Radiation Oncology   

Questions discussed in this category


If so, what dose would you deliver and what are some contouring and planning pearls?

Would there be any benefit to surgery in a healthy/good PS patient? There is so little data on pulmonary atypical carcinoid and radiation respons...

Do you have a prostate volume/size threshold? Baseline urinary function? Any other anatomy or patient factors that may make patient not suitable for...

For example, would you use a cutoff such as PTV of 25cc, or 4cm diameter, or simply use nearby normal tissue constraints to alter your fractionation f...

Does extension to the anus affect your determination of T classification? Would you consider this a T2 tumor if it does not extend to the external sph...

Is there any alteration in approach from the medical, surgical, or radiation oncology perspective that can mitigate the risk of forming keloids withou...

For example, if 2 pre-biopsy PSAs are 23 and then 18, would you stratify as intermediate or high risk? If otherwise intermediate risk, would you treat...

In what situations would you want to include regional nodes? Particular tumor size?

What doses do you typically utilize? How does your coverage differ from your recommendation if this was an HPV-negative squamous cell carcinoma of the...

These structures are mobile and their location changes depending on bowel filling, gas, patient set-up, etc. Is there an advantage to contouring small...

Do you consider the small, but statistically significant, improvement in OS to outweigh the side effects of treatment?

If a patient has a large femoral metastasis that cannot be resected, but is to be stabilized with ORIF which will push tumor into the distal end of th...

If yes, what would be your target volume for this exceedingly rare histology for this location?

The recently published SSO/ASTRO/ASCO consensus guideline on DCIS states that "a 2 mm margin minimizes the risk of IBTR compared with smalle...

Have you utilized these gene-expression profiles in your practice? Is there sufficient data for this test to be used for clinical decisions?  

Given that azathioprine increases skin sensitivity preferentially to UVA radiation, is it safe to continue or do you counsel any increased risk of ski...

Assume patient is otherwise a suitable candidate.

In women receiving HDR intracavitary brachytherapy to treat the vaginal cuff, how do you overcome the challenge of excess lateral vaginal tissue ("dog...

If she is over 70 and has favorable enough breast cancer to forego a sentinel node biopsy, is it reasonable to assume she does not need to have her ax...

To minimize the likelihood of asymmetrical growth, when is it of sufficient concern to necessitate altering planning objects? When planning paediatri...

Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy?  Are the results of the recently published negative phase ...

Would you consider SBRT as post-chemo consolidation for a patient with a single unresectable focus of metastatic adenocarcinoma at the celiac axis?&nb...

These tumors are often low grade, but have a propensity for local recurrence.

A nuimber of options for treatment but not a lot of great data for this rare disease.

Is anticoagulation for PE an absolute or relative contraindication to IS brachy? Would you favor placement of IVC filter prior to procedure?

What fields/lymph node regions would you treat?  What doses would you use both for the postop primary and the nodal regions?  

What is your preferred dose and fractionation? Do you utilize 4D simulation? Additionally, how conservative are your constraints for ipsilateral uninv...

What dose-fractionation scheme do you utilize? Are there particular groups of patients this would not be a good option for (i.e. histologies of diseas...

Should systemic therapy or ISRT be utilized?   Is there a risk for intrabdominal spread with perforation? If the ulcer is repaired by simple...

Would you consider ISRT after 3 cycles of RCHOP, omit radiation and proceed to surgery after 6 cycles of RCHOP, or do something else?

Is there any role of radiation therapy for these patient for symptomatic relief? 

Specifically, would you consolidate initially bulky sites or allow patient to proceed to next line systemic therapy / transplant? 

Is this necessary given that they are benign lesions? What factors would make you consider tracing the facial nerve?

NCCN guidelines as of the May 2021 update state "In PORT, the CTV includes the bronchial stump and high-risk draining lymph nodes stations."  Wou...

Performance status is excellent. Second surgical opinion has also confirmed need for amputation, as the recurrence is now breaching intra and extra ar...

In the case of multiple skip lesions in the thoracic esophagus and GE junction, the PTV may encompass nearly the entire esophagus, including the supra...

For example, would you give SBRT for HCC with concurrent liver abscesses or short course radiation therapy for a perforated rectal adenocarcinoma with...

What do you recommend if the patient would need an APR because of anal sphincter involvement and/or would like to attempt non-operative management?

Are there elective neck regions you would choose treat to high risk (ie. 60 Gy) instead of low risk (ie 54Gy) dose?  Are there risk favors that ...

(1) How inferior would you take your level VI lymph nodes? (2) Would you cover the TE fistula/esophagus area?

History of CDH1 mutation and prophylactic gastrectomy in 2017 - no other primary site found beyond vagina at diagnosis. Vaginal tumor completely resp...

The recent randomized Phase II Scandinavian trial (Gronberg et al.) showed a statistically significant increased 2-year and median overall survival in...

Which neo-adjuvant or peri-operative chemotherapy regimen would you choose? NCCN guidelines recommend FLOT or FOLFOX in the peri-operative setting vs....

Is there a risk of increased radioresistance or secondary malignancy (or conversely, toxicity) for patients on TNF inhibitors...

A recent study http://www.ncbi.nlm.nih.gov/pubmed/27480153 showed an improvement in bichemical failure with higher doses. How much impact do...

What specific technique (i.e. interstitial vs intracavitary, 3DCRT vs IMRT) do you prefer? What do you consider to be the pros and cons with each appr...

These patients were not included in FAST or FAST-Forward. Can we extrapolate to the treatment of high grade DCIS?

Post-treatment PET/CT and MRI Pelvis at 3 months showed near resolution of iliac and inguinal lymphadenopathy but new avid retroperitoneal lymph nodes...

Do you recommend definitive chemoradiation? What is your treatment volume, dose, fractionation?

Assume treatment was 5 years ago and patient no longer has diverting ostomy. Would surgery or radiation be preferred given both have increased risks? ...

Or do you consider SBRT for any size lesion as long as the dose constraints for normal liver are met?

Colloid is a rare histologic subtype and considered to have more favorable outcomes compared with usual ductal adenocarcinoma, but no dedicated prospe...

What factors play into your decision whether to re-treat the brain with craniospinal radiotherapy vs irradiation of the spine only vs other measures (...

Assume a patient has both obstructive and incontinent symptoms. Is there anything to do about the expected and subsequent worsening of their urinary f...

Assume this is a PET Axumin avid node and is only site of disease. Previously this high risk prostate cancer patient had 45 Gy to the whole pelvis and...

E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.

With newly published long-term data of single fraction IOeRT (Intraoperative electron Radiation Therapy) for breast cancer on the ELIOT trial, does th...

What maximum dose do you allow to “connect” adjacent metastatic lesions receiving SRS/SRT? What is this value for one-, three-, and five-...

Previously received pelvic EBRT and intracavitary brachytherapy. IORT was administered to the node-positive side wall at the time of exenteration.

Would you consider treating the full mediastinum or any mildly enlarged nodes, even contralateral? Do you have a strategy that transitions from a pall...

The patient was started immediately on chemotherapy due to gastric bleed and scrotal irradiation is planned.

In treating an oligometastatic lesion in the sacrum, is it reasonable to extrapolate from RTOG brachial plexus contraints (eg, 8 Gy/fx for a 3-fractio...

Do you recommend chemoradiation with 5-FU and MMC or other agent? Does your elective nodal coverage change compared to typical squamous cell carcinoma...

This patient had resection of the primary, requiring multiple resections to obtain an R0 resection, followed by adjuvant radiation to the primary. The...

Do you treat in this scenario if mild/moderate infiltration? What are your thoughts on the article Fischer-Valuck, et al, PRO, 2017 (PMID: 280895...

Excellent KPS and long disease free interval from initial diagnosis. Initial recurrence 3-4cm at level of renal vessels and down to 1.3cm after chemo.

Are there any anatomical changes that would make the placement impractical or hurtful for the patient?

HDR CT planned prostate brachytherapy stipulates bladder V75% Rx<1cc. What bladder constraint is used for LDR prostate brachytherapy?

Do you manage post radiotherapy onset of tensmus differently? 

Does patient age effect your approach? Would you consider RPLND for any patients in light of the phase II SEMS trial presented at the 2021 ASCO GU Ca...

Consider a case in which you have resection with partial cystectomy, negative nodes and bladder invasion.

If so, what clinicopathologic features would indicate consideration of radiation therapy?

RAPIDO and Myerson paper don’t mention any and it looks like T4 patients were treated, presumably covering external iliacs which would likely ha...

Several articles report results with 0.5 -1 cm margins, and have suggested that with improved imaging and treatment planning, smaller margins such as ...

What can be done to promote wound healing? How far down would you delay radiation? Would you start at 6 weeks anyway if certain high risk features a...

Chemotherapy is often de-escalated and omitted in this setting. Would you also consider de-escalating radiation and treating like more favorable histo...

Is age ever a concern given the potential side effects of long term ADT? 

Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?

For conventional fractionation, should one increase total dose above 60 Gy for either close or positive margin (invasive or DCIS). What about for acce...

Do you have any reservations about the efficacy of SRS over surgery?

Would you radiate? Surgery? Chemo? Follow with short interval scans? How would size of adenopathy (e.g. <2cm vs larger) and time of recurrence (wi...

Would inhaled steroids help reduce the PO dose and/or significantly accelerate tapering?  If s, for what pneumonitis grade? What specific steroid...

GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease.  Prostate MRI pending. 

Recurrence was 2cm and PET confirmed local. Excision with positive margins. Current plan for salvage whole pelvic RT and vaginal cuff brachytherapy +/...

If no preop chemo was added, would you consider adj CRT? ARTIST2 interim results presented in 2019 does not seem to support chemoradiation, although i...

Do you prefer to treat patients with factors such as large prostate volume, significant comorbidities, anticoagulation use, history of TURP, or high A...

Would you consider induction: TPF vs cis/gem or would you proceed with chemoradiation with cis/RT and consider adjuvant cis/5FU?

Historically, IBC is traditionally treated with trimodality therapy to include PMRT with comprehensive regional nodal irradiation (RNI). However, give...

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

Addition of Cetuximab with re-irradiation SBRT in H&N Ca was mentioned previously: https://www.themednet.org/question/1936 https://www.themednet...

Is inclusion up to the bifurcation worth the bowel dose? Or are you contouring up to the L5/S1 interspace? 

What target volume (node with margin only or include other areas) do you treat and to what dose? What if patient had previous radiation? Any concurre...

Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g. skin canc...

If the inguinal node was previously treated with SBRT 30Gy/5fx and immunotherapy >6 months, what treatment would you recommend?

For a patient receiving 16 mg/day, it is frequently prescribed as 4 mg q 6 hrs.  This results in the patient being awoken at night, when sleep di...

Histology 1st described 2010, and acknowledged by WHO 2017. Probably previously usually diagnosed as Acinic Cell Carcinoma. In one source (Chiosea SI ...

In  patient with PD SCCA 15mm transverse;  5/20mm invasion; LVSI focally present; margins negative;  0/15 Left pelvic and 0/14 right pe...

How would you manage a clinically suspicious (CT/PET) but undissected (ie., level V or paratracheal) lymph node in the setting of post-op RT for an or...

Recurrence picked up incidentally on CT. No germ line mutations, somatic tumor testing of node resulted negative. PET confirmed isolated recurrence

Would you recommend radiation, systemic therapy alone, or chemoRT? What about if this recurrence occurred during or shortly after completion of adjuva...

Planning carboplatin/taxol/trastuzumab. Cervical stromal invasion on path. Looking for pelvic vs brachy and timing with chemotherapy.

If a patient has limited surgical options and a well defined lesion, would SBRT be reasonable?

I am curious if anyone has tried to split the arcs in a way that minimizes dose being pumped from the outside edge of the shoulder to reach low cervic...

Is it safe to keep median dose to the brachial plexus to ≤69 Gy per NCCN guidelines and maximum D2cc <75 Gy per Amini et al.?

This patient had a Ki67 of 27%. However, the inclusion criteria for the NETTER-1 Trial was Ki67<20%. Would Lutathera be an option if labs are withi...

Would you add radiation, if so any concurrent systemic therapy? Would you consider hypofractionation, if so, what dose/fx and reference for constrain...

Do you match on skin? What maximum hot spot do you accept? Do you do matchline shifts to feather out the hot spot and if so, how do you do that?

What is the best way to counsel families in regards to their child's risk of infertility and need for fertility preservation?

Presuming that imaging does not show distant metastatic disease, what would you offer? What about if the patient were PD-L1 negative?

What non-pharmacological interventions do you recommend? Do you routinely prescribe prophylactic laxatives to patients initiating opioids? How do you ...

What is the best evidence available for the benefit of PAB in disease control?

Can the ASCO guidelines for oral cavity be applied to other head/neck subsites? NCCN, ASTRO, and ASCO guidelines vary widely and depends on the prima...

What dose and technique do you use and how do you integrate the subsequent definitive treatment plan?

Is there a role for re-irradiation? What cumulative dose constraints do you use for re-irradiation to the central hepatobiliary tract?

