Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Between KEYNOTE A-18 and INTERLACE, for which patients would you recommend using one protocol over another?
We currently favor A-18 for stage III disease (clinical or node-positive). A-18 had a more modern RT technique both for EBRT and brachytherapy while in INTERLACE, 60% had a prescription to point A for brachytherapy. In comparison with the EMBRACE 3D brachytherapy series, pelvic recurrence rate seems...
Is 500 cGy x 5 an appropriate palliative regimen for a patient with a low-lying metastatic rectal cancer with ongoing pain and bleeding despite chemotherapy?
25 Gy in 5 fractions is my preferred regimen for palliation of a symptomatic rectal primary in patients with metastatic rectal cancer. I’ve used it numerous times with generally very favorable results for symptom palliation, local control, and tolerance. There is also a couple of series which have u...
What pathological factors do you use to consider treatment of the axillary level I/II after an axillary dissection?
We examined the risk of axillary failure in relation to the number of positive nodes AND the number of nodes removed by axillary dissection for patients undergoing mastectomy without PMRT in ECOG patients treated with chemotherapy in trials conducted from 1972-1987 (Recht et al., PMID 10561205). Wit...
When should the dissected axilla (levels I-II) be included when delivering RNI?
Please see my posting on November 2022 for more details on this subject. To summarize, most of the dissected axilla lies within breast/chest wall tangents, so it is routinely irradiated when RT is used. The upper part of Level 2 is usually outside the tangents and lateral to what is traditionally de...
Are there any radiation dosimetric considerations for patients with lung cancer that have had a TAVR?
No, the new valve solves a mechanical problem. It will have some metal in it, so it would be visible whether it is a mechanical or biosynthetic type. I'd suggest not having a direct beam hit it, as that is the area of the coronary arteries' origins, and avoid dose spillage to reduce late toxicity. T...
Would you offer adjuvant radiation to a large solitary fibrous tumor of the lung s/p wedge resection with close margins?
If a benign SFT, I'd observe. If malignant, I'd consider 50 Gy/25 fractions to the surgical bed. The role of adjuvant radiation isn't well established, with some small reports suggesting LC benefit with tumors >5 cm and/or positive margins. Given "large" and more limited surgical resection with wedg...
When would you offer single fraction adjuvant partial breast irradiation instead of a 5-10 fraction course for early stage breast cancer?
We have not offered a single fraction, and our standard is 26 to 30 in 5 fractions. Data on a single fraction is not enough to support this recommendation for now.
What is your radiation approach to metastatic pancreatic tail adenocarcinoma s/p gem/abraxane and FOLFIRI now with an oligo-progressive LUL lung metastasis?
I certainly would favor metastasis-directed therapy with SBRT, given the PFS benefit observed in EXTEND, and I think the case for utilization in the oligoprogressive state is even stronger pan-tumor compared to consolidative treatment. I'd treat 50-55 Gy/5 fractions or could consider fractionating o...
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...
In a patient with high-risk cutaneous squamous cell carcinoma of the face with extracapsular extension after ipsilateral neck dissection and rapid contralateral cervical nodal recurrence, what is the optimal management?
In various published series, around half of patients fail to achieve a complete response to cemiplimab. From the clinical details, the current active area of disease appears to be the contralateral neck with no distant disease. Curative treatment is preferred. C-POST trial established surgery + adju...