Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Is central lumpectomy always required for Paget's disease of the breast?
Radiation without surgery for patients with Paget's disease was abandoned decades ago, but perhaps unfairly. Several groups in the pioneering era of breast-conserving therapy tried this approach. Local failure rates with whole-breast irradiation with or without a boost in patients with disease limit...
Under what circumstances would brachytherapy be preferred over electron therapy for treating skin cancers?
For small (<2 cm) nonmelanoma skin cancers, I would say that brachytherapy is preferred for these reasons: Better cosmesis - 90-95% report excellent, which is better than electron series, particularly at the edge. Better for curved surfaces like the nose b/c applicator is flush on the skin with no ...
In a patient with locally advanced cervical cancer that has extensive residual disease (>7 cm in greatest dimension) after chemoradiation, how do you weigh the geometric advantages of a Syed-Neblett template against the superior toxicity profile and outpatient feasibility of an advanced hybrid applicator?
Kilar et al., PMID 41737510, explains applicator selection. If residual disease is less than 4 cm on either side (still a total of 7 cm), a hybrid with straight and oblique needles can help to cover the disease. However, if it is more than 4 cm on one side, then you have to look at geometry, and som...
Does lymphovascular invasion trump POLE mutation in early-stage uterine cancer adjuvant therapy decisions?
In the current ESGO guidelines, stage I and II POLE types are always low risk, irrespective of substantial LVSI, with a predicted risk of recurrence being less than 10 percent, and favoring observation. That being said, in practice, I do offer brachytherapy, as I feel it is a low morbidity procedure...
Do you treat adenocarcinoma in situ (AIS) or minimally invasive adenocarcinoma (MIA) of the lung with SBRT in medically inoperable patients?
The literature on this for SBRT is quite thin. We looked at our institutional experience a few years ago using SBRT for MIA/AIS. You'll have to excuse the onerous title. It was published right around when we started switching away from the term BAC, and we wanted to make sure folks could find it!We...
What tissue tolerance constraints do you use for the esophagus, spinal cord, and heart for reirradiation of a NSCLC mediastinal lymph node failure?
I opted to write a response to this question, but honestly the answer is elusive to me. With respect to SBRT: for spinal cord, I rely on Dr. Sahgal’s work (he has several papers on this topic); for other organs, there are less data.For conventionally fractionated radiation, most are familiar with th...
Is there any evidence that demonstrates an increase in rectal or bladder toxicity with protons for prostate cancer compared to IMRT?
This is a great and controversial question. I recently contributed to a review that tried to summarize the current studies to date looking at this question. As you know, there are no completed phase 3 trials comparing protons to photons in this space, and we eagerly await results from the PARTIQoL t...
How do you approach a patient with cN0 breast cancer who has high risk features but did not have a sentinel node biopsy?
For T1 and T2 disease, I usually treat levels 1 and 2 in tangent beams.
Would you offer focal prostate boost per FLAME protocol for GTV defined by PET alone without MRI?
I think there are two questions here: Can you use PSMA PET to define the boost target? Yes (with a little bit of caution). There have been several reports on the safety/feasibility of PSMA-based focal boost. Note, though, that FLAME was based on MRI, and we can expect that the PET-defined lesion may...
What dose-volume constraint should be used for the normal brain parenchyma in a patient receiving 5-fraction SBRT?
This is tough, because most of the literature is based upon single fraction SRS for 1-3 lesions. There are no one criteria for brain doses for multi-session treatments as stated above. Tumor coverage is most paramount, and I agree with the need to respect the adjacent structure doses and to optimize...