Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For a young female (<40) with HR-/HER2+ cT1-2N1, ypT1aN0 s/p mastectomy with SLNB, would you offer PMRT?
Thanks for the question. In the seminal PMRT randomized trials of patients treated with adjuvant systemic therapy, PMRT improved overall survival. B-51 was not designed to evaluate the non-inferiority of PMRT omission. Beyond being less conservatively designed to test for superiority of "RNI" with r...
Will you offer patients urea-based creams or topical diclofenac for hand-foot prophylaxis with capecitabine after the D-TORCH trial results?
This study was presented at ASCO, Abstract 12005. Patients with breast or GI cancers treated with single agent capecitabine (1,000 mg/m2 bid) were randomized to treatment with prophylactic diclofenac cream bid x 12 weeks vs placebo. Primary endpoint was incidence of grade 2 or greater HFS. HR for th...
In light of the improved outcomes seen in patients receiving IO +/- olaparib, what role, if any, do you think pelvic radiation still plays in the management of patients with advanced endometrial cancer?
The study included a wide spectrum of patients including advance stage with residual disease or recurrent with or without residual disease. Prior RT when indicated was allowed and about 40% had RT as part of care.
Will you offer single fraction SBRT for pulmonary oligometastases?
We use single fraction radiation frequently for most peripheral lung metastasis. In addition to TROG 13.01/SAFRON-II (randomized to 48 Gy/4 fx versus 28 Gy/1 fx, with the important footnote that dose was prescribed for 99% PTV coverage rather than the typical 95%), two other randomized trials - RTOG...
What brainstem constraints do you use when giving single fraction SRS for trigeminal neuralgia vs brain metastases?
Dose prescription for brain metastases is dependent on volume, location, and prior radiation exposure. With lesions in the brain stem we decrease the dose compared to the standard doses we deliver. For small volume lesions (< 1 cm3) we generally use margin doses of 20 Gy, with lower doses for larger...
What is the maximum interval you would consider delivering adjuvant radiation therapy for endometrial cancer?
The data has not been evaluated prospectively but retrospective studies suggest RT delay beyond 8-9 weeks after surgery decreases efficacy of treatment. That being said, have treated high risk patients up until 16 weeks but explained the pros and cons of treatment.https://www.ncbi.nlm.nih.gov/pubmed...
What is your preferred radiotherapy regimen for palliative treatment of cutaneous T cell lymphoma?
Cutaneous T-cell lymphomas (CTCLs) comprise numerous distinct entities in the WHO classification of hematologic malignancies. The most common CTCL is mycosis fungoides (MF) followed by primary cutaneous anaplastic large cell lymphoma. As with most hematologic malignancies, both diseases are particul...
When treating breast cancer patients with RNI, how often do you include internal mammary nodes?
Treating the internal mammary nodes (IMNs) increases heart and lung exposure; hence, the value of prophylactic IMN RT has been controversial for decades. Randomized trials suggest there may be some benefit to such treatment but disagree on which patient subgroups benefit most or not at all.A trial c...
What is the biggest mistake people make when starting a linac SRS program?
We teach a course on SBRT and Radiosurgery so I get to talk to many people starting SBRT and radiosurgery programs. I will offer one common programmatic error and highlight some common treatment planning errors. Although some will disagree, a common programmatic error is thinking that you can do it ...
For patients between 40-49 years old who undergo lumpectomy, how do you choose between offering PBI per the updated PBI guidelines or boosting based on boost guidelines?
I think this is an informed discussion that includes data on the pros/cons of each approach. One challenge is that when patients hear about a 5 fx PBI approach, it's harder to rationalize 15 fx WBI (I use SIB for my boosts). You can consider PBI for low-risk patients in this age group but I also cou...