Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you recommend ADT in a patient receiving salvage post-prostatectomy radiation with PSA <0.5 and a high Decipher score?
Certainly, this is an area of evolving management. Here’s what we know about the use of ADT in the salvage setting: RTOG 9601: 2 years of bicalutamide improved 12y OS but PSA at the time of salvage was a significant interaction term with PSA <0.7 receiving no benefit. 2 years of bicalutamide was ass...
What dose and regimen would you treat a stage I laryngeal cancer s/p R1 resection?
63 Gy at 2.25 Gy per fraction larynx only fields
How do you counsel NCCN low and very low risk prostate cancer patients who receive a high risk DECIPHER score?
I do not order Decipher in NCCN low or very low risk. I'm not sure very low risk is even a relevant category in modern practice. The 15-year results from ProtecT demonstrate excellent outcomes for those on the active monitoring arm. Critically, those patients were mostly diagnosed in the pre-MRI era...
Does Neurosurgery need to be consulted for assessment of spinal stability in patients with cervical spine mets prior to starting RT?
To address the first question, for me personally, I would feel uncomfortable not including neurosurgery. Fortunately, there has been good work in this area by the Spinal Oncology Study group to help clinically clarify the matter. That is, these folks in 2010, developed a so-called "Spinal Instabilit...
Do you recommend sentinel node biopsy or ALND in cT4 or cT3 cN0 breast cancer patients?
The major trials comparing SLNB versus ALND (i.e., Table 1 from Lyman et al. 2014) either required tumors to be small (<= 2-3 cm), or had few patients with larger tumors (e.g., NSABP B-32: less than 2% with tumor > 4 cm; ALMANAC: 2% with tumor > 5 cm). Similarly, the major surgical trials comparing ...
Would you offer definitive chemoRT for bladder cancer in a patient who had previously received prostate radiation?
It has to be individualized based on location in the bladder. Bladder neck may be harder with significant overlap from previous RT field but other locations can be done with reduced volume and avoiding including prostatic urethra in volume
What changes do you make in the management of non-endemic nasopharynx cancer compared to endemic?
a) There are 3 varieties of NPC; EBER +ve, HPV +, and non-viral There is only decent data for Induction (IC) for EBER +ve for a small survival benefit with cis-gem, and the group's follow-up suggested that pre-treatment DNA titers only showed benefit for those with high titers. I am not a HN med onc...
Does the presence of a connective tissue disorder such as lupus or scleroderma modify your radiation dose or technique for prostate cancer?
Here another article that may be of interest. It's actually a hometown favorite at VCU since the lead author is on our faculty. J Clin Oncol. 1997 Jul;15(7):2728-35.Irradiation in the setting of collagen vascular disease: acute and late complications. Morris MM1, Powell SN. PURPOSE: Based on repor...
What is your approach to management of radiation-induced bullous pemphigoid?
Bullous Pemphigoid (BP) is a pruritic autoimmune blistering disease characterized by tense bullae that is rarely caused by radiotherapy. There have been >30 reports in the literature related to RT with most being localized to the radiated location, with rare reports of BP at non-irradiated sites or ...
How would you approach the treatment of a single vertebral body involved with multiple myeloma (MM)?
If single level of involvement and no other bony disease (i.e. plasmacytoma of the spine), I would favor standard fractionation to 45-50 Gy as definitive treatment. I usually treat 50 Gy/25 fractions. If myeloma with other areas of disease, I favor standard palliative RT and cover 1 vertebral body a...