Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Should additional radiation be added to the total course in a HN patient who has an extended break during treatment?
Extending standard RT overall time, without chemotherapy, results in a "loss" of about 0.7 Gy/day for each day treatment is extended beyond standard (on the other hand, acceleration results in a "gain" of 0.7 Gy per each day). These data are based both on pre-clinical experiments and clinical experi...
What clinical factors help you to determine whether or not a patient is an appropriate candidate for spine SRS/SBRT in the setting of metastatic disease?
Although there are no right or wrong answers, I think there is the least controversy when using SBRT/SRS for progressive disease after previous conventional/palliative RT or for radio-resistant tumor (melanoma, renal cell carcinoma) in patients with limited systemic disease (oligometastatic). As som...
What is your opinion on IORT for breast with electron brachytherapy?
I have used the Intrabeam system. I use strict selection criteria, following both the TARGiT A eligibility and the ASTRO suitability criteria. I think this is a good modality for lower risk disease. I do consider this a form of APBI. The mechanism of action is not completely understood, like many ra...
How do you stereotactically treat brain metastases greater than 3 cm +/- additional brain mets?
Interestingly, we have had a number of cases where a patient presents with several small (0.5-1 cm mets) and a single dominant lesion (3-5 cm), particuarly in melanoma. Becuase of a presumed radioresistance for melanoma, we have desired to use as much single fraction or hypo-fractionation as possibl...
Should cN0 oral cavity cancers that are completely resected but have indications for RT ever receive elective nodal RT?
For the larger question of "should cN0 oral cavity cancers...ever receive elective nodal RT?", I base my decision-making on primary site location, depth of invasion, grade, perineural invasion and lymphovascular invasion. Floor of mouth primaries with >1.5mm depth of invasion should have a neck diss...
Is there solid evidence for the proper sequencing of tamoxifen/SERM and breast radiation?
My approach is like above with one more factor to be considered: some retrospective clinical data and basic science experiments suggest that the concomitant use of tamoxifen appears to increase radiation-induced pulmonary fibrosis. If patient has not started TAM, then I have her start after RT as th...
Do you treat pelvic lymph node positive prostate cancer with definitive radiotherapy?
Unfortunately, there is relatively little data to guide us in the management of clinically lymph-node positive prostate cancer. As mentioned above, previous RTOG trials included patients with clinically and pathologically positive prostate cancer, however, these only addressed the question of whethe...
What dose-fractionation do you use when treating primary NSCLC with oligometastatic disease?
The approach to the lung primary in a patient with a single brain metastasis is dependent in our experience on clearly defining the extent of disease in the chest. Thus, the unusual presentation of a single brain lesion with an isolated primary (i.e.,. no regional nodal or distant disease) in the ch...
Do you forgo adjuvant radiotherapy for men with pT3 prostate cancer who have significant urinary incontinence?
I agree that early salvage may be reasonably effective and thus one might carefully observe patients who are not ideal candidates for adjuvant RT. Both the RADICALS study and the RAVES study will examine this issue (timing of post-op RT further). Here's a recent summary of the RAVES trial: BJU Int....
For intermediate risk prostate cancer do you recommend short-term complete androgen blockade or LHRH agonist alone?
This is a good question with little data specifically addressing it. Anthony D'Amico et al. did a retropsecitve study of this issue in a cohort of high-risk patients who were treated with IMRT+brachy and showed complete blockade was associated with better prostate cancer specific mortality (Red J, 2...