Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
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...
How do you sequence radiation and capecitabine in breast cancer patients receiving adjuvant capecitabine for residual disease after neoadjuvant chemotherapy?
According to personal communication with Dr. Masakazu Toi (June 13, 2017), the corresponding author of the CREATE-X NEJM publication, radiotherapy was administered prior to capecitabine in the majority of cases on this study. It is worth noting that in CALGB 49907, a randomized trial comparing capec...
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 you use either memantine or hippocampal sparing technique to preserve cognitive function when giving whole brain radiotherapy?
Dr. @Dr. First Last and I put together the response below:We use memantine and hippocampal sparing technique for all brain metastasis patients who are planning to receive WBRT. This is based off the recently published phase III trial NRG CC001 that found hippocampal avoidance WBRT plus memantine res...
What is your radiation approach to metastatic pancreatic tail adenocarcinoma s/p gem/abraxane and FOLFIRI now with an oligo-progressive LUL lung metastasis?
I certainly would favor metastasis-directed therapy with SBRT, given the PFS benefit observed in EXTEND, and I think the case for utilization in the oligoprogressive state is even stronger pan-tumor compared to consolidative treatment. I'd treat 50-55 Gy/5 fractions or could consider fractionating o...
What resection margins are required for DCIS with a component of invasive disease?
The SSO-ASTRO-ASCO guidelines of 2016 on margin status for patients with tumors that are pure DCIS or predominantly DCIS requiring a minimum of 2 mm for those receiving RT were based on a meta-analysis of (mostly older) published studies, not individual patient data. Three much more recent studies f...
How would you manage an elderly female patient with a remote history of synchronous bilateral invasive ductal carcinoma with a new triple-negative recurrence in the left breast and axilla with extension to the contralateral breast?
Unfortunately, if no good systemic options are left including pembro/parp inhibitor then the outcome is most likely palliative. Will try a hypofractionation schedule for palliative/preoperative dose of RT.
What are best practices for radiation oncology patient and staff precautions with the COVID-19 pandemic?
COVID Update 1/30/21 Wow, it's been almost a year. Here are some updates from our practices at University of Maryland. We have successfully treated both PUIs and COVID+ patients at all of our practices. We have yet to have a patient to staff (or staff to patient) transmission. We do not break patien...
What factors do you consider when selecting dose/fractionation for whole brain radiotherapy?
I assume this question is for brain metastases patients who are not eligible for hippocampal avoidance WBRT (ineligible criteria including but not limited to - mets 5 mm within either hippocampus, germ cell/small cell/lymphoma, leptomeningeal disease, etc.) - my default WBRT dose fractionation is 30...