Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For a patient with localized, high-risk prostate cancer (Gleason >8, staged with PSMA PET), is prostate SBRT a reasonable treatment choice, and if so, what duration of ADT would you utilize in this setting?
Yes, I offer SBRT as a reasonable option for high-risk prostate cancer. This is admittedly an extrapolation from PACE-B, which studied treatment of intermediate-risk cancer, but it seems justified in my view. Safety is well established. Efficacy is supported by PACE-B, with an asterisk coming from N...
Do you offer low-dose radiation therapy for osteoarthritis of the spine?
DEGRO has published guidelines on this very topic, so I would respectfully disagree with a comment arguing a lack of data. Of course, if one is looking for level 1 data on irradiating benign diseases in general, there may be little to satisfy.That being said, there's no level 1 data espousing the be...
In an elderly patient with limited transportation issues, is there a hypofractionated regimen you have found acceptable for a localized squamous cell carcinomas of the eyelid?
I am fortunate to work with a “XRT for skin cancer” guru, Dr. W.H. Morrison, and sought his counsel to answer this question, as largely with the conversion of skin cancers from a radiation-treatable disease to a surgical disease with the advances in Mohs surgery and oculoplastics, at MDA we rarely s...
How long can you delay the start of radiation in a patient who has received adjuvant chemotherapy after lumpectomy/mastectomy?
I generally start radiation between 3 and 8 weeks following the last dose of chemotherapy. Since most protocol guidelines specify radiation should start within 12 weeks of the last day of chemo is within the last surgical procedure, I use that as an outside window I am comfortable with for the most ...
How do you interpret recent large retrospective analyses comparing radical prostatectomy vs. radiation for prostate cancer?
There have been numerous comparisons of RT vs. RP from a variety of study teams with various conclusions, and it often seems like the principal conclusion of the study is best predicted by the subspecialty from which the authors originated (urology vs. radiation oncology). As the question partially ...
Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?
Though some clinicians have been exploring the idea of targeted therapy for EGFR mutant brain metastases, this has been done in the absence of strong evidence. Reasons for pushing this idea are that sometimes the lesions seem to respond, and this has been seen in some single arm studies and anecdota...
When do you start ADT for a patient with a new diagnosis of node positive prostate cancer receiving radiation?
I would reverse the question order. For node-positive disease, I start ADT once staging imaging is complete. If logistically practical (as with high-risk localized), I often perform the simulation and start ADT at the same time, then start RT without a neoadjuvant period. Evidence for neoadjuvant AD...
For a pathologic Stage I squamous cell carcinoma of the oral tongue with negative margins and adequate neck dissection, is perineural or lymphovascuar invasion alone an indication for adjuvant radiotherapy?
I think Dr Eisbruch is spot on- patients with PNI do worse in the surgical literature, but the benefit of XRT in this scenario to obviate recurrence is far from robust. My personal belief is that PNI is not a sign of neurotropism like in melanoma or adenoid cystic ca, but likely another surrogate fo...
How would you apply the results of CheckMate 204 in an asymptomatic patient with 10-20 metastatic brain lesions on dual immunotherapy for melanoma?
The results of CheckMate 204 showed that systemic therapy with both nivolumab and ipilimumab has clinically meaningful efficacy in patients with asymptomatic, untreated melanoma metastases to the brain. In this phase 2 study, however, only 22% of the patients had 3 or more lesions. Nevertheless, int...
How do you decide between initial radiotherapy vs systemic therapy in patients with metastatic melanoma and brain metastases?
An interesting question the answer to which is changing!For discussion we will assume that the patient is not previously treated. Presence or absence of CNS symptoms is likely the most important way to dichotomize these patients. Other issues include number and size of the brain metastases, whether ...