Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Given the updated results of the PREOPANC study, how can gemcitabine-based neoadjuvant chemoradiation be best incorporated into the treatment of resectable or borderline resectable pancreatic cancer?
The PREOPANC-1 trial and the study by Jang et al., PMID 29462005 are currently the only 2 published randomized trials comparing pre-op CRT vs up-front surgery for resectable/borderline resectable PDAC- each of which has now demonstrated an overall survival benefit. The obvious critique is the standa...
How would you approach a patient with a primary splenic DLBCL who has residual PET avid disease after 6 cycles of R-CHOP?
The treatment of DLBCL arising in the spleen would be very similar to the treatment of DLBCL at most other sites. After a full course of chemoimmunotherapy, if the patient has not achieved a complete response by PET-CT (Deauville 1-3), then the treating physicians need to make a judgment. The primar...
Would you hold cabozantinib for radiation therapy, or is concurrent use safe?
Cabozantinib is a VEGFR-TKI which potentially carries a risk of hemorrhage and bowel perforation when given together with high dose RT or SBRT though, tangible data are lacking. We will typically hold the drug for 3 days before starting SBRT and will resume 3 days after SBRT (not evidence-based).
What is your strategy for managing radiation dermatitis in breast cancer in the prophylactic, erythema/dry desquamation, and moist desquamation stages?
Good question. Everyone seems to have a favorite home remedy with very little good supporting data. I am unaware of any good prophylaxis rx. The best thing is good treatment planning to minimize inhomogeneity. There are phase III data demonstrating the efficacy of soap and water cleansing for rx of ...
Would you consider eliminating PMRT to the chest wall in select cases of T3N0 breast cancer?
There are a number of studies, including the one below, that suggest that favorable ER/PR+, HER2 negative patients with T3N0 have low local recurrence rates without PMRT. Every case is individualized and should take into consideration all factors including size, margins, and other adverse features b...
How would you mange true anal margin squamous cell carcinoma (with no involvement of anal canal) if wide local excision cannot be done and chemoradiation therapy is being used instead?
There are many facets to this question. First, it is critical to know that this is a surgical disease, and radiation therapy should only be used as a last resort. If there is no involvement of the anal canal, that strengthens the argument for the use of surgery. The situation is rare when radiation ...
How do you assess whether a patient is suitable for prostate SBRT?
At UCLA, we do not routinely use a prostate volume/size threshold when considering whether a patient is a good candidate for SBRT or not. There are data from the Georgetown group that suggest that men with prostate volumes ≥50 cm3 may have slightly increased acute grade ≥2 GU toxicity; these res...
How do you treat inoperable T1-2N0 apical lung cancers near the brachial plexus but without extension outside the lung?
This is a challenging question, and there are certainly a range of reasonable answers. I would agree with @Dr. First Last that the Forquer/Timmerman paper establishes there is significant risk of plexopathy when exceeding 24-26 Gy in 3 fractions. On the other hand SBRT offers superior local control ...
What cumulative dose would you allow the pharyngeal carotid to receive for a course of reirradiation for a retropharyngeal node?
No dosimetric data available. I don't use a carotid OAR in my cases, and just ensure the disease is appropriately covered, while limiting cord/brainstem primarily.From the literature, highest risk cases are those with skin involvement (ie tumor from skin to carotid). Risk of 1-5% for carotid blowout...
Would you treat a NSCLC with a hypofractionated course daily or every other day?
The rationale for every other day dosing dates back decades, but in the SBRT/SABR space was perhaps most clearly demarcated for most of us in the RTOG 0236 protocol. In this study, when delivering 54 Gy/3 it was stated that "A minimum of 40 hours and a maximum of 8 days should separate each treatmen...