Radiation Oncology

Stereotactic Body Radiotherapy   

Questions discussed in this category

Does tumor location play a role (central vs peripheral) in making the decision?  The question stems from an oral presentation at ASTRO 2014 inves...

Would you alter your SBRT dose? How long would you hold the VEGF inhibitor before and after? Does the primary matter (e.g. NSCLC vs. colorectal)?

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

Are pre-treatment PFTs actually correlated with treatment-related toxicity? If no absolute cutoff, do you have an ideal lower limit for PFTs...

Is there a benefit to one fractionation schedule v. the other?

For example, would you modify your SBRT dose next to the azygous vein? While we talk frequently about OAR constraints for the great vessels, it seems ...

I am treating a left lower lobe NSCLC and my PTV is so close to the spleen that a small portion of the spleen is getting significant dose.  I can...

Would you consider treating 3-5mm lesions with SBRT or wait until they are a certain size? I am concerned I will not be able to see them adequately on...

I see the LungTECH trial dose constraints, but, they seem really conservative when you have something large and close the PBT resulting in use of 60 G...

There seem to be a lot of different fractionation schemes in the literature. Is there one that is most standard?

Do you prefer breath-hold techniques (ABC, DIBH) or abdominal compression regardless of tumor motion? Or do you use a general threshold number of cc's...

The Indiana report and RTOG published a "danger zone".  There was a catastrophic "case report" for 50 Gy in 5 fractions.  Are there alternat...

Is there a dose response relationship, as suggested in the phase I MSKCC dose escalation study presented at ASTRO 2017?

In a patient with a cavitated lesion with underlying chronic infection (identified as cocci) and SqCC, are there additional risks to SBRT? Should spec...

In patients with aberrant anatomy due to previous surgery with lung PTV overlapping the stomach, how much would you dose de-escalate? Even conventiona...

Do you discuss this at the first consultation? Is there strong evidence to suggest that risks are significantly increased compared to upfront lobectom...

Is local control worse for SBRT when the tumor is invading into the bone (rib)?

Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?

Aside from steroids and PT, is there anecdotal evidence for warfarin, hyperbaric oxygen, bevacizumab etc. Any experience with these therapies?

For example, a NSCLC of the LLL abutting and potentially involving the adventitia of the descending aorta?

In a patient with pain that does not respond well to narcotics what would be your treatment approach?  Is there any data that suggests patients c...

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

If so, 50 Gy / 5 fx? 7.5 Gy / 8 fx? If so what dose constraints would you use to help determine fractionation?

Does fractionation (or location) influence this decision? What is your preferred steroid dose?

Is there a role for SBRT to the primary site? Is it required to treat the ipsilateral hilum if no adenopathy was seen on EBUS or PET?

Given the multiple retrospective studies showing benefit to higher BED fractionation schedules (most recently, http://www.redjournal.org/article/S0360...

Given the lepidic growth pattern, do you use similar margins as with frankly invasive lung tumors? Are there any challenges localizing the target with...

When treating lung tumors abutting the visceral pleura/chest wall with SBRT, chest wall or rib pain sometimes occurs. In these cases, I try to avoid i...

If given options of liver, lung, spine, brain, axilla, or other lymph nodes which sites do you pick?

Any special dosing considerations or can you approach this like any other small peripheral NSCLC?

Which imaging studies do you perform and what is the timing after treatment?

When is SBRT appropriate? Do you approach dose and fractionation differently in this setting?ƒ

Does your volume change based on fractionation (high-dose single fraction vs. 3-5 fractions)? Do you treat the entire circumference of long bones? Wha...

Are there specific conformality parameters you prioritize (105% dose volume outside of PTV, conformality index, ratio of 50% isodose volume to PTV, an...

Recently, while planning a patient for lung SBRT it was suggested by the physicist that we change the density of the PTV to higher density to improve ...

Have you ever seen toxicity related to diaphragm dose with conventional fractionation?  

And at what intervals? The published trials/RTOG call for q3 month MRI follow-up. Is this appropriate outside a clinical trial setting? 

If surgical stabilization has been performed, do you go with SBRT dosing? If so, do you treat only the involved site and not the extent of hardware? D...

What is the average healing time? What medications and/or procedures do you recommend for pain control? Does management differ for those with chest wa...

Do you specify an isodose line to prescribe to? Do you ask for a percent hot, and if so do you specify what percent or volume of the GTV/ITV should re...

Under what clinical circumstances would you consider prescribing them?

What fractionation scheme would you use?  Would you give SBRT to a hilar tumor that has N1 nodal involvement adjacent to the tumor but can be enc...

If a biopsy carries a high risk of morbidity what interventions would you recommend for the local failure?