What clinicopathological features would need to be present for you to recommend adjuvant chemotherapy? Would you treat pT3 disease? Any specific histo...

Specifically, would you offer salvage radiation to a patient who underwent a prostatectomy with PLND and had a post-op PSA of 12 with pathology reveal...

Would your counseling change if she reported a history of unplanned pregnancy? Is there any wording or waiver you might be able to use warning her of ...

Are there any circumstances that would necessitate treatment? 

The recently released STARS phase 3 RCT found improved DFS, decreased distant recurrence, with reduced toxicities for chemotherapy (cisplatin + taxol)...

The index lesion was located inferior to the left knee and excised appropriately, with an additional in-transit metastasis in the left mid leg. The pa...

Is there data to suggest that omission of elective nodal coverage to the pelvis similar to the omission of elective lung nodal coverage in lung cancer...

The patient in question has Stage IIIA DLBCL with a CR after 6 cycles R-CHOP. When would you treat the involved tonsil?

For example, in a patient with T1 disease and 1/1 node involved with a micromet and focal ENE. Would your recommendation change if the patient were r...

Do you contour to include S3 or up to the piriformis muscle?

Do you typically use the immediate post-op MRI scans or do you routinely obtain updated MR imaging at the time of CT sim?

PET/CT negative for any other sites of metastatic disease. Focal activity noted on PET (postop changes?). CSF negative. Bone marrow biopsy negative. 2...

Does your recommendation for radiation therapy and/or radiation planning change?

In a refractory DLBCL of entire circumference of leg below knee, how do you spare a tissue strip for lymph node drainage? 

Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...

If workup is negative for a primary lesion, would you consider prophylaxis of potential primary sites (anus/vulva?), and would you treat bilateral ing...

What is the role and sequence of surgery and/or RT? Which nodal levels would you include in your RT field(s)?

How would your treatment change for definitive vs post-surgical RT? Does approach differ depending on the anatomic (distal vs proximal and dorsal vs ...

Would you add concurrent systemic therapy with radiation due to concern for field cancerization?

Considering a T2+ and/or N+ GE junction adeno, do you use neoadjuvant chemoradiation therapy or perioperative chemotherapy?  Does your treatment...

If fractionating one metastasis over 3 or 5 fractions, would you also treat a small metastasis with the same number of fractions or would you give sin...

For a patient with a very locally advanced cervical cancer, what is your upper/superior limit of considering para-aortic lymph nodes to be "pelvic" or...

I trained at a place where use of a bolus for chest wall irradiation PMRT was standard practice, but this is not so at my practice right now.  As...

To avoid disfiguring surgery, would you consider treating a 2 cm well lateralized tumor without surgery? If so, would you recommend concurrent chemoth...

How do you prioritize treatment? Would you move forward with radiation to the larynx, and if so, any modification to your treatment plan?  

Should patient be considered for definitive therapy or chemo alone if pleural cytology positive but no T4, N2, or sarcomatoid features?

Do you find such markers such as biozorb to be more helpful than delineating the seroma and/or clips on CT?   When is this useful? During ...

Given publication by Spratt, et al JCO 2021, how do you sequence ADT? PMID: 33275486 JCO, 2021, Spratt D et. al, Prostate Radiotherapy With Adj...

What are the surgical and radiation options? What dose and fractionation scheme is appropriate for fractionated SRS?

Is the dose fractionation used in BR-001 (10Gyx3) appropriate for all osseous locations, for example humeral head metastases?

What dose would you use? For negative margins do you offer 50-50.4 Gy/25-28 fractions? What target volume margins do you typically recommend on t...

E.g. The case in question is for a patient planned for thoracic RT for LS-SCLC. Any medications that may help or just give much bigger expansions to c...

Does your recommendation change based on whether the patient has one or multiple lesions? 

What is the timing and role of surgery and RT at salvage for a lung recurrence?  Patient initially presented with lung metastases, but achieved ...

SWOG 9416 did not include N2 patients in their superior sulcus trial. Do you recommend definitive chemoRT followed by immunotherapy or preop chemoRT ...

When do you favor RT? What is your preferred dose/fractionation?

How does length of time from prior chemoradiotherapy influence your management?

RADICALs used >0.1 and rising or 3 consecutive rising PSA levels regardless of absolute value. RAVES and GETUG-AFU 17 used >0.2. 

There does not appear to be any guidance from the most recent published protocols on this topic. For individuals with dementia, recommendations call f...

Only when esophagus or thyroid involved? Or also when subglottis and hypopharynx involved? How do you define the CTV border? Some commonly stated bou...

In the post-op setting, would you delay 1 week even if it took them out of the 6 weeks post-op window? Meaning the loading dose of erbitux was given d...

How long is too long to wait for recovery? Is there a role for pre-procedure platelet transfusion and/or alternatives to epidural anesthesia?

Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?

Would you offer VBT alone in a completely resected vaginal cuff recurrence that is grade, recurrent stage IA endometrial cancer, is all staging imagin...

How should the need for dose homogeneity be managed relative to the proximity of these target volumes to the spine?   Are AREN0321(HR), 0532(...

For example, for a cN0 oral tongue cancer with I-III dissected with involved LN, pN1, would you use 54Gy or 60Gy for level IV? Or do you always take t...

SIBs of 55-57.5 Gy in 25 fractions are frequently mentioned with bowel volume constraints at this dose, but assuming there is no bowel nearby (e.g., b...

Conversely: In a patient with N2 EGFR+ NSCLC receiving radiation, would you still consider use of osimertinib?

How do you interpret the results from the recently published EORTC-62092: STRASS study that showed no benefit to preop RT+surgery vs surgery alone and...

Is chemotherapy recommended for M+ germinoma? CR to chemo; Spine MRI negative; CSF negative Is CSI required or whole brain radiation is sufficient f...

For example, in an upper or mid-esophageal cancer with a PET positive lesser gastric curvature node. Is it reasonable to treat PET positive areas only...

In a patient with a history of a RLE melanoma s/p WLE and right ILND, how would you treat nodal recurrence? What are the surgical vs non-surgical opt...

Is the short time to recurrence a reason to not consider definitive management with surgery/radiation? Should systemic therapy be added if pursuing d...

While we are waiting for results from B51, could we omit internal mammary radiation in triple negative, cT1N1 breast cancet pts who have a complete pa...

How many cycles do you prefer before and after? How long do you tend to wait before starting radiation after initial chemo and after radiation to resu...

In this patient dermatofibrosarcoma protuberans of the thoracic spine, which originally caused a cord compression and has since been debulked, gross r...

The CTV examples in the contouring guideline by Wu et al (https://www.ncbi.nlm.nih.gov/pubmed/26104943) don't appear to crop the CTV out of lung. Woul...

Do you treat the pelvis or omit? Do you have more tighter constraints for rectum or bowel? 

If there was no further resection and the initial LAR showed a pT4a (visceral peritoneum), pN1 pelvic nodal disease with positive radial margins, woul...

Comprehensice RNI? High tangents? Whole breast only? Does ER/PR/Her2 status influence your decision?

What dose level do you take it to if it is a buccal mucosa/retromolar trigone? Any additional factors that would change your decision?

What approaches (surgical vs non-surgical) offer the best cosmesis for keratoacanthoma (low grade squamous cell carcinoma) ? 

If so, what would your target volumes and doses be? How would you sequence with immunotherapy (eg nivolumab)?

For example, if partial breast RT results in the prescription dose to 80% of the breast, is that reasonable? 50% of the breast? 

Would you deliberately spare the area of necrosis in your WBRT treatment plan?

If you are treating a patient with liver SBRT, would you not treat a patient who cannot have fiducials? If you are treating without fiducials, are you...

What if there is residual soft tissue disease?  Would you treat a distant metastatic site if only 1 or 2 metastatic sites total with gross residu...

The STAMPEDE trial recently published in Lancet used 55 Gy in 20 fractions but did not include dose constraints.

Is there a role for radiation? Does your approach differ depending on site(s) of  disease, and/or if the patient has Basal-Cell Nevus (Gorlin) sy...

If advanced stage do you follow same guidelines as Scc? Do you use same Cth regimen? Role of total laryngectomy ? 

How long do you continue high dose dexamethasone after radiotherapy? Does your tapering regimen depend on the clinical response to treatment? 

NCCN guidelines lists adverse features as positive margin, but does not appears to include close margin. If felt to be an indication similiar to a pos...

We have encountered multiple patients whose pre-ADT Testosterone was >1500 (Normal range 264-916) and sent them to Endocrinology to evaluate for so...

Given consensus contours for prostate bed, volumes can approach the sigmoid and include a significant amount of bladder, how do you meet these objecti...

We sometimes find highly suspicious LNs by CT, PET or MRI in the undissected regional lymphatics, and surgeons may not be willing to perform another o...

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

If the patient had at treatment break not due to radiation toxicity, for >2 weeks, and had to complete the remaining course, would you consider any...

This has a big impact on treatment volume delineation if one schema classifies a lesion as T2 and the other leads to classifcation as a T4. In the T4...

Should the prostate be rebiopsied, or would you proceed with radiation therapy given the relatively high failure rate of cryotherapy as initial treatm...

Is breast conservation absolutely contraindicated? What is the true increase in risk of secondary malignancy? Is there a good reference?

How does this vary with dose-fractionation schedule or location of bone being palliated? What is the expected time frame for recovery?

Would you offer refractory doses (40-50 Gy) to the RPnodes and send for splenectomy? Or would you offer refractory doses to both RP nodes and spleen?&...

Do you give SRS/fSRS or would you ever elect to closely observe if the patient is receiving immunotherapy/targeted agents? I find postop that these l...

ASTRO 2015 esophagus guidelines recommended the abdominal para-aortic nodes to be included in the CTV whereas ARS 2020 guidelines did not. Instead, AR...

Leukoplakia is present throughout but no exophytic masses seen. Is radiation an option (dose/fractionation)? Surgery? PDT?

Given prognosis is poor per Oing, et al, Annals of Oncology, 2016, would you recommend radiation?

I've anecdotally been taught that RT rarely will help open up the lung, but we often will still offer a course of palliative treatment. How do you dec...

What is your preferred concomitant chemotherapy FOLFOX? Carbo-Taxol? Which dose would you give? SIB?

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

Have you found any of the more common medical treatments (chlorpromazine, baclofen) to be most effective in the setting of throacic radiation or head ...

Since oncoplasty is becoming more common at the time of lumpectomy, is it possible to do APBI with an HDR device like SAVI in these patients?

After multiple adjacent tissue transfers it is difficult to define a "tumor bed" with oncoplastic surgery.  Surgical clips are often useful ...

If the location of the biochemically evident cancer cannot be determined, would you re-irradiate the prostate despite absence of histologic proof of l...

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

What is considered an acceptable dose to normal breast tissue? E.g. for thymoma, PMBCL, HL, etc. 

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

Would you include any of the staple line or treat nodal stations at risk only? How would you view this situation in the context of the recently presen...

NCCN recommends chemoRT for unresectable, “locally advanced, advanced or recurrent disease” but is chemoRT necessary in a small (e.g. 2.5c...

How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?

Tumor felt to be technically unresectable due to extensive cervical/parametrial involvement. ER/PR and HER2 testing are pending.

Would your recommendation change based on disease extent? What other factors would you consider?

Would you reduce dose, e.g. from 30 Gy in 10 fractions to 20 Gy in 5 fractions, or hyperfractionate, e.g. 1.5 Gy bid to 20-30 Gy?

For instance, if you have anal canal involvement, do you cover the entire mesorectum?  Any other adjacent organ invasion that would lead to modif...

If so, what dose-fractionation do you utilize? What other factors do you take into consideration?

In particular, I have a patient who underwent lumpectomy for a T3 tumor with positive margins and 1/2 SLN+.  She is now scheduled for mastectomy ...

In a palliative setting, how long would you wait to initiate WBRT?

It seems that patients have an easier time maintaining a full bladder at the beginning of treatment compared to end of treatment. 

Can this be done right away or do you wait for the cavity to involute before you plan postop SRS to cavity?

I know many centers are exercising extra precautions in light of the new concerns with coronavirus. How are people explaining things to their patients...

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

Tumor traverses the myometrium to focally involve the serosa; 1/6 sentinels with ITC and the rest negative. 

Do you cone down to gross residual (and stop elective nodal coverage) after 36Gy or 41.4Gy? Parameningeal group III, stage III alveolar rhabdo.

Such as those meeting the eligibility criteria for NRG HN002, <10 pack years, HPV+ T1-2N1-2b, T3N0-N2b

If a patient who has undergone radical prostatectomy many years previously presents with biochemical failure and is found to have a nodule in the pros...

Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?

If post-op with clear margins would you prefer adjuvant RT or close observation with surgery for optimal reduction of local recurrence? This particula...

In treating skin cancers of the scalp,  are there any specific constraints you give to the skin itself to prevent alopecia?  How does changi...

For example, a patient with a large (>3cm), spiculated, FDG-avid lung lesion, who has poor lung function and is refusing a CT-guided biopsy?

