Radiation Oncology
Questions discussed in this category
Would extent of thrombus occlusion (non-occlusive versus fully occluded) change your recommendation?
Would you consider omitting radiation in a elderly woman with ER-positive early stage breast cancer who was placed on 4 months of letrozole prior to l...
In a patient with history of early stage breast cancer pN+(sn) treated with BCS + RT with RNI who develops isolated axillary recurrence years later, w...
If so, would you include any lymphatics in the field?
I have a gentleman in his 70s with multiple medical comorbidities who now presents with a high volume, Gleason 8 prostate cancer, PSA 29.5. PSMA PET/C...
Do you offer observation for POLE mutated tumors?
Interstitial implant was attempted under laparoscopic guidance (due to pre-brachy MRI showing potential bowel involvement). At the time of procedure, ...
If so, what dose would you utilize for the SIB? When utilizing a boost with ultra-hypofractionated whole breast RT, would you favor adding a single fr...
Assume patient has normal renal function, is not a surgical candidate, and kidney is the only site of disease.
Unable to meet small bowel constraints due to bowel falling in the field; posterior to the rectum and anterior to the sacrum. V15 is 300 cc and loweri...
Given interim analysis of PEACE V-STORM; also institutional data from SHARP consortium of using 25 Gy/5 fx for pelvic lymphatics. Can we extrapolate?
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...
How do high risk features like LVI, PNI, or peri-pancreatic fat invasion inform your recommendation?
Patient has no evidence of recurrence but has bilateral reduced sensation and weakness in her legs.
I have been using oral dexamethasone with great relief in the second-line treatment after BMX. However, there is a national shortage with no anticipat...
Would you treat with further systemic therapy vs. radiation therapy to the areas of residual disease?
RTOG 0848 presented at ASCO 2024 in abstract form: Abrams et al., Journal of Clinical Oncology 2024
What pathologic factors if any would you use to m...
SFTs are generally treated to ~60 Gy if definitive intent is intended. Due to location and surrounding OARs, not sure if SBRT could be recommended to ...
Additional risk factors include T4, EMVI, N2+, involved/threatened MRF.
For instance, VMAT planning can sometimes deliver very low doses to the contralateral base of tongue. Do you worry about this? What is your approach?
...
E.g., if tattoo-less set up is used and a patient has significant seroma shrinkage or breast swelling during treatment, do you re-simulate?
Ho...
Would you prefer alternative options such as thermal ablation if received prior SBRT?
Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is there a...
Latest PET-CT shows no evidence of distant metastasis
Would you hold Rituximab during radiation therapy? If so, how long would you recommend hold Rituximab before starting RT?
Do you consider mean ipsilateral lung dose?
If I can't get them in with a surgical oncologist for the lymph node would it be better to do the wide local excision in my office immediately and ris...
Would you target only the recurrent lymph node that was FDG avid or include other at risk lymph nodes?
What factors prompt you to offer adjuvant RT? What would be included in your field? Is elective mediastinal RT still used? Assume initial imaging was ...
Would you manage different whether ND was completed or not?
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...
If so, what dose constraints do you use?
For example, would you feel comfortable offering APBI to an otherwise low risk patient in her 50s who did not have a SNB?
Would you consider adding docetaxel to ADT and novel hormonal agents?
There is a recent publication that nicely summarizes the molecular/genetic tests for prostate cancer (Ross et al., PMID 26123120). What should be done...
Have you utilized these gene-expression profiles in your practice?
Is there sufficient data for this test to be used for clinical decisions?
If so, what dose/volume would you use? Would you cover any nodal regions electively?
Are there dietary changes or medications you find particularly helpful to reduce bowel and rectal gas? What steps do you take during daily imaging to ...
If ADT acts as a systemic treatment, we would have expected to see a benefit with an RP just like with radiation. Yet, this is not the case. What are ...
What dose is preferred for central stage III NSCLC without chemotherapy? Do you recommend higher dose hypofractionated RT or conventional RT?
Would you add any additional dose or fractions?
There is conflicting data on whether the "surprise question" performs adequately enough. Do you use this or other screening tools alone, or in c...
Is there a subset of patients you would avoid neoadjuvant CRT and operate first?
How do you incorporate this into your follow-up care and how do you instruct the patient?
The patient's lesion is a biopsy-proven adenocarcinoma that has grown over the past several months. They have bullous pemphigoid which is being treate...
There is data from NYU supporting prone APBI with 3D techniques, and the Florence trial supporting IMRT/VMAT. Is there utility or feasibility to deliv...
I had two prostate cancer patients recently take ivermectin against medical advice. Both of them had their PSA drop by 2-3 ng/ml. Are you seeing this ...
Is there a risk that the bleeding could cause microscopic spread of disease outside the lumpectomy cavity (and therefore your CTV/PTV)?
What factors would make you choose against DIBH besides non-reproducibility of a steady breath hold?
Is 60 Gy/15 fx appropriate? Is there a volume PTV cut-off cc which would switch to a more fractionated approach (60 Gy/30 fx eg)? Is there an area you...
How does patient age, grade, histology (IDC vs. ILC), and ER status affect your recommendations?
With the recent publication of PSMAfore, what are your current criteria for offering Lu-177 therapy?
If a patient has clinical or biochemical progression while on either of these radiopharmaceuticals, would you stop the treatment or continue?
