Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you ever pause or delay radiation for an infection?
Infections can be frequent, especially in patients who are immune- compromised from prior chemotherapy or concurrent chemoradiation. I think the decision to hold treatment is site specific. I would not hold pelvic RT for a patient with a bladder infection as long as I was treating the infection and ...
What are the safest dose constraints for moderately hypofractionated prostate cancer?
At Penn, we have a protocol for 70 Gy/28 fractions using proton or photon therapy for low- and intermediate-risk patients. I initially designed it with a conedown as follows, but that is not always necessary/appropriate. CTV Initial = Prostate and proximal seminal vesicles to include at least 1 cm, ...
In the setting of recurrent breast cancer after breast radiation, who receives a mastectomy and is found to have positive axillary nodes, under what circumstances would you give radiation to the chest wall and nodes vs the nodes only?
There is no absolute answer, and it is a function of time to recurrence, previous volume of RT, and potential benefit of RT (based on extent and location of recurrence and phenotype of disease). The threshold to treat is higher than upfront setting for sure. Treatment can vary from none to comprehen...
Given the long half-life of dexamethasone, what is an appropriate dose schedule?
After a discussion years ago with my fellowship-trained Neuro-oncologist friend (from Neurology track), I use dexamethasone only ever on a qam schedule. It doesn’t disrupt the sleep as much, there’s no waking for doses, the schedule is easy for patients and families to remember. In seven years of pr...
When do you add a third field for IMPORT-LOW style partial breast irradiation?
I don’t usually use the 3rd field and treat with min tangent with FIF to improve homogeneity. If planning to do conformal RT then prefer an APBI dose of 30 in 5 with VMAT technique.
What is your approach for a primary tracheal squamous cell carcinoma?
First off as you probably know this is a randomized data-free zone. So to some extent what to do here is empiric and/or based on historic outcomes, retrospective data, and so on. But here are a few quick & dirty observations...1) Surgical patients have the best survivals/outcomes. Doing tracheal sur...
What is the current paradigm for breast cancer diagnosed with isolated metastases prior to initial treatment?
Surgery of the primary did not significantly improve overall survival in which patients were randomly allocated to receive systemic therapy alone or (for responding patients) to systemic therapy followed by primary tumor resection in the trial conducted by ECOG-ACRIN (Khan et al., PMID 34995128), at...
What constraints do you use for the BID small cell lung cancer regimen?
The best validated constraints are from CONVERT (CALGB 30610/RTOG 0538). Cord D0.1cc < 41 GyEsophagus mean < 34 GyHeart V60 < 33%Heart V45 < 67%Heart V40 < 100%Lung V20 <40%Lung mean < 20 GyAlthough I tend to push for the LU005 constraints which I think are slightly more conservative.In addition to ...
Are there reasons to not use prostate SBRT when treating the prostate +\- proximal SV?
Early trials such as HYPO-RT-PC which aimed to validate a 7-fraction SBRT dose schedule by comparing it to the standard of care at the time, conventionally fractionated EBRT, utilized a treatment volume consisting of the prostate alone without the seminal vesicles (SVs). While there was some suggest...
What is the optimal duration of ADT for unfavorable intermediate risk or high risk localized prostate cancer treated with SBRT instead of conventionally fractionated or hypofractionated RT?
There is no available data from randomized trials to support any modification in the choice of ADT (GnRH agonist vs antagonist) or use of abiraterone acetate, or on the duration of ADT (4-6 mo vs 2-3 years) based on the form of radiation, and thus I follow the NCCN guidelines that provide recommenda...