At what point do you hold surgery and switch to definitive chemoradiation? What is your treatment volume? If additional surgery is preferred, do you...

Does tumor type matter? Are there issues are associated with overcorrecting anemia during radiation?

ARST 1431 indicated: 30Gy (PTV2=GTV2); 25Gy (PTV1=CTV2+2mm) in 5 fractions. With complete response to chemo, how do you defined GTV2?

Consider 6 fractions weekly chemoRT? Add cetuximab to chemoRT? Proton boost? Induction chemo prior to chemoRT? Interstitial H&N brachytherapy boos...

What advantages/disadvantages are there over OncotypeDx DCIS assay or traditional clinical pathologic factors? What other concerns do you have?

What is the appropriate timing and what factors do you consider when making such a recommendation?

NRG GU-006 included the following as part of its eligibility criteria: “Persistent elevation of PSA after prostatectomy measured within 90 days ...

For treatments such as whole brain radiation or palliative spine radiation, is there a certain hotspot value you try to limit the plan to (i.e. <10...

Would your recommendation change based on the patient's age, performance status, comorbidities, or chemotherapy details?

For example, in a patient treated with multiple systemic therapies over ~10 years, would it be reasonable to use radiation to a single asymptomatic si...

In general, how would you approach such a case with regards to creation of your treatment volumes and dose-fractionation? 

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

For instance, if the tissue came back SLL, Waldenstrom's, follicular lymphoma, or even nodular lymphocyte-predominant Hodgkin lymphoma, would any or a...

Z 0011 population, cN0 with 1-2 SLN involvement with low likelihood for additional non SLN metastases?

These situations often arise in patients with a poor prognosis and the recovery time from such a procedure may not be trivial. In what cases would you...

Would you consider 55 Gy in 20 fx to the primary followed by SBRT to oligo sites? Would you consider concurrent immunotherapy? Or would you just proce...

What constraint to the repaired carotid artery and bovine pericardial tissue used to patch the defect? How long should we wait from surgery to start o...

Does your recommendation change if the patient is elderly? Dose/fractionation/volume? Systemic therapy?

If so, what is your time threshold for when you'll start PCP prophylaxis--when you anticipate steroid courses greater than 1 week? 1 month? 3 months?&...

For those of us just transitioning over to hypofractionation, what are reasonable, but conservative, constraints that you use?

A recent NCBD analysis (Rusthoven et al, JCO 2016) suggests that the addition of prostate RT significantly improves survival compared to ADT alon...

Would you recommend re-excision or proceed to adjuvant therapy if the tissue margin is negative? Pathologist states that tumor foci at margin was only...

AREN 0532 kidney constraint is whole kidney <14.4Gy and 50% kidney <19.8Gy. If treating whole abdomen to 21Gy for diffuse unresectable peritonea...

Is radiation always indicated? AREN 0532 specified 10.8Gy flank with 10.8Gy boost to gross residual in all recurrent Wilms patients. However, NWTS-5 ...

Aquaphor, barrier cream, sitz baths, domboro, silvadene, foam dressings?

ASTRO 2019 guidelines conditionally recommends elective nodal RT in unresectable pancreatic cancer. However, NCCN states that ELNI is controversial in...

What is "clinically significant" lymphvascular invasion? What are the standards for focal vs multifocal vs embolic vs extensive? How does this serve a...

Are there factors that would make you worry about occult separate primary? For example, in a small, well-lateralized tonsilar cancer presenting with ...

NCCN vulvar guidelines only recommends inguinal LND but GOG 37 recommended PLND when groin nodes were positive. NCCN penile guidelines also recommende...

Do you have a specific pituitary dose threshold? Do you typically refer prior to or following radiotherapy?  

What dose limits do you use and in which situations will you exceed them? How do you counsel your patients on risk of severe trismus and how do you ma...

If there are small but numerous nodes involving levels II-IV and V on the ipsilateral side would you treat the lymph nodes if they had not previously ...

ASCO 2016 guidelines specified that SLNB was not recommended for T3/T4 N0 patients but uptodate allows it.

What method provides the best reproducibility? Abdominal compression? Inhale breath hold? Exhale breath hold? 

Would extent of surgical resection matter? Do these patients need CSI (like Pineoblastoma), just local radiation, or something in-between (say whole ...

Margins widely negative - 1cm, and full bilateral inguinofemoral lymphadenectomy performed. 

How do you choose between Avastin, hyperbaric O2 and other therapies?

The protocol for the James trial (NEJM 2012) states: "non-target tissue may be excluded at the discretion of treating physician." For gyn applications...

Do you limit the delineation to the initial tumor bed, or do you delineate the whole body of the flap (eventually sparing the pedicle of the flap)? A...

VC brachy, pelvic RT, +/- chemo?  Does your management change if it is confined to the endometrium without myometrium invasion or if it is only ...

When the original tumor extent is substantial (displaces normal abdominopelvic organs), but responds well to therapy (i.e. as of week 12) - How would ...

In an elderly woman who is not felt to be a good candidate for radical surgery is split course radiation alone an option for definitive intent radiati...

Assume treating to 64-66 Gy.  Do you simulate bladder cancer patients with full and/or empty bladder? Do you ever add your own delayed IV contr...

In the case of conventional fractionation or SBRT, would you constrain the implants? (No history of breast cancer.)

TBI was 20 years ago, chest wall RT was 8 years ago.  The solitary nodal recurrence in axilla was resected, but with ENE+, PNI+, with no further ...

Do you perform a DRE at consultation and/or in follow up?  Do you feel that performing a DRE changes your management?

PMH O'Sullivan et al used 50Gy/20fx or 60Gy/25fx https://pubmed.ncbi.nlm.nih.gov/18707828/ Or extrapolate from SCC larynx using 2.25Gy/fx to 63-65.2...

Liver SBRT maintaining 700 ccs of liver <15 Gy is a commonly used constrain; however, if the total liver volume is limited due to cirrhosis, prior ...

If bilateral inguinal LND showed no involved nodes and primary is unresectable (FIGO IVA), can one treat only the primary w/o elective radiation to th...

For example, in a young high risk patient who completes less than half of her prescribed treatment and wants to resume after a period of months, how w...

Would gross ENE or R1 resection trigger you to consider adding chemo? If so, do you use weekly cisplatin or cisplatin/etoposide?

E.g. Recurrent one year out from neoadjuvant chemo-immunotherapy and margin-negative lobectomy. SBRT vs. larger-field chemoRT? Difference in approach ...

The 2020 NRG endometrial and cervix contouring guideline update said the anterior margin is a straight line between the aorta and IVC. Should there be...

If so, what fields do you irradiate? The initially involved nodal regions? Do you offer after PR as well? If not, do you consolidate at any point...

For T2bN0 or T3N0 disease, you consider radiation alone, sequential radiation followed by chemotherapy, or concurrent chemoradiation?

For example, would you treat more distally along the nerve or the involved branch if symptoms are localized?

Disease involves the lungs diffusely and bilaterally. If only palliative treatment is recommended, what should be the target volume (primary only? pr...

ACNS1123 classified patients as NGGCT if serum & CSF AFP >10 ng/mL or bHCG >100 mIU/ml irrespective of biopsy results & did not mandate ...

Would you recommend radiation therapy or immunotherapy? If proceeding with radiation therapy, what dose-fractionation and technique would you utilize?

Are there situations where you skip radiation despite risk factor(s) commonly listed or do you always give adjuvant radiation? For example, for FOM p...

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...

After initiation of anti-TB treatment and 3 negative AFB smears, would you initiate concurrent chemoRT? Would you give sequential RT then chemo to giv...

Are they necessary? Any group of patients that you use them on (concurrent ADT, anemia, or use of whole pelvis, etc)?

Patient had had multiple surgeries and non healing wounds. If so, what dose/fractionation did you use?  Did your patient have durable control of ...

In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?

If so, how would you design and deliver the treatment?

For example, do you recommend RT for close margins or focal trans-capsular invasion?

In the unfortunate setting where you cannot get an underinsured patient whose policy does not cover radiotherapy started on treatment without guarante...

There are mixed recommendations about re-testing vs simply waiting for a quarantine period prior to resuming therapy. 

For breast patients being treated in prone position. The plans generally spare the skin more so than in the supine position.  If a patient has a ...

NCCN recommends either ISRT with rituximab/chemotherapy or ISRT alone in this scenario.  What factors help your decision making?

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

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...

Do you recomment MRI, CT with contrast or CT angiogram? And at what time intervals post-treatment do you perform surveillance scans? 

Should concurrent chemotherapy be given? How would you modify the regimen in elderly/frail patients?

Would you offer SBRT?  What criteria do you use to consider SBRT?  What dose limits do you place on the glenohumeral joint?

Would you do IMRT or 20MeV/6MV electron/photon mix (traditional moustache field)? When do you treat LNs? T3/T4? What LN levels would you include? le...

E.g. 50 Gy/5fx 2 years ago. If so, what dose and what aorta and bronchus constraints do you use?

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

There are so many available options—standard fractionated RT, moderate hypofractionation, SBRT, protons, combined EBRT and brachy—how do y...

Would you offer adj RT for a vaginal primary patient with paravaginal involvement s/p rad hyst w/ upper vaginectomy, BSO and inguinal node dissection?...

Would there be concern that the false negative rate be too high with a SLNB alone?  Is this mitigated by having the clinically involved node clip...

Does PSMA have enough data to use to guide therapy, even if the result is obtained as part of a clinical trial? Would you change your hormonal recomme...

Do you do any type of assessment to see if they would likely benefit from, or be able to tolerate, treatment with DIBH versus free-breathing?

Mini-tangents only? 3-4 fields including lightly weighed perpendicular to chest with some exit dose to lung?

In this scenario, is systemic treatment better given bilateral involvement? In a patient who has already had cataract surgery and is not at risk for c...

 Does your dose recommendation change if a patient has cord compression or has undergone surgery? There is a range of doses in the ILROG guidelin...

Does the TURP defect in the prostate affect efficacy or toxicity or SBRT?

Are there exercises, massage techniques, or support garments that are effective at preventing or reversing lymphedema of the breast?

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

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

STAMPEDE arm H uses the CHAARTED definition for bone metastases in the axial skeleton. There is no mention of patients with non-regional nodes. Would ...

Are there other practical tips for improving the patient setup in this patient population to minimize potential acute and late effects?

Would you consider adjuvant chemotherapy, radiation therapy, hormone therapy, or surveillance?

For a stage I, favorable site, group IIb (LN+) embryonal RMS where both the primary and LN have been gross totally resected (margins negative), can ra...

NCCN list T3 as an indication for PORT for all head/neck subsites including supraglottic larynx with the sole exception of glottic larynx. (Some other...

Do you use brachytherapy or external beam? What prescription / dose / regimen do you typically use? What if there is small bowel hanging into the fiel...

Would you treat with radiation (+/- surgery upfront, if resectable) or systemic therapy?

In a patient with a large primary and a negative PET/CT for nodal disease, would you push for EUS for radiation planning? Or would this be an unnecess...

Do you give cuff and chemo or pelvic CRT or chemo alone?

What would you consider if the recurrence occurs multiple times in the prostate? Salvage surgery if a candidate?  HIFU or cryo?  ADT?

Would you recommend axillary dissection, axillary dissection followed by adjuvant radiation, or axillary radiation alone? Does the number of positive ...

In contrast to lung SBRT, rib lesions may not have a clear lesion on CT that can be delineated to create an ITV after 4DCT. Do you create an ITV, and ...

Degree of subglottic extension is often difficult to determine from office scope examinations and ENTs do not always include this. Do you have any tip...

What makes you favor ADT vs local therapy? Any preferred local therapy options? Any other special considerations?

Prospective single arm studies with short term follow-up were recently presented in abstract form (Kishan et al, IJROBP, Oct 2017; Mallick et al, IJRO...

In a patient who has undergone resection and adjuvant chemotherapy who then recurs locally, how would you recommend treating?  Would you treat ju...

Do you give RT to the entire extent of disease at presentation or just regions with slow early response? Is it necessary to irradiate all known extent...

Vulvar cancer is well differentiated. Closest margin is 6mm. LVI is identified T1b N2c Vaginal cancer treated 20 yrs ago described as 5 cm in length...

Final pathology showed grade 3 spindle cell sarcoma of thee vagina involving the anterior lateral cervix 5.6cm x 4.5 x 3.4cm, <0.1cm left lateral m...

Do you radiate the paraaortic chain to 10.8Gy then boost gross residual with 1cm block edge margin to 19.8Gy or simply treat the entire paraaortic cha...

For example, in a woman who is post-mastectomy with early stage pleomorphic ILC with ITCs in a sentinel node, would the histology push you to recommen...

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

Patients can have this for many reasons including being completely anuric, incontinence, nephrostomy tubes, etc.

For instance, should post-operative radiation therapy be offered a patient with a 4 cm malar SCCA, resected with negative margins, no PNI, and a compl...

Do you treat in a response adjusted fashion as per ACNS1123 Stratum 2: 18-24 Gy whole ventricle with 12 Gy boost? Are there any situations where you d...

