Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What duration of ADT do you recommend for a patient with locally treated prostate cancer who undergoes metastasis-directed radiation therapy to a single oligometastatic bone lesion?
While I agree with @Dr. First Last that very small studies like STOMP and ORIOLE suggest that a small subset of men can delay the need for ADT by 1-3 years, this is not level 1 evidence. Most men with oligometastatic HSPC will still progress with metastasis directed therapy alone over a short time h...
Is central lumpectomy always required for Paget's disease of the breast?
Radiation without surgery for patients with Paget's disease was abandoned decades ago, but perhaps unfairly. Several groups in the pioneering era of breast-conserving therapy tried this approach. Local failure rates with whole-breast irradiation with or without a boost in patients with disease limit...
What factors, if any, (such as microscopic ENE (<=2 mm) or larger nodal size (e.g., >4 cm)) would prompt you to treat the contralateral neck for oropharyngeal cancers otherwise eligible for unilateral radiotherapy?
BOT primary that are not very lateral, as well as tonsillar ca involving the palate, have potential contralateral lymphatics, and contralateral neck RT should be considered. The ipsilateral RT series in the IMRT era are still small. The classical large OSullivan study included few patients with N2b ...
How would you approach a patient with synchronous HPV-mediated bilateral tonsil primary with ipsilateral lymph nodes who cannot receive chemotherapy?
We address this type of scenario in the guideline published last year in PRO Margalit et al., PMID 39078350. I hope the explanations there are useful, but to summarize, in the MARCH meta-analyses, most altered fractionation types improve locoregional control, but only hyperfractionation (often 1.2 G...
Is it acceptable to offer 26 Gy in 5 fractions for APBI rather than whole-breast RT?
Yes. We know 26/5 works for whole breast, either daily or weekly fractionation schedules. So, one can utilize that in patients that are APBI candidates. That being said, the toxicity data from Florence trial and my personal experience are excellent, so I do a hybrid approach. I give 26/5 to a larger...
What is a safe and effective ablative dose and fractionation for oligometastasis to humeral head or femoral neck from lung cancer with controlled disease elsewhere?
This is becoming a more common clinical scenario with the improvements in systemic therapies and growing bodies of literature supporting the utility of SBRT as a metastasis-directed therapy. A practice pattern analysis of non-spine bone SBRT dose prescriptions and treatment planning was recently pub...
What is the minimum number of hyperbaric oxygen treatments you would prescribe for late radiation toxicities?
The RICH-ART Trial from 2019 In Lancet Oncology (Oscarsson et al., Lancet Oncol 2019) utilized 30-40 sessions with good effect. We have typically used a similar protracted treatment schedule for RT cystitis, but I would be curious if others have had success with shorter schedules.
In patients who have residual bladder tumors after maximal TURBT, would you boost the GTV above typical doses, 55 Gy/20 fractions or 64 Gy/32 fractions, assuming you can meet constraint?
In the British study, (55/20 + MMC), these patients were encouraged but not required to undergo complete TURBT; ~45% in each arm of the study did not get a complete TURBT. No boost was given to those who did not get a complete TURBT. As this is the only RCT (for some reason, the RTOG never did an RT...
Are patients with MIBC and bladder neck involvement good candidates for bladder preservation with chemoradiation after maximal, but not complete, TURBT?
Both BCON and BC2001 suggest that a complete TURBT may not be essential for bladder preservation. Incomplete TURBT is a surrogate for a higher stage and predicts poorer outcomes irrespective of the modality used for treatment.Elumalai et al., PMID 36517194
How would you treat an elderly, frail patient with a bulky penile SCC with bilateral inguinal nodes?
These are challenging cases. Conventional wisdom is that patients with bulky nodes are considered rarely curable without surgery: However, this has not been my experience. Nevertheless, to achieve a durable outcome, including cure, our practice has been to use combined chemotherapy and radiation the...