Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Is stage N2a alone an indication for PORT in oropharyngeal squamous cell carcinoma with no other adverse features?
The short answer is yes, based on it falling in a list of indications for post-op xrt, which includes lymph node size > 3cm. Further, if this were an oral cavity tumor, some would argue that any node positive patient should be treated adjuvantly (ie even N1, though interestingly many oral cavity can...
What dose-fractionation do you utilize when treating at-risk and elective lymph node levels in patients with HPV-positive oropharyngeal squamous cell carcinoma?
For HPV+ OPC getting definitive concurrent chemoRT, we have been treating the elective nodal levels to 30 Gy at 2 Gy per fraction in the past 5 years (Tsai et al., PMID 35050342). For those treated with definitive RT alone (or with cetuximab) or in the adjuvant setting, we did not reduce the dose in...
In which patients do you offer adjuvant radiation for porocarcinoma?
Porocarcinoma is a rare entity, and there are very limited data on optimal management. For this, and a small number of other very rare cutaneous carcinomas, I generally apply paradigms used in cutaneous squamous cell carcinoma. Positive margins that cannot be cleared, very deep invasion, desmoplasti...
Would you use fezolinetant for hot flashes for men on ADT?
I might consider it after trying the usual agents that will at least partially relieve symptoms in the majority of patients, such as low-dose megestrol or venlafaxine (there are others, but these are the ones with which I have had the most experience and success). Fezolinetant is expensive and requi...
How does treatment management change with a positive intramammary lymph node in the setting of a negative axilla, with the inclusion of these as N1 node in the AJCC 8th edition?
I don’t think anything would change for management as I would treat the same RT field and a med onc would follow the same principle of using genomic assay (or phenotype) to decide about systemic treatment.
When do you consider the addition of concurrent pembrolizumab to breast irradiation?
With the publication of KEYNOTE-522 (Schmid et al., PMID 32101663), we are seeing this scenario much more frequently as patients continue the pembrolizumab in the adjuvant setting.A post-hoc analysis of the timing of radiation in the KEYNOTE-522 trial was presented in abstract form at SABCS 2022, (P...
What PTV margins do you use for definitive prostate radiation?
I tend to follow the RTOG/NRG trials' guidelines for each clinical situation when deciding on margins from CTV to PTV (which use progressively tighter margins based on whether one is doing standard, moderate hypo-, or extreme hypo-fractionation): For conventional fractionation, RTOG 0924 states 0.5-...
Is there any role for post-mastectomy radiation in the setting of N1mic axillary disease?
Most data based on which we predict risk of recurrence and recommend PMRT is based on studies when Ni mic was considered node-negative and thus those studies would not be applicable to Ni mic disease. The IBCSG randomized study on Ni mic (dissection vs. no dissection) did have a percentage of patie...
Would the presence of an SVC stent affect your decision to offer BID vs once-daily chemoradiation for SCLC?
There is no evidence to guide the practice one way or the other. From a biological standard point, it should not.
Do you perform EBUS-TBNA for staging in patients with biopsy proven malignant lung nodules with no lymphadenopathy on CT chest and PET scan?
I agree that incidence is low, but estimates for radiographically occult nodal disease range from 10-20% and the fact is there isn't great literature on this. A PET scan is a decent test, better than a regular CT, but there are still a significant minority of patients that are mis-staged when an EBU...