Which Radiation modality, if any, would be preferred? Typical chemotherapy does not work for SFT. In which circumstance would you use VEGF ( Temozolo...

If so, what dose-fractionation regimen do you utilize? What are your target volumes? Would you first recommend induction chemotherapy followed by rest...

If you would offer radiation, what dose do you recommend? How do you simulate and treat the patient? The patient is not a surgical or chemo candidate.

Assume PSA less than 0.5. Would axumin positive nodes change your mind? What dose do you use? Do you require biopsy first to prove pathologic nod...

What are you typical treatment volumes and doses for R0 vs R1 resections?

Is there a role for dose escalation? Would you recommend sequential or SIB? Is there more of a role for surgery vs. dose escalated RT in EWSR1-non-ET...

The NCCN guidelines categorically recommend adjuvant XRT for a cT1-2N0 rectal adenocarcinoma upstaged to a pT3N0, yet there are multipl...

Is there a certain size threshold you use? Does location of the lesion (e.g. spine) matter? What other cases do you feel are not ideal candidates for ...

Are you employing more or less primary chemoRT v. surgery for some cancers? Are you dose de-escalating? What are issues radiation oncologists should b...

For example, RTOG1203 says to include "1-2 cm of tissue anterior to the S1, S2 and S3 sacral segments" but have also heard of stopped at S2 to limit r...

Recent results from the STRASS trial suggest limited benefit from preoperative radiation therapy for retroperitoneal sarcomas.  https://pubmed.n...

There is a recent publication that nicely summarizes the molecular/genetic tests for prostate cancer (https://www.ncbi.nlm.nih.gov/pubmed/26123120). W...

-Are there settings where group II disease does not need RT?-Are there additional genetic alterations in fusion negative RMS patients that can be used...

When do you electively treat the ipsilateral versus ipsi- and contralateral neck?

Older data suggests that local control with RT alone for supraglottic tumors >6cc is fairly low. Would you employ altered fractionation (what dose...

Do you electively treat nodes and how does your approach change with intra- or extra-hepatic primaries?

Would preop RT still be the treatment option for these kind of patients? Assuming that the rectovaginal fistula was from tumor progression.

Are there certain cases or body sites where you feel daily CBCT is adequate?

 If so, do you have a threshold for number of involved sites i.e. X lesions in Y organs, etc.

Is a detectable PSA on ADT a harbinger of biochemical recurrence? Is there a threshold value above which you are concerned (ie. 1.0 vs  0.5 Ng/mL...

If you recommend adjuvant radiation, how would you treat this? Because of the cystectomy, there is no typical prostatic fossa.

The recently published executive summary from ASTRO/ASCO/AUA hypofractionated radiation therapy for localized prostate cancer states "Five-fracti...

When treating a NSCLC with extensive bilateral mediastinal disease +/- supraclavicular nodes, would you recommend exceeding certain tissue constrains ...

For example, would you consider high tangents in a patient who did not undergo SNB due to age and comorbidities, but has high risk features such as gr...

ACOSOG Z11102 mandated radiation with a boost. Hypofractionation was prohibited. This isn't how we practice nowadays and some women might otherwise me...

This assumes no current local pain symptoms or spinal cord compression. Does this recommendation change based on histology? Any other factors to consi...

Would you consider it for a patient with good PS but with limited metastatic disease? What dose fractionation would you prefer?

Patient with stage IIB cervical cancer treated 8 years ago, now with large (>10cm), isolated, symptomatic recurrence involving the left SCL and med...

RTOG 0815 protocol says 1 cm from base of SV in any direction. Some contour the SV visible in the slices within 1 cm sup/inf from base of SV.  P...

Is it possible or common for patients to have mucosal telangiectasias along the portions of the GI tract in the radiation fields? If present, would yo...

Would you go to a higher dose for the primary and/or nodal volumes? If the medical oncologist does not feel comfortable giving cisplatin or mitomycin...

Do your constraints change when treating standard fields for T3 disease versus including external iliac lymph nodes for T4 disease when treating with ...

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

Often physicians must choose between treatment with surgery or SRS. What patient factors would drive one to choose surgery or SRS?

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

The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease.   Both ARTIST and Inte...

If the oligometastatic lesions are not longer PET avid after neoadjuvant chemotherapy, would you consider further treatment with local therapy or obse...

Would you offer SBRT to both sites, SBRT to the primary and standard fractionation to the node due to proximity to the main bronchus/proximal lobar br...

Do you contour cardiac vessels and/or heart substructures? If so, which one(s) and what dose tolerances do you assign them? 

This particular case involves a patient with a frontal scalp low grade eccrine carcinoma status-post excision with positive margin complicated by...

If proton therapy is not available would you consider radiosurgery? How would your management differ if residual disease is present?

 If a SLN biopsy could not be performed and only a few lymph nodes were removed by ALND that were negative, would you treat the nodes? What facto...

In a patient who has undergone prior cryoablation for prostate cancer and develops a biopsy proven local recurrence, what dose and fractionation would...

What-dose fractionation would you utilize? What small bowel constraints would you optimally set to achieve? How would your approach differ in a surgic...

Do you consider Macdonald type sandwich treatment 45Gy with xeloda? Would you dose escalate gross node? Would you treat stomach remnant and regional...

After optimizing symptoms and reversible factors, and attempting cognitive-behavioral interventions and exercise, do you recommend pharmacologic agent...

Given CHAARTED and STAMPEDE, what would you recommend? Would lymph node vs osseous mets change your recommendation given the trial did allow patients ...

This case involves an impressive ‘high volume’ vaginal recurrence and patient was not originally planned for adjuvant therapy. Concerned t...

Since only part of the breast was treated before, would you include treatment of the whole breast now, despite no detectable disease?

The treatment of ITC and micrometastases in lymph nodes in women with breast cancer is controversial. Given the rarity of male breast cancer, complex ...

When, if ever, would you consider up-front SRS for first line therapy?

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

How reliable is MRI only diagnosis of prostatitis? Assume no prior PSA and Group grade 2 or 3. Would you treat prostatitis? How do you deal with ADT e...

Definitive RT only?  Concurrent chemo-RT? Technique, dose (for radiation and chemo, if any), fractionation?

Would you offer EBRT alone or EBRT with vaginal cuff brachytherapy after surgery and chemotherapy for stage III (T3N0) carcinosarcoma of the uterus? ...

Would you observe or radiate?What volume, dose, fractionation would you use? Systemic therapy?

A HA-WBRT patient developed brisk mucositis on the soft palate at fraction 8/10

While protocols describe using a D2% constraint, there is little description of what should happen to the DVH between 30-37.5 Gy.  It would ...

How do you decide on other chemo regimen? (Dosing, frequency, carboplatin based, non-platinum based etc.) Would you use Cetuximab? Altered fractiona...

If biopsies consistently show high grade adenoma and there is a locally advanced rectal tumor with MRF involvement on imaging, what is the next step i...

How would your recommendation change for a lesion within a non-radiated field versus a previously radiated field? What about an oligoprogressive lesio...

Given the length of the scan and higher likelihood of patients being unable to hold their bladder, do you deviate from CT simulation and treatment ins...

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

What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...

Would you recommend locoregional radiation therapy or systemic or immunotherapy alone? If you would consider radiation therapy, what would be your rec...

What dose would you consider for patients with bulkly pelvic disease and in what situations would you, if ever, dose escalate for local disease with b...

Small bowel is usually the dose limiting OAR while planning cervical HDR brachytherapy. Having the bladder empty during treatment planning and deliver...

If there is hilar LN involvement only, could you consider hypofractionated RT? 

Would you treat the primary site alone, include the hand and arm lymphatics to the epitrochlear nodes (one continious treatment volume from hand to el...

At what point would you recommend transfusion? At what point would you stop radiation?

I’ve noticed some patients develop worsening SOB and DOE months after RT and rather than interstitial diffuse pattern you would see with pneumon...

Do you ever allow patients to receive a couple of cycles of systemic therapy first if there is high burden of disease? What is the maximum time after ...

In the case of a nodal mass of several nodes matted together due to ENE but without apparent ENE at the surface, does your management change? Is ENE ...

What factors do you consider when offering retreatment? If you use repeat-SRS, what dose and fractionation?

Has anyone omitted post path fracture radiation of pelvis/long bone in favor of starting endocrine treatment first? Or would one omit RT and start a C...

I can't convince the surgeons to refer their patients for adjuvant RT because the prospective data is messy and doesn’t seem to indicate a benef...

In which situations would you consider 37.5 Gy / 15 fx or 20 Gy / 5 fx over 30 Gy / 10 fx?

In a case with negative margins, T1-2 primary, no ECE, no perineural invasion, etc, is adjuvant radiotherapy indicated based on N2a stage?

Do you include external iliac nodes as for T4b (adjacent [anterior] organ invasion) or do you maintain the same coverage you use for T3 disease with a...

Should the VP shunt be moved prior to RT?  Are there any complications of radiating a VP shunt?

More specifically there is no testicular invasion - would you cover the entire scrotal sac? What lymph node stations if any would you cover?

Are there general ages that you refer to in terms of risk of secondary malignancy or points dropped for IQ over time after treatment, or particular he...

Should they be context/disease specific?  Should use of chemotherapy before/after, or during radiotherapy modify these tolerances? Contexts: ex...

Stage 4/group 4 due to dissemination in peritoneal fluid. Translocation negative; treated per intermediate risk protocol on study arm ARST1431 VAC/VI ...

I have seen cited bronchus - smaller airways V32Gy<0.5cc and max point dose 40Gy for stenosis with atelectasis, but unsure sure if this is used in ...

Do you hold Avastin before and after radiation therapy? Do you avoid radiation in these patients? 

Does margin width play a role in your decision making? Would no tumor on ink be acceptable?  What if there was LCIS in the specimen as well with ...

Would your answer change in the postop setting for a tumor right above peritoneal reflection with positive pelvic nodes?

Would implant reconstruction prior to radiation therapy change your recommendations? Would you ever treat just the nodes and omit the chest wall/recon...

If so, what dose would you consider in the setting of complete and incomplete repeat surgical resection? How would you sequence this with salvage sys...

How can this be done logistically to coordinate the proton boost off site? Should everything be done up front? How are the logistics regarding plannin...

The patient received R-EPOCH followed by consolidative RT (36 Gy in 18 fractions) approximately one year ago and was subsequently salvaged with RICE.

For a patient with good response to immunotherapy (unable to receive chemotherapy due to kidney function, comorbidities) where previously avid LN have...

If a patient meets all omission criteria per CALGB and PRIME except age would you consider omitting RT? Is there any evidence for such an approach?

The interval since prior resection is between 3-5 years. Additionally, there is some evidence of nodal involvement but no evidence of metastatic disea...

With the recently reported START (A and B) trial data from the UK, in which patients were allowed to receive hypfractionated doses to nodal regions, i...

How long is too long to resume SBRT, and would you increase doses? Is there a number of elapsed days that would cause you to abort completion of SBRT?

Would you consider additional EBRT or vaginal cuff HDR in a patient with previous tx with EBRT (45Gy) + HDR (30Gy) for a R1 resection with a radial ma...

Would your recommendation change if the patient had prior radiation proctitis and cystitis (now resolved)? Previous treatment records limited, but pre...

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

Would you recommend adjuvant radiotherapy for a patient with positive margins for in situ disease with negative margins for invasive disease? If so, w...

Re-excision would result in amputation. And the patient had attempted pre-operative RT but quit at 16Gy due to toxicity/social reasons. Would you trea...

Does time since adjuvant cuff brachytherapy influence your radiotherapy approach, (for example 18 months vs 5 years)? Do you adjust your bladder/bowel...

The upfront plan is to use a definitive radiation dose of 66 Gy. My reading supports the use of 5FU + cisplatin but another doctor is recommending FOL...

Is diverticulosis in large bowel adjacent to a target a contraindication for SBRT? How would you manage?

The recent NELSON trial evaluates screening in a slightly different population than the USPSTF/NLST criteria. Which will you follow?

Would you boost the area of positive margin? Would you include the expander?

Assuming the patient is otherwise a candidate for APBI.

Do you use a standard margin around the mastectomy scar (ie 2cm sup/inf), or do you extend the field to include the entire chest wall?

Would you omit radiation therapy for some patients with Li-Fraumeni syndrome who would normally receive it?

Would you consider hypofractionation? If so,what dose? Would you consider a boost if there were close margins?

Would there be any indication for postoperative RT if cervical lymph nodes are negative?

Should this be based off of the response? or the site of disease such as bone vs soft tissue?What data are there to dictate that the prior (response, ...

The margins vary widely in the literature (Roa et al utilized edema +2cm while Perry et al utilized T1+C +1.5cm for CTV). 

Assuming no other sites of disease on staging scans, surgery is not an option, and the patient is otherwise healthy with reasonable life expectancy. W...

Would you use general sarcoma expansions or would smaller expansions like the ones in head and neck would be reasonable?