Progressive disease involving thorax and abdomen.
What is the harm of waiting for another recurrence after a second GTR to delay the toxicity of radiation and chemotherapy? The patient is a woman <...
If electively treating lymph node volumes, do you (for example) cover vessels that deviate far laterally higher in the pelvis, which could result in h...
How do you decide between 30 Gy/10 fx, 20 Gy/5 fx, 21 Gy/3 fx?
Assume the patient is young and active.
If the lesion is bulky and cannot be excised, would you treat with additional EBRT, or interstitial brachytherapy alone, or a combination thereof?&nbs...
Given the publication by Spratt et al., PMID 33275486, how do you sequence ADT?
The controlled trial below demonstrated improvement in dysphagia among Parkinson's patients. Might this have greater potential for benefit than modifi...
If so, what dose of radiation would you give?
Would you offer definitive radiation/chemoradiation if he is refusing cystectomy?
Is there a role for radiation in this case?
What are your action points in terms of PSA thresholds?
Is there any evidence that variation in schedule (once weekly vs. every other day in between cycles) can affect outcome? Does this vary with dose pres...
Is there data on neoadjuvant chemo-RT or chemo in this setting?
Using arthritis regimens such as 0.5 Gy x 6 fractions
More specifically, the patient had a single, positive, 3 cm inguinal LN (no ECE, negative margins) removed at the time of APR. If offering RT, would y...
When treating intact bladder cases to 63-64.8 Gy with shrinking fields, the max bowel dose is close to the rx dose. Old RTOG trials often just used V4...
Would a combination of other adverse features such as PNI, GIII, close margin, multiple positive nodes, T4 disease and others make you recommend chemo...
If so, will you recommend it universally or only for certain patient population(s)?
For example, will you lower the prescribed dose to achieve a lower mean liver dose?
Given no improvement in outcomes and increased mastectomies with preop MRI, what do the data say about who should get them and why?
RADICALS-HD trial (ESMO 2022) demonstrated metastasis free survival benefit with 24 months compared to 6 months of ADT.
NCCN, NRG contouring guidelines, and NRG-GU-009 all recommend treating non-metastatic high risk prostate cancer with dose escalation to involved gross...
She required an episiotomy intraoperatively just to perform an EUA/biopsy. She may not tolerate vaginal cylinder insertion and even if she can, I am u...
In palliating a painful bone metastasis that abuts a joint and which is associated with a joint effusion, would you treat the entire joint space to ad...
Have you encountered this scenario?
E.g. would you consider cryo inadequate upfront therapy and recommend SBRT? Or would you do surveillance and only intervene in case of local progressi...
What volumes would you treat for the primary?
I have seen small amounts of evidence for V4<20 cc and V14<7 cc, but overall, it seems like there is little published on this issue.
Would your management change given that this recurrent lesion is over 10 cm and the patient previously achieved complete response on immunotherapy 5 y...
There are case reports of chemotherapy causing rupture of an AAA infiltrated by lymphoma. Other reports suggest that radiation may actually be protect...
The patient received adjuvant chemotherapy and had an unrevealing staging PET/CT.
The 4 cm cuff recurrence occurred 3 years after definitive treatment with hysterectomy and vaginal cuff brachytherapy to 21 Gy. The recurrence had a c...
For example, if a patient with intermediate risk prostate cancer has a high risk Decipher score (10 year risk of metastasis with standard therapy of &...
Will higher doses per fraction increase the risk of fibrosis and cause permanent impediment to biliary flow?
How do clinicopathologic factors affect your selection of dose-fractionation?
Would your dose or approach differ if the patient had had prior WBRT, HA-WBRT or not?
Would you offer additional adjuvant treatment (e.g., pelvic EBRT, vaginal brachytherapy, etc.)?
Is there a subgroup of patients who benefited significantly from a specific protocol?
Are there data from trial patients who recurred, especially regarding what treatments they received?
How do you sequence chemotherapy and radiation?
E.g. would it prompt you to offer adjuvant RT in Masaoka IIA? Does the histology have a different prognosis?
Would you deliver definitive RT in place of inguinal lymph node dissection in light of new data (Stecklein et al., PMID 29336837)In the case of high-r...
I.e. FAST-Forward: 26 Gy in five daily fractions?
Are there other settings where MRI is used for nerve assessment and radiation planning such as for certain definitive RT cases?
And, for additional information, what are the differences in 5 year survival and disease specific survival for stage I NSCLC between lobectomy vs SBRT...
Would you recommend oncologic resection? Would you do neoadjuvant chemo and/or radiation (concurrent or sequential)? Pre-op radiation volumes would be...
Would you boost a resected axilla if extra-nodal extension is found in a patient with breast cancer?
What are your volumes? What if the lymph node area was not clipped?
The patient is not able to come for standard fractionation and is unable to have post operative chemotherapy or completion ALND due to insurance and s...
If so, do you give RT before or after adjuvant chemotherapy?
What pathologic features are most important when evaluating the possible need for adjuvant therapy?
Controlled extracranial disease on trastuzumab+pertuzumab for 2 years. Treatment options include switching systemic rx (T-Dxd, tucatinib) or WBRT. Not...
Do you exclude the urethra (or urethra + 3 mm) from the PTV?With the increasing volume of these cases that we are treating outside of clinical trials,...
Would you consider omitting local therapy?