In my training, we used an abdominal compression paddle, but in my current practice, my physicist says that we cannot treat through multiple parts of ...

As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?

In starting prostate SBRT at an instutution, what are issues with the treatment that one should pay special attention to?

If so what dose-fractionation do you use and what constraints for brachial plexus?

In treating an oligometastatic lesion in the sacrum, is it reasonable to extrapolate from RTOG brachial plexus contraints (eg, 8 Gy/fx for a 3-fractio...

In other words, if offered wedge or segmentectomy, should SBRT be preferred? Does size matter ie if the lesion is < 3 vs < 2 vs < 1 cm? Does ...

The BED10 for 50 Gy in 5 fractions is 100, which is significantly lower then the BED of the 54 Gy in 3 fractions regimen (151). Since the Kestin/Grill...

Our dosimetrists rarely meet the RTOG constraint using a non-coplanar technique, especially for very small lesions. I haven't been able to find a corr...

What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...

Any advice on how to safely incorporate it into our practice?

Would you consider placing a stent in this patent graft to minimize closure of the graft after SBRT?

Is there any concern about hemorrhage from treatment effect on tumor? Would SABR worsen the chance of fatal hemorrhage/hemoptysis and if so, would you...

For small overall volumes (e.g. 0.5cm solid component, 1cm total lesion size when including GGO), I imagine treating the entirety of the abnormality i...

ASTRO 2014's lung session presented data from RTOG 0236, showing a 20% intralobar failure/recurrence despite only 7% local failure. How does one recon...

RTOG 0915 allows either technique, but I've heard people say that IMRT is not "technically" SBRT. Is there is a benefit to the non-coplanar 3D techniq...

For that occasional "single lymph node metastasis" referral in patients with no other sites of disease, is there a therapeutic dose below which you're...

In SBRT, it has been said that Pencil Beam dose calculation algorithm can overestimate the target dose and understimate the normal tiss...

What dose/fractionation is appropriate and does it differ between histology?

What are the primary data that drove organ at risk and conformality dose constraints?  

