Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you consider adjuvant immunotherapy for a patient with high-risk Merkel cell carcinoma following definitive surgical resection and adjuvant radiation therapy?
Although there is no level 1 data supporting adjuvant RT in MCC, a relatively recent meta-analysis from an Italian group (Petrelli et al., PMID 31005218) showed that adjuvant RT is associated with a 75% reduction in local and locoregional relapses versus surgery alone, without a reduction in distant...
How would you approach adjuvant radiation therapy in a patient with recurrent skin SCC of the gluteus s/p multiple resections with positive margins and adjacent osteomyelitis to the ischium and pubic ramus?
In this scenario, wherein a patient with recurrent cutaneous SCC has active osteomyelitis (assuming this is being treated), it would be prudent to avoid the involved bone as an OAR. I would not include the infected bone (I'd review the best imaging with radiology to ensure there's no involvement by ...
How would you treat an isolated para-aortic recurrence while receiving adjuvant pembrolizumab after definitive chemoradiation for cervical cancer?
If the patient has failed while on pembro, I would favor holding/stopping IO and plan for definitive chemo-RT to the para-aortic region with SIB boost with weekly cisplatin.
Is there evidence supporting the role of SBRT in the management of oligometastatic stage IV NSCLC?
Yes. I would look at a great trial from Wake Forest, looking at consolidative radiotherapy after 3-6 cycles of platinum-based chemotherapy, followed by observation, so chemotherapy, then radiotherapy, then observation (no maintenance chemotherapy). The trial occurred from 2010 to 2015. This single-a...
Do you see MR Linac having a role in the treatment of CNS disease?
MR Linac has a lot of potential in the management of CNS neoplasms. To best understand its potential, it is critical to understand what the genuine value proposition of the MR Linac really is. At its heart, and rather simplistically, many view it as simply another option for image guidance to suppor...
Would you recommend large-field radiation therapy to treat SCC of the skin with field cancerization (e.g., entire forearm, scalp) in elderly patients with CLL/immune compromise who have had mixed responses to cemiplimab?
Yes, retrospective data from Australia support large fields using VMAT at a median dose of 47.9 Gy in an average of 23.9 fractions with treatment breaks as needed and using a custom bolus. The photos in the article help clarify what is meant by 'field cancerization.' This phenomenon is termed extens...
Is there any way to safely treat patients with mCRPC with 177-Lu PSMA who are on hemodialysis?
For the most part, no. Not unless you're a big academic medical center with a robust multidisciplinary team willing to tackle the significant logistical challenges associated with this scenario.I'm aware of no literature in this scenario specifically for Pluvicto, but we can look at the radiopharmac...
Is it necessary to treat the entire larynx with intermediate or elective dose in a T1/T2 squamous cell carcinoma of the supraglottic or subglottic larynx?
It would be hard to miss it without missing your target. Additionally, you have level 6 nodes with the subglottis and levels 2-4 with the supraglottis. Not a great idea. To clarify, don’t try to spare the glottis.
Do you need renal biopsy before SBRT for RCC suspicious cancer?
Yes. The teaching is usually that ≈ 20% of small renal masses (<4 cm) are benign, and this rate goes down as size increases (Thompson et al., PMID 19286217). Features such as contrast enhancement, tumor location, and sex can help to improve the malignant risk potential of these lesions, but no combi...
Is it feasible to treat central liver tumors +/- portal vein thrombus with SBRT while minding central hepatobiliary tract constraints?
Remember that biliary strictures frequently cause death in these patients because stents don't always drain after these high doses of radiation. I have personally never caused a biliary stricture. The regimens that I am using with an SBRT technique are below the threshold for biliary stricture and r...