Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In stage 4 hilar cholangiocarcinoma, after stenting the biliary tree is there value in radiating the hilar area in addition to systemic therapy so as to maintain patency of the biliary system for a longer period of time or do you depend on the systemic therapy and the stenting alone?
In the setting of metastatic hilar cholangiocarcinoma, biliary patency is one issue but the greater issue is colonization of the biliary tree with gut flora that leads to repeated bouts of cholangitis, and progressive biliary sclerosis that happens regardless of the use of radiation. These patients ...
How would you treat node positive prostate cancer with only a single peri-rectal node on PSMA PET but no other nodal basins involved?
I have encountered this situation more commonly in patients who have failed after radical prostatectomy and extensive pelvic lymph node dissection rather than in newly diagnosed patients. However, in the PSMA PET era, I believe we are seeing more patients with perirectal nodal involvement, so I have...
Would you withhold whole brain radiation therapy for pts with brain metastases from NSCLC unsuitable for resection or stereotactic radiotherapy?
The QUARTZ trial, published earlier this month, was a phase III non-inferiority trial with a primary endpoint of quality-adjusted life-days and pragmatic inclusion criteria. Patients with NSCLC who were unable to undergo SRS or resection were randomized to supportive care (OSC) with or without WBRT ...
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...
Do you consider ADT intensification with enzalutamide or abiraterone in patients receiving adjuvant radiation with ADT?
I agree with Dr. @Dr. First Last.One thing to note is ~3% of RADICALS, for example, included pT3b and high grade disease, and almost no patients in the ART vs SRT trials had N+ disease. Was largely GS7 and pT3a population and not the very high risk patients that select surgeons choose to operate on....
Does a high genomic risk score impact your radiation fields for patients with breast cancer?
Agree with @Dr. First Last. In SLN-negative situations with high scores, I would favor whole breast (rather than PBI). High genomic risk scores have been correlated with increased LRR. Elegant summary recently presented by @Dr. First Last, ASTRO – Session EDU23.
When do you include the primary site in the radiation field for a penile cancer with negative margins?
Assuming he has had partial or total penectomy with negative margins, I don't treat the primary irrespective of nodal status. Control of the local disease is rarely a problem. From a radiation perspective, the battle is won or lost in the groin where an aggressive management approach is warranted fo...
With vaginal cuff brachytherapy, do you treat to the surface or a depth and why?
We prescribe to the surface of the vagina but also attend to the dose at depth. For patients receiving only vaginal cuff irradiation we use a prescription of 6 Gy VSD x 5 qod. Although this is a modest dose, it appears to be very effective in preventing vaginal recurrences, even in high-risk cases. ...
How would you approach a patient with prostate cancer with PSMA+ non-regional lymph nodes?
If we take the question at face value, this is a patient with de novo mHSPC and the treatment recommendation would be ADT (level 1) + ARPI (level 1) + RT to primary (level 1) and consideration of RT to metastatic sites (level 3 data).However, I would use one of the multiple PSMA-RADS-like scoring sy...
Is it appropriate to use a hypofractionated regimen to treat the pelvic nodes in prostate cancer?
Much of the world uses 60 Gy in 20 fractions as their new standard of care, which is endorsed by nearly all guidelines. When treating nodes people simply use 2.1 or 2.2 Gy per fraction to 42 to 44 Gy in 20 fractions simultaneously to the nodes. It is near identical to the 1.8 Gy to 45 Gy so not real...