Neuro-Oncology   

Questions discussed in this category



Do you extrapolate from the pediatric protocols (smaller margins) or use larger margins similar to treatment of adult high grade gliomas?

If the patient has an asymptomatic local recurrence of a CNS ependymoma previously treated with a full course of radiation, would you re-treat with ra...

I have always used the RTOG standard 2cm margins off the T2 Flair to 46Gy and 2cm off the T1post for the 14Gy boost. However recently I have heard of ...

Temodar can sometimes take 2-3 weeks to arrive after prior approval. Would you start radiotherapy without Temodar or wait for it to arrive and begin c...

What is your preferred dose/fractionation? What constraints do you utilize for the brainstem and cord?

What dose/fractionation do you prefer? What is the maximum dose that you will allow to the optic nerve and chiasm?

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

Do you routinely recommend TTF in the adjuvant setting for patients with glioblastoma?

How does grade affect your decision-making? If adjuvant radiation is indicated, should the initial extent of disease be included or only the post-oper...

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

Does your surveillance schedule change dependent upon delivery of SRS vs conventional-fractionated RT?

Specifically, how do you explain potential cognitive decline in a way that explains what changes they can expect in their daily lives?

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?

Guidelines do not provide strong guidance on who will benefit from temozolomide vs PCV or when to consider re-challenging with temozolomide.

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.  

Do you have any specific concerns for patients with implanted intracranial devices?

NCCN lists PCV as category 1 (and now with analysis in Abstract 2002 from ASCO 2019 showing benefit in IDH mutated), and temozolomide as 2B, yet temoz...

Is there a role for aggressive surgical resection if the lesions are reasonably resectable or do you prefer biopsy followed by chemoradiotherapy?

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...

Given the poor prognosis of molecular subtype, do you offer a more aggressive treatment regimen than for other molecular subtypes of low-grade glioma?...

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?

Do molecular factors (1p/19q, IDH status) influence your choice of dose/volumes?

Do you insist that the staples are removed prior to sim or do you perform density overrides in the treatment planning system?

If a patient has a metastatic lesion in close proximity to one hippocampus, would you offer sparing of the contralateral hippocampus? Do your dose con...

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...

Dependent upon histology, when would you offer RT to an asymptomatic patient who refuses consideration of any future surgical intervention?

For a patient in the second trimester who wants to continue with the pregnancy, would you consider this? If so, what extra precautions would you take?...

Would you treat just the gross tumor at recurrence or the entire initial operative bed? Do your volumes and dose differ from those treated adjuvantly ...

What factors influence your choice of SRS vs more fractionated regimens?

Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?

What dose/fractionation would you use for treatment of a tumor without a biopsy?

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

Would you consider observation following surgical resection with negative margins? Would you recommend WBRT and/or ISRT? What would be your preferred ...

If you use PRVs, how do you adjust their constraints relative to their respective OAR constraint (e.g. do you allow a greater percentage or absolute d...

Do you prefer to underdose the tumor to meet critical structure constraints such as the optic chiasm? Or to you opt to aggressively treat the tumor an...

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

How do you delineate your treatment volumes? Do you modify your post-treatment surveillance of these patients?

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...

Would you modify your dose/fractionation dependent upon intracranial control of the primary tumor?

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

Despite some supportive data, it seems few institutions use these routinely. What do you view as the barriers in their utilization?

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

If so, do you have specific dose constraints you find reasonably achievable given the difficulties in achieving some of the very low dose goals noted ...

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

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

Would you include the entire original surgical cavity or only the region of recurrent disease?

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

If a patient has simple bony metastases and no neurologic compromise what are your criteria for recommending that a patient wear a collar for c-spine ...

Is there a role for neoadjuvant radiotherapy prior to attempted embolization or resection? Do you routinely electively cover the location of prior sur...

Does your recommendation change if the patient has received prior standard fractionation radiotherapy vs SRS? 

Would you ever defer radiation in patients with primary brain tumors or would you manage these patients similarly to non-MS patients? How do you ...

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?

How often do you obtain routine imaging if there has been no documented growth after 5 years?

