Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What daily/weekly imaging (MV/KV/CBCT) do you use when treating regional nodes in breast cancer?
We primarily treat regional nodes using 3DCRT. As such, we check weekly ports of all films (tangents, SCV +/- PAB). We have concurrent surface imaging which is used daily. When using IMRT (uncommon in my practice, < 10% of cases requiring RNI), I use CBCT with alignment to chest wall (IMNs).
Is there any evidence that demonstrates an increase in rectal or bladder toxicity with protons for prostate cancer compared to IMRT?
This is a great and controversial question. I recently contributed to a review that tried to summarize the current studies to date looking at this question. As you know, there are no completed phase 3 trials comparing protons to photons in this space, and we eagerly await results from the PARTIQoL t...
How would you manage a slowly progressive benign brain tumor located near critical structures such as the optic chiasm/brainstem?
This is a very common occurrence, except that frequently we don't have histology. For example, meningiomas in the region of the cavernous sinus are frequently diagnosed by imaging criteria. In any event, I recommend radiation therapy for slowly growing asymptomatic, presumed benign tumors that are n...
In patients getting concurrent chemo-immunotherapy for locally advanced cervix cancer, would you hold immunotherapy during the 2.5-3 weeks of brachytherapy?
Pembro is continued throughout the course of treatment. Initially, every 3 weeks for 5 cycles with concurrent chemo RT plus brachy and then every 6 weeks for 15.
For primary CNS lymphoma, when do you refer for whole brain radiation therapy (WBRT)?
When data are limited, consensus guidelines tend to rely on the personal clinical experiences of the guideline committee members. That may explain the NCCN guidelines. Recently, remarkable progress has been noted in the treatment of CNS lymphoma with drugs alone. Ibrutinib is particularly effective ...
Are you comfortable combining relugolix with enzalutamide or abiraterone?
I usually avoid these combinations. The challenge is that relugolix is not superior to other ADT methods in terms of efficacy (at least based on available data) but there are safety issues with considering these combinations. All three of these medications are substrates for similar enzymatic metabo...
When do you recommend post-operative radiation therapy for extracranial chondrosarcoma?
When an en bloc resection with negative surgical margins is not achieved. Typically, this means tumors of the axial rather than appendicular skeleton, as margins are typically wide in the latter. There is "oncolore" that chondrosarcomas are radioresistant tumors. This is likely true at lower pallia...
Do you offer APBI for patients with invasive disease if there is high grade DCIS present in the lumpectomy specimen?
In these situations, I am still comfortable offering PBI to patients. DCIS is seen with invasive disease in a fair number of cases so this comes up frequently and as long as other criteria are met, I view this as appropriate for PBI.
When do you recommend postoperative radiation therapy for a ureter carcinoma?
The role of postoperative radiotherapy for ureteral cancers (and, by extension/association renal pelvis cancers) is controversial. Patients who might stand the most to benefit from adjuvant radiotherapy are those with locally advanced disease; unfortunately, these patients have a high risk of distan...
What is your radiation approach/details for regionally involved prostate cancer (N1)?
For intact cases, I usually attempt to deliver a single-phase plan with multiple dose levels in 28 fractions as detailed below:Elective Pelvic LN volume (CTVn1): 50.4 Gy/28 fx. In cases of N1 disease, I would usually include the common iliacs. When the GTVn is near the cranial field edge, I usually ...