Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Given improved BFS from the phase III FLAME trial, do you recommend focal SIB up to 95 Gy for unfavorable and high risk prostate patients?
As yet, I have not tried to dose escalate to that level using EBRT, preferring to use a brachytherapy boost if I feel patients might require more than I can safely deliver to the whole gland using IMRT. That said, however, I do not think that it would be wrong to try to deliver a focal boost using I...
What treatment fields do you use for N1mi breast cancer after lumpectomy/SLNB?
We treat with modified tangents including level 1 and 2 nodes in tangential beam for micrometastases. ER, PR, and her2 neu or oncotype does influence the decision for micrometastases after lumpectomy.
What is the appropriate target volume for SBRT to a non-vertebral osseous metastasis?
For non spine bone metastases, I usually treat the GTV with a 1 cm expansion of continguous bone to CTV + 0.3-0.5 cm margin in all dimensions to PTV. With this amount of contiguous bone, I will usually treat the entire circumference of the long bone. I rarely treat GTV + a small PTV expansion as ane...
When evaluating for PMRT in patients who did not receive neoadjuvant chemotherapy and are found to be pN0, do you utilize clinical T-staging, or pathologic T-staging?
If no neoadjuvant therapy, I rely on the pathologic staging rather than clinical staging for PMRT decisions. So, for a cT3 that is a pT1-2, I would not offer PMRT. I do consider factors including receptor status, margins status, LVSI, and age.
How do you assess whether an early-stage Hodgkin's patient is unfavorable?
I personally utilize the GHSG criteria for most patients. To review, a patient has "favorable" disease if they meet all of the following criteria: 1. 1-2 involved sites 2. No bulky disease 3. No extranodal disease (which is rare in early-stage HL) 4. Favorable ESR/B-symptoms profile (ESR < 30 with B...
What fractionation regimen do you use for combination EBRT and HDR for high-risk prostate cancer?
There is a range of appropriate HDR boost fractionation options.The 2018 NCCN Guidelines list the following options:45-50.4 Gy + 10.75 Gy x 237.5 Gy (2.5 Gy fractions) + 12-15 GyRTOG 0815 (allows brachy boost as an option): 45 Gy +10.5 Gy x 2RTOG 0924 (allows brachy boost as an option): 45Gy+ 15Gy x...
In prostate cancer patients receiving EBRT, when, if ever, do you use MRI to change your seminal vesicle coverage?
Yes! I routinely get MRI as part of planning. This obviously helps with delineation of median lobe and prostate apex, but can also show involvement of the SV. I do not reduce elective coverage based on MRI images, because the decision to treat SV is related to risk of microscopic involvement. Howev...
For prostate cancer patients undergoing an HDR boost, what constraints do you use for hypofractionationated EBRT?
A randomized trial in Canada was started comparing IGRT to 78 Gy/39 Fx or 60 Gy/20 Fx vs 37.5 Gy EBRT in 15 fractions with 15 Gy x 1 HDR boost (CCTG PR15/NCT01982786). In their initial publication Vigneault E et al. Clinical Oncology 2018 they have constraints listed in Table 1 and I'd suggesting us...
Should presacral lymph nodes be included in a locally advanced endometrial cancer without cervical involvement with incomplete surgical staging (i.e. no lymph node dissection)?
The pattern of spread for lymphatics draining the uterus tend to follow a predictable pattern generally along one of two primary pathways. Lymph flows from the fundus toward the adnexa and infundibulopelvic ligaments, placing the lower para-aortic lymph node stations as a potential site for spread. ...
In patients with EGFR mutant L858R stage III NSCLC who are unresectable due to multistation N2 disease, would you consider upfront osimertinib over definitive intent CCRT?
This is a very complex question that is common among our thoracic tumor board discussions. I'll answer the latter question first. In this case, I would not offer consolidative durvalumab.There are data that immune checkpoint inhibitors (ICIs) have minimal to no benefit in the metastatic setting base...