Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?
This really boils down to two issues: CTP score and size of the lesion. For patients who are CTPA with a lesion <3 cm, RFA/MWA or SBRT are good options although there is some data from the University of Michigan (Wahl et al., JCO 2014) that lesions > 2 cm are better served with SBRT. For solitary le...
How would you approach a radiation-induced angiosarcoma of the breast after mastectomy with negative margins?
Based on this research we tend to offer RT for high grade or tumor more than 5 cm or RT induced; there is no good prospective data. Based on UF series, we offer accelerated hyperfractionation 1.5 BID to 45 to 50 Gy, treating only chest wall.
When do you consider re-irradiating patients with recurrent cervical cancer?
Because I have been seeing and treating a reasonable number of these cases for 35 years, I have some strong opinions on the matter. Although external beam re-irradiation in the setting of recurrent cervical cancer is fraught with great hazards and poor outcomes, interstitial re-irradiation has a hig...
Is there a role for stents for patients with a new diagnosis of metastatic upper rectal cancer with a near-obstructing primary?
I haven’t had much luck with stents - they hurt, they often migrate, and tumor growth or perforation is also a risk. My preferred approach is a diverting colostomy, then total neoadjuvant therapy, then resection with eventual ostomy takedown. (This assumes curative intent disease.) Of course, this d...
How do you manage persistent rectal bleeding in the setting of rectal adenocarcinoma in a treatment-naive patient?
For a locally advanced rectal adenocarcinoma in the era of TNT, treatment of the tumor with either chemoradiation or chemotherapy upfront is reasonable, and both choices are known to palliate colorectal cancers effectively. With more severe bleeding, we often consider starting with chemoradiation th...
When consolidating DLBCL with radiotherapy, do you treat all originally involved sites, or just initially bulky and partial responder sites?
When consolidating DLBCL with radiotherapy, several parameters must be taken into consideration. a) Is radiation therapy part of the treatment plan "on top" of full systemic treatment because of a certain risk situation due to not-optimal response of disease to systemic treatment (for example, FDG-a...
Would you consider adjuvant immunotherapy for a patient with high-risk Merkel cell carcinoma following definitive surgical resection and adjuvant radiation therapy?
Although there is no level 1 data supporting adjuvant RT in MCC, a relatively recent meta-analysis from an Italian group (Petrelli et al., PMID 31005218) showed that adjuvant RT is associated with a 75% reduction in local and locoregional relapses versus surgery alone, without a reduction in distant...
How would you treat a young breast cancer patient with limited nodal involvement and an isolated sternal oligometastasis at diagnosis?
Although there is limited data to support this approach, I have treated similar patients with "curative intent" with respect to the RT portion of their treatment. If the sternal oligomet is in close proximity to the ipsilateral IMNs, it can be included within the partial wide tangent fields for the ...
How do you talk to patients with intermediate-risk prostate cancer deciding between LDR brachytherapy (monotherapy) vs HDR mono vs SBRT vs EBRT, in terms of the comparative side effect profile of each approach?
It’s hard to add much to Dr. @Dr. First Last's excellent evidence-based answer, but I’ll elaborate on the counseling aspect from my perspective. Introduction: I start by acknowledging how difficult it is to weigh several totally foreign options and acknowledge the gravity of the decision. My patient...
Can the results of Checkmate 577 be applied to patients who do not undergo surgery following chemoradiation because of a clinical complete response?
The standard approach for patients with locally advanced esophageal cancer would be to proceed with surgical resection after neoadjuvant chemoradiation, regardless of clinical response. And then, if surgical pathology confirms residual disease, to proceed with adjuvant nivolumab. If the clinical res...