Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Has the HYDRA study of hypofractionated radiation, and its discussion in the 2026 NCCN guidelines for prostate cancer, changed your approach to moderate hypofractionation in either prostate-only or prostate and pelvic node radiation?
Very few of us can gain substantial wealth by giving 8 more fractions to prostate cancer. I certainly can't earn more by simply giving 28 or even 45 fractions or a 100 fx. The vast majority of us are now employed, and based on median RVU stats, a minority of us even reach a threshold to bonus or eve...
What additional work up would you do for a T1bN2 squamous cell carcinoma of the true larynx if endoscopy demonstrates a true cord lesion extending to the commissure with normal mobility and no evidence of supra or subglottic extension?
I assume that PET-CT was performed and demonstrated only the neck and the laryngeal lesion. The histology of VC cancer is usually well-differentiated. I would examine a needle biopsy of the nodes for discrepancy in histology and stain for p16 for the possibility of a second, unknown primary, which t...
Would you continue tarlatamab in CNS-only progression of small cell cancer if there is no systemic disease?
I would absolutely continue tarlatamab in this scenario. While there is evidence of at least some activity of tarlatamab in the CNS (e.g., Zhang et al., PMID 40126456), the effect can be transient, suggesting that intra- and extracranial discrepancy is possible/probable. I would handle isolated, oli...
What do you tell patients that opt for High-intensity focused ultrasound (HIFU) for favorable intermediate risk prostate cancer over AS (Active Surveillance), RP (Radical Prostatectomy), EBRT (External Beam Radiation Therapy), or brachy?
There are currently no published trials that specifically address this question, which is a very good one.My general discussion is that ablation therapies (not specifically HIFU) will have less negative impact on quality of life factors such as preserving erectile function, avoiding urinary incontin...
What treatment sequence do you follow for patients with rectal cancer who are candidates for both PROSPECT and TNT/Watch and wait?
Thanks for this question. I am not sure whether this is up to us. This is up to our patients to choose which modality they would like to omit (radiation vs surgery). I would point out that a good quality MRI rectum should be performed to r/o any T4/N2 disease or potential requirement for APR. Otherw...
What is the recommended follow-up/surveillance schedule following organ preservation treatment approach for cT1-2N0 rectal cancer?
Patients with stage I rectal cancer treated with organ preservation require close surveillance to rule out tumor regrowth and local recurrence that may be salvaged with radical surgery. The highest risk of recurrence is within 2 years after completion of neoadjuvant therapy and patients should be fo...
Would you offer hippocampal sparing whole brain radiation for patients with brain metastases due to ES-SCLC?
Until we have built-in auto-segmentation, I find the RTOG contouring atlas very helpful for manual contouring of the hippocampus. I tend to use the lateral ventricle as my main landmark, and look for the circle of gray matter located medial to it. Once I've drawn a hippocampus, I'll look at it in th...
Are there patients for whom CROSS followed by surgery and adjuvant nivolumab should still be considered, following data from MATTERHORN and ESOPEC?
ESOPEC does not invalidate CROSS—it redefines the preferred option for fit patients; in the real world, not every patient will be able to tolerate FLOT or d-FLOT: Yes. Despite the emergence of perioperative FLOT-based strategies from ESOPEC and MATTERHORN, CROSS, followed by surgery and adjuvant niv...
What is the preferred palliative regimen for elderly patients with rectal cancer who elect to forego surgery?
This is a question that comes up somewhat frequently and I don't believe really has a definitive answer. I myself have used multiple regimens in this situation. I think it really depends on the performance status and life expectancy of the particular patient. This is also a topic that may bring out ...
Are you altering your use of Active Breathing Coordination for breath hold technique patients in light of the COVID-19 pandemic?
We use DIBH, and this has not changed anything in our practice.