Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you offer re-irradiation in an adenocarcinoma of the distal esophagus s/p neoadjuvant chemoradiation + Ivor Lewis esophagogastrectomy (ypT3N0) 2 years ago now with TE groove/paraoesophageal LN recurrence with complete response on PET following 8 cycles of FOLFOX?
I generally would offer re-irradiation in this situation. If the lymph node recurrence is completely out of the prior field, it becomes an easier decision and much less technically complex in regard to radiation treatment planning. If out of field, I would treat with 50–50.4 Gy 25–28 fractions with ...
For early-stage vulvar cancer that is clinically/radiographically node negative with no surgical lymph node evaluation (e.g., patient or surgeon refusal), would elective nodal irradiation be reasonable in the absence of risk factors warranting treatment to the primary site?
It is tempting to skip elective nodal irradiation in this setting, especially if the radiographic evaluation includes a PET-CT, where the negative predictive value is probably close to 90%. However, if the risk of groin LN involvement is at least 15%, based on primary tumor characteristics such as s...
In which patients do you utilize a breast MRI as part of the initial workup for breast cancer?
I'm not a fan of routine MRI in the work-up for early-stage breast cancer, but I do agree with the fairly standard list of selective indications mentioned previously. I also obtain an MRI when there is a significant discrepancy between standard imaging and physical exam. Examples would be: One or a...
In light of the ROADS data, how are you choosing between intraoperative tile-based radiation therapy (TBRT) and postoperative SRT for newly diagnosed resectable brain metastases?
In light of the ROADS data, I would be cautious about broadly changing practice at this point. While the local control benefit with cesium-131 GammaTile is impressive and biologically plausible, reported OS is much harder to reconcile. A 26% absolute improvement in 2-year OS from a local therapy int...
How would you manage a pT2N1a invasive ductal carcinoma s/p lumpectomy and sentinel lymph node biopsy with ECE, and two mildly avid axillary lymph nodes on post-op PET/CT?
We often see mildly active lymph nodes on post-op PET/CT scans, so one important initial question is how long after the surgery the PET/CT was performed. Another question would be how many total lymph nodes were removed at the sentinel biopsy. If the scan was done ~6 weeks post-op and the patient ha...
If approved, in what settings will you consider adding aglatimagene besadenovec (CAN-2409) to EBRT as an ADT-sparing strategy in prostate cancer treatment?
PrTK03 (NCT01436968; DeWeese et al., PMID 42225101) was a phase 3 RCT randomizing patients with either NCCN intermediate or high-risk prostate cancer (>1 HRF excluded) to RT ± CAN-2409, which is an adenoviral-based immunotherapy delivered with a prodrug (valacyclovir) and stratified by NCCN risk gro...
What are your top takeaways in Neuro Oncology from ASCO 2025?
Aizer et al., JCO 2025 - A multi-instituitional Brigham Dana-Farber-led trial randomized 196 patients with 5-20 brain metastases to stereotactic radiosurgery (SRS) or hippocampal avoidance whole brain radiotherapy (HA-WBRT). Patients treated on the SRS arm had significantly less symptom burden, wit...
Do you use any strategies to minimize loss of taste from radiation for oropharyngeal cancer?
In a prospective longitudinal study of QoL in OPC patients receiving chemo-IMRT, where patient-reported dysgeusia was one of the items, we reported a significant association between severe dysgeusia and mean radiation dose to the oral cavity (P=.005) (Sapir et al., PMID 27473816). NTCP for severe dy...
Do you offer low dose RT for Achilles tendonitis?
Yes, 3 Gy in 6 fractions delivered MWF.
What dose and fractionation do you use for gynecomastia prophylaxis?
As I answered on a previous thread to a question that was similarly posed, philosophically I would prefer electrons (less integral dose/more focused - IMHO) as opposed to photons. In terms of dose, it seem these days less is better with single fraction especially. Hence, the NICE (European) guidelin...