How do you distinguish whether toxicity is related to the immunotherapy vs the radiation vs both? Are you seeing higher rates of these due to the comb...
Would you continue with RT as planned?
Do you have any preferred dose fractionation schedules? What kind of margins do you use?
For example, if the patient had several abnormal nodes radiographically vs 1-2.
What do you think is the role of radiation for this patient and how should it be timed?
The patient is a female in her 40s. No mucosal changes were evidenced on clinical exam. Chemo-RT is recommended by GynOnc at an academic center. ...
Surgical pathology found close medial margin but no other adverse features. Would you favor omission, VBT, or EBRT?
Please comment on toxicity profiles and the insufficient evidence regarding overall survival.
The patient is a female in her 60s, HIV+ since age 19, and has a current CD4 total count of 20. She has a 7 cm primary cancer without involvement of v...
Extrapolating from the ADRIATIC trial.
Additional clinical features include grade 3, diffuse type, pT4a, pN2.
Margin is less than 1 mm. Would the grade of the tumor affect your decision? Would any other factors go into your decision?
HER2 status is pending
What is your rationale for your approach?
Does your treatment in any way depend on stage, extent of RT, and/or dose to OARs?
Does it vary based on tumor site (oral tongue, FOM, gingiva, hard palate, etc.)?
The patient previously received 50 Gy in 25 fractions >5 years ago.
The Phase II Australian study mentioned here only specified a spinal cord constraint of 28 Gy in 8 fractions. Should other normal tissue constrai...
In light of the 4/2024 JCO publication by Peng et al., PMID 38215354
If radiation has a role in treatment, what is the recommended dose? Would SpaceOAR placement be helpful?
If so, what dose would you use?
In the adjuvant setting, what boost dose to vascular areas can be safely applied, assuming one has all the tech to reliably breath hold the patient an...
Would you treat with focal or CSI radiation?
Does extent of resection alter your recommendations? If treating, what dose and fractionation would you recommend?
If there were negative margins, what other factors would you consider to add adjuvant RT? Size of the tumor or depth of invasion?
The STAMPEDE trial recently published in Lancet used 55 Gy in 20 fractions but did not include dose constraints.
Have you treated such cases with systemic therapies? If so, which ones (e.g., cytotoxic chemotherapy, anti-CD20 monoclonal antibodies, or targeted age...
A patient who previously was treated to 30 Gy in 10 fraction from T2-T4 recently completed Pluvicto (lutetium Lu 177 vipivotide tetraxetan) for progre...
Per the NCCN guideline for HR HD, if treated per OEPA-COPDAC, you can omit ISRT. This patient received treatment per AHOD1331, which recommends ISRT f...
The approval for vorasidenib was granted for low-grade astrocytomas, but under certain conditions, it can also be recommended for, for example, anapla...
Eg 10-20 fraction regimens. And how (hot spot %, mean, D99) do you prescribe the dosage?
Is there objective evidence demonstrating a benefit of consolidative durvalumab or prophylactic cranial irradiation in patients with stage I small cel...
Do you always take scar to full dose or do you use specific criteria (e.g. ECE or LVI) to determine dosing and coverage? Do you routinely bolus with I...
What would be the dose and volume to treat?
Prior therapies included R-CHOP x 6 cycles, then undergoing right suboccipital craniotomy and HDMTX/HIDAC/Rituxan x 4 cycles for CNS relapse
Given the data from both INTERLACE and KEYNOTE-A18, how would you design a clinical trial to best answer the question on optimal management of locally...
Are there scenarios where one would rely on dual agent immunotherapy alone? Or would one generally err on the side of utilizing some form of metastasi...
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 with pain that does not respond well to narcotics, what would be your treatment approach? Is there any data that suggests patients can de...
What is the optimal management of pain and loss of function due to pathologic compression fractures?
Assume no epidural/cord compromise. Is kypho/vertebroplasty, radiation therapy, or conservative management (brace, antiresorptive therapy) the superio...
Is there a risk of increased radioresistance or secondary malignancy (or conversely, toxicity) for patients on TNF inhibitors...
If a patient with a positive node just above the common iliac bifurcation, and will be treated with chemoradiation --> pembrolizumab according to A...
For LINAC radiosurgery systems, when would you neither offer hypofractionated SRS or SRS for benign perioptic lesions? Is there a distance from the op...
In particular, in the modern era of multi-parametric prostate MRI and PSMA-PET, certain findings such as EPE, SVI, or pelvic lymphadenopathy may be no...
Should the boost be delivered before or after EXBRT? What is the ideal delay (if any) between the two?
Data is still lacking regarding a possible synergistic effect with radiation and TKI. Would you be concerned that this would cause more side effects t...
For a patient with high-risk prostate cancer, would you use definitive or adjuvant/salvage prescriptions and dose/fractionation schedules? Do you cons...
They underwent radical penectomy and bilateral superficial and deep inguinal LND two years prior. Would you irradiate the regional lymph nodes?
What type of bolus configuration do you favor in these settings?
Examples include bulky cancers involving curved surfaces in challenging head/n...
Do you routinely check EKGs or echocardiograms? Or do you decide only if the patient is at risk for QTc prolongation or other symptoms?
If the pacemaker receives no dose, what dose are the leads allowed to receive and still function? Should interrogation(s) be done weekly?Does dose per...
