Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When do you start adjuvant radiation with areas of delayed wound healing after reduction mammoplasty?
Great question. I have cared for many patients with delayed healing post-lumpectomy (e.g., from infection, wound failure, etc.), and that experience is likely pertinent to the mammoplasty setting. Once the wound is open, it is going to take many weeks/months to “fully” heal, and it is not practical...
What is your preferred fSRS dose/fractionation for large brain metastases?
For large intact brain metastases, my preferred fSRS dose/fractionation would be 27 Gy in 3 daily fractions. There are retrospective studies showing 1-yr local control rates of 91% using 27 Gy in 3 daily fractions vs 77% using single fraction SRS for large intact brain metastases > 2 cm (Minniti et ...
When utilizing hypofractionation for postmastectomy radiation, what is your strategy for boosting undissected nodes?
2.5 x 4 to 5. Fractions based on the response of the undissected node to systemic treatment.
Given the 10-year outcomes of UK FAST-Forward presented at ESTRO, how have you expanded the use of ultra-hypofractionation in your practice?
We offer 5 fractions to all early-stage breast cancer patients. If technically suitable, the preferred option is APBI; otherwise, FAST-Forward 26 Gy in 5, ensuring dose homogeneity as specified in the protocol.
Do you offer consolidation durvalumab in a patient who had pneumonitis requiring steroids following chemoradiation for LS-SCLC?
In the ADRIATIC trial, pneumonitis or radiation pneumonitis occurred in 38.2% of durvalumab-treated patients, and 8.8% discontinued treatment due to pneumonitis (Cheng et al., PMID 39268857). While there is emerging interest in immune checkpoint inhibitor rechallenge after successful management of i...
What volumetric dose constraints, if any, do you use for the mandible in the definitive setting for H&N cancers?
The planning directions for the mandible are typically <50 Gy. However, when the targets are adjacent to the mandible we do not constrain the maximal mandibular dose if it may compromise target dose. In that case, we plan a dose gradient across the mandible, with the mucosa and inner plate of the bo...
How would you treat a biopsy proven isolated left-sided internal mammary node recurrence 20 years after mastectomy and chemotherapy for left breast cancer?
A 20 year truly isolated IMN recurrence sounds like a pretty good example of an oligorecurrence to me… I think the historical standard of care is definitely as @Dr. First Last and @Dr. First Last have outlined above, but I wonder if it’s time to start viewing a locoregional breast oligorecurrence in...
Do you recommend chemoradiation following neoadjuvant FOLFIRINOX for resectable pancreatic cancer?
Tough question, with lots of evolution in this area in the past few years. The data would suggest that for borderline resectable pancreatic cancer, there is a benefit in terms of OS from preoperative treatment. For unresectable disease, the small chance of conversion into resectability is worth the ...
How should you manage a coronavirus infected/suspected patient who is receiving radiotherapy and cannot interrupt or delay their cancer treatment?
Hi Everyone, I agree with all the comments—this is certainly a fluid situation. We have not had a confirmed COVID-19 case, but we have developed a plan. If it is deemed a known COVID-19 patient, and it is elected to continue treatment by the treating physician, the treatment will happen at the end o...
When treating a low-lying and bulky cT2N0 rectal adenocarcinoma invading the anal sphincter muscles with neoadjuvant chemoRT for downstaging, would you electively include the inguinal lymph nodes?
Based on the paper that we published at MDAnderson in 1990, the inguinal recurrence rate is 2 to 5% if they are not treated electively in patients with tumors involving the anal canal. If the tumor is within 2 cm of the anal verge or right at the dentate line, it was 5%. If the tumor was between two...