How do the recent results from E2108 impact your practice? Would you consider locoregional therapy in patients who are good responders, have oligets, ...

How about in the setting of treatment after recurrent resected disease if it didn’t involve the skin: would you push for coverage even though pl...

Do you recommend TACE, RFA, radioembolization, systemic therapy or SBRT?  What if the size is >5 cm?

Should these patients be managed with high dose chemoradiation similar to the Danish study (Lancet in July 2015)? To what dose would you take the prim...

Do you cover the entire involved vertebral body with an elective dose volume (similar to spine mets)? How do you balance cord tolerances with coverage...

Is surgery still indicated? If no surgery is pursued, (how) would you deliver consolidative radiation therapy?

The CRITICS trial showed there was no OS or PFS benefit with adj chemo vs CRT. Is there potentially still a role for CRT to reduce heme toxicity and p...

What do you utilize for patient immobilization and what are your PTV margins? What MRI sequences do you favor for target delineation?

Specifically, when treating a tumor located in the head and neck region, would you consider treating closer to 64-66 Gy? Or would you be consistent wi...

Is there data to show efficacy of radiation in this situation? What dose/fractionation/volume?

http://abstracts.asco.org/199/AbstView_199_180760.html http://abstracts.asco.org/199/AbstView_199_187537.html  

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

Any dental extraction of the mandible could lead to healing problems and thus delaying reirradiation. 

How high would you try to boost those involved nodes if they are in a favorable location with respect to his rectum and small bowel? 

In this example, the patient had a resected melanoma with negative margins and the specimen was noted to have two nests of tumor cells in the deep der...

Would you offer definitive or neo-adjuvant chemo-RT in the setting of a single lung or bone metastasis?

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

Based on recent data published suggesting an OS advantage to the addition of ADT vs. brachytherapy boost to EBRT (Jackson et al, 2020), it is unclear ...

In the HERO trial, relugolix, a highly selective oral GnRH antagonist, demonstrated faster and sustained castration, faster testosterone recovery, and...

Would you consider it off-trial during the pandemic? There is some older data for treatment of pneumonia with single-fraction low-dose radiotherapy, w...

If the patient had high risk features (for example age 60+ and LVI) do you treat with vaginal brachytherapy or WPRT? If you treat with whole pelvis ra...

Any differences in the risks between SBRT vs. conventionally fractionation? Concurrent immunotherapy? 

Do you treat the whole bladder in the intial whole pelvic field to 45-50 Gy?

Are there certain situations where a hydrogel spacer is most useful based on treatment modality (SBRT, protons, brachy, etc) or other factors?

I care deeply about clinical trials but have always struggled on how to approach this topic. I would really appreciate tips from those of you who have...

Do you ever recommend TURP, short course of ADT or other treatments prior to RT to downsize?

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...

i.e. Should concurrent therapy be given?, Does MGMT matter? What are the current most promising therapeutic approaches? Should we always treat based o...

There seems to be a wide variety of palliative doses used in clinical practice (8 Gy x 1, 2 Gy x2, and 20 Gy in 10 fx).  Do you have a preferred ...

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...

Given the location but no other high risk features would you offer RT?  If so, what dose and fields? 

If an external boost of a gyn primary is necessitated because of the target size or extensive involvement of a critical structure how would ...

What dose constraint would you use for the neobladder? Small bowel constraint of 54Gy? Or would you recommend observation or ADT alone or low dose RT ...

In patients with cancers involving the lid requiring superficial x-ray treatment, I use an internal eye shield placed under the lid to protect the cor...

How would tumor grade, presence of LVSI, and receipt of chemotherapy factor into your decision?

For a patient not on dialysis? Outside of single agent 5FU, all other standard chemotherapeutic options would be contraindicated for nephrotoxicity.&n...

Higher radiation dose was shown to be associated with longer survival in Tao et al., JCO 2016. What dose constraints do you use when using these ...

What would be your radiation dose and target volumes? Concurrent chemo? Would you offer neck node radiation if no neck dissection was done?

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

Specifically, for a melanoma of the axilla with proximity to the brachial plexus, how would you approach such a case to minimize chance of radiation-i...

Would you consider this if the patient does not appear to have hippocampal involvement? Or is the risk of subsequently developing hippocampal metastas...

When deciding to treat what would be your dose/volumes? And would a re-staging scan play a role in your treatment planning?

Does the elapsed time from prior chemoradiotherapy impact your selection of dose/target volumes?

If a patient with a high grade sarcoma has gross residual/recurrent disease after resection and cannot undergo further surgery - would you boost this ...

Do you encourage patients to take a break from/stop taking Fosamax or similar medications for their osteopenia or osteoporosis in order to prevent dev...

What dose/volumes would you recommend for a previously radiated tumor not amenable to surgical resection?

This has been a common practice in the community. Is there a benefit for certain patients?

In a patient with early stage breast cancer that would otherwise require radiation, would you recommend treatment if the patient has active skin lupus...

Would you manage this histology any differently relative to other low grade gliomas? Is a STR a definite indication for postoperative XRT?

Are you doing more TNT to prolong time to surgery? If so, do are you starting with CRT or chemotherapy?

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

When would you offer re-irradiation in the setting of prior RT and tumors not amenable to gross total resection? 

Would you be concerned with more and higher grade hepatobiliary toxicity with concurrent use of checkpoint inhibitors (i.e. Keytruda)?

What if it was status post partial resection? And had bilateral level 2 lymph nodes?

Any comments/recommendations regarding the UK approach using 52.5Gy in 20 fractions (Chin et al., IJROBP, 2020)?

Is there a contraindication to radiation therapy for prostate cancer in patients who are carriers of ATM mutation? Would you offer surgery upfront? Hy...

Would you consider reirradiating the breast and regional nodes? Further axillary surgery? Partial breast radiation? Or other?

Would you recommend conventional fractionation or moderate hypofractionation over SBRT or brachytherapy?

At what age would you treat an early stage hodgkins lymphoma patient with ABVD + RT (adult treatment) vs OEPA x 2 or AV-PC x 3 (pediatric paradigm)?&n...

Would the degree of response (pCR vs no pCR) influence your decision making?

Is there a certain age beyond which it is not safe to do SBRT?

When using short course RT, the NCCN guidelines currently recommend short course RT followed by chemotherapy, followed by surgery. Many surgeons are h...

What is your preferred combination and order of therapy for a T4 rectal tumor invading the uterus leading to both rectal and vaginal bleeding?  ...

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

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

Dose is change based off of the radiation toxicity, such as poor wound healing vs radiation proctitis? What is the minimum amount of time that you wou...

The patient in question developed this new primary 3 years after prior chemoradiation. What dose constraints would you apply if treating with reirradi...

Do different modalities of imaging (PET vs MRI vs CT) help you to distinguish one etiology versus the others? What about other clinical characteristic...

The traditional 2-field parallel opposed field technique irradiates the whole larynx to the same dose and includes unaffected structures.  This ...

Our hospital is currently testing (PCR) for COVID-19 in all inpatients and outpatients undergoing surgical/"aerosolizing" procedures. Since radiation ...

i.e. T4 sinus tumor with advanced orbital invasion? Would your opinion and approach change in the event the patient responds favorably to neoadjuvant ...

Would you consider this even though this falls out of scope of STAMPEDE trial? Under what circumstances would you consider such an approach versus not...

For example, a heavy burden of nodal disease with diffuse ECE?  Would you treat the axilla higher than 45-50 Gy?  What would you use for a b...

What is your recommended dose/volume for large tumors s/p limited resection? What dose constraints do you use for the visual pathways?

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

My understanding is that this risk is exceedingly rare even with treatment in and around the stalk and hypothalamus. 

How do you counsel a pre-menopausal female with endometrioid cancer desiring definitive RT with egg harvesting and IVF for fertility preservation inst...

Would you treat the nodes with margin, the nodal group, or the whole untreated mediastinum?

From my review of literature, the rate of contralateral neck failures with ipsilateral radiotherapy for lateralized tonsil T1-2 N2a disease is very lo...

If so, do you give RT before or after adjuvant chemotherapy?

Is this different for de novo or reirradiation cases? Would you recommend avoidance of the nerve roots if there is gross disease present in these area...

Is there data that hilar location is a contraindication? Any increased risk of ureteral stricture or other unforeseen issues? What dose/fractionation ...

Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...

If normal tissue constraints can be met, should most patients (including ones with secretory tumors) be treated with radiosurgery and/or hypofractiona...

Is this one of the factors you use when deciding between repeat SRS vs. whole brain radiation therapy for distant brain relapses?

Please see this article for referrence https://www.sciencedirect.com/science/article/pii/S0167814020301638

The unfavorable risk factors for stage I-II Classic Hodgkin's Lymphoma differ depending on the cooperative group (GHSG, EORTC, NCCN), which criteria d...

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...

For those that tend to contour rather than set fields based on bony anatomy, how do you draw your CTVs? 

Aside from smoking cessation, what interventions have you found useful to manage patients with chronic symptomatic laryngeal edema? Steroids seem to b...

Is there such thing a definitive radiotherapy in this setting, or would this be a purely palliative approach? If you would treat, what would your targ...

Didn’t 0129 establish no difference between conventional vs Accelerated RT with the same Cisplatin regimen? Are there still thoughts of benefit ...

For example, would you consider switching to an outpatient regimen in lieu of AIM for metastatic soft tissue sarcoma?

If so, what dose-fractionation regimen do you utilize? What are your target volumes?

What pathologic features are most important when evaluating the possible need for adjuvant therapy?

Is there data to guide treatment re: SBRT vs. concurrent chemoradiation vs. sequential therapy vs. systemic therapy alone? Does the nodal location imp...

Many hormone positive patients are beginning hormone therapy until they can go to surgery. With a prolonged pause in routine procedures seeming very l...

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

Should staging and treatment decisions be made based on imaging alone?

Does your recommendation change depending on the disease-free interval?

How does recommendation change if this a favorable intermediate, unfavorable intermediate or high risk patient? Is additional imaging or biopsy recomm...

Would your recommendations change if you were treating a GI primary (e.g. rectal or anal cancer) vs non-GI primary? 

Do you consider this regimen based on the 10 year results of the UK FAST trial?

How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...

Scanning beam only machines are being increasingly marketed, it could be problematic if you can't use them to treat the one site which is most appropr...

Is it possible to get a good measurement with TLDs? TLDs can overestimate the surface dose by 10 - 40%. Do you use a skin diode measurement on the fir...

I've been prescribing sucralfate as first line symptom management but I sometimes see zero benefit. The randomized data doesn't support it's use eithe...

If so, for how long would you expect this increased susceptibility to last? Our medical oncologists often tell patients that their lymphocyte counts m...

Are your practices adjusting priorities at this time? If so, what adjustments are you making? If not, do you have metrics in place that will tell you ...

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

For example, a patient with SCC of the H&N and has a lung mass that is SCC, would these be two separate primaries or metastasis? What is the best ...

The more recent NWTS trials do not include these tumors, since rhabdoid are recognized to not be similar to Wilms, and the AREN0321 does not provide s...

Should the patient be admitted for observation which will risk exposing other immunocompromised patients to COVID-19, or should the patient be quarant...

When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...

Mitigating the spread of COVID-19 is of utmost priority now that containment measures have failed. Social distancing will help "flatten the curve" of ...

We have been receiving referrals for oligoprogressive SBRT for multiple primary tumors (NSCLC, Colorectal, Renal Cell, etc.) in the setting of diffuse...

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

For those of us who are just starting out in practice, do the seasoned pros have any advice?

If a skin flap was required due to necrosis after the mastectomy, would you still provide PMRT assuming the patient is high risk?

How do you prevent early menopause in women? Please comment on freezing of eggs, oophopexy, supine vs prone position, vaginal dialator. 

Would you consider using radiotherapy for persistent malignant pericardial effusion?  What dose-fractionation would you use, and what would your ...

Is there specific workup you perform? Are there preventive measures? Once established, are there non-pharmacological and pharmacological treatments yo...

What dose schedule would you use to treat plantar fibromatosis? How soon after resection would you begin treatment? And how happy were you with the re...

When indicated as in the setting of positive margins and/or positive lymph nodes, do you use V45 <195cc (QUANTEC), or V45 <15% (RTOG 0848), and ...

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...

As we see more TORS being done, we sometimes run into the above scenario which could have been cured with RT alone. Do you add concurrent chemotherap...

Given the recent results of the NRG/RTOG 1014 trial, would you consider it reasonable to offer breast conservation for women who meet the trial entry ...

If a non-contrast CT is not performed at CT simulation or otherwise not useable, can you plan on the contrast CT or must you re-simulate for cancers n...

Guidelines indicate RCHOPx3 +RT as category I and RCHOP x 6 below that; long term f/u for SWOG 8736 showed similar PFS and OS. Do you have and approac...

When do you offer preop RT (50Gy) before the re-excision? When do you offer post-op RT after the re-excision?

U of Alabama paper states no max dose constraints used but they try to keep V60 < 10% or 10 cc (these constraints appear to be difficult to achieve...

