Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What normal tissue constraints do you use, if any, in patients receiving vaginal cuff brachytherapy alone?
We optimize based on the PORTEC 2 and PORTEC 4 protocol recommendations. We use CT-simulation and 5mm optimization points. There are no normal tissue constraints when using this approach and 2D planning can be utilized. We do not insert, for example, bladder points. Many planning studies have demons...
Would you consider chemoradiation + chemotherapy as in PORTEC-3 regimen for p53 mutated stage IA endometrial cancer, though this trial did not include those with stage IA disease?
There are not sufficient data to recommend this regimen in patients with stage IA endometrioid endometrial cancer. In subset analysis of patients with grade 3 endometrioid cancer with + LVSI, there was no difference in recurrence free or overall survival (OS) with the addition of chemotherapy. For p...
When do you expect the 2023 FIGO staging for endometrial cancer to become adopted clinically in the US?
Agree with the previous comment. Current adjuvant RT for stage I and II are based on mainly histopathological classification (PORTEC-I/II). However, the recent publication of PORTEC-4a (Horeweg et al., PMID 37487144) for stage I/II showed molecular classification predicts response for stage I/II. Mo...
How should molecular studies, in particular the presence of POLE or p53 mutations, be incorporated into the decision to treat an "intermediate risk" endometrial cancer patient with adjuvant therapy after hysterectomy?
PORTEC, ESMO, and SGO guidelines support molecular characterization of endometrial cancer based on the TCGA/ProMisE classifications. p53 is a predictive biomarker for response and prognosis while POLE is prognostic. Based on the most recent SGO clinical practice statement, these can be used to escal...
What is your typical approach for soft tissue sarcomas of the buttock?
It is worthwhile remembering that the entire paradigm of conservative/limb-sparing surgery rather than radical surgery/amputation for extremity STS (as defined all the way back to Rosenberg et al., PMID 7114936 and Yang et al., PMID 9440743) *presupposes* that patients also receive RT. Therefore, fo...
What is your palliative radiation approach to larger volume locoregional head and neck SCC recurrences?
If there was no prior RT, for palliation-30 Gy/10 fractions or 20 Gy/2 fractions with 1 week interfraction interval. If there was prior RT, for palliation-30 Gy/12 fractions For reRT with curative intent-64.8 Gy at 1.2 Gy per twice daily fraction. ReRT the recurrence or second primary site with marg...
How do you treat locally advanced GE junction adenocarcinoma extending to the esophagus and cardia when the Siewert Type is indistinguishable between 2 and 3?
There is no "correct" answer to this question as both relevant trials seemed to have improved outcomes with this type of disease, so either approach would be acceptable. However, I think one has to keep in mind that there are (at least) 2 factors that would drive a decision. One is biology and the ...
At what PSA do you initiate ADT for a biochemical recurrence after prostate radiotherapy (adjuvant, salvage, or definitive)?
Great question, and one that highlights the variability in practice and philosophy that often emerges to fill the void when hard data and concrete guidelines are lacking. I find that the PSA doubling-time (DT) often tracks with patient and provider anxiety levels; a rapid DT (<8-10 mos or so) in an ...
How would you approach management of a large, fungating squamous cell carcinoma of the auricle if surgical management is not desired by the patient?
For a tumor this size and with cartilage invasion, I would recommend starting with induction cemiplimab to best response (generally 4-6 cycles), followed by consolidative RT, generally electrons. Prior to starting the immunotherapy, I would stage the neck with a contrast CT scan, as tumors of this s...
What dose-fractionation scheme and esophageal constraints should be used to treat an ultra-central, medically inoperable, stage I NSCLC abutting the esophagus?
For lesions abutting the esophagus, SBRT with BED >100 Gy should NOT be used due to high risk for ulceration and even fistula. Instead of SBRT, more fractionated radiotherapy with BED <84 Gy should be considered (60 Gy in 15 FX is still too high for the esophagus). In addition to maximal point dose,...