Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach adjuvant therapy of serous intraepithelial carcinoma of the endometrium?
I would favor no additional treatment as the risk of recurrence is low and no proven benefit of adjuvant RT.
What is your approach to TNT sequencing for locally advanced rectal primaries with low volume metastatic disease to liver?
This is a very common clinical scenario for which I'm not aware of a single correct answer. I assume by "low volume" metastatic disease to the liver the question implies potentially curable through some combination of liver-directed therapies. The only part of the sequencing about which I am fairly ...
When treating stage IVB cervical cancer with both systemic chemotherapy and local pelvic radiation therapy, do you incorporate the use of bevacizumab as in GOG 240?
I generally favor starting with multi-agent systemic therapy (Carbo/Taxol/Avastin +/- Pembro) upfront to confirm that the patient is going to respond appropriately and not blossom with metastatic disease prior to making a decision of radiating the pelvis in oligometastatic cervical cancer, similar t...
When do you use a vaginal cuff boost with pelvic RT for stage II endometrial cancer?
Most prospective studies studying the role of external beam in endometrial cancer have treated patients with pelvic radiation (46/2 Gy or 50.4/1.8 Gy) without any brachytherapy. These studies have reported very low rates (2-3%) of in field failure in the radiation arms, so recommending external beam...
Is there an SIB boost regimen for a dominant prostate lesion for 60 Gy/20 fx to the whole prostate?
There are no phase III data providing guidance on the "isotoxic" boost dose for a 20-fraction, hypofractionated prostate treatment similar to the experimental arm in FLAME (Kerkmeijer et al., PMID 33471548), but there are two prospective studies of which I am aware, DELINEATE and ARO2020-01, which d...
Would you treat someone following FLAME protocol for prostate cancer without fiducials if using daily CBCT?
The underlying concept within this very practical question is how we rely on on-board imaging for target localization. In my practice, in which I have high confidence in my GTV contouring accuracy and daily setup, I would feel very comfortable using CBCT instead of fiducials. My ideal process includ...
When do you choose motion management over free-breathing techniques for lung SBRT?
The take home message for everyone is that motion management, regardless of the method used, is necessary. All patients should undergo 4DCT imaging in order to construct a "motion map" to quantify tumor motion in all directions. You can never assume that tumors will move in a predictable pattern. Mo...
Is there a role for the addition of radiation to preoperative chemoimmunotherapy in NSCLC with limited N2 disease planned for surgery?
CheckMate 816 was a phase III randomized trial that demonstrated that adding nivolumab to platinum-based chemotherapy in the neoadjuvant setting improved pCR rates and event-free survival (Forde et al., PMID 35403841) and ultimately overall survival (NEJM 2025). The 5-year OS benefit was 10%, almost...
How would you approach the treatment of low grade, stage IA, triple negative apocrine adenocarcinoma of the breast in a female patient in her 70s?
I would not treat this the way I would a typical triple-negative breast cancer, since the risk of distant recurrence from occult metastatic disease is low. Assuming she had breast-conserving surgery, radiation, favoring partial breast, is reasonable. In terms of systemic therapy, if the cancer in th...
After R1 resection of a locally advanced, node-positive neuroendocrine tumor of the terminal ilium, would you offer adjuvant radiation therapy?
This is a very nuanced question, and I disagree with those suggesting radiation. The great majority of NETs occur at the terminal ileum and the great majority of these tumors are grade 1 or 2. If there was a positive margin it could take many years for that disease to manifest locally. I think radia...