Two randomized trials which included single-fraction post-op SRS as an arm reported high 1-year local failure. In Alliance N107C (12-20 Gy, 2 mm PTV m...
Would the lack of treatment response concern you enough to offer adjuvant chemo-RT, despite PROSPECT only pursuing adjuvant chemo-RT in the FOLFOX wit...
Does it improve the patient's quality of life?
Some patients have declined surgery knowing they achieved cCR. Would you observe or recommend chemoRT?
Is there any role for consolidative RT/CRT to the lung and mediastinum after initial chemo? What dose and fractionation would be most appropriate for ...
If so, what clinical indications? Are there any advantages of VMAT? Thoughts on concerns regarding lung and heart dose constraints?
What is the preferred dose, fractionation, and role of concurrent chemo?
The primary tumor was resected previously.
Is axillary radiotherapy an acceptable alternative?
The literature are limited but regimens described include arthitis-type regimens (low dose over multiple fractions), immediately preop 8 Gy x 1 and im...
What if it was found on SLNB and no axillary dissection was performed? Any risk factors that would make you consider RNI vs CW only vs observation?
Do you prefer upfront cisplatin/etoposide for 2 cycles, then 50 Gy with ENI, then resection, or induction chemo followed by definitive chemoradiation?...
Are there specific AR Pathway inhibitors that can be crushed and used through feeding tube or would you just avoid ARPIs in such patients?
Assume life expectancy > 10 years and compliance with adjuvant/outback Herceptin
How much of the flaps should be treated? Should treatment be limited to the area of the primary lesion with margin and enface matching?
Which patients specifically benefit from both mpMRI and PET-PSMA?
What is your preferred dose/fractionation? What constraints do you utilize for the brainstem and cord?
Could one de-escalate WBRT dose to <30-36 Gy if maintaining boost to residual disease to 45 Gy? How would you counsel patients on late toxicities f...
Please note that my question excludes VMAT PBI. There are papers describing VMAT breast techniques utilizing virtual bolus for skin flash and other pa...
Assume the patient is a good candidate for both and is low or favorable intermediate risk disease.
What are the best ways to choose between boosting via brachytherapy like ASCENDE-RT, a DIL micro-boost like FLAME, an SBRT SABR boost like PROMETHEUS,...
What second-line treatments do you consider when a patient has persistent significant symptoms despite management with anticholinergics/antispasmodics...
Given the results of RADICALS-HD and RADICALS-RT trials, it seems as though there was no benefit to adding ST-ADT to RT, but a DFMS benefit for LT-ADT...
Does PSADT play a factor in your decision-making? If so, how specifically?
I've tended to wait until the PSA is 10-15, re-image, and then begin...
Patient did not tolerate NSAIDs and referred 2 weeks after hip surgery for RT.
Assume that a patient has had >1 year since previous SBRT treatment, and that they are not a surgical candidate. The previous dose was 30 Gy in 5 f...
E.g., patients with small CNS mets without vasogenic edema or symptoms. Epidural disease without epidural spinal cord compression or asymptomatic low-...
While the RTOG protocol defines central in relation to the PBT, should distance to the trachea above the PBT, esophagus, heart, spinal cord, etc. be t...
How would your approach be affected by bladder and/or prostate cancer stage, margin status, and lymph node positivity?
Would you follow definitive or adjuvant/salvage treatment paradigms? Post-operative imaging reveals significant residual prostatic tissue and a stable...
Are these toxicities expected to improve over time?
When is it safe to deliver adjuvant radiation?
Efficacy and cardiovascular safety appear similar per the PATCH trial updated at ESMO 2024. How would you counsel patients who decline LHRH agonists?
If pursuing a sequential approach with boost to dominant prostate nodules as seen on MRI, what dosing and fractionation would you use in the initial a...
How would your planning be influenced by a possible, single inguinal lymph node metastasis?
My patient’s family has asked that I don’t tell her that she has metastatic cancer because it will devastate her. I am planning on palliat...
Do other factors influence your decision?
Is 80 Gy/40 Fx + ADT the new standard of care for definitive radiation of high risk prostate cancer?
GETUG-AFU 18 has shown a survival benefit over 70 Gy. There is much pressure to hypofractionate, but this is the first study showing a survival benefi...
No dural breach, biopsy only
D-TORCH compared topical diclofenac to placebo.
How do you counsel patients on efficacy, and side effects? What dose do you prescribe to?
What would be the indications and what considerations are there from the first course of treatment?
The patient is an elderly female with a good KPS who presented with a cT2N1 triple-negative breast cancer.
The patient refused chemotherapy and immun...
When treating nodes in the post mastectomy setting, what dose/coverage do you find acceptable to the nodal regions versus to the chest wall/reconstruc...
Specifically, what dose and treatment volumes are recommended?
Goodman et al., PMID 34077237
When using hypofractionated RT (i.e., 67.5 Gy in 15 fractions), can chemotherapy be delivered concurrently?
Options for systemic therapy in NCC...
If further resection is possible, would you recommend adjuvant radiation?
Would you consider definitive radiation alone?
Would you recommend convent...
Patient is 4 months s/p CRT with resolution of avid lymph nodes and no evidence of disease on anoscopy. PET avidity is currently <10 SUV from 30 SU...
Assuming the patient is to get adjuvant RT for an R1 resection on the face, would you treat using electrons? Adequate depth would require at least 9Me...
