Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you still routinely offer post-op radiation after bone fixation?
I'm a little nervous about the phrasing of the question as it implies that there is an ongoing evolution in practice here. I don't think there is. To emphasize, PORT is--and remains--the standard of care following orthopedic stabilization of bony metastases: Alcorn et al., PMID 38788923Now, it is fa...
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?
Urology and radoncs differ in their approach to this. Recent (inflammatory) social media discussions have shown this. There are limited prospective data on focal therapies versus whole-gland approaches, but the retrospective data should give us all pause. What we do know: HIFU has significant toxic...
How would you approach early stage NSCLC in a patient who is not an ideal surgical candidate and has pulmonary AVMs?
The standard volumes and flows of PFTs do not assess regional differences in what is perfused and ventilated. V/Q scans do, but their most common use for pulmonary embolism is their most common role. This serves to identify gas exchange near the primary as well as where the AVM’s reside. Target the ...
Are CHEK2 mutations a contraindication for breast conservation therapy with lumpectomy + RT?
Among women with early-stage breast cancer and moderate penetrance breast cancer susceptibility genes, such as CHEK2, decisions about breast surgery are largely based upon personal preferences. According to data from large population-based studies, women with CHEK2 pathogenic variants have about a 2...
When treating the whole brain with hippocampal avoidance, do you ever deliver SIB to gross disease?
There have been several papers and an ongoing trial evaluating the safety and efficacy of including SIB to macrometastatic disease with HA-WBRT. A recently published trial from the UT-Southwestern team was a single-arm phase II trial, which treated 50 brain metastasis patients with HA-WBRT to 20 Gy ...
When should you use single-fraction radiotherapy for spinal cord compression?
The SCORAD III trial is practice changing. But I do NOT plan to treat ALL patients with spinal cord compression with a single fraction of 8 Gy now. Here is why: SCORAD III is extremely important new study for the management of metastatic epidural spinal cord compression (MESCC) for patients with sho...
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...
Are there any volumetric constraints associated with toxicity in the dose range that is moderately above prescription (i.e. 30-35 Gy range), when planning hippocampal-sparing whole brain radiation?
This is an important question worth some discussion. As the question mentions, clinical trials of HA-WBRT have permitted a hot spot of 133% of the prescription dose of 30 Gy (or 40 Gy) to D2% of the whole-brain parenchyma as an acceptable protocol variation. Importantly, none of these trials have de...
For an non-operative patient with IB1 cervical cancer, would you recommend RT alone or concurrent chemoRT for definitive therapy?
I usually favor RT alone as local control and the outcome is excellent unless they have adenocarcinoma, a suspicious pelvic node, or multiple high risk features (high grade with LVSI on bx).
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...