Radiation Oncology

Thoracic Malignancies   

Questions discussed in this category

Do you worry about chest wall necrosis? Is surgery preferable? Does the previous RT affect your dose and fractionation? I am seeing more patients with...

What dose constraints would you prioritize for the esophagus, given that a long segment of esophagus will be in PTV?

Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?

How (if at all) would you modify your target volume if the hemorrhage was present on immediate post-biopsy CT, but resorbed by time of CT sim? What ab...

Our medical oncology team wants to give a patient Vitamin B12 and Folate 1 week before chemo- do we need to push back the RT start date to start both ...

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

In patients who have a mixed response or progression and are poor candidates for other systemic agents, would you consider consolidating the chest? Wo...

Also, how would you handle immune modulators for rheumatoid arthritis during their treatment?

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

Would you give a more definitive dose (e.g. 60 Gy/30 fractions) or follow the CREST trial (30 Gy/10 fractions)?

Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...

One example of this scenario would be a patient receiving consolidative durvalumab after chemoRT for stage III NSCLC who develops a new peripheral lun...

I've been trained to treat the larger lesion, re-stage, and then treat the other lesion if there are no new lesions (to rule out the possibility of me...

Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?

Much of this approach was designed with cytotoxic chemotherapy in mind -- wait "x" cycles, assess response, deliver radiation after chemotherapy. How ...

How do you surveil or decide to biopsy and treat these additional lesions? Are there certain size, growth rate, or imaging criteria that are usef...

In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial. https://www.ncbi.nlm.nih.go...

How do you prescribe a steroid taper? If it is grade 2, would you keep them on low dose prednisone while continuing? When do you feel comfortable re-c...

What are the major factors that impact your decision? If you opt for surgery, what factors impact your decision to offer RT preoperatively vs. postope...

Is 30Gy/10fx from the CREST trial standard? Do you ever use a more/less protracted fractionation? Does a malignant pleural effusion at diagnosis affec...

Rate of pneumonitis was low in the PACIFIC trial but does it mirror the real world setting? We are seeing increased pneumonitis in our practice.

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 feel it is important to start durvalumab within 14 days of completing cCRT?  What real life challenges do you face in doing so and wh...

Medical inoperability is clearly defined, anatomical resectability is also pretty much clear (invasion of trachea/carina/esophagus, etc). But what abo...

Would you treat to the GEJ regardless of whether the positive node was identified in the upper portion of station 8? Do surgeons routinely dissect to ...

Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? 

If you are using a standard 30/10 fractionation, is there a benefit to keeping chemo on board for radio-sensitization?

If clinically node negative, would you add elective nodal radiation?Does it depend on location (upper vs. lower trachea)?

Do you use BID treatments toward the end? Do you add additional daily treatments to exceed the prescription dose? Would you alter systemic t...

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

The EGFR subgroup appeared not have benefited as much as other patients in the publication. However, recently it was reported that the PACIFIC study m...

Is there any correlation with dose in the area of the phrenic nerve and development of referred shoulder pain and/or diaphragm paralysis?

Is there an established benefit for this? For instance if your patient has cardiac calcifications on imaging but no history of cardiac disease are the...

If all other nodes were negative but the patient was pN2 due to a level 9 LN, what volume would you treatm? 

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 ...

For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...

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...

If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?

As a for instance, a centrally located primary tumor with mediastinal adenopathy that results in a TE fistula? Currently we would recommend esophagea...

In a stable patient, do you perform standard chemoRT in 2 Gy fractions with IMRT for urgently start with a few high dose fractions (ex 4Gy/fx) and bri...

If there was a stage III adeno lung cancer and a contralateral SCC lung primary, what would be the best way to treat?

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...

Would you use a similar dose and fractionation as gastric MALT (30Gy in 1.5 Gy fractions)?

Would you recommend empiric diflucan? Would EGD be indicated? At what point would you consider hyperbaric oxygen?

No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.

This is a commonly used hypofractionated RT schedule in Canada, but the BED is lower than that for doses used in the US. If so, do you modify your dos...

What would you anticipate with regard to potential adrenal toxicity when the patient has only 1 functioning adrenal gland? There are no other sites of...

There is no primary and no distant disease seen on restaging PET. RTOG 0236 shows significant regional failure rate. Some have reported salv...

Does EGFR+ status influence your decision? What is the significance of this finding and its potential for progression? Is it simply occult disease con...

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...

How about for non-UIP vs UIP? Non-improvement of ILD with steroids? Specifically in O2-dependent patients? Does the volume of ILD sway your decision (...

Would an excellent KPS, LVSI+ or poorly differentiated histology change your decision? Would you base your decision on the ANITA trial where subset an...

Since the randomized phase II data from Gomez et al presented at ASTRO 2018 showed a survival benefit, is there concern about randomizing patients to ...

Does it factor into your decision making in the setting of restricted spirometry and normal lung volumes? Does this differ for SBRT v. chemoRT?

