Radiation Oncology

Breast Cancer   

Questions discussed in this category

What size cut off or other factors (i.e. LVI) do you consider? Do you only treat IMN and medial SCV vs include entire axilla if only SLN? 

Assuming there is no other locoregional or distant disease.  Would you treat the entire contralateral chest wall? Nodes?

Do age or margins factor into your decision making?  What dose and fractionation would you use? 

Would you recommend it for a mammographically occult primary or if the patient had dense breasts?  What if a high risk patient decides not to hav...

Are there exercises, massage techniques, or support garments that are effective at preventing or reversing lymphedema of the breast?

Z11 and AMAROS tell us that in cN0 patients, an adequate ALND is considered definitive treatment, but what about patients who have low volume biopsy p...

What are the indications for local control of the breast in patients with metastatic breast cancer?

Do you still follow the atlas guidelines and contour the breast to the latissimus muscle laterally the the pectoralis muscle posteriorly or since the ...

Alliance Z-1071 cohort had 5% with cN2 and <1% fixed or matted and the current Alliance trial 011202 only allows cN1. ALND has never been shown to ...

If there is a pCR in the breast and nodes do you treat the breast/chest wall SCV and full axilla?  IMNs?  Would the type of surgery (lumpect...

Do you think about it in the same way as DCIS in terms of radiation decision making (i.e. grade, margins, age of patient)?  Is Paget's disease le...

For instance, would you be more inclined to treat a patient with T3N0 disease and no other risk factors?  What if there were a small neighboring ...

For instance, in a woman with small volume disease in the breast, is your posterior border still the lung interface?  Do you cover all drain site...

What high risk pathology factors would you consider in making your decision one way or another?Would it matter if this patient was elderly vs young? W...

For standard tangential radiation would you pull the field edge forward to avoid radiation dose to the entire implant?  

What advantages/disadvantages are there over OncotypeDx DCIS assay or traditional clinical pathologic factors? What other concerns do you have?

In a patient with their second cancer, with oligometastatic disease, do the risks of RT related second malignancies outweigh the benefits?

What specific technique (i.e. interstitial vs intracavitary, 3DCRT vs IMRT) do you prefer? What do you consider to be the pros and cons with each appr...

What techniques are most effective to minimize contralateral breast, heart, and lung dose? Do you recommend conventional fractionation?

Are there any quantitative measures that you use to help select patients such as  breast size or heart dose? Or do you use a case-by-case qualita...

For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...

Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...

What is your preferred approach to PMRT with inflammatory breast cancer with adverse risk features (i.e. age <45, close/positive margins or poor re...

These devices give off a significant amount of artifact on CT and some devices say they are a relative contraindication with adjuvant RT.

Do you use portal or orthogonal imaging or both?

Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?  

If so, what clinical indications? Are there any advantages of VMAT? Thoughts on concerns regarding lung and heart dose constraints?

Some oncologists wait 1 day, 1 week or 1 month? Is there a preferred waiting period?

What size of DCIS would make you concerned? Would you estimate the risk of recurrence with and without radiation?

What's the minimum isodose coverage line you accept for coverage of higher level axillary lymph nodes?

Do you find such markers such as biozorb to be more helpful than delineating the seroma and/or clips on CT?   When is this useful? During ...

Does the T stage influence your decision (for example, T1mic)? Would multiple positive nodes showing isolated tumor cells sway your decision? 

Do you always recommend treating breast cancer patients with getting reconstruction with their tissue expanders in place? Or is there a scenerio you w...

Would you consider hypofractionation? If so,what dose? Would you consider a boost if there were close margins?

Although these patients are included in the Danish trials, Taghian et al. & Floyd et al. both showed ~ 7% LRR in this group of patients witho...

NSABP B-39/RTOG 0413 prescribed a dose of 38.5 Gy using two fractions of 3.85 each daily, but prescribed to the ICRU 50 reference point dose (usually ...

Do you use CBCT or kV images? Do you match to the breast or the chest wall?

An ASTRO APBI update readers are warned “the combination of IORT and WBI should be used only with caution and limited to women with higher risk ...

NCCN states that daily imaging is discouraged but in practice many radiation oncologists are doing daily cone beam for non-IMRT breast 

There have been case series published on this topic (most recently, PMID:26853347) with reported depigmentation within the RT treatment field.