Meattini et al., PMID 39675376
If a patient presents with de novo oligometastatic (i.e., meeting STAMPEDE low met burden criteria) prostate cancer with no prior history of primary t...
How have diagnostic tools and therapies, such as PSMA, MRI, fusion biopsies, genomic classifiers, and second gen anti-androgens, changed those outcome...
Initial tumor causing cord compression and neurologic deficits.
Generally, the margins are uncertain in this scenario and re-excision is usually not possible.
What are your volumes and dose/fractionation for external beam boost in lieu of tandem and ovoid or tandem and ring implant?
Would you use 30/10, 20/5, or 8/1, and why?
Are there any subgroups that would still benefit from RNI?
What dose and fields of treatment would you recommend?
Would you feel confident in omission for residual disease in the breast and only 1 LN removed during SLNB, which is the same node that was biopsied up...
It still lists 4-6 months for unfavorable intermediate risk, but I can't find the previously recommended "1.5-3 years" in the latest version.
Specifically, headaches thought not to be related to increased ICP.
For example, the prostate bed/bladder neck receives 70 Gy and the seminal vesicle bed receives 60 Gy? Based on current randomized trials, what dose of...
How do you decide between ureteral stent and percutaneous nephrostomy for decompression?
Are you more inclined to offer brachytherapy boost instead of EBRT boost?
What makes you favor ADT vs local therapy? Any preferred local therapy options? Any other special considerations?
After discontinuing the ACE inhibitor, the angioedema resolves three to four days later and does not recur when radiation is resumed.
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...
One particular circumstance involved detecting a ROS1 fusion upon the metastatic recurrence. Is this pneumonitis risk seen with osimertinib alon...
The patient is a male in his 60s who underwent inguinal orchiectomy and spermatic cord resection of a 5 cm malignant fibrous histiocytoma of the sperm...
This boost would be in addition to the standard regional nodal irradiation delivered post-op.
NCCN states that per an AS paradigm for low risk and FIR prostate cancer, a PSA should not be collected any more than every 6 months, with DRE, mpMRI ...
Of note, there is ~150 cc small bowel left and no further surgery was offered.
How would you dose?
If you recommend or use induction chemotherapy, what is your preferred chemotherapy regimen?
If so, what dose would you recommend? What other management options would you consider?
With low #s of patients on the durvalumab PACIFIC trial with EGFR mutated disease, and LAURA trial design of osimertinib until progression, should we ...
For a patient with prior WBRT + SRS, or SRS + SRS to the same area, who has a convincing in field recurrence, would you ever consider a third course o...
Patient had had multiple surgeries and non-healing wounds. If so, what dose/fractionation did you use? Did your patient have durable control of diseas...
If a patient is considered high risk for surgery, with another primary cancer (HCC) and has an incidental renal finding that is highly suspicious for ...
What if positive margin is felt to be from a DCIS skip lesion (initial DCIS margins widely negative but small focus DCIS found in additional tissue wi...
Guidelines do not provide strong guidance on who will benefit from temozolomide vs PCV or when to consider re-challenging with temozolomide.
What dose/fractionation do you prefer? What is the maximum dose that you will allow to the optic nerve and chiasm?
If so, what is the evidence for this?
In what circumstances would you offer adjuvant radiation after resection of vulvar mucosal melanoma?
If so, what would your target volumes and doses be? How would you sequence with immunotherapy (eg nivolumab)?
For example, if MRI revealed prostate-confined disease but PSMA had moderate avidity in the bilateral seminal vesicles, would you obtain further biops...
Given that the recurrence is peri-gastric, with what dose would you consider treating it and to what constraint would you limit the stomach? Of note, ...
If so, what do you typically prescribe?
Would you treat this patient any differently than any other very high risk prostate cancer patient? Are there any additional dose constraints for the ...
What fractionation would you use?
Would it matter if the patient did or did not have a pathologic CR in the breast?
There is variability in how different atlases and references contour this volume: some stop contours after the obturator artery passes lateral to the ...
If so, how long do you continue medication and when do you discontinue? Does treatment with surgical resection versus radiation alone change your mana...
That nodal region has previously received 55 Gy in 25 fractions.
What would you choose as the dose, fractionation and technique of following palliative scenarios with bone metastasis considering there are other visc...
There seems to be a wide variety of palliative doses used in clinical practice (8 Gy x1, 2 Gy x2, and 20 Gy in 10 fx). Do you have a preferred dose? D...
Do you use the same regimen for primary treatment, re-treatment, and post-op?
If so, what are your typical treatment volumes in this scenario?
Given the importance of minimizing financial toxicity, for patients who have borderline unfavorable intermediate characteristics, is it reasonable to ...
If a patient has a limited number of brain metastases (e.g., <3 total) but the additive volume of these intracranial metastases is high (e.g., each...
Patient had previous 54 Gy in 25 fx to anal cancer with treatment of pelvic lymphatics, now with presacral local recurrence. He had a resection of rec...
If the patient has PSMA-positive pelvic nodes and biopsy-proven inguinal nodes, would you use RT in addition to ADT? Or would you recommend ADT only? ...
For example, a large iliac or sacral plasmacytoma causing symptoms. Both medical oncologists and radiation oncologists get nervous about RT-related cy...
Is there a dose response between 4500 and 5040 cGy?
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 can...
I am not sure there is much efficacy for a regimen that does not include asparaginase. The patient received 2 cycles of P-GemOx, then was admitted for...
