Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you approach pelvic radiation therapy for a patient with multiple myeloma who needs more intensive therapy (e.g., Dara-KRd or impending CAR-T) with a risk of cytopenias?
The role of RT in MM is palliative in nature, and the focus should be on symptomatic improvement while minimizing marrow toxicity.Rad Oncs, as a whole, should not generally be using solid tumor palliative doses (such as 3 Gy x 10) routinely in MM as that ablates the marrow in that area without hope ...
How likely is late radiation induced lumbosacral plexopathy from treatment of anal cancer with chemo-RT 20 years ago and how would you manage it?
It's difficult to say "how likely" since we don't really have good long-term reporting for this specific late complication. I would say it's rare, but certainly possible. Late lumbosacral plexopathy has been reported as far out as 36 years from pelvic RT (Krkoska et al., PMID 36510189).In general, t...
What is your preferred approach in a patient unable to fill their bladder during prostate radiotherapy?
If a patient is willing to do a penile clamp or foley, then sure, go for it. Some patients want to 'do everything' and either is reasonable. Whether or not they need to is another question. Most Grade 3+ GU toxicity is either hemorrhage or stricture. Unfortunately, there isn't great data for any con...
Is 10 Gy x 5 an acceptable dose to use for lung SBRT in tumors with favorable location (eg. not central and not encroaching on the chest wall?)
The paper cited, which my colleague Kevin Stephans authored, used our large institutional data base with long term follow up to carry out a retrospective review of BED adjusted SBRT schedules and showed no difference in overall survival, but slightly improved local control, with higher BED schedules...
How do you counsel patients with Stage IIIA EGFR+ lung cancer regarding treatment intent with concurrent chemoRT + consolidative systemic therapy?
I think one of the crucial take-home points from the LAURA clinical trial (Lu et al., PMID 38828946) is how often we (the medical oncology community) tell patients we are treating them with "curative intent" but ignore the incredibly high relapse risk among patients with EGFR mutant NSCLC with stage...
When do you start ADT for a patient with a new diagnosis of node positive prostate cancer receiving radiation?
We usually start upfront and start RT in a few months. This helps to see nodal response, can also sometimes help meet small bowel constraints with regression, and can also adjust the total dose if needed. ASTRO 2022: Predictive Value of Ga68-PSMA PETCT-Based Response to Neoadjuvant Androgen Deprivat...
How do you approach conventionally fractionated radiotherapy for treatment of an acoustic neuroma?
With 12 Gy single-fraction radiosurgery producing excellent tumor control, low complication rate, and good hearing preservation, we have rarely been using conventional fractionated radiotherapy for acoustic neuroma. If one uses conventional fractionated radiotherapy, the PTV margins will depend on t...
Considering the surgical margins used in TORS, is it necessary to cover the entire tongue base with an elective dose in IMRT of cT1-3 HPV+ squamous cell carcinoma grossly involving one side of the base of tongue?
Frankly, I see no point in doing TORS if a patient is likely to require postop RT unless you believe that you can safely treat neck only (which includes unavoidably part of the ipsilateral oropharynx to irradiate the RP nodes). And I do not (but have been wrong before). Particularly HPV positive non...
What systemic therapy would you recommend for a patient with metastatic triple negative breast cancer (HER2 1+) who has progression of brain mets after WBRT and while receiving first line chemotherapy?
There is early evidence of untreated intracranial metastasis activity (overall response rate 73%; 11/15 patients) with trastuzumab deruxtecan (T-DXd) in patients with HER2+ breast cancer (1), but such data are not yet available for HER2-low breast cancer. Therefore, I would advocate a standard appro...
Do you escalate the dose in adjuvant pancreatic cancer radiation therapy similar to how many are treating locally advanced disease with dose escalation?
A few points to consider about this modern perspective on adjuvant CXRT for pancreatic cancer are: A positive margin is one of the least controversial indications for adjuvant CXRT in pancreatic cancer. If you get a case to treat, you don't want dose to be the reason for failure. 50.4 Gy has been th...