Papers discussed in this category

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Radiother Oncol, 2014 Mar

Int J Radiat Oncol Biol Phys, 2002 Mar 15

Radiat Oncol, 2007 Jun 7

Int J Radiat Oncol Biol Phys, 2012 Feb 1

JAMA, 2010 Mar 17

Lancet Oncol, 2015 Feb

J Thorac Oncol, 2009 Jul

N Engl J Med, 2012 Jun 14

J Clin Oncol, 2006 Oct 20

Int J Radiat Oncol Biol Phys, 2012 Aug 1

Int J Radiat Oncol Biol Phys, 2014 Jul 1

Radiother Oncol, 2009 Jun

J Thorac Oncol, 2011 Dec

Int J Radiat Oncol Biol Phys, 2013 Aug 1

Radiother Oncol, 2011 Nov

Int J Radiat Oncol Biol Phys, 2010 Mar 1

J Thorac Cardiovasc Surg, 2013 Jan 12

Med Phys, 2013 Sep

Int J Radiat Oncol Biol Phys, 2010 Jun 1

J Thorac Oncol, 2009 Aug

Int J Radiat Oncol Biol Phys, 2007 Oct 1

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Sarcoma, 2013

Cancer, 1998 Mar 15

Int J Radiat Oncol Biol Phys, 2012 Nov 1

Int J Radiat Oncol Biol Phys, 2017 Mar 15

Int J Radiat Oncol Biol Phys, 2015 Nov 15

Radiother Oncol, 2013 Aug

Radiother Oncol, 2016 Oct

Int J Radiat Oncol Biol Phys, 2016 Dec 1

Pract Radiat Oncol, 2018 Apr 10

Radiat Oncol, 2013 Jan 3

Cancer, 2007 Nov 15

Cancer, 2015 Apr 1

JAMA, 2012 Jul 11

JAMA, 2008 Mar 5

J Clin Oncol, 2008 Jul 20

J Clin Oncol, 2011 Aug 1

J Clin Oncol, 2008 Jul 20

Int J Radiat Oncol Biol Phys, 2011 Sep 1

Am J Clin Oncol, 2011 Feb

Int J Radiat Oncol Biol Phys, 2013 Dec 1

JAMA, 2007 Jan 17

Cancer, 1987 Jun 15

Ann Surg, 2007 Nov

Int J Radiat Oncol Biol Phys, 2014 Dec 1

Int J Radiat Oncol Biol Phys, 2014 Apr 1

Radiother Oncol, 2009 Dec

Int J Radiat Oncol Biol Phys, 2012 Oct 1

Med Phys, 2010 Aug

Int J Radiat Oncol Biol Phys, 2015 Jun 1

J Clin Oncol, 2010 Jan 10

J Natl Cancer Inst, 2014 Aug

Front Oncol, 2011

Eur Urol, 2015 Jul 16

BJU Int, 2009 Feb

Eur Urol, 2014 Jun

Int J Radiat Oncol Biol Phys, 2008 Oct 1

J Clin Oncol, 2016 Jan 20

Technol. Cancer Res. Treat., 2014-06-01

Lancet Oncol., 2015 May 13

J Clin Oncol, 2008 Nov 1

Semin Radiat Oncol, 2015 Oct

J Appl Clin Med Phys, 2010 Aug 19

Technol Cancer Res Treat, 2015 Jan 28

Int J Radiat Oncol Biol Phys, 2012 Jan 1

Lancet Oncol, 2015 Dec

Int J Radiat Oncol Biol Phys, 2010 Dec 1

Front Oncol, 2014

Radiother Oncol, 2013 Oct

Int. J. Radiat. Oncol. Biol. Phys., 2016-09-01

Radiother Oncol, 2012 Mar

J Clin Oncol, 2014 Dec 1

Lancet Oncol., 2016 Oct 24

Int J Radiat Oncol Biol Phys, 2015 Sep 1

J Thorac Oncol, 2016-07-01

Br J Radiol, 2016 Mar

Int. J. Radiat. Oncol. Biol. Phys., 2006-02-01

Int J Radiat Oncol Biol Phys, 2009 Feb 1

N Engl J Med, 2007 Aug 16

Lancet, 2015 Jan 3

Clin Lung Cancer, 2011-11-01

Int. J. Radiat. Oncol. Biol. Phys., 2016-08-01

Hematol Oncol Clin North Am, 2006 Feb

Pract Radiat Oncol, 2014 Mar-Apr

Ann Palliat Med, 2016 Jan

Clin Oncol (R Coll Radiol), 2015-05-01

Cancer, 2010 May 1

J Pain Symptom Manage, 2008 Mar

Lancet, 2005 Aug 20-26

Front Oncol, 2017

Int J Radiat Oncol Biol Phys, 2008 Sep 1

Int J Radiat Oncol Biol Phys, 2014 Sep 13

Int J Radiat Oncol Biol Phys, 2009 Sep 1

J Clin Oncol, 2009 Apr 1

Acta Oncol, 2006-01-01

J. Cancer Res. Clin. Oncol., 2015-07-01

Semin Radiat Oncol, 2017-07-01

N Engl J Med, 2017 Nov 16

Int J Radiat Oncol Biol Phys, 2008 Apr 1

Int J Radiat Oncol Biol Phys, 2016 Jul 1

Radiother Oncol, 2013-11-01

J Clin Oncol, 2011 May 20

Front Radiat Ther Oncol, 2011-01-01

Int. J. Radiat. Oncol. Biol. Phys.,

Int J Radiat Oncol Biol Phys, 2009 Apr 1

J Neurosurg Spine, 2012 Jul

Int J Radiat Oncol Biol Phys, 2010 Jun 1

J Clin Oncol, 2013 Sep 20

Future Oncol, 2015

Future Oncol, 2015 Oct 15

J. Clin. Oncol., 2009 Sep 08

Int J Radiat Oncol Biol Phys, 2014 Sep 1

Clin Lung Cancer, 2016 Nov

Radiother Oncol, 2014 Aug

Int J Radiat Oncol Biol Phys, 2013 Jan 1

Ann Surg Oncol, 2002 Jul

Int. J. Radiat. Oncol. Biol. Phys.,

Clin Oncol (R Coll Radiol),

Clin Lung Cancer, 2017 Jul 10

J Thorac Oncol,

Clin Lung Cancer, 2018 Feb 17

Int. J. Radiat. Oncol. Biol. Phys., 2017 Mar 15

Radiother Oncol, 2016 Jun

Pract Radiat Oncol, 2018 Oct 11

Pract Radiat Oncol, 2017 Aug 16

Med Phys, 2011 Nov

Clin Lung Cancer, 2017 Mar

Int J Radiat Oncol Biol Phys, 2012 Dec 19

N. Engl. J. Med.,

PLoS ONE, 2015 Nov 24

J. Clin. Oncol., 2019 May 08

Lancet, 2019 Apr 11

Cancer, 2011 Sep 1

Int J Radiat Oncol Biol Phys, 2015 Jul 1

Cancer Treat Rev, 2017 Feb

Strahlenther Onkol, 2019 Feb 08

Radiother Oncol, 2018 Jul 09

Eur Urol Focus, 2019 Jun 24