Isn't there a tradeoff of increased lung dose?
Do you approach similar to pleomorphic adenoma since it is still non-invasive? If there are indications for treating the primary, do you also elective...
FDG PET, Axumin PET, Bone scan? Or just proceed with salvage ADT/RT?
How would you manage a patient with a high-risk asymptomatic bone metastasis with a driver mutation?
For example, if the patient had an ALK+ NSCLC initiating targeted therapy, would you offer prophylactic radiotherapy as per Gillespie et al., PMID 377...
How do factors such as the stability of the bleed, tumor histology, and patient condition influence your decision?
What would be your RT volumes and dose?
Would a higher Decipher score, despite low risk for nodal disease based on MSKCC nomogram or Roach formula, encourage you to treat the pelvic lymph no...
Do you prefer SpaceOAR vs Barrigel and why?
Disease is not responding to systemic therapy.
Would you expect a difference in skin reaction?
We have been receiving referrals for oligoprogressive SBRT for multiple primary tumors (NSCLC, Colorectal, Renal Cell, etc.) in the setting of diffuse...
Additionally, would you consider prophylactic stent placement and/or gastrostomy in anticipation of a fistula?
Would you consider the addition of carboplatin/paclitaxel + dostarlimab to radiation as opposed to radiation alone?
Are you routinely offering a 16-fraction course of hypofractionated PMRT for patients undergoing breast reconstruction versus a traditional 25-fractio...
Assume surgery is not an option. Would you encompass the entire involved muscle and treat with fractionated RT, or would you use SBRT to treat the dis...
Patient with pT2 N2a (6/9 LN+, 5 with macromets, 1 with focal ENE) ER/PR+, Her2- s/p mastectomy.
Is there compelling reason to start PMRT prior...
The study showed no benefit in terms of cancer control or toxicity. There was a significant finding of worse sexual function, but this was deemed to b...
If no enlarged lymph nodes on imaging, and no other high risk features. Would your opinion change if the patient has had prior breast radiation?
Surgical pathology found negative pelvic/inguinal nodes, but revealed also focal LVI/PNI
Given the very low lymphedema rates associated with these procedures, does it impact your choice for axillary management?
Would you consider this stage IVA (spread to adjacent organ) or IVB (spread to distant organ)? For instance, would the presence of direct lumbar verte...
Any published reports or anecdotal experience to guide us?
Post-operative endometrial with high-risk features for nodal recurrence, planning VMAT wit...
Re-staging is otherwise negative; patient's disease has FIGO grade 1 endometroid histology
Would you recommend concurrent chemoradiation or targeted therapy with lorlatinib?
Should the recent publication of Chen et al., PMID 27207358 dose escalation study for inoperable SCC esophageal cancer patients treated with CCRT, sho...
Should concurrent chemotherapy be given? How would you modify the regimen in elderly/frail patients?
Would you continue corticosteroid therapy even with a normalized serum IgG4 concentration?
How do you advise patients who strongly desire chemotherapy?
Would you offer chemotherapy after radiation is completed?
When would you recommend chemotherapy alone, radiation alone, and combined chemoradiotherapy? When treating with RT, what volumes and doses do you use...
Should the answer differ for cN1 luminal disease vs. cN0 TNBC?
Additionally, is there a difference in surgical outcomes with long course chemoradiation + consolidative chemo vs. induction chemo + long course chemo...
Would your definitive radiation dose be different, would the duration of ADT be different? Would you recommend additional biopsies? Would ...
Should external beam radiation be 'maxed out' before use of lutetium-177?
Do you find that starting with chemoradiation increases the risk of complete obstruction secondary to transient tumor inflammation, or do you favor st...
Al-Ibraheem et al., PMID 33731050
Specifically, after chemo and RT to 36.0 Gy/15 fx with stable to slight progression of disease at 6 months, what (if any) regimen of reirradiation wou...
How should ECE influence radiotherapy in breast cancer?
For T1-2 patients with N1 disease after sentinel node biopsy alone and upfront mastectomy (gr...
Should lymph nodes ever be targeted? If bone invasion or erosion is present, and surgery is not feasible, is radiation appropriate, and to what dose?
Would you hypofractionate or be more conservative at 2 Gy per fraction? Would your management be affected knowing the patient is on hydroxyurea?
Specifically, will the higher rate of local failure in the TNT (short-course RT) arm lead you to consider a TNT approach with long-course CRT?Dijkstra...
Should external beam radiation be 'maxed out' before use of lutetium 177?
Assuming the recurrence is above the prior radiation field, would you cover the paraaortic region with an SIB or treat only the involved node? What do...
A series of 46 patients showed excellent local control with SBRT (91% at 9 years). Should SBRT only be offered to patients formally deemed inoper...
Any best evidence for a given schema?
Would you treat with curative intent (neoadjuvant chemotherapy, surgery, and radiation to include the sternum)?
Would you be willing to treat an elderly patient on blood thinners who has PSMA+ PET, elevated PSA, and multiple urologists have deemed biopsy too ris...
What were your “Top 3” Presentations/Studies from the meeting this year? How will it impact your clinical practice?
Treating to 12 to 16 Gy in 1 fraction, I based on the new ASTRO Clinical practice guideline, PRO April 2024
Would you cover the chest wall alone or would it be chest wall plus regional nodes?
