Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
Are there any alternative, hypofractionated RT courses for patients with DLBCL that can be used during the COVID-19 pandemic?
ILROG recently came out with guidelines pasted below: Synopsis of ILROG Recommendations for Administering Radiotherapy for Hematological Malignancies During Emergency Conditions of the COVID-19 Pandemic • We are facing an increased demand for RT to substitute or complement systemic therapy deemed i...
Should hippocampal-avoidance WBRT be the default option for WBRT?
I think this is a difficult question to answer as a lot depends on the particulars. Here's a list of some of those issues: Radiosurgery is very easily administered & frequently free of toxicity. Systemic agents are showing improved efficacy in the brain. Surveillance MR imaging = lower incidence of ...
How are the long term results of RTOG 9802 being incorporated into practice in the treatment of "high risk" low grade gliomas?
Answer was written along with Cleveland Clinic resident, Ehsan Balagamwala, MDThe decision to treat low grade gliomas (LGG) can be very challenging. At our institution, we typically utilize the EORTC risk factors to stratify our patients. EORTC high risk is defined as having 3 or more of the followi...
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 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...
Do the results and approval based on ADAURA trial suggest a role for adjuvant osimertinib in patients with stage IIIB-C, EGFR mutant patients treated with concurrent chemoradiation?
ADAURA trial was not designed to address this issue. But that being said, we need to remember few things before considering "maintenance durvalumab" in patients with EGFR-mutant lung cancer, following chemo-radiation: 1. EGFR-mutant NSCLC patients may not derive any clinical benefit from single-agen...
Would you omit RNI in a patient with locally advanced TNBC with N1 disease who has an ALND and is found to have a pCR in the nodes?
This is the topic of the NRG B-51 randomized clinical trial which recently closed to new patient accrual. Until we have data from this trial, my default will be to prefer RNI in my triple negative patients known to have nodal involvement at the time of diagnosis, even if they experience a nodal pCR....
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...
Is a stereotactic/ thin-slice MRI of the brain absolutely necessary to determine eligibility for hippocampal sparing whole brain radiation therapy?
The small size of the hippocampal dentate gyrus (3-4cc) can render it difficult to delineate and conformally avoid if both the brain MRI and the treatment-planning CT simulation are not obtained with thin-slice axial images (not exceeding 1.5mm on the MRI, not exceeding 2.5mm on the treatment-planni...