Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you interpret nodes with minimal increased uptake on PSMA PET in prostate cancer?
This question is relatively similar to another recent question on indeterminate PSMA PET (#26360), where I provided a longer answer in a bit more detail. The summary is that this essentially relies upon your clinical judgement, and there is no definitive algorithmic way to determine the true nature ...
Would you offer empiric lung SBRT for two growing FDG-avid lung lesions in a patient with severe COPD on oxygen?
This is a good question! The short answer is yes, most likely. Many patients are too high-risk to receive biopsies; this is decided by surgery/pulm/IR. Unless the patient has contraindications to RT or something like severe IPF (where treatment may be worse than the disease), I would likely offer th...
When would you recommend abiraterone concurrently with RT for high-risk prostate cancer?
The trial got published in NEJM. It confirms survival advantage and skeletal mets advantage with abiraterone for metastatic disease similar to the Latitude study. This will certainly be an option for metastatic disease at presentation (along with docetaxel until comparative studies comparing docetax...
How do you approach adjuvant radiation recommendations for low-risk endometrial cancer in which the patient was unable to undergo pelvic sentinel node mapping?
Nodal assessment would not change much for me, as it’s a low-risk disease, and PORTEC data have shown the risk of nodal recurrence is low. For focal LVSI, one may consider brachy alone.
Under what circumstances do you consider an enbloc resection versus biopsy for a lower lumbar spinal column tumor?
Typically, a biopsy is performed prior to en bloc resection rather than “either or.” A biopsy is necessary if there is a differential diagnosis based on imaging, and if the diagnosis will affect management: radiation and chemotherapy alone vs. intralesional resection/debulking and adjuvant therapy v...
What dose constraints do you use for 15-25 fraction hypofractionated RT for cholangiocarcinoma?
5Fx 10fx 15fx 25fx Ablative dose 50Gy 60Gy 67.5Gy 75Gy GI tract pt dose (0.2cc) 30Gy 40Gy 45Gy 60Gy Bile Duct pt dose (0.2cc) 40Gy 65Gy 70Gy 80Gy Liver – GTV Mean dose + 700cc below + 1/3 liver over 15Gy 20Gy 24Gy 28Gy Mean dose CP...
What are your typical dose and fractionation schedules for post-prostatectomy radiotherapy for a patient with involved pelvic lymph nodes?
I typically use conventional fractionation for post-prostatectomy RT. The recently published experience from Wisconsin showing a continuous development of significant late effects with longer term follow-up for moderate hypofractionation in this setting, I believe, is cause for concern, so I have no...
Do you obtain MRI for cutaneous SCC with microscopic PNI to assess for gross perineural tumor spread?
I would recommend both an MRI as well as consulting the pathologist regarding the exact nature of the PNI. We had an experience with more than 100 patients (Sapir et al., PMID 27475277). Those with gross PNI (evidenced by MRI, with or without cranial nerve deficit) and microscopic extensive PNI (>2 ...
Do you typically recommend placement of a rectal spacer prior to definitive radiotherapy, regardless of dose/fractionation?
In my opinion, the potential and role of rectal spacing in minimizing toxicity is not debated. The concern about spacing relates to risks of the procedure and its associated additional cost to treatment may be greater than the potential improvement in toxicity for the patient. As we continue to show...
For epidural spinal cord compression in good-performance/prognosis patients who are otherwise inoperable, do you still aim for 30 Gy in 10 fractions, or are you fine with 20 Gy in 5 fractions?
In general, if prognosis is good (e.g., greater than roughly 6-12 months), 30 Gy in 10 fractions is preferred, given a lesser risk of recurrence with epidural spinal cord compression (ESCC) as compared to lower dose regimens such as 4 Gy x 5 in the longer term (e.g., from Rades et al., PMID 15908648...