaneous plane, compared to 24% of patie...
What dose-fractionation would you recommend for a small basal cell carcinoma of the nasal ala in a patient with poor performance status or transportation difficulties?
This patient appears to be an excellent candidate for HDR brachytherapy. An appropriately selected surface applicator (Leipzig or Valencia) may be advantageous compared to electrons by allowing for homogeneous dose distribution to a small area conformality to an irregular/curved surface shallow dos...
Do you offer partial breast irradiation to women with tumors infiltrating the dermis (not epidermis) who otherwise fall in the "suitable" ASTRO category?
All the randomized trials in APBI suggested that it is more beneficial for low-risk patients, i.e., the SUITABLE in the ASTRO guidelines or very simply the T1No ER+, >50 years old. With a dermal infiltration, it could be an area not receiving the full dose and the patient is not a low risk anymore. ...