If imaging is negative for other sites of dissemination within the CSF, do you treat with craniospinal RT or use more localized fields?

Would you delay/defer adjuvant radiation and/or temozolomide until completion of IV antibiotics? Would you still treat with a significant skull defect...

For a lesion that appears radiographically consistent with a high grade glioma, would you treat empirically if there is hesitancy to perform a high ri...

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?

For patients with eGFR of < 30, there is a risk of irreversible nephrogenic systemic fibrosis with gadolinium. Would you prefer whole brain for the...

Do you modify your dose/fractionation depending on the amount of prior intrathecal therapy?

Do you routinely offer re-irradiation? If so, what is your preferred dose and technique?

Would you start radiation without temodar if there is a delay in temodar rx?

What is the role of the 3T MRI mprage sequence? Is there any literature to support a certain approach?  

If choosing systemic therapy, do you prefer bevacizumab with or without irinotecan? Have you used anti-PD1 agents (e.g. nivolumab) off label? 

Would you feel comfortable treating with palliative radiation without neurosurgical assessment? Are these patients at increased risk for neurolog...

Does it matter whether the intracranial lesions have been treated with whole brain or SRS/SRT?

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

Would you insist that they shave or cut the beard?  Is there a way to make the simulation reproducible without removing the beard?

The plans appear so much more conformal.  If not, what is the rationale?

If utilizing conventionally fractionated radiation, do you cover just the gross disease or do you cover the preoperative tumor volume? What if you are...

Is it reasonable to go with surveillance instead and keep radiation as a salvage option?

Do you approach it similar to a de novo GBM? Would you be more inclined to offer hypofractionated radiation given the poorer prognosis?

When can you feel confident that the growth is from tumor vs. radionecrosis?

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? 

What dose fractionation and volume do you use? What factors influence your decision?

In particular, for patients without clinical symptoms, would you image the spine based on any histologic, molecular, or other risk factors?

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?

What adjuvant treatment should be offered after a complete resection?

Is there data related to types of metastases (tumor histology, anatomic distribution, hemorrhagic, diffuse, size, edema etc.) and risk for seizure?&nb...

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage.  Is t...

Would you include the hygroma in your cavity volume? Does your decision change if you are treating a low grade vs high grade glioma? Are there other c...

Several radiation oncologists have switched from 6MV to 10MV for cranial IMRT plans to prevent alopecia. Is this theoretical or do we have data? And a...

If a WHO II glioma was treated with RT and recurs and is now a WHO III glioma would you retreat with radiation?  What would be your target volume...

In particular, would you offer memantine to those with WHO II or III gliomas and a good performance status but larger treatment volume?

Do you have a size cut-off in cases where OAR tolerances are not otherwise exceeded?

Two randomized trials which included single-fraction post-op SRS as an arm reported high 1-year local failure. In Alliance N107C (12-20 Gy, 2 mm PTV m...

Are GTV, CTV, PTV expansions adopted from pediatric studies? Given our ability to treat the craniospinal axis with accuracy, what would the "mode...

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

Some prefer radiation alone, while others do chemotherapy followed by RT (possibly to lower dose vs. RT alone).

If a patient has increasing FLAIR and T1 enhancing activity, should both be included in the treatment volume? What factors to you consider in making y...

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

What are the best options to treat a patient with brain metastasis confined to the posterior fossa if the patient is young, has a favorable cancer, gr...

What is your interpretation of the recently published QUARTZ trial? Is there a population of patients that you would consider withholding radiation th...

When would you recommend chemotherapy alone, radiation alone, and combined chemoradiotherapy? When treating with RT, what volumes and doses do you use...

Do you have a preference for specific steroids? Some practices may switch to prednisone during this time.   Patients with gliomas are often on d...

RTOG 0539 takes a dose painting approach for Group III to treat edema to 54Gy and lesion to 60Gy.  However, this significantly increases target v...

Can the drug continue during radiation therapy or should it be discontinued at a specified time prior to initiation of radiation?

Does the MGMT status change your decision-making? Should we be routinely testing MGMT for elderly patients?

The textbook "Shaped Beam Radiosurgery" recommends MRI q 6 months x 2 years, then annually through year 5.  "UpToDate" recommends annual MRIs thr...

