Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach a cutaneous squamous cell carcinoma with primary tumor completely excised, but multiple foci of LVI at the peripheral specimen margin and no other high-risk features?
In a prospective study that assessed clinical and pathological risk factors for primary tumor site recurrence after margin negative excision of cutaneous squamous cell carcinoma, the presence of desmoplasia was reported to be the primary variable associated with this event. The authors specified tha...
In what situations would you treat elective regional lymph nodes for a squamous cell carcinoma of the skin on the extremity/trunk that was clinically node negative?
Nodal metastasis from small, to medium size [up to 3 cm in diameter] squamous cell carcinoma on the extremity is not that common. Considering the morbidity of nodal treatment in a patient with clear margins of resection I would not prophylactically treat the nodes. If the tumor shows perineural or l...
What volume and dose would you use for a Stage I MALT lymphoma of the lung?
MALT lymphomas are highly radiosensitive. Curative standard doses are 24 Gy in 12 fractions and 30 Gy in 20 fractions. The latter and slower dose fractionation (30 Gy in 20) is best used specifically in the setting of stage IAE Gastric MALT - a unique site with significant risk of radiation induced ...
Would you consider adding abiraterone to ADT and salvage RT in a prostate cancer patient with pN1 disease at radical prostatectomy?
This is a question that is being addressed in the salvage setting by NRG GU008. Currently, we have high level evidence that adding abiraterone to ADT is superior to ADT alone for subsets of patients with metastatic disease and the combination with RT is superior to ADT alone plus RT for both clinica...
Do you base liver SBRT dose fractionation on size, volume, or proximity of normal tissue?
I think about this differently than most people do. My goal is to deliver an ablative dose (100 Gy BED) regardless of the proximity of organs at risk or the size of the tumor. The more common thing to do is to reduce the dose of radiation below an ablative dose to 40 or 30 Gy in 5 fractions. I'm not...
When recommending salvage RT post-prostatectomy for an ultra-sensitive PSA level <0.1, do you still recommend concurrent hormonal therapy?
There is potentially an interaction between ADT's benefit and the PSA at the time of treatment. This was most well delineated in RTOG 9601 (Dess et al., PMID 32215583), but since then, using modern LHRH agonists, that interaction has been less well established (GETUG-AFU16, SPPORT, and RADICALS-HD)....
Do you ever dose escalate radiotherapy to the primary in low volume metastatic prostate cancer?
Background: STAMPEDE Arm H (SOC ± RT to prostate) allowed for two fractionation schedules, 55 Gy in 20 daily fractions (67 Gy EQD2[α/β = 1.5]) and 36 Gy in 6 weekly fractions (77 Gy EQD2[α/β = 1.5]), without correction for treatment duration), and approximately half of participants received each sch...
How do you talk with your patients regarding radiographic expectations on surveillance CT after lung SBRT?
In general, especially when I have a discussion about the 3-month follow-up scan and tell patients that the lesion may likely be stable in size, which is often normal, and not to panic. There may also be post-radiation changes that make it more difficult to initially interpret. I think this highligh...
Do you prescribe prophylactic steroids to patients receiving radiosurgery for AVMs?
I do not use prophylactic steroids when treating AVMs with stereotactic radiosurgery. In fact, usually SRS of AVMs is rarely associated with edema and these patients rarely require steroids in the observation period after SRS.
In patients with low grade gliomas that are older than 40 y/o or have subtotal resections, do you ever withhold upfront RT off protocol?
Yes. We should be humble about the data supporting RT in this scenario (that is, for IDH-mutant tumors). I would suggest that for IDH wild-type tumors (i.e., molecular GBMs) RCTs in the '70s established an OS benefit for RT and that withholding of RT is not supported.For IDH-mutant tumors, data from...