Patient factors: no prior radiation therapy
Guidelines support standard fractionation when tumors are large or have brainstem compression but what would indications be for moderate hypofractiona...
Surgical data suggests improved survival with pelvic lymphadenectomy and is recommended by NCCN guidelines, however the same is not seen with RT data....
The patient has a history of a lymphoplasmacytic lymphoma with a CR after chemotherapy but presented with a large frontal lobe mass that was biopsied ...
NCCN states that all operable NSCLC patients should be evaluated for pre-op therapy with strong consideration of nivolumab + chemotherapy for those wi...
Some consider T4N3 Stage IIIC to be a borderline case. None of these patients were included in either PACIFIC or KEYNOTE-024 for example. Would y...
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 is ideal timing between radiation and surgery? Would you recommend implant first and then radiosurgery? Any additional constraints to the acousti...
For instance, would you incorporate use of Oncotype DX in this patient population to guide decision making on the use of regional nodal irradiation?
If delivering 300 cGy per fraction to the DIL, what urethra dose constraints to you use for 26 and 28 fraction regimens?
Specifically, in the case of a complete response following chemotherapy, do you approach with resection or radiation? If you are treating with RT, wha...
What dose would you give for ECE in this setting?
In patients with bone metastases and osteoarthritis, if it is unclear if the pain is from cancer or OA, how do you decide on the radiation dose/fracti...
The Mayo Clinic protocol recommends initial fields -1.5 Gy BID initially to 45 Gy followed by a Brachytherapy boost. If HDR /LDR is not available, wha...
If so, what safety precautions would you have?
Would you consider standard definitive chemoRT (EBRT + HDR brachytherapy)?
With the advent of PSMA PET/CT, this is my study of choice for high risk prostate cancer. Are there scenarios where standard FDG PET is useful? For ex...
Patient is not a candidate for ablation or resection. Would you consider induction systemic therapy to hopefully shrink the disease away from the pace...
Would you consider 36 Gy in 6 once-weekly fractions?
What dose constraints are you most worried about in the re-irradiation setting with such high doses prior?
Such as breast plans with < 200 cGy mean heart dose
For example, when would you recommend clinical exam for surveillance versus imaging with MRI, CT or PET?
E.g. higher central hotspot in solid lesions? Any data on differences in toxicity?
Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...
Cervical cancer FIGO stage IIIC2. Bloodwork shows elevated ESR and CRP.
No LN dissection was performed as it was for a suspected CIN III. Final pathology showed +LVSI, -margins (>10mm), -parametrial extension, and 1.2mm...
The patient has extensive disease, and requires palliative radiation to the scapular area (proximal to the brachial plexus) in a region overlapping wi...
Based on the recent guidelines, should prostate SBRT dose be no higher than 3625 cGy in 5 fractions?
The recently published executive summary from ASTRO/ASCO/AUA hypofractionated radiation therapy for localized prostate cancer states "Five-fracti...
I.e. would you offer additional radiotherapy and if so, what technique and dose would you use?
How do you construct the caudal extent of your volume - for example, pelvic floor via RTOG/international consensus vs 4 cm below gross disease via RAP...
If so, what dose would you use?
Do you start neoadjuvantly? Concurrently?
Long-term ADT is deleterious to multiple organ systems (bone/sexual/psychiatric) and increases the risk of MACE. What level 1 evidence do we have to c...
Specifically, on re-staging imaging, would the tumor regression be strictly defined by reduction in cranio-caudal direction only, or would other measu...
For a non-metastatic head and neck cancer patient in his early 80s with an ECOG PS of 3 who has already lost about 20 pounds, how would you favor appr...
Bentzen et al., IJROBP 2023
On the EMBARK trial (Freedland et al., PMID 37851874), 25% of men had a prostatectomy and the publication states, "Patients were excluded … if ...
What fields? Would you treat the pelvis? What factors would help you determine this?
Would you offer radiation and chemotherapy, vorasidenib, or observation?
The patient has an asymptomatic metastasis in the left atrial appendage.
Would you start off with immunotherapy then add radiation later, or visa ver...
Particularly in the setting of "higher risk" features such as grade 3 and a negative, but close margin, would you still consider offering surveillance...
Are there any recent publications or resources regarding which immunotherapy agents are contra-indicated with the use of RT or that outline interactio...
Do you perform NGS on all specimens? If so, how much do you rely on that alone to determine clonality?
The SOUND trial looked at sentinel node versus observation in patients of any age with breast cancer up to 2 cm and a negative preoperative axillary u...
Would prior RT (>30 years ago in this case) to the breast or ATM mutation alter your recommendations?
Are there situations in which one imaging modality has clear advantages over the other?
PSMA or Flucyclovine defined focal nodule
This includes duodenum, stomach, small bowel, colon, kidney, liver, etc.
Would you continue it until progression of disease? Or would you switch immediately to next line systemic therapy?
Any pitfalls to be aware of?
Compared with other thyroid carcinomas, Hürthle cell cancer has a lower avidity for 131I; therefore, treatment with radioactive iodide has l...
In what circumstances would you offer or avoid APBI in a woman with an oncoplastic closure after lumpectomy?
For example, would you offer 4 Gy x 5 fx (vs 24 Gy/12 fx) in a patient with isolated recurrent follicular lymphoma of the breast after RCHOP and maint...
