Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What PTV margins do you use for definitive prostate radiation?
I tend to follow the RTOG/NRG trials' guidelines for each clinical situation when deciding on margins from CTV to PTV (which use progressively tighter margins based on whether one is doing standard, moderate hypo-, or extreme hypo-fractionation): For conventional fractionation, RTOG 0924 states 0.5-...
Is there any role for post-mastectomy radiation in the setting of N1mic axillary disease?
Most data based on which we predict risk of recurrence and recommend PMRT is based on studies when Ni mic was considered node-negative and thus those studies would not be applicable to Ni mic disease. The IBCSG randomized study on Ni mic (dissection vs. no dissection) did have a percentage of patie...
Would the presence of an SVC stent affect your decision to offer BID vs once-daily chemoradiation for SCLC?
There is no evidence to guide the practice one way or the other. From a biological standard point, it should not.
Do you perform EBUS-TBNA for staging in patients with biopsy proven malignant lung nodules with no lymphadenopathy on CT chest and PET scan?
I agree that incidence is low, but estimates for radiographically occult nodal disease range from 10-20% and the fact is there isn't great literature on this. A PET scan is a decent test, better than a regular CT, but there are still a significant minority of patients that are mis-staged when an EBU...
How would you optimally boost patients with high or very high risk prostate cancer receiving definitive radiotherapy in 2025?
Micro-boost is my preferred strategy for dose escalation. The FLAME trial demonstrated a bDFS benefit (Kerkmeijer et al., PMID 33471548). The secondary analysis demonstrated reduced regional+distant metastasis and reduced local recurrence, as well (Groen et al., PMID 34953603). These benefits were ...
What is the appropriate timeline to start post mastectomy chest wall/regional nodal XRT (+/- reconstruction) after surgery?
If the patient received neoadjuvant chemotherapy, we typically give RT prior to additional chemotherapy (ex. xeloda for triple negative with residual, TDM1 for HER2+ with residual) and try to start 4-6 weeks post-op given that they are well healed and/or reconstruction/expanders completely filled. I...
In a patient with node-positive limited-stage small cell lung cancer, how do you approach radiation in a patient whose small primary tumor resolves after one cycle of chemotherapy?
In the case of imaging CR, I delineate CTVp based on pre-chemo volumes and apply PTV margin. If less than CR, I use post-chemo volumes to delineate GTVp and then utilize 4DCT to construct ITVp followed by appropriate CTV and PTV margins. Both approaches are consistent with ESTRO ACROP guidelines pub...
Is the presence of carcinoma in situ at the staple line after lobectomy completed for invasive disease an indication for PORT?
Usually not, in my opinion. Not all CIS will progress to become invasive disease, and in many patients the pace of any progression will be slower than competing comorbidities (or even other areas of CIS). The typical situation is that the radiographic mass is resected, and the CIS has no clear radio...
How would you approach a primary small cell carcinoma of the vagina in a patient with an intact uterus and cervix?
We treat with the same principle as cervical small cell with combination of concurrent chemo with cis and RT (EBRT plus brachy) followed by adjuvant cis and etoposide. No pCI.
Would you consider spine re-irradiation after Pluvicto?
This question will become more common as more patients undergo PSMA-based radiopharmaceutical therapy (RPT). The focus of this question seems to be related to the additional dose to which RPT may expose the cord and the ensuing risk of myelopathy. In summary, I do not believe there is (or could be) ...