Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you treat synchronous high-risk prostate and rectal adenocarcinomas in an elderly man where the rectal cancer was resected secondary to obstruction (T3N0)?
Start with androgen deprivation. EBRT 45 to 50.4 Gy at 1.8 Gy per fraction to the pelvis. Boost prostate with brachytherapy if feasible or EBRT to somewhere around 80 Gy depending on the small bowel. Adjuvant chemo is unlikely to be tolerated.
How does the presence of indeterminate lymphadenopathy on PSMA PET scan alter your management of unfavorable intermediate-risk prostate cancer?
Summary: In practice, I usually review the imaging myself and attempt to evaluate for common pitfalls of interpretation or evidence that may convince me of a true positive. Often, I find a second review by a blinded radiologist helpful. Unless I am highly suspicious of a false positive, I often err ...
How would you approach radiation for node-positive prostate cancer in a patient with an aortic and/or common iliac arterial aneurysm not meeting criteria for surgical repair?
Literature has shown a correlation of brain irradiation associated with the development of intracranial aneurysms - I believe that is the concern this question is raising.The good news is that other studies have shown that, at least for the aorta, existing large artery aneurysms are not worsened by ...
Is there a limit to the size of a prostate cancer oligometastasis for SBRT?
I think that, in general, the direct answer to this is 'no'; there is no specific size cutoff that makes SBRT not feasible in this setting. There is some data in other settings that suggest local control is not consistently impacted by the size of oligometastatic tumors, and there is little data to ...
What are your recommendations for holding bevacizumab before and after SBRT to the lung?
As @Maria Werner-Wasik notes, our experience at Memorial Sloan Kettering has indicated that giving SBRT for ultra-central lung tumors in a patient who has also been exposed to VEGF inhibitors may be an extremely dangerous combination associated with a high risk of fatal pulmonary hemorrhage. This wo...
For a patient with a solitary kidney, what dose constraints would you use for SBRT to a nearby site?
I use the UK Consensus on Normal Tissue Dose Constraints for SRS & SBRT.For a solitary kidney, the SBRT 5 fxn OAR constraint is Mean <10 Gy V10 Gy <10% (optimal), but can go up to <45% (mandatory) This is based on the ABC-07 & SPARC trial protocols.
How do you manage hot flashes in men with prostate cancer on androgen deprivation therapy?
I prescribe Effexor extended release (XR) 37.5 mg increasing to 75 mg if needed. Serves double duty since many men would benefit from an antidepressant anyway. Works for women as well.
For a breast cancer patient treated with a mastectomy who has clear indications for post-mastectomy radiation therapy, what do you consider to be the longest acceptable delay prior to initiating PMRT following surgery?
The longest I've ever waited is 6 months, and that was in a young patient with T4b N3b M0 disease that progressed on weekly taxol and then experienced a complete pathologic response to FAC. I felt that this patient had a substantial risk of local-regional recurrence and that even if the benefit of r...
Would you hold abemaciclib during adjuvant chest wall/axillary radiation after mastectomy?
I agree. There are some concerns that put cells into cell cycle arrest may also impact the benefits of radiation therapy. So it is recommended to hold abemaciclib during radiation therapy.
Do you recommend axillary dissection for women with ER+ breast cancer and low risk Oncotype or Mammaprint if single node positive with only 1-2 SLN removed, to ensure <4 nodes positive?
No, I see no need to do dissection in this setting. Unless there is clinical or imaging evidence of gross disease, radiation should adequately control microscopic residual disease in the axilla.