Assume you have good margins and the cavity abuts the implant. Are there any specialized techniques that you would recommend?

Do you use NRG/RTOG, IMPORT LOW, single institution data, or retrospective data?

An example of an air expander is located at: https://www.airxpanders.com/index.php   How do you ensure accurate dosimetry with the use of air ...

Specifically, any data or experience regarding Ehlers Danlos syndrome?

If the patient meets the CALGB criteria for the current cancer, are there situations where you would omit RT in a patient who has never had RT? What i...

Would you recommend mastectomy? What would you irradiate?  What are your fields?

Updated NCCN guidelines say there is no data to support radiation for pleomorphic LCIS. Previous discussion recommended radiation for LCIS https:...

If planning standard fractionation, what factors would you consider in omitting a boost (ie age, LVSI, etc)? 

https://www.abstracts2view.com/sabcs18/view.php?nu=SABCS18L_568 Any concerns regarding toxicity with APBI?  

Do your recommendations differ if patients are pre or postmenopausal given the data?

If a patient is on rituximab for multiple sclerosis, do you recommend a particular fractionation to minimize chance of MS flare during treatment? If a...

Would you recommend a patient get mastectomy to avoid radiation? If treating a breast cancer patient with ILD, what lung dose constraint do you use?

In particular, I have a patient who underwent lumpectomy for a T3 tumor with positive margins and 1/2 SLN+.  She is now scheduled for mastectomy ...

If a patient is due for their yearly mammogram on the breast that has been diagnosed with cancer but is still undergoing active treatment (chemo or ra...

Would you recommend this for a focally +, diffusely +, grossly + margin? What would you expect local recurrence rate for diffusely (+) microscopic mar...

Would you do anything different than usual regarding bolus, energies, skin dose desired for post-mastectomy chest wall radiation if a nipple-sparing m...

Is there concern for increased risk of chronic nipple pain with NAC in the boost field? 

 At what energy of electrons would it be better to use photons?  How many fields and what field angles should be used for photon boosts?&nbs...

What techniques have you used to evaluate for field overlap given the different setups? We have used a thick wire placed at midline during the verific...

Do you consider this regimen based on the 10 year results of the UK FAST trial?

Assume patient is otherwise a suitable candidate.

If a patient has early stage disease with peau d'orange but does not meet criteria for inflammatory breast cancer, is PMRT indicated?

Should LVI be considered present in a patient with positive nodes? MSKCC showed that LVI is a risk for LRR with 1-3 positive nodes...

Would you treat both chest walls at the same time? What fields would you use for the contralateral side:  chest wall and lymph nodes? or just lym...

Particularly for patients too large for prone breast treatment, do you use a breast immobilization device or bra?   Do you change your fractionat...

Assume your patient did not receive radiation upfront and they had an axillary dissection due to recurrence. Would you recommend radiation? What would...

Any consideration on standard vs hypofractionation?

There has been shifting concerns with medication side effects (such as osteoporosis, blood clots), duration, and potential non-compliance.  

What volumes and dose would you treat? Would you treat the regional nodes alone (including IMN)? Would you treat the chest wall?

Would you consider traditional breast doses or higher? Would you consider treating only the axilla if the mastectomy specimen showed widely-negative m...

I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...

Does it make sense to resect only the axillary nodes, but not the other involved nodal regions?  Regional nodal radiation will be given.  

Patients are understandably concerned about the risks and benefits of radiation to an oozing, bleeding, ulcerated breast.  

How significant does the moist desquamation need to be? Does the length of tretment remaining ( i.e. 1 v. 3 weeks) or use of medication effect your de...

What if this was an electron vs photon boost? What fractionation scheme would you use?

Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate?  Is there a decent equatio...

Has the publication of the recent EBCTCG metaanalysis changed your practice?

Is breast conserving surgery followed by radiation therapy an option? 

Inflammatory breast cancer is a contraindication for immediate reconstruction at the time of surgery, but is there a disease free interval after all t...

What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...

After the publication of ACOSOG Z11 we are seeing these patients in increasing numbers.

Do patients > 60 years old with no high risk features have any significant benefit? Has the recent update of the EORTC boost trial affected your pr...

What if it was found on SLNB and no axillary dissection was performed? Any risk factors that would make you consider RNI vs CW only vs observation?