Would you consider SBRT and if so what dose/fractionation would you use if the lesion was in the head of the mandibula? If not would you give a fract...

NCCN recommends achieving margins of 2.0cm or at least the size of the lesion, but assuming the patient did not have adequate lung function for lobect...

If a patient has been treated sucessfully for Graves but has persistent symptoms of diplopia, is radiation therapy helpful? Or is this just a dry and ...

In a patient with a positive SLNBx, would triple negative or Her2+ status affect your decision on whether or not to proceed with a full ALNDx?

Would it be acceptable to treat a patient with locally advanced breast cancer (ex pT2N2a) s/p lumpectomy with a short course 4 week treatment ins...

*What dose and fractionation do you recommend for metastases >4cm in favorable positions (ie. not abutting mucosal tissue)? 

Would you consider this standard in asymptomatic patients for workup and treatment planning? Or do you reserve MRI for symptomatic patients only?

For that occasional "single lymph node metastasis" referral in patients with no other sites of disease, is there a therapeutic dose below which you're...

Generally, the margins are uncertain in this scenario and re-excision is usually not possible.

Insurance authorization for protons is pending, but if the patient cannot have protons would you treat with standard fractionation to ~70Gy or conside...

I always wished that I received more guidance as a resident. As a result of not having been mentored myself, I feel like I don't know how to be a good...

Total neoadjuvant therapy consisted of with FOLFOX and chemoradiation therapy with Xeloda and 50.4 Gy. Would you deliver a boost to the area and if s...

The case in question is a radiation-induced spindle cell sarcoma at the thoracic spine previously treated for a plasmacytoma to a dose of 60 Gy in 30 ...

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

Do the potential late effects offset any benefit of mediastinal XRT in a young patient with bulky disease?

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 ...

Is a positive imaging enough to confirm the diagnosis? If not, what situations are appropriate for a biopsy?

NCCN recommends brachytherapy plus or minus pelvic RT for surgically staged Grade 1, Stage II patients, but these originally staged IIB patients were ...

Would a combination of other adverse features such as PNI, GIII, close margin, multiple positive nodes, T4 disease and others make you recommend chemo...

How would a much higher risk cancer affect decision making? How would you treat him? 

For standard tangential radiation would you pull the field edge forward to avoid radiation dose to the entire implant?  

For both the primary and re-resection surgeries, resection was achieved via both scrotal and inguinal incisions. And margins were reported as negative...

For a patient with an access to proton beam therapy, what dose regimen would you use in the context of a locally recurrent esophageal cancer, previous...

Sometimes wound healing can delay adjuvant radiotherapy by several months. For aggressive histology, such as high grade sarcoma or skin cancers, is th...

Is your approach to simply calculate the EQD2 for specific lung constraints from the prior SBRT and add to the current plan to use cumulative standard...

Is your size limit a function of OAR dose? If yes, is there a volume of bone that you will not exceed regardless of no dose-limiting OARs?

If a patient has had a diagnostic MRI, can you obtain another planning MRI after fiducial marker and SpaceOAR placement? 

Z11 and AMAROS tell us that in cN0 patients, an adequate ALND is considered definitive treatment, but what about patients who have low volume biopsy p...

Concurrent? Neoadjuvant and concurrent? If neoadjuvant, how long before? 

If a patient was administered GM-CSF during concurrent chemoRT, would this be an indication to hold RT, regardless of cell counts (e.g. based on Bunn ...

*Negative margins, <1cm in size, no LVI, negative SLNB, not immunocompromised, no prior surgery (as well as a negative PET/CT scan).

What dose/fractionation do you use and what elective nodal areas do you cover? What studies do you order to aide in treatment planning (PET/CT? MRI?) ...

Would you be more mindful of bladder dose or hotspots? Are urinary outcomes different if the surgical procedures are done before or after radiation?&n...

Specifically with reference to rural settings where the logistics of early in the week delivery may be more challenging.

Patient had superficial parotidectomy, with negative margins. No nodes on imaging. Specifically, treat parotid bed alone? Add nodes if N0 on scanning?...

What size cut off or other factors (i.e. LVI) do you consider? Do you only treat IMN and medial SCV vs include entire axilla if only SLN? 

Assuming there is no other locoregional or distant disease.  Would you treat the entire contralateral chest wall? Nodes?

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...

How long do you allow for response before deeming it suspicious for residual disease? What work up (imaging, biopsy) do you recommend? How do you sa...

Patient had multiple positive margins and is on ADT.  What would your treatment volumes be and to what dose?

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?

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

Do you recommend before and/or after procedures? Do you have the same recommendations for any or all the below: hydrogel space, fiducial placement, LD...

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 ...

This question has come up most frequently with respect to the flu vaccine recently. Also, frequently this has been asked about the shingles vaccine an...

Given the publication by Malone, et al (JCO, 2019), how do you sequence ADT relative to the start of RT? https://ascopubs.org/doi/full/10.1200/JCO.19....

Adverse features include increased nuclear size, nuclear atypia, and mitotic activity up to 10/50 HPF.

Do you routinely include pelvic lymph nodes, prostatic urethra, and prostate?

Do age or margins factor into your decision making?  What dose and fractionation would you use? 

Would you recommend it for a mammographically occult primary or if the patient had dense breasts?  What if a high risk patient decides not to hav...

If so, how do you address the Joint Commission's cleaning requirements? The Joint Commission recently inspected our hospital including the radiation o...

Benzodiazepines are not ideal in this population. Are there superior alternatives, perhaps antipsychotics, that are effective and superior?

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

Since there is no overall survival benefit, does the local control benefit outweigh the increased risk for distant metastasis? How do you select patie...

If re-resection would yield negative margins, is observation appropriate? Does the presence of focal PNI push you toward adjuvant RT (without re-resec...

Patient had neoadjuvant ADT. Are there any preferred isotopes, seed activities, etc for small prostate brachytherapy?

Do you routinely employ dental wax? Does it depend on the material (titanum vs. other)? Do you take the extra time to replace metal with porcelain whe...

For a stage IAE DLBCL (in this case, of the oral cavity) that was completely excised, s/p R-CHOP, is the ISRT target volume just the preop volume plus...

I have a patient with metastatic NSCLC and a concurrent head and neck primary.

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

Any difference if patient is undergoing HDR vs LDR? For example, prescription doses are 45Gy for EBRT and 10.5Gy x 2 for HDR boost. 

How do you account for the change in tumor volume? Do you use pre or post-chemo volume? Do you alter dose based on response?

i.e. doxorubicin, ifosfamide + RT. Do you worry about decreased locoregional control or increased toxicities with the use of G-CSF in combination with...

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

If there were negative margins, what other factors would you consider to add adjuvant RT? Size of the tumor or depth of invasion?  

What are the indications for local control of the breast in patients with metastatic breast cancer?

The German trial included patients with tumors up to 16cm from the anal verge, while the Swedish trial update found no local control benefit for tumor...

NCCN allows a range from 5.4-9 Gy for adjuvant boost and German trial used 55.8 Gy. What factors might sway you to give a higher / lower dose? Is mor...

Do you still follow the atlas guidelines and contour the breast to the latissimus muscle laterally the the pectoralis muscle posteriorly or since the ...

-The data on induction for adult H&N ca has been mixed (excluded NPX) but recent data suggest a benefit for adult NPX. -Given that this is standa...

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

For the management of stage II endometrial cancer, NCCN says pelvic RT and/or vaginal brachytherapy.   Do you ever add vaginal cuff boost to pelv...

Would you recommend radiation to the prostatic fossa and/or the oligometastatic site? How would you dose these areas? Would you recommend ADT?

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

For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...

Alliance Z-1071 cohort had 5% with cN2 and <1% fixed or matted and the current Alliance trial 011202 only allows cN1. ALND has never been shown to ...

If there is a pCR in the breast and nodes do you treat the breast/chest wall SCV and full axilla?  IMNs?  Would the type of surgery (lumpect...

Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...

Recurrence is in the radiation field right at the border of graft and scalp, and started to surface at about 20-24 Gy. It is visibly enlarging over se...

Would your recommendation change with the following aggressive features: 8 cm, pericolic extension, positive radial margin, perineural invasion presen...

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...

For what is clearly a oropharyngeal primary, with clear extension up the soft palate and into the nasopharyngeal lateral wall, should the intermediate...

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

The patient's urologist will not offer testosterone supplementation unless he undergoes definitive therapy of his early stage prostate cancer. Are the...

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

NCCN recommends annual CT surveillance indefinitely after year 5, but I’m curious how many physicians continue and for how long?

The patient had an initial partial vulvectomy and nodal dissection 6 years prior to recurrence, with no adjuvant RT offered initially due to lack of c...

Would you alter your SBRT dose? How long would you hold the VEGF inhibitor before and after? Does the primary matter (e.g. NSCLC vs. colorectal)?

When covering with radiation what dose and technique do you favor, electrons, IMRT, brachytherapy, protons?

The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.

Do you think about it in the same way as DCIS in terms of radiation decision making (i.e. grade, margins, age of patient)?  Is Paget's disease le...

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

The patient is not a transplant candidate due to multiple co-morbidities. Some of the sites in question have had a complete response and other have ha...

For instance, would you be more inclined to treat a patient with T3N0 disease and no other risk factors?  What if there were a small neighboring ...

Based on the RADICALS-RT trial presented at ESMO, can RT be omitted in post op prostate patients in favor of salvage RT? If not which group of patient...

Do you recommend for EUA/biopsies/tonsillectomies to look for primary as well as neck dissection (at the same time to save a trip to the OR), or attem...

Do you prescribe to 5mm/apex or use a margin? Do you add time for tumor growth or allow less than the prescription dose to the apex?

Patient being treated for cervical cancer noted to have a < 1 cm posterior vaginal fornix defect with a small focus epiploclia herniating into the ...

If there was still was PSMA PET/CT activity in the prostate after a year of ADT would you offer RT to the prostate +/-nodes? 

Does time interval from initial radiation therapy matter. Assume this is in the case of castrate resistant prostate cancer in which all other avenues ...

 Assuming the answer is quite low, the next question is why?

Will your recommendation change if there is suspicious/confirmed locally recurrent nodule in the prostate bed?

For instance, in a woman with small volume disease in the breast, is your posterior border still the lung interface?  Do you cover all drain site...

Do you include the whole seminal vesicles and prostate, or just the whole seminal vesicles? Do you add external iliac lymph node coverage in this scen...

In young adults (20-30), would you provide perioperative radiotherapy f if they have actually developed HO?

68 y.o. Male underwent inguinal orchiectomy and spermatic cord resection of a 5 cm malignant fibrous histiocytoma of the spermatic cord. Margins of re...

Would certain patient/disease characteristics make you choose RT therapy over chemotherapy or other locally ablative therapies? What dose/fraction wou...

What high risk pathology factors would you consider in making your decision one way or another?Would it matter if this patient was elderly vs young? W...

Would you consider post-operative adjuvant treatment more favorable? Does resectability influence your decision? Would grade of the tumor affect your ...

Would your recommendations change if the mass were significantly smaller, say 1-2 cm, and was completely excised with negative margins?  

MRI and cervical biopsy are negative for cervical involvement 

Especially in the setting of prior “standard” adjuvant dose and refusal of the patient to undergo more extensive surgery. Do you recommend...

Burnmeister data from 2012 showed a local control benefit for radiation therapy in selected patients, but that was without immunotherapy. Is adjuvant ...

Do you favor tongue depressor instead? Does this change based on what primary you're targeting (i.e. base of tongue)?

Would there be a substanital increase in the risk of toxicity using such a scheme?  We frequently have patients who have to travel long distance...

Is this practice still relevant to the modern IMRT approach where skin toxicity is much lower?

Would you require the rituxan to be held prior to radiation?  Would this matter if it was in the post-prostatectomy setting?

Would you consider "neoadjuvant" RT to 45-50.4 Gy followed by a resimulation and a boost to a "definitive" dose of 54+ Gy depending upon disease respo...

What is your normal dose-fractionation in this scenario? Do you change your dosing if the lesion is in a weight bearing structure (femoral head/neck,...

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

Did the publication earlier this year by Gundle et al. JCO 2018 (http://ascopubs.org/doi/pdf/10.1200/JCO.2017.74.6941) alter your concept of close mar...

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?

Provided that staging PET/CT showed no residual disease or neck involvement, would you recommend completion surgery and neck dissection? Or do you vie...

Is urgent whole brain radiotherapy indicated for certain histologies such as choriocarcinoma from GTN or testicular origin? If SRS is employed, how sh...

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

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...

What margins (if any) do you consider appropriate to not require adj RT? And would you ever consider neoadj RT?

Our patients seem to hate the 20% benzocaine spray (cherry) saying that it burns and causes their eyes to water. Looking for other options. 

In December 2018, Horn et al reported the results of a phase 3 clinical trial in the NEJM (N Engl J Med 2018; 379:2220-2229). This trial included prev...

Assuming good liver function currently, without evidence for recurrent cirrhosis? Would your decision be affected if it was a primary HCC vs Liver me...

