Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In light of the recently published Alliance A021501 trial, what is your approach to incorporating SBRT for the treatment of borderline resectable pancreatic cancer?
My approach is the same as it always has been. I have never used low-dose small volume "SBRT" for BRPC or LAPC because it does not make sense. Treating an infiltrating neurotropic tumor that spreads along arteries with millimeter margins on the gross tumor and leaving the regional lymph nodes untrea...
How do you approach treatment of an optic nerve sheath meningioma?
I typically do 50.4 in 28 fractions with a stereotactic technique. We use both co-planar and non-coplanar arcs. I keep the optics point max to 54 Gy. Several single institution series including: MacLean et al. IJROBP 2013, Bloch et al. (UCSF) JCNeuroSci 2012, Ratnayake et al. (Australia) JCNeuroSci ...
Does receipt of chemoimmunotherapy for LS-SCLC impact your recommendation for PCI?
Historic data showed that the addition of PCI for patients with limited-stage small cell lung cancer showing response after chemoradiotherapy improves overall survival and decreases brain failure rates by about 50%. Recently, the addition of consolidation immunotherapy after concurrent chemoradiothe...
How would you approach reirradiation in a patient with a history of whole-breast RT many years ago, now with a small intermediate-grade DCIS s/p lumpectomy with an elevated DCISionRT?
I would favor PBI with 40 in 15 or 45 in 30 (BID) with VMAT/IMRT.
Do you modify dosing and monitoring of Lu-177–PSMA therapy for patients with prior large-field RT involving substantial active marrow compared with patients who only had focal bone SBRT?
No, we do not modify dosing and monitoring of PSMA therapy with prior large-field RT. In the VISION trial, the vast majority of patients were heavily pre-treated, presumably many with pelvic radiation for definitive treatment or treatment for bCR prior to metastasis. Assuming that the patient had ap...
Can you give Pluvicto with concurrent palliative EBRT?
Short answer: Yes, you can, and I do not modify my dose. I have no issues with this and have done it multiple times for patients who need more immediate symptom relief (pain, bleeding, etc.).Why? Because Pluvicto is a medium energy isotope with a relatively short path length of around 2 mm. Even nea...
What is your preferred dose and fractionation schedule for a patient with a stage III non-small cell lung cancer, whose comorbidities preclude chemotherapy, but has good enough performance status to warrant an attempt at longer-term local control?
This is a very good question. I'd say the answer to this one is evolving! Typically the patients who cannot tolerate either sequential or concurrent chemotherapy for locally-advanced NSCLC are quite frail and/or have comorbidities that are significant. The results using radiation alone for Stage III...
What is the role of radiotherapy in a newly diagnosed patient with parameningeal rhabdomyosarcoma w/ intracranial extension, a positive CSF but no extra-CNS metastases?
The question as to the role of RT in patients with parameningeal (PM) RMS with CNS leptomeningeal disease is complex and one lacking scientific evidence to support one’s answer. My response represents a historic viewpoint gained from hearing the discussions of the Intergroup Rhabdomyosarcoma Group (...
How would you manage an isolated nodal recurrence of breast cancer in a patient with a prior history of mantle-field radiation?
Nodal recurrences, especially in unresectable regions, are especially challenging cases in the context of reRT. At a high level, the first thing to think about is resectability. If resectable, the usual approach is surgery, then adjuvant RT to unirradiated areas, and adjuvant chemotherapy. If unrese...
How does one interpret the LUMINA trial in the FLORENCE APBI ERA?
This is a common scenario. My practice is to discuss this with the patient. I discuss 5 fraction PBI or 5 fraction WBI depending on the scenario, as well as endocrine therapy and the differences in toxicity profiles. Given compliance rates of 50-60% with endocrine therapy long-term, many patients pr...