Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How does SUPREMO alter your recommendations for PMRT?
The recent SUPREMO trial provides data that might alter my prior posts on the topic of PMRT. The SUPREMO trial demonstrates that chest wall RT alone, in a relatively favorable subgroup of patients, is not helpful.Regarding T3N0, I previously wrote on MedNet: "When treating PMRT in the pT3N0 setting,...
What constraints do you use for a non-weight bearing bone when treating a patient with sarcoma?
The only long bone that is truly not weight bearing is the fibula. (This is why ENTs can harvest fibula for mandible reconstruction and not reconstruct the fibula.) All other long bones are weight bearing under at least some circumstances. Femur and tibia are obviously WB with ambulation. However, t...
Given that ESOPEC did not mandate PET staging, are the conclusions of the study still applicable for patients who are staged with PET?
I believe the study results are still applicable to patients who are staged with PET.ESOPEC supplementary data show that 7 patients (all in the pre-op CRT group) had M1 disease at diagnosis, which was discovered due to PET staging. The total number of patients in each study arm with M1 disease prior...
How do you approach an early stage breast cancer patient s/p BCS in which ECE is found on a positive sentinel node?
These are cases that we are facing more commonly and my thought is the answer shouldn't change whether this is BCS or mastectomy (though less data in this setting).I will discuss with the patient the limitations of Z011 and AMAROS with respect to ENE. With focal microscopic ECE, I will often proceed...
What is the role of adjuvant radiation in R0 node positive resected pancreatic adenocarcinoma in light of the recently presented RTOG 0848 abstract?
There are three options here in my practice. 1) Treat, 2) don't treat, and 3) "watch and wait, then ablate" (for a local recurrence). In general, I treat patients with CXRT who have positive margins (IMRT 45 Gy/25# to regional volume with SIB of 62.5 Gy to the margin. If it is an R2 resection (which...
What is your approach to brain reirradiation in the setting of recurrent/progressive gliomas?
A lot of factors need to be considered prior to offering brain reRT in such a setting, most importantly- interval since the 1st course of RT, patient's ECOG and neurologic function, age, perceived life expectancy, size of the lesion, location of the lesion, WHO grade of glioma, patient's expectation...
What adjuvant treatment approach would you recommend for a patient with early-stage MSI-high gastric cancer who received neoadjuvant ipilimumab (×2) and nivolumab (×6) per the NEONIPIGA regimen, followed by R0 resection with no pathologic response?
I would favor FOLFOX x6 as per classic. This scenario raises the question: Was this truly MSI-H? I would confirm MSI status with next-gen sequencing. I would have expected a response if MSIH on ngs with concomitant high TMB. Our institutional practice has been to review all MSI-H IHC cases done outs...
Do you consider tertiary grade pattern, LVI or PNI on prostatectomy specimens as adverse features to recommend EBRT and ADT for patients with unfavorable intermediate prostate CA after prostatectomy with undetectable PSA?
No, I don’t think there is any current available evidence to define a benefit for ADT in the post-operative setting for patients with an undetectable PSA. The two major trials which define a benefit for ADT in this setting, RTOG 9601 and GETUG AFU-16 had a lower limit of a PSA of 0.2 at treatment in...
What is the value of resection in high risk (but small or early stage) skin cancers at the medial canthus?
The value of resection of a high risk small or early stage skin cancer at the medial canthus is potential assurance of complete removal of the skin cancer by confirmation of negative margins. Depending on the extent of disease and surgical approach, this may or may not be straightforward. There are ...
How do you simulate and treat a prostate cancer patient with a persistently full rectum?
Simulation should lead to reproducible and desirable treatment positioning of the patient and their anatomical orientation. For prostate cancer, the state of bladder and rectal filling need to be considered. I think that a "comfortably" full bladder is widely used for simulation and treatment, but r...