Radiation Oncology

Stereotactic Radiosurgery   

Questions discussed in this category

Is there evidence that supports/refutes the safety of concurrent use?

Will this disappear over time on its own or should I be concerned that the necrosis will worsen over time, and repeat MRI more frequently?

Do you utilize fMRI or other advanced sequences (DTI, etc) in the planning process?  

I have seen small amounts of evidence for V4<20cc and V14<7cc, but overall it seems like there is little published on this issue.  

What dose/fractionation do you prefer for small vs large metastases?

How should they be prioritized? V10, V12, mean brain dose, prior WB radiation? To what extent should tumor coverage, conformality and homogeneity be c...

Do you fractionate? Do you look at composite doses and/or apply any constraints given the limited data?

Can a second course of SRS be completed? If so, what dose do you recommend?

Is SRS reasonable if there is no evidence of more diffuse disease?

How do you sequence imaging and headframe placement? Do you fuse a 3D CTA to the planning CT?

There are data for improved outcomes for inhomogeneous dose distribution in patients with intact brain tumors (Lucia et al, Radiother Oncol 2018), but...

Do you treat on consecutive days or more protracted interfraction intervals? Does tumor type (benign vs malignant) or size influence your choice? &nb...

Would you ever de-escalate your prescription dose in order to reduce cochlear dose when treating younger patients with intact hearing?

Is there an optimal time to give SRS to brain metastases for patients receiving ipilimumab and nivolumab?

Do you modify your dose/fractionation if the target volume abuts surgically implanted hardware?

This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...

If so, what constraint is most clinically relevant? The EORTC LungTech trial (60Gy/8 fractions) does not specify a chest wall constraint. I have...

It becomes challenging to keep track of different metastases, especially for patients who have undergone one or more prior SRS treatments.

Would you offer 3-5 fractions for larger lesions instead or would you favor more traditional standard fractionation regimens?

Do you routinely pause systemic therapy when administering SRS? Which agents do you view as relative or absolute contraindications with SRS?

Do you decrease total dose, increase the number of fractions, or both? What factors, in addition to size and location, do you consider?

In our clinical experience, we have used the treatment planning system's auto-match method, and then manually fine tune adjustments checking skull, IA...

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

In light of the recent consensus contouring guidelines (Soliman et al, IJROBP 2017): 1) Are you routinely expanding along the dura up to 5-10 mm ...

The small series by Lowell et al (IJROBP 2011) suggests significant toxicity risks following SRS.

What is your cavity size/volume cutoff in selecting hypofractionated SRT over SRS?

For treatment of multiple brain metastases, the V12 can often exceed the traditional dose constraint of 10 cc, especially as the number of lesions bei...

Are there treatment planning considerations that are different for a large cystic lesion as compared to a solid metastasis?

If you do treat both nerve roots, how long do you wait between fractions?  Do you modify anything because you are treating bilaterally?

There are solid data from Emory, Korea and others suggesting that is as effective as single fraction SRS but has less complications. 

To what degree, if any, is a neurosurgeon involved in the planning of SRS for brain metastases?

The 2014 "Choosing Wisely" list, released this past September, includes the assertion that we should not "routinely add adjuvant whole brain radiation...

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

One study comparing these techniques (https://www.ncbi.nlm.nih.gov/pubmed/12873685) showed 75% hearing preservation in the single fraction group ...

If there was true residual disease, do you offer whole brain RT, partial brain RT, SRS boost to the resection cavity, or observation?

There are retrospective data (i.e. PMID 15072456) that seem to associate posterior fossa location with increased risk of leptomeningeal disease a...

For instance, in a patient with Her2(+) breast cancer and 3x small newly diagnosed asymptomatic brain metastases, would you consider a trial of TDM-1 ...

How much do you factor in the possibility of radiation-induced second malignancies for the treatment of benign conditions in younger patients?

Do you adjust your dose based on previous whole brain radiation? What time interval would you wait following whole brain or would you treat with upfro...

In keeping with prior randomized trials, Alliance N0574 demonstrated that SRS+WBRT provides superior intracranial disease control but w...

A recent gamma knife retrospective study from Cleveland Clinic (Mohammadi et al, JNS 2016) argues for the RTOG dose of 24 Gy, although the cumula...

Assuming other variables, such as number/volume of brain lesions, KPS, and extra-cranial disease status are equal, would HER2 status in a breast cance...

Should it include the entire brain (normal brain + target) or just the normal brain (brain - target)?  How does the V10 or V12 constraint change ...

Based on recent ASTRO data, what is your selection criteria and size cutoffs?

In patients with contraindications to receiving an MRI scan, are other imaging modalities sufficient to treat patients with SRS?

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

If progression is proven by imaging modality (MRI spectroscopy, perfusion and PET/CT), is there evidence for retreatment with a second course of SRS?&...

While the Duke randomized study found similar rates of control with 1mm v. 3mm margins and higher radionecrosis with 3mm, it did not look at treating ...

