Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What are your recommendations for holding bevacizumab before and after SBRT to the lung?
As @Maria Werner-Wasik notes, our experience at Memorial Sloan Kettering has indicated that giving SBRT for ultra-central lung tumors in a patient who has also been exposed to VEGF inhibitors may be an extremely dangerous combination associated with a high risk of fatal pulmonary hemorrhage. This wo...
For a patient with a solitary kidney, what dose constraints would you use for SBRT to a nearby site?
I use the UK Consensus on Normal Tissue Dose Constraints for SRS & SBRT.For a solitary kidney, the SBRT 5 fxn OAR constraint is Mean <10 Gy V10 Gy <10% (optimal), but can go up to <45% (mandatory) This is based on the ABC-07 & SPARC trial protocols.
How do you manage hot flashes in men with prostate cancer on androgen deprivation therapy?
I prescribe Effexor extended release (XR) 37.5 mg increasing to 75 mg if needed. Serves double duty since many men would benefit from an antidepressant anyway. Works for women as well.
For a breast cancer patient treated with a mastectomy who has clear indications for post-mastectomy radiation therapy, what do you consider to be the longest acceptable delay prior to initiating PMRT following surgery?
The longest I've ever waited is 6 months, and that was in a young patient with T4b N3b M0 disease that progressed on weekly taxol and then experienced a complete pathologic response to FAC. I felt that this patient had a substantial risk of local-regional recurrence and that even if the benefit of r...
Would you hold abemaciclib during adjuvant chest wall/axillary radiation after mastectomy?
I agree. There are some concerns that put cells into cell cycle arrest may also impact the benefits of radiation therapy. So it is recommended to hold abemaciclib during radiation therapy.
Do you recommend axillary dissection for women with ER+ breast cancer and low risk Oncotype or Mammaprint if single node positive with only 1-2 SLN removed, to ensure <4 nodes positive?
No, I see no need to do dissection in this setting. Unless there is clinical or imaging evidence of gross disease, radiation should adequately control microscopic residual disease in the axilla.
Under what circumstances would you pursue completion ALND in a patient with multiple positive sentinel nodes after breast-conserving surgery?
For clinical/imaging node-negative disease with 1-2 positive nodes, now there are 7 plus clinical studies (ACOSOG Z0011, AMAROS, OTOASOR, SENOMAC, IBCSG 23-01, AATRM, SINODAR-ONE) which have shown no difference in axillary recurrence, DFS with dissection, but higher lymphedema as expected. The most ...
How do you reconcile the differing results of the C-POST and KEYNOTE-630 trials when discussing treatment options with high-risk CSCC patients?
I explain that the two trials enrolled different risk populations, which likely accounts for the apparent discrepancy in outcomes — but when you look closely, they actually lead to the same clinical conclusion. C-POST deliberately enriched for very-high-risk patients (using well-established adverse ...
How would you treat a patient with Gleason 8 or 9 prostate cancer, pretreatment PSA 15-24, with retroperitoneal adenopathy?
I would offer a similar approach to that described nicely by @Dr. First Last and @Dr. First Last: definitive RT+ADT+abiraterone, with SIB to the grossly positive nodes. My caveats and additions are: I start with a frank discussion with the patient re: evidence for various scenarios and general prog...
How would you manage a patient with non-mutated oligometastatic NSCLC with a brain met who underwent resection of the brain met, had 4 cycles chemoIO, and had resection of the primary lung CA with pCR and now is NED?
This is a great question, and this scenario does come up occasionally within our Thoracic Tumor Boards. What makes this scenario more complicated is the integration of immune checkpoint inhibitors into standard practice. However, this question has been addressed in the pre-immunotherapy era with num...