Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your approach for a brachytherapy boost in prostate cancer patients with extracapsular extension?
In general for patients with documented extracapsular extension, the combination of external beam radiation along with brachytherapy is a very appropriate treatment intervention. For such patients, we generally initiate treatment with the brachytherapy and make sure that seed placement is well cover...
How do you approach isolated recurrence in a para-aortic lymph node following definitive radiation for localized prostate cancer?
This is a challenging situation with no data to guide therapy; it is not unreasonable to pursue novel PET imaging (PSMA on trial, fluciclovine) to ensure there is no evidence of other sites of metastatic disease. The treatment of oligometastatic disease continues to evolve. In this situation, I woul...
Do you routinely treat postoperative extremity soft tissue sarcoma with IMRT?
Historical tidbit: In the early days of IMRT, and I'm talking like ~2000-2003, there were actually approved diagnosis codes for IMRT (oropharynx was allowed e.g.). There were likewise codes that were exclusionary for IMRT (I remember breast and gastric cancer e.g. being disallowed early on). Soft ti...
Would obtaining a breast MRI for patients going to be treated with APBI be beneficial?
The published outcome data for APBI does not suggest routine use of MRI as part of the work up and have shown a low local recurrence rate. A recent randomised published study by GEC estro also did'nt mandate MRI as part of work up and showed low recurrence rate and equivalent outcome to whole breast...
What is your approach to left sided PMRT in patients with on-going cardiac issues (ie. cardiomyopathy, heart failure, coronary heart disease)?
In this circumstance, like for any medical intervention, we need to carefully weigh the risks and benefits of treatment. The likelihood of radiotherapy-induced cardiac injury appears to dependent on two variables: 1) Cardiac dose. This is variably defined - I think mean heart dose may be the best su...
When would you recommend definitive radiation or surgery + PORT for a resectable skin cancer metastatic to the parotid?
Surgery and adjuvant radiotherapy based on the experience of many groups show superior outcomes in this situation. I am pretty sure this topic is not up for debate. The only exception might be Merkel cell carcinoma, but otherwise, in almost all skin cancers I can think of, this is the preferred trea...
Is a fluciclovine (Axumin) PET scan an adequate imaging modality for prostate cancer re-staging after a biochemical failure?
Fluciclovine (Axumin) [FACBC] PET scan was FDA approved in May 2016 for recurrent prostate cancer – FDA approval was based on high accuracy of PET uptake when correlating with biopsy. As with any diagnostic imaging test, Axumin has higher diagnostic yield with increasing PSA. While Axumin can assist...
Would you treat the supraclavicular field and IMNs for a patient with cT3N0 breast cancer who has a complete response following neoadjuvant chemotherapy?
For T3N0 who have upfront mastectomy and the pathological nodal status is negative, if I offer PMRT, I usually treat chest wall only without treating the nodal region, as data suggests almost all locoregional recurrences are in the chest wall.For clinical T3N0 who get neoadjuvant chemo and have resi...
Should definitive radiotherapy and ADT be offered to patients with PSA > 100 who have no evidence of metastatic disease?
PSA > 10,000 ng/mL would be a valid indication not to proceed . . . Otherwise, I would not let a case be ruled by labs in the absence of definitive radiological or pathological evidence of incurability . . .
What heart dose constraint should be used when treating locally advanced NSCLC?
I use V50 <25%, then again I was the senior author on one of those 3 papers, so I'm a bit biased! To be clear, though, I think the punchline here is that the metric being use is fundamentally less important than just using a metric that is more stringent than the historic constraints. It is well est...