Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What cochlear dose constraint (if any) would you use when treating an acoustic neuroma without serviceable hearing on that side?
I don't think it's necessary to spare the cochlea when treating an acoustic neuroma in a patient who has no serviceable hearing left on the same side of the neuroma. Even if the patient has residual hearing, radiation treatment is likely to lead to complete hearing loss. However, when hearing preser...
For a patient post-prostatectomy with a high PSA (>1), a negative MRI pelvis, and a negative PSMA PET scan, do you pursue any other imaging?
The sensitivity of PSMA scan for PSA above 1 is about 75-90%. I would proceed with salvage RT plus ADT like we did in the era when PSMA was not available.
How would you manage a patient with a high-risk asymptomatic bone metastasis with a driver mutation?
It seems that the unexpected outcome of a survival benefit was likely due to the prevention of fractures that likely led to hospitalization then death. This was a phase II study and OS was a secondary outcome, but it does make sense. Complicating metastatic cancer with a femur fracture leading to ho...
How do you manage a patient who presents with a tracheoesophageal fistula from a lung or esophageal primary that is non-metastatic?
My experience with this has typically been with primary esophageal cancer presenting with TEF. It's obviously a challenging and individualized situation requiring multidisciplinary input and extensive clinical assessment and discussion. I generally recommend induction chemotherapy since the ideal sc...
When using Quad Shot regimen for palliation of unresectable head and neck cancers, would you treat concurrently with chemotherapy?
No. If palliative RT, I usually don’t recommend concomitant chemo.
In asymptomatic patients with castrate resistant prostate cancer who have failed chemotherapy and have progressive PSMA-avid vertebral body metastases, when do you prescribe lutetium 177 (Pluvicto) vs prophylactic spinal radiation?
It's rarely either/or. I would say that pretty much any patient like the one described in the question should be getting Pluvicto as it has a demonstrated OS benefit. But sometimes the patient may also need more immediate palliation with EBRT before Pluvicto can get up and running. The main issue he...
Do you offer prostate RT to men with 0-3 bone metastases on conventional imaging when PSMA PET shows a very high number of M1 lesions?
This would be a hard no from my standpoint.I get the rationale here. STAMPEDE found a survival benefit for prostate-directed RT in men with "low volume" disease, which was defined based on the CHAARTED trial with conventional imaging. Therefore, men with low-volume disease on conventional imaging fi...
What would you recommend for a stage I diffuse large B cell lymphoma (IPI 0-1) involving a single lymph node that is completely removed with an excisional biopsy?
Some more info woud be helpful such as age of pt, size and location of node, margins of resection. In general 6 cycles of RCHOP is prefered with RT in almost all instances. 3 cycles is reserved for the most favorable patients. I would add ISRT adhering to recent guidelines from Intl Lymphoma Radiati...
What RT fields would you recommend for a patient with early-stage diffuse large B-cell lymphoma who refuses or is unfit for systemic therapy?
For a patient with stage I DLBCL, RT fields should encompass the involved site with a generous margin, the latter not precisely defined but dependent on what the site is and what side effects need to be considered with larger volumes. RT fields should not change much if the patient is not receiving ...
Does long term use of 5 alpha reductase inhibitors change the way you evaluate a PSMA PET?
I am not aware of any specific studies that answer this question, but you could consider this situation similar to a patient on ADT, where there is the possibility that treatment may reduce the sensitivity of imaging. (n.b., a prior post discusses the influence of ADT on PSMA-based PET/CT). In this ...