In a setting of standard fractionation, we would sometimes consider going to 66Gy total dose to the boost cavity, so how would you "translate" this to...

The recently published SSO/ASTRO/ASCO consensus guideline on DCIS states that "a 2 mm margin minimizes the risk of IBTR compared with smalle...

For conventional fractionation, should one increase total dose above 60 Gy for either close or positive margin (invasive or DCIS). What about for acce...

When would you omit or include a boost for DCIS after whole breat irradiation?

In START B ~ 23 % of women received some form of cytotoxic chemotherapy, and the trial was conducted in the trastuzumab era, but there is no ment...

The Canadian trial showed conventional fractionation might be better in the Grade 3 subset, but this was not shown in the START A/B update. What can e...

What dose calculation algorithm to you utilize (eg AAA, Acuros, etc)? Do you prefer a particular algorithm for certain sites? Do you take in...

Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...

I trained at a place where use of a bolus for chest wall irradiation PMRT was standard practice, but this is not so at my practice right now.  As...

Assume no history of radiation, no evidence of distant disease and no nodal disease on dissection. Would you treat the chest wall or the&nbs...

Is the dose fractionation used in BR-001 (10Gyx3) appropriate for all osseous locations, for example humeral head metastases?

Assuming the patient has N2-3 disease, would you consider omitting IMN? What other techniques would you consider to limit lung exposure?

http://www.nejm.org/doi/full/10.1056/NEJMoa1612645?rss=searchAndBrowse&#article_abstract If so, how do you sequence it with adjuvant radiotherapy...

Is there a dose constraint you are using for LV-V5? https://www.ncbi.nlm.nih.gov/pubmed/28095159?dopt=Abstract

At what point would you decide to forego local control managment (RT or mastectomy) in favor of chemotherapy alone?

This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...

Would patient age factor into your decision, such as a patient <30 or 40? If you would not give RNI for a favorable pT3N0, are there other risk fac...

CALGB 9343 included ER positive patients but did not separate them out based on herceptin status. Does the study help inform their risk?

Would you recommend any imaging of the axilla before lumpectomy? Would you recommend standard breast fields vs high tangents to cover the lo...

Assume the patient had no radiation, what would your volumes be? Would you recommend radiation if the patient had whole breast/chest wall radiati...

When do you institute a treatment break for skin reaction for patients who receive breast radiation?

There is anecdotal concern regarding history of estrogen replacement therapy causing stimulation of breast tissue and therefore potentially increased ...

In other words, if there are borderline indications for PMRT (ex initial T3N0 or T2N1 disease) with a pCR, would the suspicious IM nodes lead you to o...

What is the maximal amount of time you would allow between the surgery the start of adjuvant RT? What other factors would you consider when deciding w...

Do you use the typical indications for PMRT (nodal status, size of primary, LVSI, age, etc)?  Or,  do you recommended PMRT more frequently (...

When would you recommend that SLNB be performed prior to neoadjuvant chemotherapy? When would you recommend additional staging (completion axillary di...

Would you treat the regional nodes alone (not previously irradiated) or would you also re-treat the breast/chest wall?

What factors would help you make your decision? (Age, genetics of lung or breast cancer, triple negative, LVSI, T2, etc?)

Would you rather they delay the start of treatment so that it was >3 months from date of surgery or have a break of several weeks during XRT? Assum...

And does the fact that the breast is lactating affect radiation toxicity in anyway?

For hypofrac breast patient (such as 40 Gy in 15 fractions), what is the maximum hot spot that you will accept anywhere in the breast?  107-8%? 1...

Comprehensice RNI? High tangents? Whole breast only? Does ER/PR/Her2 status influence your decision?

When trying to eliminate dose heterogeneity during field in field planning for hypofractionated breast radiation with a large separation, the resultin...

The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.

If the patient meets CALGB criteria but has EIC would you lean towards giving RT? What other factors would lead you to give whole breast RT an elderly...

Is the risk of IBRT any greater than in non mutation carriers?

Does neoadjuvant chemotherapy with complete response in the axilla alter your management preferences?

If a male has early stage breast cancer and would otherwise meet criteria for the CALGB or PRIME II trials, would omission of radiation be an option? ...

e.g. how does the tumor burden on axillary dissection, sentinel biopsy only, extracapuslar extension, and the size of hte metastasis play into your de...

