Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you manage a solitary, painful, lytic bony lesion in a patient with negative PET/CT but bone marrow biopsy confirmation of multiple myeloma?
This is a palliative scenario, but the approach may differ based on the clinical circumstances. If Heme Onc is planning on administering systemic therapy, then a short course of palliative RT to expedite pain control would be appropriate. Treatment of many sites (e.g., femur) can be done very quickl...
What, if any, radiation regimen would you use for knee arthrofibrosis in a patient undergoing repeat arthroscopy with lysis of adhesions?
The high-dose single fraction regimens seem to be adapted from heterotopic ossification protocols and would be my choice if there was a concern for HO. If the concern is for the reaccumulation of fibrotic tissue, I favor LDRT such as 0.5 Gy 2-3 doses weekly for 6-8 fractions. There will be more sust...
Do you typically recommend avoiding neupogen during radiation treatments?
It depends on the reason and expected benefit. If myelosuppression is holding up RT for cervical cancer patients, then I would not hesitate to give neupogen to avoid or minimize a treatment break. There would be more benefit to neupogen and continuing RT than a downside. Usually, I would try to give...
In a patient with gastroesophageal adenocarcinoma treated with neoadjuvant chemoimmunotherapy who had a good response but is unable to undergo surgery, how would you approach radiation therapy?
As the ARTDECO study did not show a difference in local control between 50.4 Gy and 61.6 Gy (given with carbo/taxol, but FOLFOX is also an option per PRODIGE5, depending on chemotherapy used as part of the initial chemo-IO), I would suggest 50.4 Gy.
When would you consider initial induction chemotherapy (e.g. FOLFOX) followed by neoadjuvant chemoradiation, over neoadjuvant chemoradiation alone, in patients with locally advanced rectal cancer?
At MSKCC, we now routinely recommend induction chemotherapy (8 cycles of FOLFOX) to any rectal cancer patient who requires preoperative chemoRT. Initially, we adopted this approach for patients with particularly bulky or node-positive disease (as per @Dr. First Last's answer above) but now do it for...
For marginal recurrences of skin cancers after prior hypofractionated radiation therapy (i.e., 30 Gy/5 fx, 55 Gy/20 fx) where there is concern for overlapping fields, could reirradiation with a hypofractionated course be considered?
For a marginal recurrence of a cutaneous malignancy after definitive hypofractionated RT, I would not necessarily offer reirradiation. I would have my plastic/dermatologic surgeon see the patient for consideration of surgical salvage, which may likely require an advanced reconstruction. If the patie...
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 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.