Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Would you include the supraclavicular basin in adjuvant radiation treatment fields if there were multiple positive axillary sentinel lymph nodes with ECE discovered at the time of resection of a proximal arm cutaneous SCC?
Short answer, I wouldn't. I'd do good restaging (PET vs contrasted CT or both) and ensure you're just dealing with microscopic residual or to guide boosting to gross disease dose if gross residual in axilla, and just treat your involved axilla and primary site if indicated. This is a patient who wou...
As consolidative thoracic radiation (cTRT) was prohibited on the seminal chemoimmunotherapy trials in ES-SCLC, how do you approach cTRT in practice?
There are two trials showing benefit for TRT for patients with ES-SCLC, one from Yugoslavia and one from the EORTC (though, the primary endpoint was not met). The Yugoslavian trial was not considered practice changing, while the EORTC study has made me consider adding TRT in certain patients, even w...
How would you approach a patient with recurrent grade 3 oligodendroglioma (MGMT-methylated, IDH mutant, 1p/19q co-deleted) 1 year after gross total resection and adjuvant chemotherapy and radiation?
There are multiple options to consider for the recurrence of grade 3 gliomas after prior chemotherapy or radiation. Regardless of whether or not the recurrence overlaps completely or partially with the prior treatment fields, options include systemic therapy (including IDH-targeted therapies for IDH...
Are there any indications to boost the axilla for women with locally advanced breast cancer who do not have clear gross residual/undissected axillary disease?
There is no indication for a boost in absence of undissected gross node for upfront surgery or residual node, which is not removed after neoadjuvant chemotherapy.
What surveillance do you recommend for a patient with locally advanced rectal adenocarcinoma who had a complete clinical response to total neoadjuvant therapy and declines to undergo surgery?
It is important to watch these patients closely since ~15-20% will have local regrowth/recurrence that are salvageable (Dossa et al Lancet 2017). The OPRA trial, recently presented at ASCO 2020, included 324 patients treated with TNT regimens and WW if complete response. Organ preservation rates wer...
How would you alter your PTV margins for a lung SBRT target adjacent to the rib?
Overall, while I generally do not alter my margins substantially for an SBRT target adjacent to the rib, there are some circumstances in which I might make small/subtle changes. My driving thought process is that (in particular for stage I NSCLC) tumor control remains the most important factor, as c...
Is it appropriate to use SBRT on unresectable pancreatic tumors invading the duodenum?
Duodenal invasion would be considered an absolute contraindication to SBRT at our institution. If you look at the early SBRT experiences, such as the Danish phase II trial (PMID 15990186) which treated with larger margins than we use today and did not pay as close attention to the duodenal dose, the...
Given the results of PLATO anal cancer study, is 4140 cGy the new standard for early stage anal cancer?
The original Nigro regimen using 30 Gy was effective for anal cancer treatment, and so it is not surprising that 41.4 Gy for early stage anal cancer is similarly effective. The Lancet publication is a pre-planned secondary endpoint of cCR, and not the primary endpoint of the trial which is 3-year lo...
In the post-mastectomy setting, are there situations where only the regional nodes or targeted nodal basis are covered?
Thanks for asking this question. People occasionally ask this. Essentially all of the trials that show a survival advantage with PMRT used comprehensive local-regional therapy. So, doing something other than both the chest wall and nodes would not be based on the available data. Cancer is sneaky, i...
What is the optimal/safest regimen for re-irradiation of a partial chest wall following surgical resection of an isolated chest wall recurrence?
I agree with Ben that this is a difficult scenario. Resection with new tissue is ideal, but cannot always be done. Removal of the gross disease with some type of resection is also optimal if possible. Use of chemotherapy for isolated chest wall recurrence is controversial, but is often done. I pers...