Radiation Oncology

Stereotactic Radiosurgery   

Questions discussed in this category


Do you ever boost the areas of residual tumor or do you treat the cavity and tumor as a homogeneous target volume?

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

Given the proximity of the optic chasm and risk of compromised hemianopsia, the lack of adequate central vision adds another layer of risk.

When do you decrease your SRS dose or consider fractionated SRS regimens?

How does the presence of prior WBRT alter your treatment plan?

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

With the publication of the ARUBA trail results, should management of AVMs shift toward medical management?  

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...

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?

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

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2004-05-01

International journal of radiation oncology, biology, physics, 2004-11-01

Int J Radiat Oncol Biol Phys, 2000 May 1

International journal of radiation oncology, biology, physics, 2016-10-01

Radiation oncology (London, England), 2012-07-11

CNS Oncol, 2016 Jul

Neurosurgery, 2003-04

Journal of neurosurgery, 2013-02

J. Neurosurg., 2016 Apr 29

N Engl J Med, 2007 Aug 16

J Clin Oncol, 1999 Jul

Lancet, 2015 Jan 3

International journal of radiation oncology, biology, physics, 2011-11-01

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

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2017-12

Lancet Oncol., 2017-05-01

The New England journal of medicine, 1999-08-12

BMC Cancer, 2015-08-15

Journal of cancer research and therapeutics, 2012

International journal of radiation oncology, biology, physics, 2012-05-01

Neurosurgery, 2013-10

Practical radiation oncology, 2015

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

JAMA, 2016-07-26

Radiation oncology (London, England), 2014-09-30

Cancer, 2016-06-15

The New England journal of medicine, 2018-12-06

Lancet, 2019 Oct 04

J Clin Oncol, 2020 Aug 10

Lung Cancer, 2014 Aug 02

N Engl J Med,

Lancet Oncol, 2020 Apr 03

The Lancet. Oncology, 2009-11

JAMA, 1998 Nov 4

J Clin Oncol, 2011 Jan 10

Journal of neurosurgery, 2010-12

Lancet Oncol, 2014 Apr

J Neurosurg, 2014 Dec

Stereotactic and functional neurosurgery, 2017

Cancer treatment reviews, 2011-11

International journal of radiation oncology, biology, physics, 2018-03-15

International journal of radiation oncology, biology, physics, 2016-06-01

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

Radiat Oncol, 2011-05-15

International journal of radiation oncology, biology, physics, 2006-02-01

Clin Oncol (R Coll Radiol), 2017 Oct 13

Journal of neurosurgery, 2015-08

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

The Lancet. Oncology, 2015-12

Expert review of anticancer therapy, 2011-11

International journal of radiation oncology, biology, physics, 2016-06-01

Radiat Oncol, 2011-12-21

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-12-01

The Lancet. Oncology, 2016-12

Journal of neurosurgery, 2017-07

Frontiers in oncology, 2017

World neurosurgery, 2014

International journal of radiation oncology, biology, physics, 2010-08-01

Stereotactic and functional neurosurgery, 2005

Medical physics, 2010-08

Neurosurgery, 2010-03

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

International journal of radiation oncology, biology, physics, 2010-01-01

International journal of radiation oncology, biology, physics, 2014-11-15

Int J Radiat Oncol Biol Phys, 2009 Sep 1

International journal of radiation oncology, biology, physics, 2008-01-01

International journal of radiation oncology, biology, physics, 2018-02-01

International journal of radiation oncology, biology, physics, 2011-11-15

Journal of neurosurgery. Spine, 2012-07

International journal of radiation oncology, biology, physics, 2010-06-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-09-20

Future oncology (London, England), 2015

Future Oncol, 2015 Oct 15

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2009-10-20

Neuro-oncology, 2011 Jun 10

J. Neurooncol., 2016 Mar 09

International journal of radiation oncology, biology, physics, 2012-05-01

International journal of radiation oncology, biology, physics, 2012-02-01

International journal of radiation oncology, biology, physics, 2010-03-01

Journal of radiosurgery and SBRT, 2011

Neurosurgical focus, 2010-09

J. Neurosurg.,

Neurosurgery, 2017-05-01

The New England journal of medicine, 2018-08-23

International journal of radiation oncology, biology, physics, 2019-03-01

International journal of radiation oncology, biology, physics, 2018-01-31

The Lancet. Oncology, 2019-01

Neurology, 2015 Oct 07

International journal of radiation oncology, biology, physics, 2011-07-15

JAMA oncology, 2019-05-01

Journal of neuro-oncology, 2019-07

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

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

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

Journal of neurosurgery, 2006-06

Neurosurgery, 2016-08

International journal of radiation oncology, biology, physics, 2014-03-15

International journal of radiation oncology, biology, physics, 2017-09-01

Radiother Oncol,

Radiat Oncol, 2014 Jun 10

Radiat Oncol, 2020 May 28

Journal of computer assisted tomography, 2014

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

Oper Neurosurg (Hagerstown), 2015 Aug 01

International journal of radiation oncology, biology, physics, 2000-03-15

Movement disorders : official journal of the Movement Disorder Society, 2017-05

Journal of neurosurgery, 2019-01-11

Journal of neurosurgery, 2004-11