Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you treat a schwannoma of the breast with a positive margin that is not amenable to re-excision?
If it's pure schwannoma, it's benign pathology, and I would not do anything for microscopic residual disease.
How do you approach brain SRS for patients currently receiving Trastuzumab deruxtecan with progressive brain lesions?
Trastuzumab deruxtecan is an antibody drug conjugate targeting HER2 cells. This agent has recently been compared to a similar antibody drug conjugate T-DM1 (Kadcyla) and was found to improve disease progression and lower the risk of death for patients with relapsed HER2 metastatic breast cancer (Cor...
What are the indications for PMRT in an ER/PR(+) Her-2(-) patient with a complete pathologic response in the nodes after neoadjuvant chemo, but with residual disease in the breast?
This is an area where there is still a paucity of information. Hence, all guidelines need to be very tentative. I recommend PMRT for all patients having biopsy-proven axillary node involvement prior to chemotherapy, as I am concerned these are the patients at highest risk of local-regional failure. ...
Would you ever recommend testosterone replacement for men with incomplete T recovery after ADT for prostate cancer?
I have been hesitant to agree to supplemental testosterone after prostate cancer treatment, especially within the first few years. Prostate biopsies during that time often show atypical cells that are suspicious or adenocarcinoma with treatment effect. Androgens are pro-survival and the full effects...
When do you refer patients receiving CNS-directed radiotherapy to endocrinology?
In my practice, patients with pituitary tumors are followed by a pituitary endocrinologist. For all the other skull based tumors, I usually don’t refer patients to endocrinology unless a patient is found to have abnormalities with their pituitary function tests. We screen most patients with skull ba...
In what setting is PMRT indicated for T1-2N0 breast cancer?
In general, I do not offer PMRT to node negative patients with the exception of broadly positive margins. However, there is data to support the use of CW and RNI in the recently published EORTC 22922 trial in which more than 40% of patients were node negative (25% of patients were mastectomy patient...
What are your constraints when treating an abdominal site with SBRT?
There are many published guidelines and no single "right" answer for dose constraints when treating patients with abdominal SBRT. Guidelines should also always be taken with a grain of salt, as there may be relevant clinical factors for a specific patient that would make the general guidelines inapp...
Does liver-directed therapy (SBRT, Y-90, TACE, RFA, microwave ablation, etc.) improve overall survival?
This is a loaded question. The issue is that many of the studies detailing the use of TACE, RFA, and MWA do not collect QOL data. Survival is also not collected due to lack of long term follow up. SBRT data is mostly in the retrospective setting although there is some QOL data in Phase II prospectiv...
Do you use any particular dose constraints in patients receiving whole-brain radiation in the setting of prior SRS?
If a patient remains a candidate, I prefer to offer hippocampal sparing WBRT whenever possible, respecting the hippocampal constraints outlined in RTOG 0933 (Hippocampus D100% <= 9Gy; dmax <16Gy).In terms of other dose constraints, I don't typically enforce any constraints that would impact the cove...
For concurrent chemoradiation in head and neck cancers, how important is the timing of weekly radiosensitizing cisplatin early versus late in the week?
Our protocol for concurrent cisplatin-RT demands that the drug will be infused 1-2 hours before RT, usually on Mon. The assumption is that it will allow maximal drug concentration in the cancer cells at the time RT is delivered after chemo on that day, early in the week, while some radiosensitizatio...