Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Who is a good candidate for pre-operative SRS for resectable brain metastases?
In our study, the vast majority of our patients treated with pre-op SRS had tumor volumes between 5 and 35 cc (maximum dimensions of slightly above 2 cm to 4 cm). We do not treat patients who need emergent surgery for significant AMS or emergent hydrocephalus or herniation for example. Patients unde...
Is post-operative radiotherapy indicated in HPV associated, < 10 pack year smoking, low volume (i.e. T1N1) squamous cell carcinomas of the head and neck when the only adverse risk feature present on pathology is LVSI?
LVSI has been shown to increase the risk of regionally recurrent and metastatic disease as an independent risk factor (and even worse in terms of DFI and DFS in patients with concurrent PNI). The question I'd ask is what is the appropriate volume of disease to treat. These days we are minimizing our...
When does perineural invasion for a squamous cell carcinoma of the skin of the head and neck merit adjuvant radiotherapy?
In cutaneous squamous cell carcinoma, the presence (vs absence) of perineural invasion is associated with a higher likelihood of local tumor recurrence after a margin negative excision. However, several recent studies have shown that for small caliber perineural invasion (invasion of a nerve <0.1 mm...
When do you prescribe steroids prior to palliative radiotherapy of bone metastases to prevent pain flare?
Thanks for the interesting question. The dexamethasone was given 8mg one hour prior to single fraction radiotherapy (RT), then 8mg po daily with breakfast for four days subsequently (not five days prior to RT). A steroid taper was not utilized. Previous studies by this trial's PI investigated both a...
In light of the 2015 ASTRO plenary session presentation about involved-field radiation vs elective nodal radiation therapy, are you including elective nodal fields (celiac, mediastinal, supraclavicular) in the treatment of locally advanced esophageal cancer?
In the Chinese study presented at ASTRO, the ENI volume treated included mediastinal levels 4,5, and 7 for any thoracic site of disease (upper,middle or lower) with some other levels added based on location. In practice, and in most studies published through RTOG, the radial margins are 1.5 to 2 cm ...
Without radiographic evidence for metastatic disease, is there a PSA value above which high risk localized prostate cancer should not be treated definitively?
The SPCG-7/SFUO-3 randomized trial randomized 875 patients to endocrine only therapy vs. endocrine therapy plus radiation therapy. 20% of the patients had a PSA > 30. The addition of radiation showed an overall survival benefit at 10 years (60.6% vs 70.4%), a prostate cancer specific survival benefi...
How would you treat Classic Hodgkin's lymphoma when the nodal sites are non-contiguous?
The question has insufficient information. I'm going to assume that the patient had chemotherapy with a PET/CT complete response. Based on that assumption, then the general principles are that if the sites of involvement are > 5 cm, that you should have multiple treatment fields, but if they are les...
What are the current thoughts for ADT and prostate SBRT for low-Intermediate risk patients?
Although I have no strong bias regarding ADT for low-intermediate-risk prostate cancer patients receiving SBRT, the growing volume of retrospective data in the same setting with HDR brachytherapy suggests that ADT is not needed. With HDR (either monotherapy or boost), I do not use ADT for intermedia...
Is liver radiotherapy contraindicated in patients with Child-Pugh C liver function?
I think one should be very cautious with regards to radiation for this group, whether palliative or definitive. The CPC patient has a very poor prognosis with a 2 year expected survival of only 30%. We have learned that patients with CPB liver disease, especially those with scores of 8 and above, ar...
Given the recent pooled analysis of STARS and ROSEL trials, can we say SBRT for early stage NSCLC is equivalent to lobectomy based on level 1 evidence?
We still do not have Level I evidence to answer such a question. Both STARS and ROSEL closed prematurely. If we read @Dr. First Last's Lancet Oncology paper more carefully, unlike others who have interpreted it as radiation oncologists running amock to claim SBRT is now equivalent to surgery, the di...