Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you manage osteonecrosis and pelvic insufficiency fractures after pelvic radiotherapy?
I have never seen osteoradionecrosis happen before in the pelvis. It should not happen in the range of doses that are tolerable in the pelvis due to the constraints imposed by the sacral plexus and the luminal GI organs. Sacral insufficiency fractures happen uncommonly, but are more common in female...
How do you manage TTFields for a patient with glioblastoma in the setting of disease progression?
Continuation of Tumor Treating Field (TTF) therapy at progression is an individualized decision for each patient.In the EF-14 trial upon which TTF was approved for newly diagnosed GBM after chemoradiotherapy, TTF was able to be continued until second progression. In this study, 18% more patients wer...
How are you using circulating tumor DNA in your clinical decisions for HPV-associated OPSCC?
We have a post-operative trial where we are using cfDNA as an integral marker to decide on adjuvant therapy for HPV+ OPC.
Which MR simulation sequences do you prefer for head and neck RT?
I prefer 1) noncontrast T1 normal fat - this makes it easier to see the tumor invading fat spaces within and in between muscle fibers in the tongue and parapharyngeal spaces. 2) T2 fat suppressed (FS) - this can show me edema volume (i.e., surrounding gross ECE involving the SCM) that I like to cove...
How does the updated classification system of gliomas impact your recommendations for radiation?
Minesh Mehta and @Dr. First Last, Miami Cancer Institute In 2021, the World Health Organization (WHO) introduced significant new changes to the classification of tumors of the central nervous system (CNS) in their 5th edition (WHO CNS5) (Louis et al., PMID 34185076). This step was the first of many ...
How do you approach adjuvant comprehensive breast or chest wall RT for locally advanced breast cancer on a CDK 4/6 inhibitor?
Prospective data in this setting is limited. Retrospective and preclinical data with palliative RT and CDK 4/6 inhibitors have shown mixed results, with some showing skin and lung toxicities and others not. Adjuvant trials allowed concomitant use, but have not reported separately. My bias for PMRT i...
In the modern era, what is the role of beta-emitting bone-targeted radiopharmaceutical therapy?
Since the approval of Radium-223 dichloride (Xofigo), I have been using it as the preferred radiopharmaceutical for patients with mCRPC. While use of Samarium-153 and Strontium-89 improves pain control, Radium-223 is an alpha-emitter and is the only FDA approved radiopharmaceutical that has been sho...
Do you recommend esophagectomy vs adjuvant chemoradiation vs surveillance for an otherwise healthy patient with a pT1b cN0 cM0 lower thoracic esophagus SCC status post endoscopic submucosal dissection?
NCCN guidelines recommend esophagectomy for pT1b SCC. This is in part because the risk of metastasis to regional lymph nodes for T1b tumor can be upwards of 30% with an even greater likelihood in tumors penetrating into the lower two thirds (sm2 and sm3) of the submucosal layer (some series showing ...
How would you manage an osseous lesion that received palliative SBRT with no pain relief?
This is certainly a challenging clinical scenario, without meaningful published literature to guide recommendations. If faced with this scenario, I would try to really determine the etiology of the patient’s pain in order to determine the best treatment. First of all, did the patient have pain relie...
Would you treat the prostate in a case of oligometastatic disease with well-controlled UC?
Yes, I would with a clear discussion of risks and benefits. While there is not extensive data, the retrospective literature and my personal experience are that men with well controlled inflammatory bowel disease are at little additional risk. Some studies show an increased acute toxicity risk and ot...