Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach post-operative SRS for resected brain metastases in the presence of residual disease?
I try to dose-escalate to gross disease, based on first principles. Of course, there is not exactly a standard dose and fractionation for SRS/SRT, so judgment is in play for each case based on size, location, and maybe histology. Still, homogeneity is not a priority for SRS, and it makes sense to pu...
Is pre-treatment nodal ultrasound evaluation necessary if a patient undergoes upfront PET/CT for staging?
The answer to this question depends greatly on the local capabilities to conduct regional nodal ultrasound. If this can be done, then we find ultrasound to be very helpful. In today’s environment, it is difficult to obtain insurance approval for PET in the staging of node-positive breast cancer. Bey...
Is it possible to use radiation to treat Morton's neuroma in a patient who continues to have symptoms after steroid injections and alcohol ablation?
I just got a consult for this very diagnosis. I've been treating a lot of arthritis/tendonitis/bursitis in the past 2 years, and since MN is also an inflammatory condition, I am going to treat it similarly. Did you end up treating your patient?
How should verrucous carcinomas of the head and neck be managed?
This is a very interesting question. Most of the data and information regarding the management of this entity is obtained from case series and small retrospective series. There are 3 main issues to consider with regards to the use of radiation therapy for verrucous carcinomas of the head and neck. C...
How would you approach local therapy (surgery or RT) in a patient with radiographic complete response after chemoimmunotherapy for non-small-cell lung cancer?
Only 1/96 patients (0.6%) of patients on CheckMate 816 had a complete response by RECIST so I don't think our current paradigms are really driving these kinds of responses. Additionally, there is clearly a disconnect between clinical response rates by RECIST (0.6%) and pathologic complete response (...
How do you manage a recurrent brain metastasis in a surgical cavity that contains mixed radiation necrosis and viable tumor in the setting of prior SRS?
This diagnosis is made at our center by combining MRI, MR perfusion, and PET data. Management depends on the presentation of the patient, if there is mass effect and/or neurological deficit then surgical re-resection is preferred. As a matter of interest, the pathology on the infrequent resections d...
What SBRT dose do you recommend for an oligomet of the lung from prostate ca?
No reason not to go with standard >100 BED approaches (54/3, 48-50/4, 50/5, 60/8), as we don't necessarily have prospective data for prostate cancer specifically.
What dose/fractionation would you recommend for a large brainstem metastasis?
This is always a difficult clinical decision; for "large" (however one chooses to define this) pontine/medullary/brainstem mets, most have moved away from single fraction SRS to 3 fraction SRS (27 Gy in 9 fractions), based largely on the results of the Italian trial. In this trial, 289 patients with...
In a patient with an R1 resection of a chordoma who has declined proton therapy, what alternative radiation modality would you recommend?
Chordomas are aggressive and locally invasive tumors that commonly arise in the sacrum, skull base, or rarely the mobile spine. Resection is considered the first-line treatment; however, wide margins are difficult to achieve without significant morbidity. By nature of their site of origin near or ad...
Would you use triplet chemotherapy FLOT in lieu of chemoRT for patients with localized esophageal squamous cell carcinoma?
This is a timely question in esophageal SCC (ESCC), even as we adjust to the now markedly diminished role of pre-operative chemoradiation vs. FLOT in esophageal/GEJ adenocarcinoma, based on the recent phase III ESOPEC study [Hoeppner et al., ASCO 2024; LBA1] (as well as the NeoAEGIS study that prece...