Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
What dose do you use for definitive treatment of squamous cell carcinoma of the cervical esophagus?
Our institutional preference is to employ a total dose to 70 Gy with concurrent chemotherapy for squamous cell carcinoma of the cervical esophagus, because a local failure in would require salvage surgery with pharyngo-laryngo-esophagectomy. The role of dose escalation in squamous cell carcinomas of...
What is your preferred dose to gross lymph nodes when treating non-metastatic high-risk prostate cancer?
I treat the grossly involved node as high as I can, while respecting OAR constraints, up to the dose for the prostate. I tend to favor zero or minimal PTV margin (depending on the proximity of OARs--usually bowel) and allow the penumbra to serve as a functional "PTV."
Do you recommend definitive chemoradiation for unresectable gastric adenocarcinoma in a medically unfit patient?
Definitive is probably not the best term for what can be done. Only palliative doses are possible because the stomach is so sensitive, the GTV is difficult to clearly define, impossible to see on CBCT, the stomach changes shape from day to day, and moves with respiration. There would only be a less ...
For a patient with metastatic melanoma with small, asymptomatic brain mets what is your preferred systemic therapy?
In this scenario, I default to using a combination of ipilimumab plus nivolumab. We know from prior clinical trials that have looked at this combination of patients with asymptomatic brain metastases that immunotherapy seems to work similarly well intracranially as it does extracranially. This was e...
What criteria would you consider to select patients for 20 Gy consolidative RT in DLBCL/HGBL?
The primary endpoint of the study was 5-year local control. The study was powered to estimate this endpoint after the last patient had at least 2 years of potential follow-up (which will be reported at ASTRO). Local failures after 2 years are uncommon. The estimated 5-year freedom from local recurre...
How would you approach adjuvant radiation therapy in a patient with recurrent skin SCC of the gluteus s/p multiple resections with positive margins and adjacent osteomyelitis to the ischium and pubic ramus?
In this scenario, wherein a patient with recurrent cutaneous SCC has active osteomyelitis (assuming this is being treated), it would be prudent to avoid the involved bone as an OAR. I would not include the infected bone (I'd review the best imaging with radiology to ensure there's no involvement by ...
How do you choose between Grenz ray in a short course (e.g., ~5–7 fractions) versus longer-course superficial/megavoltage external beam regimens for large, ill-defined lentigo maligna on the cheek when surgery is not feasible?
The practical answer to this question is based on resource availability. There is a significant body of literature from Europe demonstrating the efficacy of Grenz ray therapy (albeit in retrospective, observational studies, with all of the usual caveats). To my knowledge, Grenz ray therapy is not wi...
What dose of reirradiation would you consider for locally recurrent breast cancer after mastectomy, excised with positive margins?
These are complex cases and lots of factors to consider when planning adjuvant therapy (age and comorbidities, tumor biology, other pathologic features like LVI, reason for the positive margin, plans for systemic therapy, presence of reconstruction, the volume of prior radiation, extent of clinicall...