Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you consider neoadjuvant chemotherapy for patients with muscle-invasive bladder cancer who are cisplatin-ineligible?
We have level 1 evidence supporting neoadjuvant cisplatin-based chemotherapy followed by cystectomy, there is no evidence supporting non-cisplatin based chemotherapy. Patients unfit for cisplatin should proceed directly to surgery.
For patients with inoperable stage III NSCLC who are unable to receive or refuse definitive chemoradiation, how do you decide among radiation alone, pembrolizumab alone, or radiation followed by either pembrolizumab or durvalumab?
So, this is a challenging question – actually two questions – 1) unable, 2) refuse. With respect to unable, this typically would (I assume, and in my practice) refer to patients whose functional status is sufficiently poor to prevent one from giving chemotherapy along with radiation. Note that esse...
How do you time re-staging studies and adjuvant durvalumab for stage III NSCLC treated with definitive cCRT?
In the PACIFIC study, 713 patients who received at least 2 cycles of platinum-based chemotherapy with radiation (CRT) and did not develop disease progression were randomly assigned in a 2:1 manner to receive durvalumab at 10 mg/kg every 2 weeks up to 12 months or placebo. Randomization took place be...
How do you monitor response for stage III NSCLC patients receiving consolidation immunotherapy?
Generally, the first imaging post chemoradiation (CRT) would have been performed about 6-8 weeks following completion, and this has changed as we start durvalumab within 42 days following CRT. I perform a baseline CT chest prior to starting durvalumab. I proceed to monitor with CT chest about every ...
What is your preferred fSRS dose/fractionation for large brain metastases?
For large intact brain metastases, my preferred fSRS dose/fractionation would be 27 Gy in 3 daily fractions. There are retrospective studies showing 1-yr local control rates of 91% using 27 Gy in 3 daily fractions vs 77% using single fraction SRS for large intact brain metastases > 2 cm (Minniti et ...
When utilizing hypofractionation for postmastectomy radiation, what is your strategy for boosting undissected nodes?
2.5 x 4 to 5. Fractions based on the response of the undissected node to systemic treatment.
What volumetric dose constraints, if any, do you use for the mandible in the definitive setting for H&N cancers?
The planning directions for the mandible are typically <50 Gy. However, when the targets are adjacent to the mandible we do not constrain the maximal mandibular dose if it may compromise target dose. In that case, we plan a dose gradient across the mandible, with the mucosa and inner plate of the bo...
How would you treat a biopsy proven isolated left-sided internal mammary node recurrence 20 years after mastectomy and chemotherapy for left breast cancer?
A 20 year truly isolated IMN recurrence sounds like a pretty good example of an oligorecurrence to me… I think the historical standard of care is definitely as @Dr. First Last and @Dr. First Last have outlined above, but I wonder if it’s time to start viewing a locoregional breast oligorecurrence in...
When treating a low-lying and bulky cT2N0 rectal adenocarcinoma invading the anal sphincter muscles with neoadjuvant chemoRT for downstaging, would you electively include the inguinal lymph nodes?
Based on the paper that we published at MDAnderson in 1990, the inguinal recurrence rate is 2 to 5% if they are not treated electively in patients with tumors involving the anal canal. If the tumor is within 2 cm of the anal verge or right at the dentate line, it was 5%. If the tumor was between two...
When would you offer post-operative concurrent chemoradiation in anaplastic thyroid cancer?
The management of ATC has evolved considerably over recent years with the most significant being a dichotomy of management based on Braf mutation. We typically offer postoperative XRT, including in patients with either a limited or stable DM disease. However, in a multidisciplinary setting, there so...