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

Should cystectomy remain standard of care? (Recently debated in JAMA Oncology: http://jamanetwork.com/journals/jamaoncology/article-abstract/2520055...

I treat early-stage nodularity and cording, but am not sure whether to treat knuckle pads.

If you do rechallenge is there anything that can be done to prevent the recall reaction from happening again?

How long after hysterectomy would you consider delivering adjuvant radiation therapy? Would this differ for external beam versus brachytherapy? Are t...

Some specific questions: Would you recommend repeat biopsy to confirm residual disease? How would your recommendations vary if the patient had pre...

Do you recommend definitive therapy? Would your approach change if there are more than 1 site of bone metastases, such as 2-3?

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.  

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

In a patient with their second cancer, with oligometastatic disease, do the risks of RT related second malignancies outweigh the benefits?

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

These patients are often not surgical candidates, but radiation complications may also be underappreciated.  Do you refer to vascular surgery pri...

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

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...

If the breast was previously radiated 15 years ago, would that change your decision?  If there was residual lymphoma on cytology of a chronic se...

If yes, do you have any specific criteria for whom you offer these BID days?

Specifically the groin region? Or are there techniques or a change in the management style of radiation at these sites you would employ to minimize to...

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

If a patient had biopsy proven gleason 6 disease 3-5 years ago and has had a slowly rising PSA to between 15-20 over the past year or 2, would you req...

Would this location be adequate for SABR, if so what dose scheduling would be recommended?

Is extrascleral extension or optic nerve invasion an indication?  I can find little in the literature or textbooks discussing this issue, likely ...

Would you recommend RCHOP x 3-6 or RCHOP x 3 + ISRT?  If you end up doing ISRT, would your target be any different than the principles that guide...

What techniques are most effective to minimize contralateral breast, heart, and lung dose? Do you recommend conventional fractionation?

Per the ALSYMPCA study, they excluded patients with > 3cm lymphadenopathy. Patient is currently on Xtandi and Lupron and refuses taxotere.

For instance, in borderline cases for neoadjuvant therapy (e.g. T2N1 disease), should both be obtained to increase accuracy?

This is an uncommon clinical scenario where textbooks suggest to cover the primary tumor and elective coverage of levels II-IV Do you cover any addit...

In a patient with indication for adjuvant radiation (ie. positive margins) after surgery without recurrence, when would you opt for observation only, ...

Would you give chemotherapy concurrently with radiation? Would you change your radiation dose?

Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...

Would you offer definitive management with radiation and ADT? Or systemic therapy alone such as with ADT+abiraterone?

Do you prescribe antiandrogen beyond the typical 2-3 weeks after starting LHRH agonist therapy to prevent testosterone flare? If so, for how long do y...

If so, are there any lymph node cut-offs you would have in terms of lymph node number or pathological ECE before you would add contralateral RT? What ...

Is your scoring based on SUV uptake vs the subjective interpretation of the radiologist? How do you go about reconciling Deauville scoring when there ...

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...

Would you offer palliative radiation? Would you fractionate differently?

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

Are there any quantitative measures that you use to help select patients such as  breast size or heart dose? Or do you use a case-by-case qualita...

Could you discuss how you decide between IMRT or SBRT boost for a patient who is not able to receive intracavitary or interstitial HDR or LDR brachyth...

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

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.

What factors do you consider in offering adjuvant radiation to the primary and/or elective nodes in nasal SCC? What volumes would you cover?

are there any positive or negative synergies from combined megestrol/RT treatment?

For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...

Some ENTs advocate for a neck dissection as a way to avoid chemotherapy if there is a high chance there is no ECE. This is without removing the primar...

What clinical criteria would make you prefer TORS as the initial treatment approach?  

Would you follow an algorithm such as the one proposed by Hall et al? How do you decide between intrathecal chemotherapy vs systemic therapy with HD-...

Would you proceed with induction chemotherapy (eg TPF or cis/gem) to downstage or neoadjuvant chemoRT? Would your approach be different if there is or...

For example, if a patient had a very infiltrating lipoma or one that is compressing critical structures, would you offer RT?  If so, what would b...

Should these patients be managed similar to p16 positive anal squamous cell carcinoma, and allowed six months or more for complete regression before c...

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...

Does it matter if it's within the treatment area (such as breast cellulitis in a breast patient or a UTI in a pelvic RT patient) or outside the treatm...

Have you seen RAI or lenvatinib be efficacious for locally advanced disease — allowing for better surgical outcomes?  Do you utilize EBRT?

Is there any role for definitive prostate radiation extrapolating from the Stampede and recent RTOG 0521?

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 use same contour guidelines of nasopharyngeal cancer? What levels would you cover on the involved neck side? When would you electively cover t...

Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...

Would you consider scrotum contaminated and consider including it in fields?

If so, how do you choose your region of treatment? Dose? And elective nodal volume?

Do you look at max dose or are there specific volumetric constraints you use for the small or large bowel? 

Would you administer extended field radiation therapy?  Would you omit radiation therapy?

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

What chemotherapy and sequencing with radiation therapy would you recommend? IS surgery a component of the treatment?

Our hospital has an aggressive and talented interventional radiology group. We have wanted to start a stereotactic liver radiotherapy program but are ...

What are your dose constraints for treating axillary nodal basin in melanoma with the Ballo protocol 30Gy/5fx?

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

What is your preferred approach to PMRT with inflammatory breast cancer with adverse risk features (i.e. age <45, close/positive margins or poor re...

For example, when a patient has received 60-70 Gy with concurrent chemotherapy, do you consider dmax, BED, and interval between repeat courses of trea...

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

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

Does the update of RTOG 96-01, presented at ASTRO 2015, change your practice for these patients? Or should ADT be limited to a particular subgroup?

These devices give off a significant amount of artifact on CT and some devices say they are a relative contraindication with adjuvant RT.

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

Do you have any preferred dose fractionation schedules? What kind of margins do you use?

What field size and dose/fractionation would you use? Would you treat lymph nodes? 

If so, how would you approach your radiotherapeutic plan and what dose-fractionation would you utilize?

Do you use portal or orthogonal imaging or both?

Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?  

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

Repeat EGD and additional biopsies of the stomach were all negative for MALT lymphoma and H. Pylori. A CT of the C/A/P was done showing no evidence of...

How does it vary by technique (standard fractionation, hypofractionation, or SBRT)? Does your PTV change if you are treating pelvic lymph nodes?

For example, if the patient has low PSA, Gleason 6 disease but has high volume (>50% positive cores) would that discourage you from recommending ac...

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

SBRT vs more comprehensive nodal RT with SIB to involved node? Would you include the prostate bed in your treatment volume? ADT duration? What other f...

If margins are clear, would this tumor necessitate adjuvant radiotherapy? Synovial sarcomas often occur in a young patient subset, would this cause yo...

Is there a role for an altered fractionation regimen as an organ-preservation approach? This pathological variant is uncommon and the older literatur...

This will influence the decision to operate or not, so you want to give it enough time to see a response, but given that it's a disease predisposed to...

Is is safe to use curcumin during radiation therapy? Is is safe to use with chemotherapy? Do you recommend this? What dose of curcumin is appropriate?...

If so, what patients do you select for the boost? And what data do you give to adequately satisfy the insurance review and win approval?

Would you consider a re-biopsy after chemoRT to confirm viable tumor and if so, how long would you wait after chemoRT before biopsy?  If you did ...

Do you prefer LDR prostate brachytherapy first or as a "boost" following external beam radiation therapy?

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...

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

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

Colonoscopy reveals inflammation in the colon and rectum due to Crohn's and patient also has perianal fistula due to Crohn's.

Is there a benefit to one fractionation schedule v. the other?

If so, what clinical indications? Are there any advantages of VMAT? Thoughts on concerns regarding lung and heart dose constraints?

What percentage of unresectable T4N0 pancreatic body adenocarcinomas with celiac axis involvement and no response to 6c chemo, will convert to resecta...

Some oncologists wait 1 day, 1 week or 1 month? Is there a preferred waiting period?

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

Is there a strong rationale for treating the whole prostate (not prostatic urethra) electively to 41-50 Gy?

What size of DCIS would make you concerned? Would you estimate the risk of recurrence with and without radiation?

What's the minimum isodose coverage line you accept for coverage of higher level axillary lymph nodes?

NCCN Guidelines do not address this rare form of H&N cancer. What dose/fractionation would you use for definitive radiation? Is elective nodal co...

Is there an age in which you would not offer definitive treatment? How do systemic therapy options, dose, and field sizes change with age of the pati...

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...

Does the T stage influence your decision (for example, T1mic)? Would multiple positive nodes showing isolated tumor cells sway your decision? 

For example, would you go ahead with 20 Gy of ISRT if medical oncology has already treated a stage I-IIA patient with 2 cycles of ABVD meeting all oth...

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

Do you always recommend treating breast cancer patients with getting reconstruction with their tissue expanders in place? Or is there a scenerio you w...

Per NCCN, treatment options include endoscopic resection (preferred) or definitive RT. The recommended dose is 60.75 Gy in 27 fractions for in-situ vs...

Although these patients are included in the Danish trials, Taghian et al. & Floyd et al. both showed ~ 7% LRR in this group of patients witho...

What dose and fractionation would you use. What is your target volume?

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...

NSABP B-39/RTOG 0413 prescribed a dose of 38.5 Gy using two fractions of 3.85 each daily, but prescribed to the ICRU 50 reference point dose (usually ...

Surgeon is not planning vulvectomy, since biopsies showed 2 mm depth of invasion. Also tumor board felt dose to the primary site should be only about...

Do you use CBCT or kV images? Do you match to the breast or the chest wall?

If they are symptomatic do you relax that time interval? Do you ever consider partial brain radiation instead of whole brain to minimize neurotoxicity...

At what point would you introduce the discussion of weight management, whether for risk reduction or overall health?

Should these patients have surgery if resectable? Should RT (SBRT) be directed at metastases during/concurrently with immunotherapy down the road?&nbs...

In a patient who absolutely cannot receive chemotherapy due to impaired performance status, what dose would you use for WBRT and what dose would you u...

An ASTRO APBI update readers are warned “the combination of IORT and WBI should be used only with caution and limited to women with higher risk ...

Do you just contour all the visible breast density? If you wire what's palpable (which is a bit subjective), do you include everything within the wire...

NCCN states that daily imaging is discouraged but in practice many radiation oncologists are doing daily cone beam for non-IMRT breast 

SPCG-07 (Widmark et al) and a large Norwegian registry study (Aksnessæther BY IJROBP 2018) use 12-15Gy/1fx with electrons, but others use 3...

Would you consider EBRT alone, brachytherapy alone, or EBRT with a brachy boost? Would you counsel these patients differently regarding short/long ter...

I am currently managing two patients (one esophageal and one anal) with this scenario and the referring physicians and patients are reluctant to under...

There have been case series published on this topic (most recently, PMID:26853347) with reported depigmentation within the RT treatment field.

The NCCN recommends either systemic therapy + brachytherapy or pelvic RT + brachy or brachy alone or observation. How do you decide among these option...

Assume you have good margins and the cavity abuts the implant. Are there any specialized techniques that you would recommend?

If so, what high risk features would influence your decision? Would + margins, PNI, LVSI etc be reason to treat LN?  If you would treat lymph nod...

The data is scarce- do you recommend chemotherapy only or would you consider RT for local control? 

Do you use NRG/RTOG, IMPORT LOW, single institution data, or retrospective data?

Acknowledging the mixed data, would you feel comfortable that radiation could compensate for the R1 margin? Would you push the surgeons to re-resect?

Please share your tips on dealing with short and long term xerostomia.

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

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...

An example of an air expander is located at: https://www.airxpanders.com/index.php   How do you ensure accurate dosimetry with the use of air ...

If the patient had pelvic adenopathy, would you include that in your treatment volumes?  What dose and fractionation would be considered appropri...

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...

How do you balance the goal of effective definitive treatment while minimizing the risk of injury to critical structures?

The original study used 50% of positive cores, but the MSKCC nomogram can give a high risk of EPE with just 4-5 positive cores out of 12

Do you modify your dose based on p16 or extent of ECE (e.g. microscopic vs macroscopic)?

Specifically, any data or experience regarding Ehlers Danlos syndrome?

Some emerging data of improved up front therapy shifting recurrence to CNS as sanctuary site, is focal RT approach (i.e. SRS) reasonable or is CSI a s...

Given that it is cleared from the body by renal filtration, are you concerned about clearance issues?

Would you treat Dupuytren’s contracture shortly after surgery or wait till patient develops new contracture? What dose and fractionation do you ...

Prior trials of systemic therapy including alkylating agents and rituximab have failed and the patient is medically inoperable with no history of Hepa...

For example, in standard high-risk we generally cover proximal 2cm to elective dose, before doing cone down boost to prostate and proximal 1cm. If a ...

The staging bone marrow biopsy was negative. The staging manual simply states "bone involvement is identified using appropriate imaging studies."...

Is there any further benefit of hyperthermia monotherapy, for example, continuation of hyperthermia after the course of radiation has completed?

