Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your approach to radiographically suspicious lung nodules for which initial biopsy was negative for malignancy?
It depends on how suspicious the nodule is for malignancy clinically and on the biopsy. The following criteria play into my decision-making: If the kinetics (steady growth over multiple scans) and morphology (solid and spiculated) on CT as well as hypermetabolism on PET-CT are highly suggestive of ...
Would you favor PCI or CABG for younger patients with radiation-associated cardiac disease in the absence of any significant valvular abnormalities?
Despite the fact that the common and most serious radiation-induced coronary stenosis (RICS) are ostial lesions of the left main and ostial RCA, we heavily favor PCI when feasible due to fibrotic mediastinal changes causing significant technical challenges during CABG. Restenosis is another challeng...
In which scenarios do you stage breast cancer using CT and nuclear bone scans versus PET-CT?
In a recent study (Dayes et al., PMID 37235845), systemic staging with FDG PET-CT more frequently changed the clinical stage from IIB or III breast cancer to stage IV disease (23% metastases detection rate) than staging with CTs of the chest, abdomen, pelvis, and a bone scan combined (11% metastases...
How would you treat a limited stage small cell carcinoma of the larynx?
70 Gy/35 fractions or equivalent with altered fractionation and small cell chemo with Elective nodal RT. I’ve only treated a few and have not cured one due to distant mets.
How do you manage stage III resectable NSCLC patients treated with neoadjuvant chemoimmunotherapy per CheckMate 816 with residual disease who subsequently refuse surgery?
(1) Carefully analyze what happened with the patient, their medical oncologist, and thoracic surgeon, (2) restage the patient with an FDG-PET/CT and brain MRI to rule out distant metastatic progression, (3) confirm with their medical oncologist that CRT-> Durva is still an option, (4) confirm that a...
How would you approach radiation for an elderly patient with pT2N1 TNBC s/p MRM and ALND who refused chemo-immunotherapy?
RT will offer improved local control in this patient, as she has an elevated risk of LRR (positive LN, triple negative, large-ish T2, grade 3, LVSI). It will be unlikely to change her survival, as the data for PMRT did not show survival benefit until the chemotherapy was good enough to decrease dis...
What is your approach in deciding to include the entire tongue or a smaller volume (tumor surgical bed + margin) for adjuvant radiation in oral tongue cancer?
I would treat the large majority of the tongue, unless I had a very good method to immobilize the tongue (which I do not have; a bite block is not enough).
Is it safe to continue capmatinib during palliative radiation to a bone lesion in patients with metastatic lung cancer?
This a great question, and to my knowledge, there is no good literature (prospective or retrospective) to guide the treatment decision. That said, we have anecdotal experience continuing capmatinib during palliative radiation to osseous metastases, and that is the approach I favor.
How would you treat a gliosarcoma s/p GTR with leptomeningeal spread?
This is an extremely challenging clinical situation. The overall annual incidence of gliosarcoma in the US is <250 cases. These tumors, which usually contain both an astroglial and a sarcomatous cell population have a propensity to spread throughout the CNS, using CSF flow pathways, and hence leptom...
What is a reasonable dose to treat the entire bladder for an muscle invasive, multi-focal bladder cancer in a non-surgical patient?
A variety of dosing schemes have been used in bladder-sparing trimodality (TMT) experiences from the US (RTOG/NRG trials) and the UK (BC2001 and BCON trials). In BC2001, one of the randomizations in the 2 x 2 design was to treatment of the entire bladder to the prescription dose (64 Gy in 32 fractio...