Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What institutional recommendations guide the choice between brachytherapy and MR-linac-guided SBRT for locally advanced prostate cancer, given that no large trials have directly compared the two?
There is randomized data demonstrating the superiority of brachytherapy boost over EBRT alone mainly from the well-discussed ASCENDE-RT trial. To my knowledge, there is no such data for SBRT (whether alone or as a boost) in this patient population. So, I do not see how they can be considered equal o...
How does neoadjuvant chemo-immunotherapy impact your decision on hypofractionation/dose fractionation for locally advanced NSCLC, now getting RT alone?
If a patient has already received 3-4 months of a platinum-doublet chemotherapy during the chemo-immunotherapy phase, then it's always my preference to omit further chemotherapy and recommend RT alone. The rationale for this recommendation is that we don't administer additional chemotherapy to patie...
What is your preferred skin surface maximum dose constraint for skin brachytherapy?
In a recently published study of electronic skin surface brachytherapy, we used a technique that delivered approximately 8.7 Gy per fraction to skin surface (125% of the prescribed dose of 42 Gy in 6 fractions of 7 Gy delivered to 3 mm depth from skin surface). This publication demonstrates the acut...
What is the role for chemoimmunotherapy in the up front setting in non-metastatic head & neck cancer outside of clinical trials?
Phase III studies of immunotherapy concurrent with chemo-RT vs chemo-RT alone, JAVELIN Head and Neck 100 and KEYNOTE-412, didn’t demonstrate a survival benefit of the immuno-containing regimens (while post hoc analyses suggested that PD-L1 positive patients may have benefited). These studies did not...
When would you offer neoadjuvant immunotherapy prior to Mohs surgery in a locally advanced squamous cell carcinoma for which clearance may require enucleation?
I would flip this question around and answer that radiotherapy is often a terrific option around the eyes, and it should always be considered in this area, especially when a radical surgical procedure is being entertained. Between en face therapy with a shield (superficial, electrons) and IMRT/VMAT,...
How would you manage T3N0M0 sarcomatoid carcinoma of the prostate with adenosquamous differentiation s/p prostatectomy?
Sarcomatoid prostate cancer is an aggressive histological subtype. It may be locally aggressive, and post-operative PSA monitoring may be less helpful for this histologic subtype, which interferes with the usual trigger for initiation of salvage RT (Grignon, PMID 14976541). Despite the lack of high-...
How do you counsel eligible patients on lung cancer screening who are hesitant because of the cancer risk from CT scans?
This is simple. The risk of lung cancer in patients who have smoked for >20 years is orders of magnitude higher than the theoretical risk of medical X-ray-induced cancers from low-dose CT (LDCT) screening. A typical LDCT scan exposes patients to approximately 1.5 mSv of radiation, equivalent to abou...
What is your approach to women with breast cancer who opts for a staged approach with up-front lumpectomy and SLN biopsy (pN-) when there are indications for adjuvant radiation therapy but she plans for a later mastectomy (=>6 months)?
That is not a common approach I have seen, and I would question the rationale of putting a patient through two surgeries when one can be done and forgo RT. If pN0, it would depend on what significant delay is, and I would extensively counsel the patient on recurrence risk should they end up forgoing...
When do you prefer pre-operative SRS over post-operative SRS for brain metastases?
For patients with brain metastases that benefit from resection, our approach is to always treat pre-operatively unless the patient requires immediate surgical intervention. Pre-operative SRS has several advantages including clear target delineation. Post-op SRS has best results with expanded volumes...
For a patient with large volume glioblastoma, what do you do if they are found to have a subdural infection in the middle of chemoRT requiring repeat surgery?
In this scenario, the patient will likely stop the daily treatments for a variable period of time that I would estimate to be measured in weeks while recuperating from surgery and receiving IV antibiotics. When cleared for radiation, I would start by doing a new Simulation using an updated MRI to ac...