Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What data is used to show cystectomy is superior to concurrent chemoradiation for muscle invasive bladder cancer?
In the absence of valid randomized clinical trials, Stein et al., PMID 11157016 1000+ Rad Cystectomy is often considered the benchmark article for Urologists when addressing this question. The paper is from the pre-adjuvant chemo era so some will say the survival is actually 5 to 10% higher than rep...
Do you use a tumor-bed boost following whole breast irradiation for patients with DCIS?
Good question as we are lacking prospective data on this topic while awaiting TROG 07.01. In the absence of prospective data, I generally omit a boost in DCIS with the exception of women <50 with high grade DCIS (as per criteria used in RTOG 1005) or women with DCIS who present with a palpable mass.
Would you recommend PMRT using a hypofractionated course to the chest wall and nodes?
With recent publication of Chinese data with median follow-up of 5 years showing no difference in any end point, we routinely offer hypofractionation to patients 65 and above with non inflammatory breast ca and no immediate reconstruction. For patients who have reconstruction done or planned, we enr...
Is it appropriate to offer definitive trimodality therapy, as an equivalent option to neoadjuvant chemotherapy followed by radical cystectomy, in patients with muscle-invasive bladder cancer regardless of fitness or platinum eligibility?
There are now several retrospective studies utilizing advanced statistical techniques suggesting that outcomes after trimodality therapy (TMT) are very similar to those after surgery (e.g., Zlotta et al., PMID 37187202, Brück et al., PMID 37517601, and Kulkarni et al., PMID 28410011). These findings...
How would you manage a recurrent uterine leiomyosarcoma, now status post secondary cytoreduction, with no gross residual disease?
NCCN guidelines recommend that isolated metastases that have been resected can be considered for treatment with postoperative systemic therapy and/or postoperative external beam RT. Observation is also an acceptable alternative for those who have no evidence of disease on postoperative imaging. This...
What is your cutoff for the maximum number and size of brain metastases that you will treat with SRS?
Sadly, the level 1 evidence needed to truly delineate the greatest benefits from SRS will probably never be realized beyound what we already know: SRS shows an OS benefit to pateint with 1 intracranial met and a CNS-DFS benefit to 2-3 mets. Beyond that, it's better in terms of preservation of neuroc...
What is your approach to management of a subtotally resected pineal parenchymal tumor of intermediate differentiation (CNS WHO grade 2)?
In full disclosure, I have had only one adult patient with PPTID. Although PPTID was first described in 1993, it was not recognized by the WHO until the 2000 classification and represents only 1% of primary central nervous system tumors. Prognosis falls somewhere between that of a pineocytoma and pi...
Would you consider omission of radiotherapy in patients 70 years and older with invasive ductal carcinoma who had initially positive lumpectomy margins, but had no residual disease upon re-excision?
The only data I know of on this specific subject comes from the subgroup analysis of the PRIME II trial, which randomly assigned patients to endocrine therapy alone or with radiation therapy. Its eligibility criteria included age 65 or older, tumor size 3 cm or smaller, grade 1 or 2, either grade 3 ...
When giving total neoadjuvant therapy for rectal cancer, do you sequence radiation and chemotherapy differently depending on the tumor distance from the anal verge?
With all of the emerging data in rectal cancer and, particularly, if considering non-operative management, I think it is crucial to discuss these patients as part of a multidisciplinary team now more than ever. Prior to starting any therapy, we try to ensure that all of our newly diagnosed rectal ca...
For a glioblastoma patient who had an MRI immediately postoperatively and you are able to repeat one closer to the time of CT simulation, do you use the more recent scan or the immediate postoperative scan for contouring (T2/FLAIR and T1 post)?
We usually obtain a repeat MRI closer to the time of CT sim, ideally on the day of sim, for several reasons. First, surgical cavities have a tendency to collapse which may impact target volume delineation. Secondly, peritumoral edema T2FLAIR signal infrequently subsides, which may also affect target...