Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In asymptomatic patients with castrate resistant prostate cancer who have failed chemotherapy and have progressive vertebral body metastases, when do you prescribe lutetium-177 vs prophylactic spinal radiation?
Goals are different. Pluvicto is administered to improve pain, PFS, OS, and quality of life so it is SOC for patients who fail chemotherapy and have PSMA avid disease while good prophylactic RT is to prevent local bone-related events only.
For patients with large, partially or nearly obstructing rectal cancers, how do you sequence TNT in order to avoid complete obstruction and surgical diversion?
I personally favor starting with RT/chemo, but starting with chemo can work well. The more important issue is the side questions. First, there is a huge difference between a lesion that is large and one that is nearly completely obstructing. Unfortunately, many endoscopists use the term "obstructing...
Would you consider proton therapy as part of TNT for rectal cancer?
Show me the data. Our results with conventional 3D XRT are excellent with a low rate of chronic toxicities and even lower rates of pelvic recurrences.
Would you offer inguinal nodal RT to a patient with anal SCC (pT1N1a, + inguinal node) following APR in the setting of prior prostate + pelvic nodal radiation?
Inguinal lymph node dissection is not typically part of APR procedures. Even when surgical dissection of the inguinal lymph nodes is performed, the recurrence or failure rates in this region can still be significant, with some studies reporting failure rates of around 10-15% despite extensive surger...
How would you manage an aortocaval nodal recurrence of prostate cancer in a patient who previously received salvage radiation to the fossa and pelvic nodes?
One can do either with some rationale but more data on SBRT in this setting with the goal to either delay initiation of ADT (STOMP and ORIOLE) or maintain eugonadic status (EXTEND).These trials for OM did include patients with pa nodal recurrence.
What is your preferred fractionation scheme for spine SBRT for radioresistant histologies?
As long as it's safe, and I can meet the OAR constraints, I escalate the GTV (but not the entire VB) to 20-24 Gy in 1 fx, 28 Gy in 2 fxs, 30-33 Gy in 3 fxs, 35-40 Gy in 5 fxs. While more work has been published in escalation with single fraction, I find that it's easier to safely escalate those to 4...
If a patient has multiple PET-avid level 3, supraclavicular, or IMN nodes that are small and would have been considered negative by size criteria with traditional imaging, that are no longer positive on PET after chemotherapy, would you try to boost these nodes?
I'd certainly cover the initially involved nodal regions, treating typically to 50 Gy and then, if they were small initially and became PET negative after chemo, stop there. The only time I'd consider boosting if there was preserved glucose avidity following chemo. Obviously respect for normal tissu...
Do you still offer adjuvant chemotherapy and chemoradiation for NSCLC after neoadjuvant chemoimmunotherapy?
In the pre-neoadjuvant era, the options for patients who had R1 (positive margin) or R2 (gross residual disease) were: re-resection followed by adjuvant chemo; sequential adjuvant chemo followed by radiation; or concurrent chemoradiation. There is retrospective data suggesting a survival benefit fro...
What is the recommended adjuvant dose for neuroendocrine cancer in the head and neck?
I assume it's a high grade NEC (small cell or LCNEC) and in that case, I'd treat to 50 Gy in the adjuvant setting with a tumor bed boost (for ECE) to 60 Gy. The volume would be dependent on the location of the primary and the nodal stage.
Is post-mastectomy chest wall radiotherapy indicated for DCIS with very close (<1 mm) or positive margins?
As with most clinical situations with limited data, individualized decision-making is key. Based on small series, I do not generally offer RT post mastectomy for DCIS if it is close. If it is clearly involved after reviewing with the pathologist, I would discuss with the surgeon and patient taking i...