Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach SBRT in a pacemaker-dependent elderly patient with Stage I NSCLC whose SBRT plan Dmax exceeds the pacemaker tolerance?
For any patient who has a pacemaker, we always send them to be evaluated for the device by a cardiologist before simulation and after finishing all fractions of the SBRT. In addition, we check their vital signs daily after each fraction of SBRT. For SBRT planning, we will minimize irradiating the p...
What is your preferred sequencing of adjuvant chemotherapy and PMRT for node + breast cancer?
I addressed this issue for patients treated with breast-conserving surgery in May 2023; please see that answer for more details. To summarize, the toxicities from chemotherapy may be greater and its effectiveness reduced (at least for high-risk patients) when given after RT instead of before (Recht ...
Is there evidence that prostatectomy improves overall survival in local recurrence of prostate cancer post-definitive radiation?
I am not aware of any prospective clinical trial data to suggest that salvage prostatectomy for locally recurrent prostate cancer improves overall survival as compared to any other comparator. Such evidence would be very difficult to generate given that historically, most prospective studies have fo...
Can trastuzumab deruxtecan be continued during radiation?
Data is limited, with the suggestion of higher necrosis with SRS. For other sites for palliation, I would not say it’s contraindicated, but caution needs to be exercised especially for the risk of increased lung and GI toxicity (because of independent toxicity from the drug and the potential for sen...
How do the results of INSEMA and SOUND impact the decision of omitting SLND in young women with breast cancer and offering adjuvant RT to patients who would otherwise be candidates for omission?
Both trials required radiation so I would recommend it for a young woman not getting sentinel lymph node evaluation, and would lean toward whole breast irradiation. INSEMA required whole breast irradiation and SOUND allowed partial breast irradiation (10% of patients) but the majority of patients re...
How would you treat a locally advanced rectal squamous cell cancer with vaginal invasion?
If the anterior wall of the vagina is free (i.e., the 5 cm refers to the cephalo-caudad length of the tumor), and this proves to be a case of a high grade but potentially resectable (assuming adequate response to preoperative tx) T4 rectal cancer. I've treated cases with exactly this histology and p...
Would you consider modifying T&O fractionation during the COVID-19 pandemic?
We have been using 7gy x 4 instead of 5 fraction regimen in the past. A 2 fraction regimen showed lower local control in comparison to 4 fractions in the IAEA randomized trial.
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...