Are you waiting for final publication of NRG CC-001? If already routinely using, any challenges with insurance approval, plan turnaround time, or oth...

Specifically, is hyperbaric oxygen therapy (HBO) an effective treatment for refractory radiation cystitis?

If considering that it is not gastroesophageal junction, what margin do you place on the clipped GTV to formulate CTV? Is there any role for SIB to PE...

Do you prefer covering bilateral neck in all cases or do you make exceptions? There appears to be conflicting opinions in the literature: https://ww...

In particular would it affect the decisions for brachytherapy or androgen deprivation? How do you monitor for treatment response since they may not m...

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

Are there problems with volume changes from the spacer dissolving while the patient is on treatment? What is your department's protocol for these type...

There is no RTOG consensus on boost volume, except to say that it should include the entire mesorectum/presacral region at involved levels + 2 cm in c...

If the patient meets the CALGB criteria for the current cancer, are there situations where you would omit RT in a patient who has never had RT? What i...

Do you have formal constraints and evaluate cumulative doses on the composite plan? Do you use traditional constraints but account for repair? 

Would you recommend mastectomy? What would you irradiate?  What are your fields?

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...

If so, what dose and dose constraints would you consider? How would you counsel the patient about risk of trachesophageal fistula?

Is it sufficient to use fluoroscopy to assess total motion, fuse MRI and PET to create an ITV, and use abdominal compression to limit motion?

Updated NCCN guidelines say there is no data to support radiation for pleomorphic LCIS. Previous discussion recommended radiation for LCIS https:...

If planning standard fractionation, what factors would you consider in omitting a boost (ie age, LVSI, etc)? 

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?

What about in the metastatic and non-metastatic setting, specifically? Any additional treatment (dose/fractionation) or toxicity considerations for th...

After and extensive en bloc resection, is there further surgery that would be recommended? Is radiation alone sufficient? 

What features would make you more likely to recommend radiation therapy with chemotherapy?

https://www.abstracts2view.com/sabcs18/view.php?nu=SABCS18L_568 Any concerns regarding toxicity with APBI?  

Do you use a trimmed 10 mm expansion on HR-CTV? Do you also include the entire initial extent of disease? How much does your IR-CTV coverage affect yo...

Assuming no advanced imaging is available, what lymph node morphologic criteria (ie. lack of fatty hilum, size, number of nodes, etc.) do you use to u...

If a patient's PSA goes from undetectable to minimally detectable (ie 0.03-.05) would you wait to offer salvage radiation?  Would your recommenda...

a. For example, an 8cm rectal GIST that was incompletely excised (assuming the patient will be receiving imatinib). b. Additionally, would you ever co...

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

For example, are PET Axumin or PSMA studies being ordered in the upfront setting? 

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?...

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...

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 ...

Would you recommend additional surgery for the violated neck? Or, would you proceed with adjuvant radiation therapy? If so, would you treat ipsilatera...

Which risk estimator is felt to be the most accurate and what threshold? What's the best contouring guidelines for ENI for prostate?

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

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...

Do your recommendations differ if patients are pre or postmenopausal given the data?

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

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

Surgical salvage is indicated but not possible in all cases due to comorbidities or patient preference. Would you re-irradiate and how? Would you co...

Detailed instructions regarding lymph node coverage have been published, but how do you think about coverage of the anastamoses from the gastrectomy?

How do you adequately balance treating a gross retropharngeal lymph node and limiting dose to the carotid? What would you quote the risk of carotid bl...

Do you ever start radiation +/- 24-48 hrs from C1D1 for chemotherapy due to logistical barriers? Do you prefer chemotherapy to start at beginning of ...

If a patient is on rituximab for multiple sclerosis, do you recommend a particular fractionation to minimize chance of MS flare during treatment? If a...

In this case, I have a patient with widely metastatic cutaneous melanoma (BRAF wild type, NRAS mutated) who is progressing through pembrolizumab and i...

Would you recommend a patient get mastectomy to avoid radiation? If treating a breast cancer patient with ILD, what lung dose constraint do you use?

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

Anal cancer guidelines mostly refer to anal canal tumors with less information about tumors of skin in perianal area (ie true anal margin). Would IMR...

If the patient is in remission for metastatic melanoma but continue to take an anit-PD1 therapy, it giving ADT, EBRT + brachytherapy safe for a high r...

What volumes and doses of radiation would you recommend? To what dose would you limit the rectum, especially in a patient with no salvage surgical opt...

Do you consider diversion colostomy, or abdominoperineal resection up front?

For example, do you change your prescription dose, treatment schedule, or OAR constraints? Have you noticed increased toxicity in older patients, e.g....

For example, for the first 25 fractions, you would treat the rest of the pelvis in 1.8 Gy/fx to 45 Gy, and then using a SIB treat the prostate/proxima...

If a patient is due for their yearly mammogram on the breast that has been diagnosed with cancer but is still undergoing active treatment (chemo or ra...

Which appetite stimulants are the most effective? How do you respond to patients who request medical marijuana?

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...

Female in her 60s who had presented originally with well-differentiated endometrioid adeno clinically and radiographically involving bilateral paramet...

For a woman with complete resection of serous intraepithelial carcinoma of the endometrium, would you recommend adjuvant radiation or chemotherapy? Wh...

Should the recent publication of Chen et al. dose escalation study for inoperable SCC esophageal cancer patients treated with CCRT, showing an 8% 5-ye...

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 (...

What factors would you consider? What if this meant treatment of the full kidney? If treatment is recommended, would you utilize an SBRT approach...

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 ...

Would you treat these sites to definitive or post-operative doses? If not, is there a dose constraint you use at these sites? Do you use tighter margi...

Would you recommend this for a focally +, diffusely +, grossly + margin? What would you expect local recurrence rate for diffusely (+) microscopic mar...

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

Current NCCN guidelines suggest that vaginal brachytherapy is optional, and there may be concern for over-treatment locally given competing risk of di...

Would you do anything different than usual regarding bolus, energies, skin dose desired for post-mastectomy chest wall radiation if a nipple-sparing m...

Is there concern for increased risk of chronic nipple pain with NAC in the boost field? 

Is concurrent chemotherapy necessary for these patients?

The surgical bed created by reconstruction is often quite larger than the surgical bed from tumor resection and neck dissection.  

Does the histology (primary salivary gland vs metastatic squamous from a skin primary) affect your decision making? Any other factors that influence ...

Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...

If you would re-irradiate, what dose/fractionation would you use? What systemic therapy would you use concurrent with treatment, if any?

In view of higher risks of rectal cancer after pelvic radiation, is more frequent screening warranted?

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

Do you use a different set of dose constraints for situations requiring treating much of the pelvis, e.g. rectal cancer, versus partial pelvis, e.g. a...

Do you generally always boost the scalp and/or soles even if those sites are not involved with disease?  

Does the lack of D2 dissection automatically necessitate adjuvant chemoradiation therapy (ie <5 LN obtained)? Would the presence of high risk facto...

 At what energy of electrons would it be better to use photons?  How many fields and what field angles should be used for photon boosts?&nbs...

Does papillary histology influence your decisions regarding surgery, chemo, radiation dose or nodal coverage?

For a patient with cT3-4N0 rectal cancer, does the dose of the previous RT affect your decision making (for example, 45 Gy to the pelvis with boo...

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

Would you continue treating the patient (in spite of the risk of causing a frank perforation, sepsis, and subsequently devastating consequences), or w...

Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...

Node-positive patients were not eligible for ASCENDE-RT, and the current NCCN guidelines do not list brachy boost as an option for regional ...

What techniques have you used to evaluate for field overlap given the different setups? We have used a thick wire placed at midline during the verific...

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

Routinely? Only with oropharyngeal cancer etc.? Given that low expression of EGFR subset did better, do you believe there is a true benefit in cetuxim...

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

In a patient being treated with a palliative course of radiation for a bony metastasis from lung cancer is it safe to start immunotherapy for POD or w...

Do you consider palliative SBRT 25Gy in 5 fractions? I often find that these patients are in severe pain and my typical regimen is 30 Gy in 10 fractio...

What is the upper limit of size you would consider offering a patient a five fraction regimen?

Do you have a "threshold" quantity/dose of opioids above which you are uncomfortable prescribing?

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

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...

If so, what dose? What if there is positive a PA lymph node but no signs of distal mets? 

How often do patients become unable to tolerate the dilator during the treatment course secondary to discomfort related to acute toxicity?

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...

What radiation doses would you use? Would the radiation dose and fields be the same as for squamous cell carcinoma? What chemotherapy would you recomm...

Is it preferable to do HPV RNA FISH testing or p16 immunostain testing to determine HPV status?  Is one test more accurate than the other? &...

Do you routinely offer definitive head and neck chemoradiation and aggressive local therapies to the oligometastatic sites?

The CROSS trial showed a survival benefit with 4140cGy and concurrent carbo/taxol, but I was always trained to treat to 5040cGy. Is anyone de-escalati...

Patient's with Fanconi's anemia can have severe/fatal toxicity with chemotherapy and radiation but unfortunately can also present with aggressive head...

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

What factors do you consider when determining this constraint? For example, in a patient who was previously treated to 30 Gy in 10 fractions, how woul...

A case series from Colorado raises concern over significant radiation necrosis with SRS. However, there doesn't seem to be much additional negative li...

On the heels of the discussions regarding skin toxicity prophylaxis and treatment, I am interested in your thoughts and current practice regarding pat...

If a patient has early stage disease with peau d'orange but does not meet criteria for inflammatory breast cancer, is PMRT indicated?

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...

Should LVI be considered present in a patient with positive nodes? MSKCC showed that LVI is a risk for LRR with 1-3 positive nodes...

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...

Because patients with locally advanced H&N cancers are at increased risk for aspiration, and radiation may increase that risk, some clinicians rem...

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

Would you treat both chest walls at the same time? What fields would you use for the contralateral side:  chest wall and lymph nodes? or just lym...

If so, would you offer pelvic lymph node irradiation in these patients if they have pathologically node positive disease?

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

A literature search indicates that most port site recurrences are managed fairly aggressively with chemoRT or RT doses 45-66 Gy. This is understandabl...

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

Do you change your treatment volumes, particularly when treating the seminal vesicles, to avoid the ureters?

Is there a dose response relationship, as suggested in the phase I MSKCC dose escalation study presented at ASTRO 2017?

At what point would you consider the treatment break to be too long for curative treatment?

For example, in a patient status-post WLE with a close (2.5 mm) deep margin and negative neck node sampling, would clinical (but not pathologic) ...

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

Sequentially or do you integrate the cuff brachy with the EBRT and if so what schedule, BIW, weekly, etc?

How long do you advise them to refrain from unprotected sex following RT? I was trained to discuss these issues with patients but the gonada...

With the recent publication of multi-institutional trial data, should this now become standard of care?

Do you have concern for aberrant lymphatic drainage? Do you cover more generously (ie. add IB/V on the contralateral cN0 neck etc.)?

Do you use a specific threshold number of sites to make your decision? Apart from assessing for cytopenias, do you consider any other patient factors?

What would be your preferred management, surgical resection or radiation? If radiation is contemplated, what dose would be appropriate and would HPV s...

Hydrogen peroxide douches? Antibiotics? (If so, what are you covering?) When do you initiate hyperbaric oxygen? Do you find pentoxyfyline helpful? How...

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

What features would help you decide between TACE vs. TARE vs. external beam radiation therapy?

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

Would you treat this patient any differently than any other very high risk prostate cancer patient?  Are there any additional dose constraints fo...

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

Would the translocation status influence your decision? Are there specific subsites where elective radiotherapy likely offers a higher therapeutic rat...

In an asymptomatic patient, would this be safe? Is there any reason to withhold radiation such as in case of T1N0 breast cancer advising patient to n...

When you prescribe your dose at 0.5 cm depth of the vagina? For instance, if you measure a vaginal length to be 8 cm, would you prescribe to treat 4 c...

Particularly for patients too large for prone breast treatment, do you use a breast immobilization device or bra?   Do you change your fractionat...

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

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.

Do you maximize rectal emptiness at the time of sim (ex with enema if needed) or do you simulate with a full rectum since this is most reproducible?&n...

Assume your patient did not receive radiation upfront and they had an axillary dissection due to recurrence. Would you recommend radiation? What would...

Would organ invasion (bladder/rectum), size, feasibility of T&O, or size of nodes push you toward neoadjuvant chemotherapy?

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

What dose and field margins would you add? Is a 50% response rate realistic to counsel a patient? What would you quote as a realistic rate for seconda...

Specifically, would the addition of a brachytherapy boost impact his ability to receive future intravesical therapy?

The patient had a bilateral orchiectomy (pathology demonstrated no invasion of the tunica) followed by R-CHOP x 6 and IT Mtx with a PET CR in a para-a...

While EBRT + brachy may be preferred, what treatment would you offer if surgery has been performed? What dose and volume of EBRT, brachytherapy, or bo...

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...

How do you weigh this concern with the need to prophylactically treat non-involved, high risk para-aortic lymphatics?

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