Specifically, what factors contribute to your dose-fractionation schedule? In what circumstances (if any) would you recommend 25 Gy in 5 fractions?

In a patient who received full dose to the spinal cord 10+ years prior, would SBRT be appropriate salvage therapy or is hyperfractionation prefer...

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

Are the interim results of EF-14 (Stupp et al) practice changing? 

For a patient who has completed 40 hyperbaric sessions with steroids with little improvement, what other options exist?

The recent Roa trial (JCO 9/21/15) found that 25Gy/5fx was non-inferior to 40Gy/5fx in terms of OS, PFS, and QOL. Is 25Gy in 5 daily fractio...

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

In a patient with multiple brain metastases from NSCLC, is this reasonable?

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

The long term data indicating an OS and PFS benefit with the addition PCV with RT when compared to RT alone were reported in a NCI press release (http...

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

The most frequent argument against whole brain RT is debilitating toxicity. However, I am having a hard time finding the most evidence based data on h...

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 ...

While there are clearly well-defined margin guidelines for GBM (which nonetheless differ between RTOG and other groups), little has been written about...

In a large unresectable grade 2 astrocytoma of the temporal lobe, what dose and GTV margin should be used?

Should an agressive attempt at resection be made? Do factors like age, KPS, MGMT status play a role in how aggressive of a push for surgery you make?

Do you feel that it must start on day 1 with RT, as strict as even 4h prior to RT (recommended by some folks for maximal “Radiosensitization&rdq...

In reading through the policy of one of my state's private insurance companies, I came across something with which I'm not familiar, namely treating p...

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...

I'm aware of a number of publications that suggest that after 1-2 years, the cord should be able to handle about 50% of the original tolerance dose. &...

RTOG 9802 showed a large overall survival benefit for the addition of PCV to radiotherapy in patients with "high-risk" low grade glioma (eit...

Do you really feel the failure was because people crossed over to bev at progression, or is it simply that bev does not affect overall survival?

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...

We rarely treat grade III oligos with sequential PCV and RT, despite the positive results of phase III trials. We do TMZ alone until progression which...


Papers discussed in this category


Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2010-06-20

International journal of radiation oncology, biology, physics, 2009-09-01

Clinical oncology (Royal College of Radiologists (Great Britain)), 2007-09

Radiation oncology (London, England), 2014-01-03

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

Proceedings of the National Academy of Sciences of the United States of America, 2011-03-15

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-01-20

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2006-06-20

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

American journal of clinical oncology, 2014-04

Radiation oncology (London, England), 2014-06-06

Current oncology (Toronto, Ont.), 2007-06

The New England journal of medicine, 2005-03-10

Lancet Oncol, 2009 May

CNS oncology, 2013-09

Clin Oncol (R Coll Radiol), 2014 Jul

International journal of radiation oncology, biology, physics, 2007-05-01

Radiother Oncol, 2010 Dec

International journal of radiation oncology, biology, physics, 2011-10-01

Journal of neuro-oncology, 2010-08

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-12-01

Journal of neurosurgery, 1987-06

Neurology, 1980-09

International journal of radiation oncology, biology, physics, 2010-11-15

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2002-03-15

Practical radiation oncology, 2016

Br J Radiol, 2013-02-01

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

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2012-09-01

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

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

CNS Oncol, 2016 Jul

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Lancet Oncol., 2017-05-01

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BMC Cancer, 2015-08-15

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Radiat Oncol, 2011-12-21

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-02-10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2011-08-01

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World neurosurgery, 2014

J Neurooncol, 2014 Jan

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

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

Journal of neuro-oncology, 2012-01

American journal of clinical oncology, 2012-02

Eur. J. Cancer, 2017-03-01

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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

Journal of neurosurgery, 2008-11

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-03-10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-02-20

The New England journal of medicine, 2016-04-07

Anticancer Res.,

International journal of radiation oncology, biology, physics, 2010-11-15

Practical radiation oncology, 2016

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J. Neurooncol., 2016 Mar 09

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Neurosurgery, 2017-05-01

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

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2012-07-20