Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you recommend neoadjuvant 177Lu-PNT2002 followed by MDT per the LUNAR trial as your preferred treatment approach for oligorecurrent prostate cancer, as opposed to MDT and PSMA-radioligand therapy used as temporally separate treatments?
I believe this randomized trial does provide high-level evidence that adding 177Lu-PNT2002 prior to SBRT improves PFS compared with SBRT alone. If it were available off trial, yes, I would personally recommend it as an option. Currently, that is not the case.We chose this sequencing because we thoug...
What SBRT dose would you give to a single external iliac lymph node recurrence (1 cm size) for a patient previously treated with salvage radiation to the pelvis?
35 Gy/5 is fairly safe in the re-irradiation setting, and in our experience, it's quite effective for nodal disease.
How do you manage the elective lymphatics in high risk squamous cell carcinoma of the skin?
For the high risk features mentioned in the question, elective RT to draining nodes and neural pathways should be considered. The acceptable dose/fx for elective RT in SCC is generally 50 Gy in 25 fx (ranges from 45-54 Gy). <1.8-2 Gy/fx is acceptable in dose painted plans. For the nodal fields a goo...
How would you approach a cutaneous squamous cell carcinoma with primary tumor completely excised, but multiple foci of LVI at the peripheral specimen margin and no other high-risk features?
In a prospective study that assessed clinical and pathological risk factors for primary tumor site recurrence after margin negative excision of cutaneous squamous cell carcinoma, the presence of desmoplasia was reported to be the primary variable associated with this event. The authors specified tha...
In what situations would you treat elective regional lymph nodes for a squamous cell carcinoma of the skin on the extremity/trunk that was clinically node negative?
Nodal metastasis from small, to medium size [up to 3 cm in diameter] squamous cell carcinoma on the extremity is not that common. Considering the morbidity of nodal treatment in a patient with clear margins of resection I would not prophylactically treat the nodes. If the tumor shows perineural or l...
What volume and dose would you use for a Stage I MALT lymphoma of the lung?
MALT lymphomas are highly radiosensitive. Curative standard doses are 24 Gy in 12 fractions and 30 Gy in 20 fractions. The latter and slower dose fractionation (30 Gy in 20) is best used specifically in the setting of stage IAE Gastric MALT - a unique site with significant risk of radiation induced ...
Would you consider adding abiraterone to ADT and salvage RT in a prostate cancer patient with pN1 disease at radical prostatectomy?
This is a question that is being addressed in the salvage setting by NRG GU008. Currently, we have high level evidence that adding abiraterone to ADT is superior to ADT alone for subsets of patients with metastatic disease and the combination with RT is superior to ADT alone plus RT for both clinica...
Do you base liver SBRT dose fractionation on size, volume, or proximity of normal tissue?
I think about this differently than most people do. My goal is to deliver an ablative dose (100 Gy BED) regardless of the proximity of organs at risk or the size of the tumor. The more common thing to do is to reduce the dose of radiation below an ablative dose to 40 or 30 Gy in 5 fractions. I'm not...
When recommending salvage RT post-prostatectomy for an ultra-sensitive PSA level <0.1, do you still recommend concurrent hormonal therapy?
There is potentially an interaction between ADT's benefit and the PSA at the time of treatment. This was most well delineated in RTOG 9601 (Dess et al., PMID 32215583), but since then, using modern LHRH agonists, that interaction has been less well established (GETUG-AFU16, SPPORT, and RADICALS-HD)....
Do you ever dose escalate radiotherapy to the primary in low volume metastatic prostate cancer?
Background: STAMPEDE Arm H (SOC ± RT to prostate) allowed for two fractionation schedules, 55 Gy in 20 daily fractions (67 Gy EQD2[α/β = 1.5]) and 36 Gy in 6 weekly fractions (77 Gy EQD2[α/β = 1.5]), without correction for treatment duration), and approximately half of participants received each sch...