Stereotactic Body Radiotherapy&nbsp;&nbsp;&nbsp;

How do you manage chest wall pain due to SBRT?

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 can de...

How does the presence of interstitial lung disease affect your decision to offer SBRT for early stage NSCLC?

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

6 Answers available

For unresectable typical carcinoid, what is the appropriate radiation regimen?

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

How do you approach treatment planning for lung SBRT in a patient with a lesion within 1 cm of a defibrillator?

The patient is not pacemaker dependent.

5 Answers available

When should SBRT be preferred in operative patients who cannot undergo a lobectomy?

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 ...

Would you use SBRT to treat a >5cm NSCLC with chest wall invasion in a medically inoperable patient?

How do you treat inoperable T1-2N0 apical lung cancers near the brachial plexus but without extension outside the lung?

Is it possible to do SBRT?

What dose constraint do you use for the proximal bronchial tree for when treating NSCLC to 60 Gy/8 fx?

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 would you treat a patient with oligometastatic disease to the lung for whom SBRT/SABR is not feasible?

How would you approach treatment if SBRT was not technically possible? How would you opt to treat if SBRT was instead not covered by insurance, and w...

Would you treat an inoperable <5 cm NSCLC tumor involving the hilum with SBRT?

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...

How do you modify your dose constraints when giving lung SBRT to a new lesion in a patient previously treated with lung SBRT?

How does your approach change for same lung but now a different lobe v. different lung? How do you adjust your constraints?

Do you ever consider small vessel doses when determining your dose for SBRT?

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 ...

How do you approach a patient with NSCLC and 3 oligometastatic lesions that are 4-5 cm in muscles of the extremities?

What dose would you recommend? Is SBRT needed?

What radiation dose and fractionation schedule do you use to treat atypical carcinoid tumors in patients who are medically inoperable?

Would you offer SBRT over standard fractionation of smaller tumors?

What is an acceptable distance between tumor and heart or aorta to treat a non-small cell lung cancer with SBRT?

Would close proximity to the heart/aorta affect your dose and fractionation?

Do you use minimum cutoff values for any PFTs below which you would not offer conventionally fractionated chemoradiation or SBRT for NSCLC?

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

Should lung SBRT fractions be delivered on consecutive days, every other day, or perhaps an even more prolonged schedule?

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

7 Answers available

Should special precautions be taken when treating oligometastatic disease in the sacrum or pelvis with SBRT in a patient with a long life expectancy?

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 place any constraint on Dmax when developing plans for linac-based SRS or SBRT?

Do you ever consider a dose constraint to the spleen when treating lung tumors with stereotactic radiotherapy?

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...

What follow-up imaging do you recommend after SBRT/SABR for lung cancer?

And at what intervals?

Is it safe to deliver SBRT to progressive lung metastases to patients with metastatic RCC receiving concurrent pazopanib?

Do you have a size criteria when treating lung oligometastases with SBRT?

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...

Is there a current 'standard of care' dose and fractionation in treating lung cancer with SBRT?

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

When do you choose motion management over free-breathing techniques for lung SBRT?

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...

Is there really substantial evidence to avoid central lesions for SBRT?

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

5 Answers available

What potential risks of SBRT do you counsel patients on when treating early stage lung cancer with an underlying chronic lung infection?

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

How do you manage a stage I LLL medically inoperable lung cancer in close proximity to the stomach?

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

Is there concern for hemorrhage after SBRT to a lung metastasis that directly involves a branch of the pulmonary artery?

What dose and fractionation would you consider if surgery is not an option?

How do you counsel patients in regards to the options and risks for salvage lobectomy/wedge after SBRT?

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

Is surgery preferable over SBRT for peripheral NSCLC invading into ribs?

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

What factors do you use to decide between phase based vs. amplitude based gating for lung SBRT?

Does proximity to or involvement of the aorta effect the dose and fractionation you use for an early stage NSCLC?

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

Is is okay to offer SBRT for central lung tumors in direct contact with the esophagus?

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

How do you approach a peripheral, T1 lung cancer with a positive mediastinal node by EBUS?

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?

How would you approach treatment of an early-stage lung cancer adjacent to a prior lung cancer previously treated with SBRT?

Is another course of SBRT possible? If so, what are the important planning considerations?

Do you treat adenocarcinoma in situ (AIS) or minimally invasive adenocarcinoma (MIA) of the lung with SBRT in medically inoperable patients?

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

Is there a firm rib dose constraint when treating lung tumors abutting the visceral pleura/chest wall with SBRT?

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...

Is SBRT appropriate for a small endobronchial tumor distal to the proximal bronchial tree?

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

How do you follow patients after SBRT for NSCLC?

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

Are the conformality constraints still important when organ at risk constraints are met for lung SBRT?

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

What dose constraint, if any, do you use for the diaphragm when treating liver or lung tumors with SBRT?

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

How do you manage a rib fracture caused by SBRT?

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...

How do you best communicate SBRT planning directives, specifically in regard to how "hot" the plan should be?

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 prescribe steroids prior to each fraction of lung SBRT?

Under what clinical circumstances would you consider prescribing them?

Would you utilize SRS/SBRT in a patient with oligometastatic disease from adenocarcinoma of the lung who is unable to receive standard chemotherapy?

For example, in a patient minimal brain and liver metastasis, would you treat all sites definitively?

What are your criteria to determine if there is a local failure versus post treatment changes after SBRT for inoperable early stage NSCLC?

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

For T1b or T2a NSCLC cancer, approached with SABR, should chemotherapy be considered in the adjuvant setting?

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

Do you use the PET scan hypermetabolic lesion to help contour the GTV for lung SBRT, especially in setting of peripheral atelectasis?

If so, how? Or would you avoid SBRT in such a situation?

For early stage NSCLC to be treated with SBRT, is there any difference in the technology being used such as robotic v. linac based VMAT?

Given the recent pooled analysis of STARS and ROSEL trials, can we say SBRT for early stage NSCLC is equivalent to lobectomy based on level 1 evidence?

Will the NCCN guidelines change based on this study?

Do you require a biopsy prior to SBRT for pulmonary metastases from oligometastatic disease?

Specifically from a GI primary?

For 5 fraction lung SBRT, is 11 Gy per fraction superior to 10 Gy per fraction?

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...

What is the clinical significance of R50 in lung SBRT?

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 is an acceptable SBRT dose for a central lung cancer encasing a coronary artery bypass graft?

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

How do you approach lung tumors with vessel encasement, especially in someone with active hemoptysis?

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...

How do you approach volumes and dosing when using SBRT for a biopsy-proven NSCLC lung nodule with a central solid component and surrounding ground glass opacity (GGO) appearance?

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...

What are your criteria for treating a patient with lung SBRT in the absence of a biopsy?

Roughly what percentage of patients are treated without a biopsy?

Is local failure following SABR higher then previously thought?

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...

Is 3D non-coplanar conformal radiotherapy preferable over arc therapy for lung SBRT?

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...

What is the best management for a local recurrence for a stage I NSCLC treated previously with SBRT?

Should fractionated EBRT be administered or can repeat SBRT be used?

In SBRT for lung tumors, does Monte Carlo dose calculation algorithm versus AAA dose calculation give a better representation of lung target dose and normal tissue dose?

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

When is it appropriate to use SBRT in treating lung metastases (oligomet, up to 3 mets etc.?)

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

How were decisions made about what dose constraints to use in the recent RTOG protocols for lung SBRT?

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

What is the biggest mistake people make when performing lung SBRT?