Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach the management of a patient with metastatic non‑small cell lung cancer who previously received whole brain radiation therapy three years ago and now presents with 20 new brain metastases on MRI?
How aggressive I would be depends on KPS (which sounds to be good in this case), the patient's extracranial disease status (which sounds to be controlled on current therapy in this case), plans from a systemic therapy perspective (will the patient continue on the same therapy and what was the patien...
Would you give PMRT to a young woman with a T1-2 breast cancer with a micromet on SLNB?
No great data as far as I know. In general, I treat micromets as ~pN0. @Dr. First Last and colleagues reported on LRR rates and prognostic factors for failure in pN0 patients treated with mastectomy to identify subsets of node-negative patients with sufficiently high risk of LRR who might benefit fr...
What dose do you use for definitive treatment of squamous cell carcinoma of the cervical esophagus?
Our institutional preference is to employ a total dose to 70 Gy with concurrent chemotherapy for squamous cell carcinoma of the cervical esophagus, because a local failure in would require salvage surgery with pharyngo-laryngo-esophagectomy. The role of dose escalation in squamous cell carcinomas of...
What is your preferred dose to gross lymph nodes when treating non-metastatic high-risk prostate cancer?
I treat the grossly involved node as high as I can, while respecting OAR constraints, up to the dose for the prostate. I tend to favor zero or minimal PTV margin (depending on the proximity of OARs--usually bowel) and allow the penumbra to serve as a functional "PTV."
Do you recommend definitive chemoradiation for unresectable gastric adenocarcinoma in a medically unfit patient?
Definitive is probably not the best term for what can be done. Only palliative doses are possible because the stomach is so sensitive, the GTV is difficult to clearly define, impossible to see on CBCT, the stomach changes shape from day to day, and moves with respiration. There would only be a less ...
For a patient with metastatic melanoma with small, asymptomatic brain mets what is your preferred systemic therapy?
In this scenario, I default to using a combination of ipilimumab plus nivolumab. We know from prior clinical trials that have looked at this combination of patients with asymptomatic brain metastases that immunotherapy seems to work similarly well intracranially as it does extracranially. This was e...
How do you select which patients with H&N primary tumors benefit from proton therapy?
Surprising to see that the expert opinion after TORPEdO results is that IMPT is also a great choice. Granted, it contradicts the MDACC-led study, but we should have nuance and critical analyses. The rates of feeding tube dependence in the IMRT arm in the MDACC-led study are astronomical. I have neve...
How will your management of head and neck cancers change with the COVID-19 pandemic?
Short answer: Most head and neck cancer radiation is as necessary as it gets. At this point, my management won't change very much. That may change as the pandemic evolves. Use all the appropriate precautions to stop the spread of COVID-19 and other viruses (we are using masks for every staff member,...
What are the treatment options for a patient with unfavorable intermediate risk PCa who desires future child bearing?
The best option for such patients would be sperm banking prior to treatment, whether they undergo RT+ADT or surgery. See this prior post on this forum regarding the impact of RT on fertility. Given the expected internal scatter dose to the testes during a course of fractionated RT, it would not be s...
Is 60 Gy in 40 fractions BID an appropriate regimen to use for LS-SCLC now?
So as to answer the question and not to bury the lede: IMHO, yes.Here's an XRT-style-vs-XRT-style trial showing a survival advantage. How rare is that in radiation oncology? There are probably less than 10 such trials in medical history (wild guess). I can't recall the last time that outright pure d...