Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In what scenario would you recommend induction chemotherapy prior to chemo-radiation in head and neck cancers and what would be the preferred regimen?
The use of a sequential approach to treating locally advanced SCC of the head and neck is not generally recommended since three studies from Spain, the Dana Farber Cancer Institute, and the University of Chicago failed to demonstrate a survival benefit from three cycles of TPF (platinum, paclitaxel/...
How do you approach a NSCLC case with extensive nodal disease that results in a radiation plan that cannot meet normal tissue constraints?
This is an interesting question as there are multiple, complementary approaches that can be taken: If using > 60 Gy, drop the dose down to 60 Gy in 2 Gy fractions. Some practitioners continue to use > 60 Gy in the post-RTOG 0617 era, which is not unreasonable based on retrospective data and first pr...
How would you approach a cT4 cN2 (22 cm in size) TNBC that shrank to 9 cm with KN-522 regimen but remains inoperable at the end of treatment?
This sounds like a tough situation. I will offer up an opinion but I know others will have their thoughts and more than one is important here. Obviously, this person is at very high risk to have occult metastatic disease. However, I think this biology is also interesting. For a tumor to have reached...
What criteria do you use for choosing (or, pointedly, not choosing) parotid sparing with IMRT in patients with bilateral neck nodal disease from a mucosal head and neck cancer?
When I prepared for our oral board exam, we knew that certain examiners felt that patients with bilateral neck disease were not true candidates for parotid sparing IMRT. You may have had to back down on IMRT with certain examiners and say that there wasn't a strong rationale for treating with that t...
Do you hold osimertinib when delivering partial or whole brain 3D radiation?
I typically don't mandate holding osimertinib while administering SRS for brain metastases unless my medical or neuro-oncologist has concerns. In such cases, I might consider delaying the initiation of osimertinib for about a week. Notably, there are two prospective studies (NCT03769103 and NCT03497...
Do you recommend holding tyrosine-kinase inhibitors for extracranial metastases being treated with SBRT?
In general, yes I would recommend holding TKIs during SBRT. Anecdotally from both my own experience and others, there is a small risk of severe pneumonitis in patients on concurrent or recent TKI (much of this with osimertinib which has a reasonably high risk of symptomatic pneumonitis on its own) a...
How do you manage a patient who finished chemoRT for head and neck cancer and loses >10% body weight within 2 weeks post-treatment?
Very contextual question. We are all mostly taught that we should avoid feeding tubes at all costs. And this teaching comes from our beloved head and neck attendings at tertiary centers, with inpatient oncology, infusion on site, nutritionists, speech and swallowing specialists, and IR/GI on demand ...
How do you approach definitive radiation in a patient with an indwelling catheter due to obstruction from locally advanced prostate cancer?
This is a situation I encounter several times per year. The answer depends on whether or not I am being consulted strictly for palliation of the obstructive symptoms, or for curative intent therapy. For strictly palliation in a man who has already been on ADT/Abi/Enza/Chemo etc with progression, whe...
What are best practices for oncologists during the national platinum shortage?
In breast cancer, we are prioritizing patients with curable disease in which platinum agents are a critical part of the regimen or have actually shown a clear advantage (the only example of this is shown below in bold).Use an alternative to a carboplatin-based regimen whenever possible. If no altern...
How do you manage multiple brain metastases from small cell lung cancer?
In general, I think WBRT is a reasonable treatment for small-cell lung cancer (SCLC) brain metastases. That being said, our institution has considered SRS for select patients depending on a variety of factors as the treatment paradigm for this is evolving. There have been some studies addressing SRS...