Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
Would you offer liver SBRT without fiducial placement?
When we first started doing liver SBRT cases in the early Paleolithic 2000s (refs), we never used fiducials and just managed by using the nearest liver surface contour (or diaphragm if using a breath hold technique) and/or any other intrahepatic anatomy that was distinguishable once we added CBCT. I...
In your practice, what is your goal dose for boosting positive PA nodes in either the adjuvant or definitive treatment for cervical cancer?
The dose of RT is based on the risk of tumor recurrence tempered by normal tissue constraints. In general, known or suspected gross nodal disease is treated to 60 Gy; higher doses of 62-66 Gy may be used for large nodes that are not immediately adjacent to the duodenum, particularly if a portion of ...
Which patients with relapsed/refractory NHL are appropriate for pre-CAR-T bridging radiation therapy?
Before answering this important question, I think that we, as Radiation Oncologists, should give serious consideration to moving past the terminology of "bridging radiation therapy" and instead refer to it as "pre-CAR-T infusion radiation therapy." Bridging therapy was initially an apt name; we were...
How do you best communicate SBRT planning directives, specifically in regard to how "hot" the plan should be?
This is where common language becomes uncommonly important. There are two languages one can speak re: doses in external beam radiation therapy. In language one, the 100% line always equals the MD's prescribed gray* dose. In language two, the 100% equals the maximum gray dose in the plan. Most of my ...