The retrospective series quote a local control rate of 85-90% at one year and the current NCCN guidelines list this as an option following surgery for...

We are in the process of implementing a BrainLab SRS program for intracranial sites.  In my previous experience, all of the planning and set-up f...

It is my impression that for brain metastases >3 cm it may be preferable to deliver fractionated SRT versus the RTOG dose of 15 Gy SRS, if WBRT is ...

Our neurosurgeons have been pushing for definitive and postop SRS in patients with a poor performance status. Should I consider this or is it tot...

Papers discussed in this category

Lancet Oncol, 2012 Sep

Lancet Oncol, 2012 Jul

J Clin Oncol, 2004 May 1

Int J Radiat Oncol Biol Phys, 2004 Nov 1

Int J Radiat Oncol Biol Phys, 2000 May 1

Int. J. Radiat. Oncol. Biol. Phys., 2016 Jun 15

Radiat Oncol, 2012 Jul 11

CNS Oncol, 2016 Jul

N Engl J Med, 2007 Aug 16

J Clin Oncol, 1999 Jul

Lancet, 2015 Jan 3

Int J Radiat Oncol Biol Phys, 2011 Nov 1

Int. J. Radiat. Oncol. Biol. Phys., 2006-09-01

J Thorac Oncol, 2017 Sep 4

Lancet Oncol., 2017-05-01

N. Engl. J. Med., 1999-08-12

BMC Cancer, 2015-08-15

J Cancer Res Ther, 2012 Jul-Sep

Int J Radiat Oncol Biol Phys, 2012 May 1

Neurosurgery, 2013 Oct

Pract Radiat Oncol, 2015 Jan-Feb

J. Neurosurg., 2005-01-01

J Korean Neurosurg Soc, 2011-08-01

Radiat Oncol, 2014-07-08

BMC Cancer, 2015-03-04

Acta Neurochir (Wien), 2013-01-01

Lancet Oncol, 2009 Nov

JAMA, 1998 Nov 4

J Clin Oncol, 2011 Jan 10

J Neurosurg, 2010 Dec

Lancet Oncol, 2014 Apr

J Neurosurg, 2014 Dec

Stereotact Funct Neurosurg, 2017 Oct 11

Cancer Treat Rev, 2011 Nov

Int J Radiat Oncol Biol Phys, 2018 Mar 15

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

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

Radiat Oncol, 2011-05-15

Int J Radiat Oncol Biol Phys, 2006 Feb 1

Clin Oncol (R Coll Radiol), 2017 Oct 13

J Neurosurg, 2015 Aug

Int. J. Radiat. Oncol. Biol. Phys., 2013 May 15

Lancet Oncol, 2015 Dec

Expert Rev Anticancer Ther, 2011 Nov

JAMA, 2016 Jul 26

Int J Radiat Oncol Biol Phys, 2016 Jun 1

Radiat Oncol, 2011-12-21

J Clin Oncol, 2014 Dec 1

Lancet Oncol., 2016 Oct 24

J Neurosurg, 2016 Aug 5

Front Oncol, 2017

World Neurosurg, 2014 Jul-Aug

Int J Radiat Oncol Biol Phys, 2010 Aug 1

Stereotact Funct Neurosurg, 2005

Med Phys, 2010 Aug

Neurosurgery, 2010 Mar

Int. J. Radiat. Oncol. Biol. Phys., 2016-07-15

J. Neurosurg., 2009-09-01

J. Neurosurg., 2008-08-01

Oncotarget, 2016-11-08

J. Neurooncol., 2012-08-01

Int. J. Radiat. Oncol. Biol. Phys., 2009-08-01

Int J Radiat Oncol Biol Phys, 2010 Jan 1

Int J Radiat Oncol Biol Phys, 2014 Sep 13

Int J Radiat Oncol Biol Phys, 2009 Sep 1

Int J Radiat Oncol Biol Phys, 2008 Jan 1

Int. J. Radiat. Oncol. Biol. Phys., 2018-02-01

Int J Radiat Oncol Biol Phys, 2011 Nov 15

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

Neuro-oncology, 2011 Jun 10

J. Neurooncol., 2016 Mar 09

Int J Radiat Oncol Biol Phys, 2012 May 1

Int J Radiat Oncol Biol Phys, 2012 Feb 1

Int J Radiat Oncol Biol Phys, 2010 Mar 1

J Radiosurg SBRT,

Neurosurg Focus, 2010 Sep

J. Neurosurg.,


N. Engl. J. Med.,

Int. J. Radiat. Oncol. Biol. Phys., 2018 Nov 02

Int. J. Radiat. Oncol. Biol. Phys., 2018 Jan 31

Lancet Oncol., 2018 Nov 22

Neurology, 2015 Oct 07

Int J Radiat Oncol Biol Phys, 2011 Jul 15

JAMA Oncol, 2019 Mar 07

J. Neurooncol., 2019 May 24