Is it still acceptable to deliver hypofractionation for what was previously a Stage I TN breast cancer, now Stage IIIA? Should RNI be considered? Or e...

Do you attempt to have the pacemaker moved? If the patient is non-dependent, would you ever treat with the pacemaker in field?

Do the same concerns as post-mastectomy radiation of implants apply? There are some small case series' (https://www.ncbi.nlm.nih.gov/pubmed/21346535 ...

Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound?  I...

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage.  Is t...

E.g. someone with high grade and/or >2.5cm disease? If we use age as a cutoff in invasive disease to omit adjuvant radiation based on the...

Her2 status was not evaluated as part of the PRIME 2 or CALGB trials and luminal Her2 patients likely represent a small minority of those enrolle...

Would you recommend a mastectomy for her breast cancer in attempts to avoid RT?  If the patient undergoes a lumpectomy or needs PMRT, would you a...

How would you approach a young woman (under the age of 50) with DCIS with favorable disease (ER+, low grade, small size <5mm, negative margins)?

For instance, are you more likely to offer PMRT to a man who is node negative but with several high risk features such as high grade, LVI, high oncoty...

This is rarely done, but recently came up in a tumor board discussion.  Which chemotherapy would you consider using, and when?

Do you ever use BID fractionation?  What patient factors do you use to individualize the treatment?

How many intercostal spaces do you include? Do you vary these parameters based on the disease characteristics?

Is there a practical way to quanitfy risk of LRR in patients with T1-2 N0 with multiple high risk factors in such as multifocal disease, high grade, L...

These patients were not eligible for Z0011 and represents less than 5% of the patient population in AMAROS. Thus, can you apply these two trials to ju...

After multiple adjacent tissue transfers it is difficult to define a "tumor bed" with oncoplastic surgery.  Surgical clips are often useful ...

Would you send the patient to a surgeon for consideration of a mastectomy?  Would you then consider post mastectomy radiation when the risk of re...

What are indications for adjuvant radiation for a early stage well differentiated adenosquamous carcinoma of the breast? What is the best radiation th...

What factors in particular guide your recommendation of PMRT for invasive lobular carcinoma?

Would your management change if including the drain sites requiree treating more lung or adding separate electron fields?

What factors do you consider when offering PMRT? Would you change your dose/fx and/or field size?

Women with cN1 disease at diagnosis who are ypN0 after neoadjuvant chemo can be randomized on NSABP B-51, but not those with cN0 disease and treatment...

What about in cases of a tunneled lumpectomy cavity using a circumareolar incision?

Do you always stick with a conventional fracionation, or in some cases, are you comfortable hypofractionating? Do you ever use a wait and see approach...

What factors do you consider when adding post-lumpectomy radiation therapy for treatment of an intracystic papillary carcinoma?

Randomized trials in the 1980s demonstrated equivalent survival and disease control outcomes for lumpectomy + RT vs mastectomy, but several recent pop...

Do you have a formalized approach, or is it a case by case decision? Do you use bolus differently for a TRAM, tissue expanders, implants, etc?

Do you prioritize certain dosimetric parameters over others (e.g., considering the Darby report, mean dose to the heart vs. mean LAD dose?)  

In a patient who recently completed NAC, TM/LND and PMRT for a hormone positive locally advanced breast cancer and is then found to have a contralater...

If there is a signifcant amount of breast tissue contacting the couch in the prone position, are there strategies that can be used to mitigate po...

Should patients be managed similar to BRCA patients and consider bilateral mastectomies as an alternative to BCT?

In a patient not receiving adjuvant chemotherapy who has a delayed consultation due to complications/personal issues, etc, is there a time delay ...

Comparison of prone versus supine positioning showed that 85% of patients with left sided breast cancer benefit more from the prone versus supine posi...

Since we know that both the "Canadian" fractionation and partial breast irradiation work as treatment for early stage breast cancer in the same patien...

The Hughes study looked at women > 70 years of age. In light of the PRIME II results, can women aged 65 - 70 avoid RT or is longer follow up needed...

Would you change your management based on receptor status (ER/PR+/HER2 neg vs triple neg) or menopausal status (pre vs post menopausal)? Would you tre...

Would this be considered acceptable in an older woman with high grade disease?

Dose in many studies were often prescribed to a point rather than a volume and with 3D planning, we may be upping the breast dose.  The D2eq dose...

