Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Which radiation modality for definitive prostate cancer has the lowest risk of erectile dysfunction?
This is a great question. Historically, we have considered brachytherapy to be superior, with the caveat that I am not aware of any randomized data to support this. What is interesting is the ProtecT trial showed almost no difference in erectile dysfunction at 6 years between the Radical Radiotherap...
Can post-lumpectomy radiation be omitted for ER/PR(+) low-volume (2 mm) low-int DCIS, with > 2 mm margins in a post-menopausal patient who will be taking tamoxifen?
This is an individualized decision weighing the benefits and potential toxicity. We know from many prospective trials that none of the clinical features mentioned sufficiently put the recurrence risk low enough (often defined as <10%) to omit radiation. However, radiation also likely will not have a...
What dose and volume would you treat in a patient with diffuse large B-cell lymphoma confined to the stomach after complete response to R-CHOP?
In a patient with stage IE gastric DLBCL in a complete response (Deauville 1-3) after R-CHOP, I would consolidate with 30 Gy of RT. The volume would depend upon the size of the original tumor and how defined the original disease was on PET-CT and upper endoscopy. In a patient with a smaller lesion i...
For ES-SCLC with a distant cCR and local cPR after systemic therapy sustained for at least 1 year, how would you approach consolidative thoracic RT?
The CREST trial by Slotman referenced enrolled patients with the findings above after 4-6 cycles of chemotherapy, and required patients initiate radiation therapy within 6 weeks. If this patient truly has not progressed 1 year after chemotherapy, I am not clear on what the additional benefit of radi...
What is the role for RNI in a postmenopausal female with clinically N+, hormone receptor positive breast cancer s/p lumpectomy and ALND with low volume nodal disease (e.g., 1/12 nodes positive)?
When thinking about low volume nodal disease in cN+ patients, I tend to think about MA20 which included patients undergoing an ALND and 85% had 1-3 LN involved. I will offer these patients adjuvant RT to the breast and RNI (SCV/axilla with consideration of IM nodes based on dosimetry) based on the i...
If a patient with low metastatic burden has bulky retroperitoneal adenopathy without osseous metastasis, would you recommend prostatic radiation?
We could debate whether "bulky" retroperitoneal adenopathy is a truly low volume metastatic disease, but technically it would fit the definition used in the STAMPEDE Trial. In addition, patients presenting with nodal metastatic disease may have a more indolent course than those presenting de novo wi...
Would you offer consolidative RT to a patient with early stage, non-bulky, high-grade non-Hodgkin's lymphoma of the orbit after 6 cycles of RCHOP + IT chemotherapy?
Yes I would. The high grade nature of disease and the location would be enough to convince me. There are now several large, single institution series that show that the pattern of failure is the same in patients with unfavorable DLBCL (non GCB type, DH/DL, Ki-67> 90, CD5+, Burkitt’s type DLBCL etc.)...
How does the management of nasopharyngeal cancer in kids/young adults differ from adult patients?
The approach for managing pediatric patients with NPC has generally followed the recently published COG trial, at least in the United States. This approach uses induction chemotherapy with CDDP/5FU, followed by chemoradiation for the higher risk patients. Lower risk patients—Stage I/IIa or T2N0—can ...
In patients who had a lumpectomy alone without nodal evaluation for early stage breast cancer, how do you determine whether additional surgical LN evaluation is necessary?
In general, unless a patient is 70 and above with favorable phenotype breast cancer where choosing wisely favors no assessment of axilla surgery, everybody at this point gets SNLN bx. There are ongoing studies exploring skipping SNLN in clinically negative early stage breast cancer for other age gro...
How do you approach treatment of a non-seminoma brain metastasis with a partial response to chemotherapy?
Assuming one rules out leptomeningeal spread, I would still prefer to treat the non-seminoma brain metastasis with either stereotactic radiosurgery (18 Gy in one fraction if max. diameter is less than 2 cm), or fractionated stereotactic radiation (8 to 9 Gy per fraction x 3 if the metastasis is larg...