Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you recommend axillary dissection for women with ER+ breast cancer and low risk Oncotype or Mammaprint if single node positive with only 1-2 SLN removed, to ensure <4 nodes positive?
No, I see no need to do dissection in this setting. Unless there is clinical or imaging evidence of gross disease, radiation should adequately control microscopic residual disease in the axilla.
How do you reconcile the differing results of the C-POST and KEYNOTE-630 trials when discussing treatment options with high-risk CSCC patients?
I explain that the two trials enrolled different risk populations, which likely accounts for the apparent discrepancy in outcomes — but when you look closely, they actually lead to the same clinical conclusion. C-POST deliberately enriched for very-high-risk patients (using well-established adverse ...
How would you treat a patient with Gleason 8 or 9 prostate cancer, pretreatment PSA 15-24, with retroperitoneal adenopathy?
I would offer a similar approach to that described nicely by @Dr. First Last and @Dr. First Last: definitive RT+ADT+abiraterone, with SIB to the grossly positive nodes. My caveats and additions are: I start with a frank discussion with the patient re: evidence for various scenarios and general prog...
How would you manage a patient with non-mutated oligometastatic NSCLC with a brain met who underwent resection of the brain met, had 4 cycles chemoIO, and had resection of the primary lung CA with pCR and now is NED?
This is a great question, and this scenario does come up occasionally within our Thoracic Tumor Boards. What makes this scenario more complicated is the integration of immune checkpoint inhibitors into standard practice. However, this question has been addressed in the pre-immunotherapy era with num...
What is your preferred approach for managing oligoprogressive NSCLC during second-line or later systemic therapy if patient is otherwise responding well at other sites of disease?
I would offer metastasis-directed therapy with SBRT or if necessary based on site, hypofractionated (8-15 fractions) RT to oligoprogressive disease in this setting which we now have Phase 2 randomized data to support due to the nice work of Dr. @Dr. First Last and her team in the CURB trial. Patient...
What adjuvant treatment would you give to a locally advanced esophageal adenocarcinoma status post neoadjuvant FLOT s/p resection with positive margins?
For an R1 resection, considerations would include re-resection if feasible or chemoradiation. I would not favor chemotherapy unless there was evidence of a really convincing response from FLOT. I assume MSI testing was done.
Given that ESOPEC did not mandate PET staging, are the conclusions of the study still applicable for patients who are staged with PET?
I believe the study results are still applicable to patients who are staged with PET.ESOPEC supplementary data show that 7 patients (all in the pre-op CRT group) had M1 disease at diagnosis, which was discovered due to PET staging. The total number of patients in each study arm with M1 disease prior...
How do you approach an early stage breast cancer patient s/p BCS in which ECE is found on a positive sentinel node?
These are cases that we are facing more commonly and my thought is the answer shouldn't change whether this is BCS or mastectomy (though less data in this setting).I will discuss with the patient the limitations of Z011 and AMAROS with respect to ENE. With focal microscopic ECE, I will often proceed...
What is your approach to brain reirradiation in the setting of recurrent/progressive gliomas?
A lot of factors need to be considered prior to offering brain reRT in such a setting, most importantly- interval since the 1st course of RT, patient's ECOG and neurologic function, age, perceived life expectancy, size of the lesion, location of the lesion, WHO grade of glioma, patient's expectation...
What adjuvant treatment approach would you recommend for a patient with early-stage MSI-high gastric cancer who received neoadjuvant ipilimumab (×2) and nivolumab (×6) per the NEONIPIGA regimen, followed by R0 resection with no pathologic response?
I would favor FOLFOX x6 as per classic. This scenario raises the question: Was this truly MSI-H? I would confirm MSI status with next-gen sequencing. I would have expected a response if MSIH on ngs with concomitant high TMB. Our institutional practice has been to review all MSI-H IHC cases done outs...