Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Why is there a benefit of ADT for high risk prostate cancer treated with radiation, yet no large trials describing benefit of adjuvant ADT after radical prostatectomy?
From a high level, the magnitude of the benefit of ADT with radiation seems proportional to the aggressiveness of the disease (i.e. low risk has no significant benefit, int risk weighs risk features and cardiac health, and high risk the benefit of ADT can trump cardiac risk). In that context, we hav...
What CTV margin do you use for IDH-mutant WHO grade 3 or 4 astrocytoma?
IDH-mutant (IDHm) WHO grade 3 or 4 astrocytomas carry a better prognosis than their IDH-wild type (IDH-wt) counterparts. These patients tend to live significantly longer than the IDH-wt. Current NRG consensus guidelines call for a 2 cm expansion over the GTV1 (T2/Flair) and GTV2 (cavity and any resi...
What SBRT dose and constraints would you use for a primary endobronchial NSCLC that is too thick for brachytherapy?
It really depends on the size and location of the lesion with respect to the proximal bronchial tree and other mediastinal structures (such as the esophagus). SBRT, as commonly understood (e.g., 50 Gy in 5 fractions), strikes me as risky in most such scenarios. Something more like 60 Gy in 15 fracti...
If a stage I laryngeal cancer completely responds to FU-based chemotherapy (given for another malignancy) would you consider observation?
We expect a 60-80% response rate with induction chemo data, with 20% having a complete response. That doesn’t preclude local treatment but predicts for better outcome.
Does the presence of cribiform histology at biopsy in prostate cancer affect your management in an otherwise intermediate-risk prostate cancer?
There have been no trials on this specific question, so there is room for debate and more science (hoping our recent grant submission in this area gets funded...). Here is my current thinking. This is for generally healthy patients with long life expectancy (≥10 years, but especially if ≥15 years). ...
How would you approach adjuvant radiation therapy in a patient with recurrent skin SCC of the gluteus s/p multiple resections with positive margins and adjacent osteomyelitis to the ischium and pubic ramus?
In this scenario, wherein a patient with recurrent cutaneous SCC has active osteomyelitis (assuming this is being treated), it would be prudent to avoid the involved bone as an OAR. I would not include the infected bone (I'd review the best imaging with radiology to ensure there's no involvement by ...
How would you treat an isolated para-aortic recurrence while receiving adjuvant pembrolizumab after definitive chemoradiation for cervical cancer?
If the patient has failed while on pembro, I would favor holding/stopping IO and plan for definitive chemo-RT to the para-aortic region with SIB boost with weekly cisplatin.
Is there evidence supporting the role of SBRT in the management of oligometastatic stage IV NSCLC?
Yes. I would look at a great trial from Wake Forest, looking at consolidative radiotherapy after 3-6 cycles of platinum-based chemotherapy, followed by observation, so chemotherapy, then radiotherapy, then observation (no maintenance chemotherapy). The trial occurred from 2010 to 2015. This single-a...
Do you see MR Linac having a role in the treatment of CNS disease?
MR Linac has a lot of potential in the management of CNS neoplasms. To best understand its potential, it is critical to understand what the genuine value proposition of the MR Linac really is. At its heart, and rather simplistically, many view it as simply another option for image guidance to suppor...
Would you recommend large-field radiation therapy to treat SCC of the skin with field cancerization (e.g., entire forearm, scalp) in elderly patients with CLL/immune compromise who have had mixed responses to cemiplimab?
Yes, retrospective data from Australia support large fields using VMAT at a median dose of 47.9 Gy in an average of 23.9 fractions with treatment breaks as needed and using a custom bolus. The photos in the article help clarify what is meant by 'field cancerization.' This phenomenon is termed extens...