Does the recent Danish Breast Cancer Group IMN study (JCO 11/23/15), showing a survival benefit to IM irradiation in patients with early stage no...

If not, do you have any experience with acceptable late toxicity and cosmesis with whole breast radiation in these patients?

We sometimes find highly suspicious LNs by CT, PET or MRI in the undissected regional lymphatics, and surgeons may not be willing to perform another o...

Can the IMNs ever be spared, or would you consider it mandatory for all inflammatory breast cancers?

E.g. breast? I have found no literature on skin tolerance acutely or chronically.

The GEPAR trials presented at ASCO 2015 showed increased LRR with the omission of RT in patients who had a pCR after neoadjuvant chemotherapy.

Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.

Is your decision influenced by factors such as the location of the intramammary nodes and/or the mapping of sentinel nodes to the axilla?

I sometimes receive pathology reports that state the margin is negative but do not quantify DCIS proximity to margin. I typically like a margin of 2-3...

There seem to be good prospective studies (Australian study and Canadian study) which debunk the thought that deodorants/antiperspirants increase skin...

If the patient has no pathologic risk factors that would ordinarily necessitate PMRT, do you omit it? Does triple negative subtype affect your decisio...

Would the risk of radiation-induced second malignancy outweigh the benefit of locoregional control for a young patient with high grade DCIS? 

Do you have any concern for increased toxicity when you treat a patient with radiation therapy who has an autoimmune disorder? (hypofractiationation v...

With conventional RT, the dose to the brachial plexus should be no more than 50-55Gy max. One exception to this is the addition of PAB in conventional...

What is the best evidence available for the benefit of PAB in disease control?

Do you look at pretreatment breast MRI or post surgical assessment of the tumor bed/treatment effect?  How would you resolve discrepancies betwee...

Would it be acceptable to treat a patient with locally advanced breast cancer (ex pT2N2a) s/p lumpectomy with a short course 4 week treatment ins...

In a patient with a T1 breast cancer who underwent mastectomy and ALND and recurred in the axilla a year later, would you offer RT to the chest wall a...

i.e. are there any situations where you may recommend against using hypofractionation for a patient with left sided breast cancer such as dose constra...

I have heard of long term pentoxifylline and Vitamin E daily combination that can prevent and even reverse radiation fibrosis (Delanian et al. JCO 200...

Would extensive residual DCIS (>5cm), hormone receptor negativity, Her2+ status, or age < 40 effect your decision?

Is there any literature supporting that a gentle fractionation/bid regimen (i.e., 1.5Gy bid x 30 = 45Gy) is safer than a standard fractionation  ...

Does the axilla have to be addressed surgically or with RT, given that the AMAROS trial eligibility criteria were amended to address sentinel lymph no...

If so, how do you decide which patients to treat with breath hold vs. free breathing? Do you routinely perform 4D CTs? 

A 40 year old patient receiving post-op RT for  breast cancer asked me if there is any risk for her becoming pregnant after completing RT. Eric H...

In a patient with Stage IE DLBCL, is your treatment volume postchemo ISRT or whole breast? Would you consolidate if a lumpectomy was performed prior t...

The 2013 ASCO guidelines and current NCCN guidelines recommend yearly mammograms but our radiologists are still recommending mammograms every 6 m...

If the patient has negative axillary nodes and no other signs of high risk disease other then a local chest wall failure, do I still need to treat the...

They used to be given concomitantly now they are done sequentially.  I can only find conflicting data to justify this trend.

We have a lot of push from our surgeons to do IORT, do you use the ASTRO APBI criteria? Do you treat off-protocol? Do you use Xoft or Intrabeam?

If so, do you do this routinely or only in certain circumstances? Is there data to support routine mammogram before breast radiotherapy?

In a case-control study by Darby et al in the New England Journal of Medicine, patients treated for breast cancer with radiation were found to have an...

Or for that matter, offer PMRT on the basis of a patient having triple negative disease?

With the recently reported START (A and B) trial data from the UK, in which patients were allowed to receive hypfractionated doses to nodal regions, i...

I'm not sure how to interpret the results of the study published in JNCI earlier this year.

My institution is considering a major investment/purchase of this technology to complement our existing array of breast radiotherapy options.

Has the recent 12-year ECOG update for surgical excision of DCIS without radiation therapy changed your practice management?

Papers discussed in this category

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