Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When using hypofractionated whole breast radiotherapy with a simultaneous integrated boost to the lumpectomy cavity, what IGRT strategy do you use?
My preference is CBCT daily and matched to clips/cavity. Our practice also does SGRT for all patients (tattoo-less clinic); however, that is not routinely reimbursed. If treating like RTOG 1005 (48/40 in 15 Fx) and approved for IMRT, will get approved for IGRT.
Would you consider whole breast re-irradiation in a patient with a second/recurrent breast cancer and prior history of breast radiation therapy many years ago, if the tumor characteristics are not amenable to partial breast re-irradiation?
A second lumpectomy after recurrence post-lumpectomy/RT in itself makes it amenable to APBI, i.e., the pathology or clinical factors do not matter after a 2nd lumpectomy. Since the early literature (from UPMC) to more recent prospective trials (RTOG 1014), the CTV is the lump cavity, regardless of o...
When is the ideal time in the disease course to offer radiotherapy for Dupuytren's disease for the most optimal outcomes?
Radiotherapy is most effective when fibroblasts are actively proliferating, i.e., during the cellular or proliferative phase of the disease, when there is a palpable, progressive nodule or cord but no fixed contracture.Prospective German trials show that treating during this biologically active peri...
When treating with SBRT and immunotherapy for unresectable HCC, how do you sequence the treatment?
Great question. No great data in this space regarding optimal sequencing. In general, I would sequence SBRT first, followed by initiation of immunotherapy. Some data suggest that SBRT may best prime IO if administered prior to IO. Additionally, if the IO regimen preferred is atezolizumab/bevacizumab...
How would you evaluate the role for adjuvant radiation in a very young female (20s) with a localized vulvar SCC, HPV independent, status post hemivulvectomy?
Either re-excision or observation provided no dVin at margin and at least a 3 mm negative margin for invasive disease.
Would you offer systemic chemotherapy to a patient with at least 2023 FIGO stage IC high grade serous (p53-mut) endometrial cancer with extensive LVI for whom nodal assessment was not done?
This question was addressed in a large NCDB study in 2020 by Nasioudis et al (Nasioudis et al., PMID 32675056) who looked at USC confined to the endometrium, which found that 5-year OS was 91% for chemo alone, 91% for chemoRT, 85% for those who received radiation alone, and 82% who were observed. Ad...
What is your approach to SBRT to an entire kidney infiltrated with RCC?
I have treated a patient in this situation recently, and we did end up treating the entire kidney. One concern brought up in our peer review was possible malignant hypertension from fibrosing of the whole kidney. Prior to treatment, we did get a differential renal flow scan just to ensure the treate...
What advantages does SBRT for RCC have compared to other ablative techniques?
Mainly that SBRT is non-interventional. Recall that those patients who receive percutaneous RCC therapy have either declined surgery or are poor surgical candidates due to additional medical co-morbidities. The complication rate for percutaneous ablation is overall low when compared to partial nephr...
If the patient has had prior partial nephrectomy for RCC, would you consider SBRT for a contralateral RCC?
It boils down to the estimated eGFR after SBRT/SABR. Urologists use 15 mL/min as the cut-off. Workup should include a comprehensive metabolic panel and NM renal scan to determine differential renal function. It helps to use a motion dampening technique like abdominal compression or gating to decreas...
Would you offer SBRT to a biopsy proven T1 renal cell carcinoma on a transplanted kidney?
Complex scenario. I am not aware of any cases worldwide of SBRT for RCC in a transplanted kidney. That being said, our group has previously published a case of SBRT for early stage lung cancer in a double lung transplant patient. This was one of 2 known cases at the time, and the details of the case...