Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What treatment would you offer for a patient with prior primary prostate radiation, with a biochemical progression to PSA >1.0 and negative PSMA scan?
I’m assuming the patient has already received a prostatectomy and received prostate bed radiation, with a rising PSA. First, in terms of imaging, you may want to consider a contrasted pelvic MRI, which may reveal a small lesion in the prostate bed which may have been obscured by PET activity from t...
Do you recommend any PSMA PET agent over another?
PyL aka PYLARIFY (18F-DCFPyL) and 68GaPSMA-11 are the two agents commonly used on PSMA scanning in the US. Some have said PyL might be slightly better, however, even proponents admit only rarely with clinical significance. The intensity of the signal/uptake/SUV is usually higher with PyL than with ...
How do you approach a local failure with a rising PSA following prostate SBRT?
I would obtain an MRI if not already done to help delineate local disease extent. A variety of salvage options are available (RP; HIFU; cryotherapy; and re-irradiation with brachytherapy or focal SBRT). A recent systematic review and meta-analysis of local salvage therapies was published by a group ...
What would your radiation volume be for a patient with SCC just medial to the infraorbital foramen with positive PNI who presented with pain s/p regional excision?
Probably operative bed, 5-10 mm CTV into soft tissues, and the path of the V2 cranial nerve.
How do you approach radiotherapy after the patient has a facial nerve graft as result of tumor resection?
No differently.
When would you consider neoadjuvant RT for dermatofibrosacroma protuberans?
Same circumstance as when I would offer preop RT for a low grade STS: recurrent, anticipated close or positive margins, or local recurrence unlikely to be salvageable.
Would you offer local therapy to a patient with GEJ adenocarcinoma with FDG-avid para-aortic node oligometastasis?
I have favored induction systemic therapy and interval re-assessment. If responsive or at least stable disease, I have offered extended field CRT as long as the treatment volume seems reasonable and my perception is that it would be tolerable when assessed in the context of a patient’s performance s...
Do you hold histone deacetylase (HDAC) inhibitors for patients receiving palliative radiation therapy for cutaneous lymphomas?
Histone deacetylase (HDAC) inhibitors are often used in the management of mycosis fungoides, the most common cutaneous lymphoma. NCCN guidelines include two HDAC inhibitors in their list of recommended systemic therapies- romidepsin and vorinostat. Romidepsin was FDA approved for CTCL in 2009 and vo...
What volumes would you cover for cT3N0, ypT2N0 breast cancer s/p neoadjuvant chemotherapy and lumpectomy/SLNB?
There is still little information about the patterns of failure in patients treated with neoadjuvant systemic therapy. The NSABP study of this issue found the 10-year rate of nodal failure for patients with cT3N0 lesions who had residual breast disease but negative nodes at surgery was 3.2% for the ...
How do you treat non-melanomatous skin cancers in poorly vascularized tissue?
BCC/SCC? An unusual differential. Was it biopsied? If it meets anatomic, size, and depth criteria, radiation oncology options would include electronic brachytherapy. Would likely offer 40 Gy in 10 fractions, twice weekly. Of course, would need to travel to an appropriate facility.