Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage an enlarging brain metastasis that has progressed in size three months after radiosurgery?
Before making a decision, I would want to know the tumor histology, SRS dose delivered, and whether the current site of progression is truly within the prior radiation field (using new MRI fused to the SRS plan in treatment planning software). If the lesion is within the high-dose region and the pat...
Would you add whole-pelvis radiation as MDT (metastasis-directed therapy) in a patient with 1 pelvic node and 2 osseous metastatic sites for castrate-resistant prostate cancer?
This patient would not fit the PEACE V-STORM eligibility criteria, since the trial excluded patients with distant metastases and did not include patients who were castrate resistant, so I do not think you can extrapolate the results to this patient. One could argue that what you propose to do (SBRT ...
For resected oral cavity squamous cell carcinoma with indication for adjuvant radiotherapy to the primary tumor bed, would you routinely include ipsilateral and/or contralateral nodes even with a pN0 elective neck dissection?
Since the question states "routinely", the short answer is yes, but the longer answer is there is much more nuance to this.Some will say no based on Contreras et al., PMID 31246526.It is important though to recognize that this paper is a bit more complex and the details are critical.The question ref...
How would you approach ES-SCLC presenting with small brain metastases that resolve after chemotherapy?
ES-SCLC may respond to chemotherapy, but save for a select few, it’s a palliative disease with, median survival of about a year for responders. Presenting with microscopic brain disease that responds to chemo does not change that. The Slotman report indicating survival advantage has been questioned ...
In patients with HER-2 positive breast cancer on pertuzumab/trastuzumab with newly developed asymptomatic brain metastases only, do you wait 3 weeks after administration of the targeted therapy to deliver SRS?
In a recently published study from Italy, Ippolito et al., PMID 35053467 a total of 10 patients with 32 HER2+ breast cancer brain metastases were treated with concurrent fSRT (27 Gy in 3 fractions) and Pertuzumab. Necrosis was reported in only 1 of the 32 treated lesions. The study is small but the ...
Should TNF inhibitors be held in patients undergoing radiation therapy?
We do not hold TNF inhibitors when needed for patients undergoing radiation therapy.
For gyn cancers receiving chemoradiation, how high can you boost grossly positive nodes with SIB if not near bowel?
I typically will give a simultaneous integrated boost (SIB) of 60 Gy in 30 fractions to the pelvic and para-aortic nodal CTV, which is the PET positive GTV plus a 3 mm margin. If possible I will boost the GTV of larger gross nodes (>1 cm) to 66 Gy (2.2 Gy/fx) with no margin, if constraints can be me...
What is the role of radiotherapy in cutaneous pseudolymphoma?
I generally like the term "Cutaneous B-cell lymphoid hyperplasia" to describe this entity which is characterized by a reactive B-cell proliferation within the dermis developing in response to an adverse stimulus (medication, insect bite, etc.). Sometimes the antigenic stimulus can't be identified. ...
Is it appropriate to dose de-escalate in low risk HPV+ SCC of the oropharynx outside of a clinical trial setting?
I am going to write specifically on de-escalating HPV-OPSCC in the adjuvant setting first, important caveats for adjuvant de-escalation, and then about the general philosophy on de-escalation in clinical trials.Concerning adjuvant treatment, after careful consent, we are de-escalating patients with ...
What dose constraint, if any, do you use for the diaphragm when treating liver or lung tumors with SBRT?
I treated a HCC patient with a subdiaphragmatic tumor with SBRT 54 Gy in 3 fractions. He developed right posterior chest wall pain that radiated to his right shoulder. On autopsy, he was found to have a path CR in his tumor and necrosis of the adjacent diaphragm muscle. The chest wall appeared gross...