Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For locally advanced rectal cancer, will the recent update of RAPIDO lead you to change your practice when approaching TNT?
We prefer long course chemoradiation followed by consolidation with FOLFOX and non-operative management based on the OPRA trial, which reported 60% versus 40% using this sequence versus initial chemotherapy.
How do you manage an implanted insulin pump or continuous glucose monitoring device during radiation?
We do not have an official written policy yet, but honestly, we probably should develop one, since these devices are becoming more prevalent. For CGMs, we ask the patient to place the device far from the treatment site while under treatment and to verify function with finger stick glucose measuremen...
How would you approach SBRT in a pacemaker-dependent elderly patient with Stage I NSCLC whose SBRT plan Dmax exceeds the pacemaker tolerance?
For any patient who has a pacemaker, we always send them to be evaluated for the device by a cardiologist before simulation and after finishing all fractions of the SBRT. In addition, we check their vital signs daily after each fraction of SBRT. For SBRT planning, we will minimize irradiating the p...
How would you approach early stage NSCLC in a patient who is not an ideal surgical candidate and has pulmonary AVMs?
The standard volumes and flows of PFTs do not assess regional differences in what is perfused and ventilated. V/Q scans do, but their most common use for pulmonary embolism is their most common role. This serves to identify gas exchange near the primary as well as where the AVM’s reside. Target the ...
What is your preferred sequencing of adjuvant chemotherapy and PMRT for node + breast cancer?
I addressed this issue for patients treated with breast-conserving surgery in May 2023; please see that answer for more details. To summarize, the toxicities from chemotherapy may be greater and its effectiveness reduced (at least for high-risk patients) when given after RT instead of before (Recht ...
Is there evidence that prostatectomy improves overall survival in local recurrence of prostate cancer post-definitive radiation?
I am not aware of any prospective clinical trial data to suggest that salvage prostatectomy for locally recurrent prostate cancer improves overall survival as compared to any other comparator. Such evidence would be very difficult to generate given that historically, most prospective studies have fo...
Can trastuzumab deruxtecan be continued during radiation?
Data is limited, with the suggestion of higher necrosis with SRS. For other sites for palliation, I would not say it’s contraindicated, but caution needs to be exercised especially for the risk of increased lung and GI toxicity (because of independent toxicity from the drug and the potential for sen...
How do the results of INSEMA and SOUND impact the decision of omitting SLND in young women with breast cancer and offering adjuvant RT to patients who would otherwise be candidates for omission?
Both trials required radiation so I would recommend it for a young woman not getting sentinel lymph node evaluation, and would lean toward whole breast irradiation. INSEMA required whole breast irradiation and SOUND allowed partial breast irradiation (10% of patients) but the majority of patients re...
How would you treat a locally advanced rectal squamous cell cancer with vaginal invasion?
If the anterior wall of the vagina is free (i.e., the 5 cm refers to the cephalo-caudad length of the tumor), and this proves to be a case of a high grade but potentially resectable (assuming adequate response to preoperative tx) T4 rectal cancer. I've treated cases with exactly this histology and p...
Would you consider modifying T&O fractionation during the COVID-19 pandemic?
We have been using 7gy x 4 instead of 5 fraction regimen in the past. A 2 fraction regimen showed lower local control in comparison to 4 fractions in the IAEA randomized trial.