Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach post-op radiation recommendations in patients who had neoadjuvant chemoimmunotherapy for HPV mediated OPSCC s/p TORS who have a complete pathologic response (pCR)?
Neoadjuvant immunotherapy for patients with TORS-eligible HPV-positive malignancies should not be done off study. KEYNOTE-689 did not include early-stage HPV+ oropharyngeal cancer patients, and as such, there is no prospective data to suggest a benefit to neoadjuvant immunotherapy in this patient po...
What features or presentations would prompt you to offer radiotherapy for paraganglioma vs. continued surveillance?
I think aside from symptomatic disease, other criteria I would consider for treating vs surveillance for paraganglioma include size/location where tumor growth in a particular location may lead to progressive/permanent neuropathies and therefore prophylactic RT may be warranted. I am also more likel...
How do your PMRT recommendations change with ITCs after neoadjuvant chemotherapy if they had SLNB only versus ALND in light of B51?
Data such as from Dana-Farber/Brigham and Women’s Cancer Center and the National Cancer Database (Wong et al., PMID 31228134), as well as the OPBC-05/ICARO study (Montagna et al., PMID 39509672), indicate that patients with isolated tumor cells in axillary nodes after neoadjuvant chemotherapy (ypN0i...
What are the indications for PMRT in an ER/PR(+) Her-2(-) patient with a complete pathologic response in the nodes after neoadjuvant chemo, but with residual disease in the breast?
This is an area where there is still a paucity of information. Hence, all guidelines need to be very tentative. I recommend PMRT for all patients having biopsy-proven axillary node involvement prior to chemotherapy, as I am concerned these are the patients at highest risk of local-regional failure. ...
In the era of NSABP B51, how do you approach patients with occult primary who achieve a pCR in the nodes?
One can go either way, but would look at pre-chemo phenotype, nodal size, nodal number and location, and if any one of them favors RNI along with breast RT.
Would you consider omitting PMRT in cT3N0 triple negative breast cancer with a pCR?
These are challenging cases with limited data as Dr. @Dr. First Last notes. In a young patient with cT3N0 disease with a pCR, I would discuss the lack of data and that RT may reduce rates of LRR with unclear survival benefits. I would discuss the pros and cons but I would be comfortable offering the...
What is your strategy for managing radiation dermatitis in breast cancer in the prophylactic, erythema/dry desquamation, and moist desquamation stages?
Good question. Everyone seems to have a favorite home remedy with very little good supporting data. I am unaware of any good prophylaxis rx. The best thing is good treatment planning to minimize inhomogeneity. There are phase III data demonstrating the efficacy of soap and water cleansing for rx of ...
How do you approach adaptive planning in lung cancer?
The role of adaptive radiotherapy in lung cancer is still under investigation. I do daily CBCTs on my definitive NSCLC and small cell lung cancer patients. I only adapt plans if there is a change in anatomy such as opening of a collapsed lung or tumor growth outside of the PTV. I do not shrink volum...
When (if ever) would you offer radiotherapy for renal cell carcinoma following nephrectomy?
There is no indication for any type of radiation after nephrectomy in resected RCC. Often a 'positive' renal vein margin is not a true positive, but rather an artifact of having a renal vein thrombus and this should be discuss with the Urologist and Pathologist and clarified in the report. Having sa...
How would you approach the management of a patient with metastatic non‑small cell lung cancer who previously received whole brain radiation therapy three years ago and now presents with 20 new brain metastases on MRI?
How aggressive I would be depends on KPS (which sounds to be good in this case), the patient's extracranial disease status (which sounds to be controlled on current therapy in this case), plans from a systemic therapy perspective (will the patient continue on the same therapy and what was the patien...