Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
At what PSA level do you offer early salvage radiotherapy?
For a patient with pT3 disease or positive margins, once the PSA is confirmed detectable, rising, and the patient is well-healed, it is appropriate to treat. Given the results from the now 7 adjuvant vs. salvage trials, delaying well past a PSA of 0.2 is associated with the need for more aggressive ...
How long would you stop standard GBM radiotherapy if the patient had a fall with minor head trauma?
I would do everything possible to minimize or ideally avoid treatment breaks, given no intracranial bleed. I would evaluate skin dose over the area of laceration and consider adapting the plan to meet skin constraints or lower dose to the suture if possible and not already low. If significant swelli...
What is the role of radiation in intra labyrinthine (cochlear) schwannoma?
This is a bit of a tricky question to answer without knowing the size of the lesion, the age of the patient, their current symptoms, and whether they have serviceable hearing.If the tumor is small, and the patient has residual serviceable hearing, it might be best to delay treatment and order a repe...
When utilizing hypofractionated radiotherapy in the post mastectomy setting, are the nodal regions dose painted to a different dose or the same dose as the chest wall/reconstructed breast?
Our usual dose to the reconstructed breast/chest wall is 45 Gy in 18 fractions, requiring at least 95% of the PTV to receive 100% of the prescribed dose. The prescribed dose to internal mammary nodes (when treated) is the same, with a slightly lower acceptable dose (95% of the PTV receiving 95% of t...
How do you approach hemorrhagic brain metastases in melanoma?
This is a symptomatic brain metastasis from melanoma. Such patients had poor outcomes in the CheckMate 204 trial with dual IO therapy alone. Local control with RT therapy is advised. In our practice, we start with IO-therapy and radiation joins in whenever they are ready with the plan (as GKRS plan ...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
For NSCLC patients treated with neoadjuvant chemoimmunotherapy and surgery with ypN2 disease, what factors would cause you to recommend PORT?
This question is a tough one, and the multidisciplinary teams I work with are still trying to figure it out. This is mostly because only 13% (67/501) of randomized participants in the Lung ART study received neoadjuvant chemotherapy, and 0% received neoadjuvant chemoimmunotherapy; all had pN2 or ypN...
Do you recommend adjuvant treatment for nodal isolated tumor cells in an otherwise low-risk endometrial cancer?
Do you recommend adjuvant treatment for nodal isolated tumor cells in endometrial cancer?No, I don’t recommend adjuvant treatment for endometrial cancer patients based on the presence of isolated tumor cells (ITCs) alone, in the absence of other poor prognostic factors. A recent survey on sentinel l...
How would you manage leptomeningeal disease of the spine in the setting of prior WBRT?
This is an extremely challenging clinical situation. The decision points depend on treatment goals: If the goal is local palliation, simply treat local areas of disease, e.g. spinal segments. If effective systemic therapeutic options are available, obviously consider those first, including intrathe...