Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
When do you refer patients for TURP prior to prostate radiotherapy?
Good question - my experience for both brachy and EBRT prostate cancer patients - has been the clinical narrative. That is - for patients with significant LUTS - who are already on alpha blockade prior to RT, and who are still having issues of urine flow - is to see if there is a mechanical reason -...
What special considerations do you take when treating cancer patients with severe intellectual disabilities?
Caring for patients with any type of disability is both a privilege and a challenge. Severe intellectual disability poses additional challenges due to logistical, ethical, and moral dilemmas. Additional factors including patients' socioeconomic status, support system, language spoken to individuals ...
What is your management strategy for patients with positive lymph nodes after radical prostatectomy?
There is a good retrospective study from Milan that shows considerable benefit to postoperative radiation therapy for node postive patients. DaPozza et al published this in "European Urology 55 (2009) 1003–1011". Their conclusions state: "Our data showed excellent long-term outcome for node-positi...
Would you offer palliative radiation to a patient with hematuria from squamous metaplasia of the bladder that is not responding to endoscopic therapy?
No.
What, if any, resources exist with recommendations regarding the timing and toxicity of radiation in patients who have received or are currently on immunotherapy?
Concurrent immunotherapy (PD1/PDL1) with chemoradiation is now not advised, given the two negative lung cancer trials (PACIFIC 2, CheckMate 73L). Concurrent immunotherapy with radiation alone is still an interesting area to explore, as the two published studies (SPRINT, Ohri et al., PMID 37988638, a...
What is your approach for bulky stage I primary mediastinal B-cell lymphoma in a patient with a positive post-chemotherapy PET-CT (residual mass and Deauville 5)?
Interpreting end-of-treatment PET in PMBL can be tricky. False positives here are very common! Fake-outs include thymic rebound masquerading as refractory disease; avidity at rim (which is almost always biopsy-neg); or residual avidity throughout residual mass which again can be biopsy negative. I w...
What references do you use for multi-parametric MRI delineation of the GTV in prostate cancer for prostate nodule?
In FLAME, the boost volume was the GTV on mpMRI as judged by the treating physician without any formal contouring guidelines (Kerkmeijer et al., PMID 33471548). There were differences in MRI protocols and physician judgement resulting in significant differences in tumor volumes between centers (van ...
If you must start adjuvant radiation more than 6-8 weeks postoperatively, whether due to complications or healing, do you accelerate treatment in any way?
This is a controversial area with varied opinions. Here are a few of my takeaways: For delayed patients especially with high risk pathology, I usually re-image (preferably with PET) before making a recommendation. This is based on multiple series (Shintani et al., PMID 17889447, Kibe et al., PMID 3...
Would you add ADT to EBRT for favorable intermediate risk patients with T1c prostate cancer by DRE and bilateral prostatic lobe involvement by MRI?
Let's break down the question: If the patient has favorable intermediate risk disease, but cT1c by DRE, then he must have either: Grade group 2 (Gleason 3+4), PSA <10, and percent positive cores <50%; or Grade group 1 (Gleason 3+3), PSA 10-20, and percent positive cores <50% For scenario 1: Havi...
In high or very high risk prostate cancer, do you utilize combined androgen blockade in patients receiving definitive RT?
Since I had initially posted this, the STAMPEDE investigators have released a new publication reporting the utility of intensified androgen axis blockade (abiraterone ± enzalutamide) in high-risk non-metastatic patients which included high-risk N0 (≈ 60%) and N1 patients (≈ 40%). For this combined p...