Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What dose do you use for definitive treatment of squamous cell carcinoma of the cervical esophagus?
Our institutional preference is to employ a total dose to 70 Gy with concurrent chemotherapy for squamous cell carcinoma of the cervical esophagus, because a local failure in would require salvage surgery with pharyngo-laryngo-esophagectomy. The role of dose escalation in squamous cell carcinomas of...
What is your preferred dose to gross lymph nodes when treating non-metastatic high-risk prostate cancer?
I treat the grossly involved node as high as I can, while respecting OAR constraints, up to the dose for the prostate. I tend to favor zero or minimal PTV margin (depending on the proximity of OARs--usually bowel) and allow the penumbra to serve as a functional "PTV."
Do you recommend definitive chemoradiation for unresectable gastric adenocarcinoma in a medically unfit patient?
Definitive is probably not the best term for what can be done. Only palliative doses are possible because the stomach is so sensitive, the GTV is difficult to clearly define, impossible to see on CBCT, the stomach changes shape from day to day, and moves with respiration. There would only be a less ...
For a patient with metastatic melanoma with small, asymptomatic brain mets what is your preferred systemic therapy?
In this scenario, I default to using a combination of ipilimumab plus nivolumab. We know from prior clinical trials that have looked at this combination of patients with asymptomatic brain metastases that immunotherapy seems to work similarly well intracranially as it does extracranially. This was e...
How would you approach adjuvant radiation therapy in a patient with recurrent skin SCC of the gluteus s/p multiple resections with positive margins and adjacent osteomyelitis to the ischium and pubic ramus?
In this scenario, wherein a patient with recurrent cutaneous SCC has active osteomyelitis (assuming this is being treated), it would be prudent to avoid the involved bone as an OAR. I would not include the infected bone (I'd review the best imaging with radiology to ensure there's no involvement by ...
How do you choose between Grenz ray in a short course (e.g., ~5–7 fractions) versus longer-course superficial/megavoltage external beam regimens for large, ill-defined lentigo maligna on the cheek when surgery is not feasible?
The practical answer to this question is based on resource availability. There is a significant body of literature from Europe demonstrating the efficacy of Grenz ray therapy (albeit in retrospective, observational studies, with all of the usual caveats). To my knowledge, Grenz ray therapy is not wi...
What whole brain radiation dose would you recommend for primary CNS lymphoma with partial response to HD-MTX-R and R-ICE and planned for concurrent ibrutinib?
There are many uncertainties in how to optimal treat patients with PCNSL. It is clear that high-dose MTX-based regimens should be pursued when feasible. The role, if any, of RT is controversial. If pursued, a WBRT-based approach is generally considered most appropriate.With that said, if a patient o...
Do you recommend adjuvant radiation in patients with intrahepatic cholangiocarcinoma (IHCC) resected with a positive margin (R1 resection)?
When considering the competing risk of distant mets, the probability of isolated local failure in this disease is probably very low and treatment of the positive margin may not result in a clear benefit. Patients with intrahepatic cholangiocarcinoma have about a 70% or more distant failure rate, and...
For stage III NSCLC treated with definitive intent chemoRT, how do you decide to proceed with surgery vs consolidation immunotherapy?
When we initially evaluate a patient with locally advanced NSCLC, we make the decision upfront about whether the patient will be managed surgically or not, and then we stick to that plan as long as everything proceeds as expected. So someone treated with definitive intent would get durvalumab (shown...
How do you dose or sequence therapy to overcome radioresistance from oligometastatic disease from RCC?
RAPPORT (NCT02855203) [Siva et al., PMID 34953600] was a phase I/II trial which used a combination of RT and pembrolizumab. RT was given with SBRT (20 Gy/1# prescribed to the 80% isodose line) or conventional radiotherapy (30 Gy/10#) when the treatment volume was in close proximity to a dose-limitin...