Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you weigh upfront nodal burden when deciding to omit PMRT in a patient with cN1, ypN0 disease after neoadjuvant chemo, mastectomy and ALND?
Pre-chemo imaging if it shows 4 or more abnormal nodes (N2) then would offer RNI irrespective of response.
For T1b or T2a NSCLC cancer, approached with SABR, should chemotherapy be considered in the adjuvant setting?
It is not standard of care to give adjuvant chemotherapy in IA NSCLC.It can be considered in certain situations of stage IB, although there is no strong prospective data. The group with > 4 cm size tumars had some benefit in an unplanned subgroup analysis of the CALGB study. If other risk factors be...
Would you offer definitive CRT for stage III(N3) NSCLC treated with neoadjuvant immunotherapy who had a complete radiographic response?
I am not aware of any strong data supporting the omission of definitive local therapy based on response to neoadjuvant systemic treatment. Would strongly recommend definitive chemoRT. If the patient is not a candidate for chemotherapy, then hypo-fractionated RT (45-60 Gy in 15 fractions). In genera...
In p16-positive oropharyngeal squamous cell carcinoma, when induction therapy is considered before definitive chemoradiation, how do you choose between a traditional TPF regimen and carboplatin/paclitaxel/pembrolizumab?
Sequential therapy, as defined by induction chemotherapy followed by chemoradiation, is generally reserved for patients at high risk for recurrent or metastatic disease. The published randomized data offers no improvement in survival with TPF followed by CRT versus CRT. Thus, such an approach can be...
Do you routinely offer post-operative radiotherapy for resected retroperitoneal sarcomas?
I do not routinely offer post-operative RT for resected RP sarcomas. Our approach is to offer pre-op. If pre-op is not given, regardless of R0/1 resection, we do not offer post-op. In these case, we will follow with surveillance scans and if recurrence is noted consider pre-op followed by surgical r...
Would you consider whole breast re-irradiation in a patient with a second/recurrent breast cancer and prior history of breast radiation therapy many years ago, if the tumor characteristics are not amenable to partial breast re-irradiation?
A second lumpectomy after recurrence post-lumpectomy/RT in itself makes it amenable to APBI, i.e., the pathology or clinical factors do not matter after a 2nd lumpectomy. Since the early literature (from UPMC) to more recent prospective trials (RTOG 1014), the CTV is the lump cavity, regardless of o...
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...
In a patient with rectal cancer, when would you consider brachytherapy monotherapy or brachytherapy boost after CRT?
For a patient with cT2N0 disease, the most appropriate use of brachytherapy would be sequential with pelvic radiotherapy, the bulk of data being with long-course CRT. Brachy can either be done prior to CRT or sequenced afterwards. We routinely use brachytherapy in appropriate candidates in our pract...
For patients with metastatic cancer on a systemic therapy regimen that includes bevacizumab, are you comfortable treating brain metastases (SRS or WBRT) without holding bevacizumab?
Multiple prospective trials have demonstrated the safety of combined bevacizumab and radiosurgery (from both recurrent GBM and brain mets) with some data to actually demonstrate a protective effect against radionecrosis. No significantly increased synergistic risk of intracranial bleed has been obse...
Do you perform EBUS-TBNA for staging in patients with biopsy proven malignant lung nodules with no lymphadenopathy on CT chest and PET scan?
I agree that incidence is low, but estimates for radiographically occult nodal disease range from 10-20% and the fact is there isn't great literature on this. A PET scan is a decent test, better than a regular CT, but there are still a significant minority of patients that are mis-staged when an EBU...