If a patient clearly has N1 disease with high SUV on PET, do you routinely recommend EBUS or mediastinoscopy to evaluate for N2 disease?

If there is no other evidence of metastatic disease, would you offer thoracic radiation? Either upfront with chemo or after initial system therapy if ...

What chemotherapy and radiation doses/fractionation would you use once the airway has been stabilized to provide reasonably safe and effective palliat...

Would your answer differ based on whether the patient is receiving concurrent chemotherapy? Are there other factors that would influence this decision...

Is this recommended in a certain subset of patients (EGFR positive or 1 metastasis only)? Or should we await maturation of the MD Anderson/Colorado/On...

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...

For a Stage III NSCLC looking to do definitive chemoRT who required IVIG and high-dose prednisone for paraneoplastic myopathy (mimicking dermatomyosit...

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...

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...

For example, would a + vascular margin, extranodal extension of N1 disease, translobar disease, or high risk histologies (large cell neuroendocrine, s...

Would you repeat PET or is it adequate to change to CT surveillance? Although surveillance PET/CT is not recommended by NCCN guidelines, these are oft...

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

Would you use the same schedule as early stage NSCLC primary?

The current NCCN guidelines reserves radiation for patients who are not resectable after induction chemotherapy. Does it make sense to offer concurren...

Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?

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

Would anyone consider elective mediastinal XRT to 45-50Gy then boost involved LN to 60-66? Or treat involved lymph node only?  The patient will r...

A recent phase III trial published in JCO describes the NVALT-11/DLCRG-02 study, evaluating PCI vs observation in patients with stage III NSCLC s/p co...

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

I recently saw a patient who had been treated with concurrent pembrolizumab-RT elsewhere. Is this an acceptable practice outside the setting of a clin...

Or would you wait to start coincident with the start of cycle 2? If a shorter time from the start of any therapy to the end of radiation (SER) is sign...

Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?

If so, what fields do you irradiate? The initially involved nodal regions? If not, do you consolidate at any point in the future (ie after a loca...

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

For a patient with a new contralateral primary or recurrence and previous pneumonectomy, what lung constraints do you prioritize (ex mean lung dose, V...

By the definition this would be M1 disease, but would definitive treatment be appropriate? Is there clear data that a single pleural nodule has no cha...

In elderly patients (>70-75) with a good performance status, does the risk of neurocognitive decline outweigh the benefit of PCI?

Under what circumstances would you treat elective nodal regions? Would you consider treating the ipsilateral hilum if it was not PET avid?

In a patient with newly diagnosed small cell lung cancer with disease limited only to the thorax would you treat with definitive chemoRT in the presen...

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...

If so, would you recommend adjuvant chemotherapy and PCI after?

The NCCN guidelines for post-operative RT for Stage I lung cancer with positive margins is PORT to 54-60 Gy (in event re-resection is not feasible). I...

Do you electively treat the tracheobronchial tree? Or a certain length of the trachea and bronchus? Does the volume and dose depend on location (...

When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?

These patients have been largely excluded from these trials.  What if the infection is well controlled?

If you are considering chemotherapy and radiation in the definitive, postoperative, or nodal failure scenarios, would you prefer sequential treat...

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

What are some guidelines or principles that you use to recommend adjuvant radiation after complete resections of sarcoma? 

If you treat pre-chemotherapy volumes, is there a benefit to induction chemotherapy even in bulky disease. If so, how do you define disease that ...

What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?

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 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...

Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...

Would you treat if there is active infection?  How much improvement would you expect?

Would you treat if the patient is asymptomatic?  If you do treat, what dose/fractionation would you use?

Is a pleural effusion not oligometastatic by definition? The best evidence for consolidative RT was the MD Anderson/U Colorado/Western Ontario phase I...

Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?

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

Are there any rules you follow? Do you shrink target volumes if you notice a significant response (via CBCT) in a bulky lung tumor with fractionated r...

How does this approach change with mediastinal lymph node involvement? What are the indications for definitive or adjuvant radiotherapy +/- chemothera...

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

What is the best evidence for what dose to use? When would you give it in relation to the checkpoint inhibitors? Which metastatic sites do you choose ...

How would you approach the lung constraints in a patient that received definitive RT doses >2 years ago and develops a new primary amenable to SBRT...

Now that RTOG 0915 shows 5 year data with no difference in OS, DFS, and toxicity, should single tx be routinely offered? Are there specific  pati...

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

Would a large number of peribronchial nodes but negative nodes at the hilum and mediastinum (LN stations 7-10) affect decision making or volumes? What...

When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...

When patients have a single site of progression while on systemic therapy is it reasonable to consider stereotactic and/or conventional radiation to d...

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

Although elective nodal irradiation is not standard, what you treat lymph node stations that are adjacent to involved lymph nodes? For example, i...

Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage? 

Similarly, would SBRT be an option for a small central persistent node? What maximum total BED would you accept before no longer recommending addition...

Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...

After sublobar resection and well dissected mediastinum, would you soley focus on the area of the positive margin or would you include ipsilateral hil...

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

Does the site of oligometastasis matter (ex. brain v bone)? In this trial https://www.ncbi.nlm.nih.gov/pubmed/27789196 20% of patients were ...

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...

Do you use V5, V30 (as per Dess, JCO 2017)? V50 (Speirs, JTO 2017)?  Mean (Wang JCO 2017)? What is the most evidence based criteria? How do you b...

Is there any role for consolidative RT/CRT to the lung and mediastinum after initial chemo? What dose and fractionation would be most appropriate for ...

Would a postiive margin or extracapsular extension altar your recommendations? Does size play a role in your recommendation?

Under what clinical circumstances would you consider prescribing them?

For instance with isolated progression at one metastatic site, with all other disease stable and clinically doing well. 

How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation? 

For example, there is a retrospective series out of MD Anderson (Kim, Acta Oncologica 2008) wherein 37 patients with gastric cancer were treated with ...

There are varying reports in the literature which seem to suggest increased rates of Gr 4-5 pneumonitis in IPF patients.  How do you manage these...

What is the expected rate of pneumonitis with this approach? What dose/fractionation, and constraints would you use?

Additionally, would you give elective nodal coverage or just the postop bed?

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...

The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib. 

In the study published by Slotman et al (Lancet 2015), nearly all the patients in the thoracic RT arm started with PCI. For patients with gross diseas...

In my experience, it seems like the post-SBRT area of fibrosis is more than I would have otherwise expected with GGOs.  I have usually advised wa...

What if there was a pT1aN0 invasive adenocarcinoma that was separate from the focus of adenocarcinoma in situ which resulted in the positive margin. &...

If so, what adjustments do you make? Does your recommendation change based upon how long the lobe has been collapsed and/or its presumed functionality...

For example, would you offer a patient SBRT with 3-4 lung SCC nodules? If so, how do you approach planning?

Our lung cancer screening program does not enroll anyone who has previously been deemed to be a nonsurgical candidate.  I see that there is no ev...

If not what radiation fractionation regimen is preferred for otherwise good KPS patient? 

Should surgery followed by adjuvant chemotherapy and radiation be considered for non-bulky single station N2 disease?

Would adjuvant chemotherapy suffice, or would you also consider RT in a patient with a PS of 0-1?  Would your recommendations change if it was N0...

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

The NCCN guidelines call for pathological mediastinal lymph node staging for all NSCLC except in solid tumors <1cm and non-solid lesions < ...

Is it reasonable to dose escalate beyond 60 Gy if meeting all dosimetric criteria and with some room to spare? RTOG 0617 would suggest 60 Gy should be...

Following lung RT, I have rarely seen patients present with pneumonia-like symptoms of radiation pneumonitis. I'm more likely to see a patient with wo...

Most trials establishing CRT as standard of care for IIIB NSCLC excluded patients with separate ipsilateral lung nodules given that they were categori...

Is standard chemoradiation the standard of care or conventional fractionation dose-escalated (>60 Gy) radiotherapy without chemotherapy or some for...

What are some appropriate dose fractionations?  What about dose constraints for bronchial tree that previously got 70Gy?

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

The NCCN guidelines discourage the use of PET/CT surveillence but the recent analysis of RTOG 0235 found post-CRT PET uptake to be associated with wor...

Based on the European data published in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961085-0/abstract), are you s...

Do you treat the hilum and ipsilateral mediastinum?  Just the lymph node levels that were positive at surgery?  I have not found good guidel...

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...

Does IFRT include only the involved lymph nodes + margin or the entire involved lymph node station as specified by the Michigan Atlas?

Are your constraints different than the standard constraints used for patients who have not had surgery?

I am aware that chemotherapy can obviate the need for RT in patients with SVC syndrome, but I'm not sure if this can be extrapolated to spinal cord co...

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

Should elective mediastinal irradiation still be avoided? For example, if you have a T2 RLL lesion, and let's say, a positive AP window node, do you n...

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...

In the case where there is a PET avid subpleural nodule in the exact same location as needle biopsy 3 months prior, is this considered a chest wall me...

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...

Do you define it as whole lungs (inc. tumor) or whole lungs minus GTV, CTV,  ITV, or PTV?

We've seen quite a few patients present with NSCLC with a single brain metastasis and a good performance status. Would you advocate for an aggressive ...

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...

The patient underwent lobectomy and nodal staging for a presumed non-small cell lung cancer.

Dose/Fractionation? Concurrent v. sequential chemo? What literature do you use to backup PORT for a positive margin?

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

I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...

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?  

Is a biopsy needed? Do you consider treatment palliative or curative?

I've found that very few patients have a regular breathing cycle, which makes respiratory gating very difficult. Any other solutions?

Papers discussed in this category

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Lancet Oncol, 2015 Feb

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