Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In a patient with prior RT to the prostate and SVs and newly diagnosed, locally advanced rectal cancer at 10-15 cm, would you offer preoperative chemoradiation?
"Locally advanced" rectal cancer was traditionally described as T3/4N0M0 or TxN+M0 cancer, but we have advanced much farther on the characterization of this now.We also know that the local control of patients undergoing resection for high rectal cancer (10-15 cm from the anal verge) is much better t...
Would you include the tract in your treatment field in a patient with squamous cell carcinoma of the anal canal presenting with an ano-cutaneous fistula?
I don't know that there is an evidence-informed answer, but I just had this in a patient recently. We had him get a diverting colostomy prior to starting CRT, then treated him with standard CRT with 5FU/MMC. I included the fistula tract in an intermediate dose, but with a margin on the boost to tumo...
How do you incorporate DCISionRT testing in the setting of close (<2 mm) or positive DCIS margins?
No matter how much Panera Bread they bring you, the answers are these: Positive margin? Surgical re-excision. <2 mm margin? Surgical re-excision. Why? Because the SSO guidelines say so. That's why. "But she doesn't want surgical re-excision for the positive margin." Ok. Then you recommend radiation...
How do you counsel glioblastoma multiforme patients on which types of clinical trials to pursue?
This is a great question! In general, I think that a clinical trial gives someone access to promising therapies (and of course glioblastoma is an aggressive tumor for which we have no cure), but enrolling in one may not feel like the right decision for all patients (for a variety of reasons). I thin...
How would you treat a patient with ER/PR positive breast cancer with a single site of bone metastasis?
I would still treat with hormone therapy and a CDK 4/6 inhibitor. Not clear if the question refers to denovo disease or not. I generally do not treat asymptomatic bone mets with radiation, as there are late effects in patients who have a relatively long life expectancy and no data to suggest that ra...
In what circumstances would you consider use of IDH inhibitors in high-grade astrocytomas?
Please forgive me for the length and directness of my response, but I believe it is important to first go over the INDIGO trial and explain why, in my opinion, it was a highly questionable study, with multiple significant methodological flaws and dubious evidence of Vorasidenib's efficacy.INDIGO tri...
How do you manage a spinal intramedullary metastasis following resection?
Complete surgical removal (gross total resection) of an intramedullary metastasis may not be possible without damaging normal spinal cord tissue, especially for more infiltrative tumors. Postoperative radiation therapy is therefore used to treat any residual tumor cells that were left behind to pres...
How can you manage a patient with bilateral PCNs who requires Pluvicto administration?
We've treated several of these folks. In general, we ask the patients to ensure they are emptying the bags frequently for the first three days to minimize the volume of urine next to the skin. There have been reports of radiation dermatitis from Foley/PCN bags that are left in the same spot against ...
Would you offer neoadjuvant chemotherapy prior to trimodality therapy in a fit patient who refuses surgery for muscle-invasive bladder cancer?
Unfortunately, this is a question without a clear answer at this time. Trimodality therapy, consisting of maximal TURBT, chemotherapy, and radiation, appears to have equivalent outcomes and has NCCN Category 1 recommendations for patients with MIBC. We do not routinely do neoadjuvant chemotherapy fo...
How do you treat a patient with early-stage breast cancer s/p lumpectomy and oncoplastic reconstruction with a positive margin, when re-excision is not feasible?
It depends on the level of oncoplastic surgery done. If level 1, we can identify the surgical site and can boost after whole-breast RT of 26 in 5 or 40 in 15. If level 2 or 3, then just increase the whole breast dose to 42.5 in 16, as we can’t identify the boost area.Han et al., PMID 40024440