Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What criteria would you consider to select patients for 20 Gy consolidative RT in DLBCL/HGBL?
The primary endpoint of the study was 5-year local control. The study was powered to estimate this endpoint after the last patient had at least 2 years of potential follow-up (which will be reported at ASTRO). Local failures after 2 years are uncommon. The estimated 5-year freedom from local recurre...
How would you approach adjuvant radiation therapy in a patient with recurrent skin SCC of the gluteus s/p multiple resections with positive margins and adjacent osteomyelitis to the ischium and pubic ramus?
In this scenario, wherein a patient with recurrent cutaneous SCC has active osteomyelitis (assuming this is being treated), it would be prudent to avoid the involved bone as an OAR. I would not include the infected bone (I'd review the best imaging with radiology to ensure there's no involvement by ...
How do you choose between Grenz ray in a short course (e.g., ~5–7 fractions) versus longer-course superficial/megavoltage external beam regimens for large, ill-defined lentigo maligna on the cheek when surgery is not feasible?
The practical answer to this question is based on resource availability. There is a significant body of literature from Europe demonstrating the efficacy of Grenz ray therapy (albeit in retrospective, observational studies, with all of the usual caveats). To my knowledge, Grenz ray therapy is not wi...
What dose of reirradiation would you consider for locally recurrent breast cancer after mastectomy, excised with positive margins?
These are complex cases and lots of factors to consider when planning adjuvant therapy (age and comorbidities, tumor biology, other pathologic features like LVI, reason for the positive margin, plans for systemic therapy, presence of reconstruction, the volume of prior radiation, extent of clinicall...
What whole brain radiation dose would you recommend for primary CNS lymphoma with partial response to HD-MTX-R and R-ICE and planned for concurrent ibrutinib?
There are many uncertainties in how to optimal treat patients with PCNSL. It is clear that high-dose MTX-based regimens should be pursued when feasible. The role, if any, of RT is controversial. If pursued, a WBRT-based approach is generally considered most appropriate.With that said, if a patient o...
When would you offer neoadjuvant immunotherapy prior to Mohs surgery in a locally advanced squamous cell carcinoma for which clearance may require enucleation?
I would flip this question around and answer that radiotherapy is often a terrific option around the eyes, and it should always be considered in this area, especially when a radical surgical procedure is being entertained. Between en face therapy with a shield (superficial, electrons) and IMRT/VMAT,...
What dose constraints do you use for the left anterior descending artery (LAD) for breast radiation?
We published in the Red Journal in 2022 a single-institution analysis of LAD/heart dosimetry and association with cardiac events in 375 patients with a history of left-sided breast or chest wall irradiation: Zureick et al., PMID 35483540LAD Dmean EQD2 of 2.8 Gy and LAD Dmax EQD2 of 6.7 Gy were found...
Do you still routinely offer post-op radiation after bone fixation?
I'm a little nervous about the phrasing of the question as it implies that there is an ongoing evolution in practice here. I don't think there is. To emphasize, PORT is--and remains--the standard of care following orthopedic stabilization of bony metastases: Alcorn et al., PMID 38788923Now, it is fa...
Do you recommend adjuvant radiation in patients with intrahepatic cholangiocarcinoma (IHCC) resected with a positive margin (R1 resection)?
When considering the competing risk of distant mets, the probability of isolated local failure in this disease is probably very low and treatment of the positive margin may not result in a clear benefit. Patients with intrahepatic cholangiocarcinoma have about a 70% or more distant failure rate, and...
For stage III NSCLC treated with definitive intent chemoRT, how do you decide to proceed with surgery vs consolidation immunotherapy?
When we initially evaluate a patient with locally advanced NSCLC, we make the decision upfront about whether the patient will be managed surgically or not, and then we stick to that plan as long as everything proceeds as expected. So someone treated with definitive intent would get durvalumab (shown...