Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you balance short-term efficacy against increased low-grade toxicity and quality-of-life considerations for higher single-fraction regimens in recurrent glioma patients?
When considering radiation options for recurrent glioma, in my mind, one size does not fit all. I consider several aspects of the specific patient’s clinical situation: Patient’s prior treatments: time interval, volume, location, and anatomic site, response to prior treatment, response duration from...
When do you prefer pre-operative SRS over post-operative SRS for brain metastases?
For patients with brain metastases that benefit from resection, our approach is to always treat pre-operatively unless the patient requires immediate surgical intervention. Pre-operative SRS has several advantages including clear target delineation. Post-op SRS has best results with expanded volumes...
Do you still recommend protons for grade 2 and grade 3 glioma, following the Soprano study results showing a survival detriment?
I should start by saying that I generally do not recommend proton therapy for grade 2-3 gliomas in adults unless there is a clear and specific indication. Modern photon techniques such as VMAT are highly conformal, efficient, and safe, and they form the backbone of the evidence base that guides our ...
Do you boost a breast cavity for a high Ki-67 index in the absence of other risk factors?
Ki-67 has some level of subjectivity with inter-individual variation. If genomic testing, like Oncotype or Mammaprint, has been done, I would favor using that to decide whether the patient is low risk or not over k1-67 alone.
Would you offer PMRT to a patient with potential metastatic disease?
If an additional ER scan is planned, I will wait to see the results. If there are unequivocal mets, I would not offer PMRT; otherwise, I would offer PMRT. If PMRT is offered, I will start endocrine therapy, but add the CDK4/6 inhibitor after RT is done.
How do you fractionate SBRT for NSCLC abutting the chest wall or in which the PTV encompasses part of the chest wall?
To reduce the incidence of chest wall pain, we typically treat lesions abutting chest wall to 70 Gy in 10 fractions. However, if the lesion is small (<3 cm), 50 Gy in 4 fractions can also be considered if we can meet the chest wall dose volume constraints (30 Gy < 30 CC ideally- if not, 30 Gy < 50 c...
How do you contour proximal SV for definitive prostate EBRT?
Few people may know where the idea of the proximal seminal vesicle CTV came from. After the RTOG had completed it's 9406 phase II dose-escalation study with 3DCRT, we began the 0126 phase III trial of 70.2Gy vs 79.2Gy with 3DCRT. For the intermediate-risk patients, the predecessor 9406 study had a c...
How do you approach the treatment of de novo, brain-only metastatic HER2 positive breast cancer?
Patients who present with de novo, brain-only metastases of HER2+ breast cancer are rare, and hence, there is no good clinical experience or clinical trial basis upon which to base clinical practice recommendations. The current ASCO guidelines for the management of HER2+ brain metastases call for ap...
How do you counsel patients about prognosis with FIGO 2018 IIIC cervix cancer managed in the new era of chemoradiation plus immunotherapy?
The prognosis is still a function of nodal location, number of nodes, local T stage, histology, and response to the EBRT portion of treatment. The local control is closer to 90% with a predominant pattern of failure being distant (around 20-25%). Also based on A-18, 3 years PFS is around 70% and OS ...
How would you manage new symptomatic brain metastases (10-15) in a young woman with HER2+ metastatic breast cancer?
A lot of nuance to answering this on a per-patient basis.First question, how symptomatic? (As in, are there bulky mets that we should be considering surgical management upfront plus this also guides my discussion about whole brain vs systemic)If not acutely symptomatic and requiring a crani/resectio...