Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you optimally boost patients with high or very high risk prostate cancer receiving definitive radiotherapy in 2025?
Micro-boost is my preferred strategy for dose escalation. The FLAME trial demonstrated a bDFS benefit (Kerkmeijer et al., PMID 33471548). The secondary analysis demonstrated reduced regional+distant metastasis and reduced local recurrence, as well (Groen et al., PMID 34953603). These benefits were ...
What is the appropriate timeline to start post mastectomy chest wall/regional nodal XRT (+/- reconstruction) after surgery?
If the patient received neoadjuvant chemotherapy, we typically give RT prior to additional chemotherapy (ex. xeloda for triple negative with residual, TDM1 for HER2+ with residual) and try to start 4-6 weeks post-op given that they are well healed and/or reconstruction/expanders completely filled. I...
In a patient with node-positive limited-stage small cell lung cancer, how do you approach radiation in a patient whose small primary tumor resolves after one cycle of chemotherapy?
In the case of imaging CR, I delineate CTVp based on pre-chemo volumes and apply PTV margin. If less than CR, I use post-chemo volumes to delineate GTVp and then utilize 4DCT to construct ITVp followed by appropriate CTV and PTV margins. Both approaches are consistent with ESTRO ACROP guidelines pub...
Is the presence of carcinoma in situ at the staple line after lobectomy completed for invasive disease an indication for PORT?
Usually not, in my opinion. Not all CIS will progress to become invasive disease, and in many patients the pace of any progression will be slower than competing comorbidities (or even other areas of CIS). The typical situation is that the radiographic mass is resected, and the CIS has no clear radio...
How would you approach a primary small cell carcinoma of the vagina in a patient with an intact uterus and cervix?
We treat with the same principle as cervical small cell with combination of concurrent chemo with cis and RT (EBRT plus brachy) followed by adjuvant cis and etoposide. No pCI.
Would you consider spine re-irradiation after Pluvicto?
This question will become more common as more patients undergo PSMA-based radiopharmaceutical therapy (RPT). The focus of this question seems to be related to the additional dose to which RPT may expose the cord and the ensuing risk of myelopathy. In summary, I do not believe there is (or could be) ...
How would you treat locally advanced melanoma of the scalp with several in transit lesions and a metastatic lesion to the parotid if the patient is progressing on immunotherapy such as pembrolizumab?
I think it is important to first define whether this is truly primary progression or whether the patient may have a delayed response. The Society for Immunotherapy of Cancer (SITC) has some consensus guidelines for defining this:Kluger et al., PMID 32238470 It is important to recognize that these ar...
What is the appropriate RT dose for an advanced stage follicular lymphoma?
Based on the study for patients of early stage low grade lymphoma treated with curative intent, the dose should be 24 Gy.For those treated with palliative intent, 2gy x2 should be preferred, as the majority have good palliation with that dose. In the minority where symptoms persists, one can treat a...
How long after intrathecal chemotherapy do you typically wait before giving whole brain radiation?
This depends on the diagnosis and the reason for pursuing whole brain radiotherapy after intrathecal chemotherapy. For example, if this is a primary CNS lymphoma case with a patient who has progressed despite intrathecal chemotherapy I would likely proceed with whole brain radiotherapy relatively so...
How long would you wait after a cycle of IT MTX to treat a spinal lesion causing cord compression in a patient with stage IV DLBCL?
Intrathecal methotrexate has biphasic half-lives of about 5 hours and 14 hours (Bleyer, Cancer Treat Rep 1977). ILROG recommends typically waiting minimum interval 2 weeks between last IT or high-dose IV methotrexate before starting CNS radiotherapy for CNS leukemia, but urgent radiotherapy may be c...