Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Given the results of PORTEC-4A, what adjuvant therapy, if any, would you offer a patient with a POLE-mutant endometrial cancer who also has a p53 mutation and substantial (>5 foci) of LVSI?
When you have dual mutation, the better of the two mutations drives the outcome, so it would be treated like a POLE-type. If substantial LVSI and pathological nodal assessment are done, I would favor Brachy alone. If nodes are not assessed, I would favor EBRT. The link below has references about dua...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
How would you apply the results of CheckMate 204 in an asymptomatic patient with 10-20 metastatic brain lesions on dual immunotherapy for melanoma?
The results of CheckMate 204 showed that systemic therapy with both nivolumab and ipilimumab has clinically meaningful efficacy in patients with asymptomatic, untreated melanoma metastases to the brain. In this phase 2 study, however, only 22% of the patients had 3 or more lesions. Nevertheless, int...
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...
How would you manage an enlarging brain metastasis that has progressed in size three months after radiosurgery?
Before making a decision, I would want to know the tumor histology, SRS dose delivered, and whether the current site of progression is truly within the prior radiation field (using new MRI fused to the SRS plan in treatment planning software). If the lesion is within the high-dose region and the pat...
Would you offer adjuvant therapy for patients with resected NSCLC <3 cm with visceral pleural involvement and no lymph node involvement?
The short answer is "no", I do not typically recommend adjuvant systemic therapy or radiotherapy for people with completely resected, small (<3 cm) T2aN0M0, stage IIA NSCLC.The NCCN guidelines state that "adjuvant chemotherapy is recommended for high-risk features" in people with resected stage IB o...
For a patient with large volume glioblastoma, what do you do if they are found to have a subdural infection in the middle of chemoRT requiring repeat surgery?
In this scenario, the patient will likely stop the daily treatments for a variable period of time that I would estimate to be measured in weeks while recuperating from surgery and receiving IV antibiotics. When cleared for radiation, I would start by doing a new Simulation using an updated MRI to ac...
For early-stage vulvar cancer that is clinically/radiographically node negative with no surgical lymph node evaluation (e.g., patient or surgeon refusal), would elective nodal irradiation be reasonable in the absence of risk factors warranting treatment to the primary site?
It is tempting to skip elective nodal irradiation in this setting, especially if the radiographic evaluation includes a PET-CT, where the negative predictive value is probably close to 90%. However, if the risk of groin LN involvement is at least 15%, based on primary tumor characteristics such as s...
What is the expected timeframe for the development of radiation myelitis and therapies that have helped with neurologic symptoms?
The incidence and the timeframe of the development of radiation myelopathy are influenced by total radiation dose, radiation dose per fraction, time between courses of radiation, and associated chemotherapy or immunotherapy. Older age, the presence of diabetes, and previous exposure to radiation are...
Is there a role for selective arterial embolization of RCC before primary SBRT?
An interesting question! A good way to approach this question is with a list of potential advantages and a list of potential disadvantages. For the record, this is all hypothetical. I am not aware of any published literature that has explored this concept.Advantages: Significantly reduce the size of...