Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Do you use minimum cutoff values for any PFTs below which you would not offer conventionally fractionated chemoradiation or SBRT for NSCLC?
We have historically not used a cut-off lower-limit for FEV1 or DLCO when selecting patients for SBRT for stage I NSCLC. This is supported by both our own (PMID 19487961) and the Indiana University (PMID 18394819) series in which patients were divided into quartiles by baseline PFT's. In both series...
Under what circumstances, if any, would you wait on initiating a TKI for metastatic recurrence of a Stage III NSCLC which occurred while on consolidative durvalumab to minimize pneumonitis risk?
Hepatotoxicity is of greater concern with ALK/ROS1 inhibitors. ALK inhibitors such as crizotinib or alectinib in combination with anti-PD1/PD-L1 agents led to higher than expected rates of hepatic and/or dermatologic AEs (Spigel et al., PMID 29518553; Kim et al., PMID 35875467). The field has learne...
How do you manage a supraclavicular only recurrence in NSCLC previously treated with chemoradiation for Stage III disease?
If the patient is otherwise fit and wishes to pursue aggressive therapy, I would consider definitive dose radiation therapy either as consolidation after systemic therapy, or concurrent with systemic therapy.While any recurrence of lung cancer is often a harbinger of systemic progression, a minority...
Would you offer a palliative or more aggressive course of radiation therapy for a symptomatic isolated supraclavicular recurrence of a squamous cell carcinoma of the esophagus?
Such early disease progression suggests there was likely occult involvement of the supraclavicular lymph node at the time of initial diagnosis. My decisions on management would hinge upon the extent of initial CRT field.If the supraclavicular lymph node was in field, I would favor a systemic treatme...
Given RADICALS-HD, are you completing 24 mo vs 6 mo of ADT with XRT following RP?
Initial: We know 2 years of ADT works. Adding to the classic RTOG 9601, RADICALS-HD demonstrated an improvement in the primary and clinically-relevant endpoint of MFS.Who should be offered 2 years is a more nuanced question. I rely heavily on the PSA to guide as I am influenced by the significant in...
Would you ever include the proximal seminal vesicles in your prostate SBRT volume?
I tend to include the proximal SVs for my intermediate risk prostate cancer patients getting SBRT. I usually use 8 Gy x5 for the prostate and 5 Gy x5 for the proximal SVs. I use the regimen from a colleague at UCLA and it seems well tolerated.
Given the improved ability to spare heart, kidney and liver, should IMRT be the standard of care for gastric MALT lymphoma (despite the low dose needed to effectively treat these patients)?
Gastric MALT lymphoma is a tantalizing disease to utilize IMRT. The target is typically irregularly shaped and surrounded by critical normal structures, including the heart, liver, and kidneys. The standard dose for gastric MALT lymphoma is 30 Gy. Thus, one needs to be mindful of dose to all of thes...
How do you approach post-prostatectomy pelvic lymph node only recurrence found on advanced imaging in a patient with a low PSA (~0.5)?
A lot will depend on the history of the patient. What were the initial parameters at the time of diagnosis (stage, initial PSA, Gleason score)? Were there positive margins at the time of surgery? How long of an interval before the time of recurrence? How was the "lymph node only" recurrence detected...
Is it reasonable to delay radiation therapy following surgical decompression for a patient with spinal cord compression if systemic therapy must be started as soon as possible?
I think it's unwise to delay RT for the usual solid tumor. 1) Surgical decompression seldom removes much tumor. 2) Most of these pts have already received significant chemo decreasing the chances of a meaningful response. 3) A rapid hypofractionated course of RT can usually be given resulting in onl...
What is the role of adjuvant radiation for gastric cancer found to be locally advanced after up-front surgery in the setting of <D2 but R0 resection?
I think one has to be very careful making blanket statements regarding management of the type of tumor described. The only real data supporting the standard use of RT in virtually all of these patients was the Macdonald trial from a couple of decades ago (and the patients were often treated three de...