Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How do you manage PSA progression while a patient is on Xofigo or Pluvicto?
The tl;drPSA is very much an imperfect tool for these patients. The data show that PSA may initially increase over multiple cycles before decreasing, though this is a minority of patients. Most patients whose PSA increases early have resistant disease, and you should investigate further with imaging...
Would you treat a male breast cancer patient with post-mastectomy radiotherapy for a single positive sentinel lymph node and a low Oncotype?
In the setting of a mastectomy with a positive SLN and no ALND, I tend to extrapolate from AMAROS. While Z0011 had no mastectomy and AMAROS limited mastectomy patients, I am comfortable extrapolating axillary management to mastectomy setting.In this case, I would offer PMRT to chest wall and regiona...
What is your approach to definitive RT for nasal vestibule squamous cell carcinomas?
I would use IMRT. For N0, I would treat at a minimum levels 1B, 2, and the in-transit facial lymphatics that used to get included in the traditional "moustache field". These in-transit lymphatics have been designated as level IX in the 2014 consensus nodal guidelines. For node-positive, I also treat...
What target expansions do you use when treating with 60 Gy in 15 fractions for the lung?
Is CTV needed with hypofractionated radiotherapy, such as 60 Gy in 15 fractions for stage III NSCLC, in the modern era of IGRT? Reducing the irradiated volume is crucial for improving the therapeutic ratio for locally advanced NSCLC (LA-NSCLC) patients. Technological advancements in radiotherapy tar...
Would you offer adjuvant chemotherapy or radiation to a resected MSS T3N0 high-rectal lesion with low anterior resection without pre-op therapy?
For patients with T3N0 upper rectal cancer with no significant risk factors (R0, CRM clear, no EMVI) who undergo high quality TME surgery as suggested by an intact TME pathologic specimen, the 5-year risk of pelvic recurrence without the delivery of adjuvant radiotherapy is < 5%. I do not recommend ...
How do you approach SBRT liver constraints when the total liver volume is <700 cc?
We consider 3 different methods of thinking about liver constraints when evaluating a plan: 1) Sparing 700 cc's to < 15 Gy (for 3 fractions), and <17 Gy (for 5 fractions). 2) Liver mean dose constraints (as in RTOG 1112 for CP A cirrhosis, <14 Gy), and <15-16 Gy for non-cirrhotic patients depending ...
Should high risk prostate cancer patients be placed on more potent ADT (abiraterone or enzalutamide) in the upfront setting with definitive RT instead of the standard LHRH agonist?
With STAMPEDE suggesting improvement with the addition of abiraterone in very high risk N0 patients, this is certainly becoming a consideration. Duke is completing a trial of concurrent abiraterone/STADT/definitive radiation for intermediate and lower high risk prostate cancer. Results forthcoming. ...
What are reasonable SBRT dose constraints for the lumbosacral plexus?
There are published dose tolerance guidelines for the sacral plexus with the AAPM TG101 report Benedict et al. Med. Phys 37(8): 4078-4101, 2010. Realize these have not been validatedOn page 4086, there is a table with suggested dose constraints for a 3 fraction regimen that include a threshold dose ...
For patients undergoing bladder preservation therapy with trimodal therapy, how do you manage the urinary urgency and frequency during and after treatment?
This can be a difficult problem to manage because I try to avoid treatment interruption if at all possible, which is different from my approach in patients with prostate cancer, where treatment interruption is a safe and effective alternative. In patients with bladder cancer, the first thing I will ...
How do you approach liver SBRT in patients with hepatocellular carcinoma who aren't candidates for surgery or other interventional procedures when the overall liver volume is small making it difficult to achieve liver constraints?
These are tough situations. I have used proton and photons for HCC. In the situation you described, I would generally favor IMPT due to improved low dose distribution and keeping the parenchyma not treated to a minimum while still giving an ablative dose more comfortably. Although the mean liver dos...