Would chemoRT be preferred over surgery if there is LVI or PNI?
For example, do you recommend RT for close margins or focal trans-capsular invasion?
In my experience, high tangents are commonly used for patients with pN1mic disease, and occasionally for higher risk patients with pN0 disease. The re...
The NCCN lists concurrent chemoradiotherapy as a primary treatment option in these patients. If so, what total dose do you deliver to involved ly...
Which criteria/factors would you use to decide whether to de-intensify prostate bed/fossa treatment? For instance, surgical margin status or biochemic...
While ESOPEC excluded squamous cell carcinoma, the Japanese JCOG1109 NExT trial also showed superiority of fluoropyrimidine/platinum/taxane over chemo...
What is the expected rate of pneumonitis with this approach?
What dose/fractionation, and constraints would you use?
Or do you start with systemic therapy and then reassess?
Especially if using an escalated dose such as 58 Gy in 29 fractions for a T3-T4 primary
Is there data supporting the idea that chemotherapy must be onboard prior to delivering radiation for maximal radiosensitization (particularly for hea...
STAMPEDE answer is yes, intuitively it seems there must be a line somewhere though.
For patients staged only with PET that is widely M1, should a CT ...
Would treatment be palliative (i.e. for ureteral obstruction) or definitive? Is there a role for chemotherapy or hypofractionation/SBRT?
Biphenotypic sinonasal sarcoma is a recently described malignancy showing dual differentiation with both myogenic and neural elements.
Current NCCN guidelines recommended not combining relugolix with these agents until more data is available.
Any drug interaction concerns or ot...
Found small reports using SRS or fractionated SRS, but not feeling comfortable with this approach due to limited data. Would you consider surgery + co...
How do the results affect your recommendations for workup and management?
How do you use 105%, 107% and max dose metrics differently compared with non-reconstructed cases?
Does performance status, age, or urinary incontinence after surgery affect your recommendations?
Assume the patient is a good surgical candidate, and the perforation happened prior to initiating any treatment. Is the stent enough reason to avoid c...
Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?
Do you consider hypofractionation rather than a volume staged approach?
Should they be context/disease specific?
Should the use of chemotherapy before/after, or during radiotherapy modify these tolerances?
Contexts...
Would you offer palliative (4 Gy) radiation therapy to the stomach mass vs. definitive doses (24 - 30 Gy) encompassing all of the disease?
Do you increase the dosage of the TKI or switch to a different generation TKI? How does your answer differ for EGFR vs. ALK, and for discrete brain me...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
Do you use decipher, or other genetic testing to determine whether you will include pelvic lymph nodes when you give definitive EBRT? Can you comment ...
Can adjuvant radiation therapy compensate for the potential increased local recurrence risk?
No disease elsewhere. Previous history of treated rectal cancer a few years ago.
Based on results from Zhang et al., PMID 38631536. Would we select patients based on planned lung V20 to avoid excess toxicity? Any further considerat...
I have always used the RTOG standard 2 cm margins off the T2 Flair to 46 Gy and 2 cm off the T1post for the 14 Gy boost. However, recently I have hear...
For example, do you favor using different induction chemotherapy (gemcitabine/cisplatin or TPF) for endemic vs non-endemic disease?
Do you favor usin...
The patient is in her 70s, was first diagnosed with vulvar cancer two years ago, and underwent a radical vulvectomy with clear margins and negative ly...
The patient has undergone a vulvectomy years ago. The disease now involves the vulva, perineum, and peri-anal regions.
Tumor is PD-L1 positive and HER2 positive
ESOPEC compared perioperative FLOT vs neoadjuvant chemoradiation per the CROSS trial, and showed superior OS with perioperative FLOT. What concerns do...
Patient has not received radiation therapy in the past. If not, what would you offer for palliation of pain?
Is there any data to suggest higher risk of malignant transformation with hypofractionation? Does concurrent Temozolomide change your approach?
Given that LU002 has failed to meet its progression free survival benefit in results presented at ASCO, will you offer consolidative radiotherapy for ...
If using adjuvant chemotherapy, should the patient receive carboplatin or use a more intensive regimen because of the positive margin status?
In which situations or patient populations do you find this useful? How is it sterilized?
What would you consider when thinking about your boost?
Due to multiple complicating factors including travel distance of ~1 hour each way, this patient (mid-60s) refuses to come any more often than 2 days ...
NCCN guidelines allow the heart to get 105% of PTV prescription for 5 fractions to 55 Gy, but Timmerman tables from 2021 state the heart should be bel...
Would a specific Gleason score, age, pathological feature, or PSA be an indication for covering the pelvic nodes? Would giving concurrent ADT affect y...
For higher risk patients, eg PSA >0.5 or high risk gleason score, etc, would you consider dose escalation still? Prior data had suggested benefit t...
Would you recommend post operative radiation in an adult patient with a thoracic spine osteosarcoma?
S/P neoadjuvant chemotherapy and followed by oncologic surgical resection but with positive margins.
Are GTV, CTV, PTV expansions adopted from pediatric studies? Given our ability to treat the craniospinal axis with accuracy, what would the "mode...
How would your treatment change for definitive vs post-surgical RT?
Does approach differ depending on the anatomic (distal vs proximal and dorsal vs ...
Some references and papers suggest 8 mm for adenocarcinoma and 6 mm for squamous cell carcinoma (Giraud et al., PMID 11072158). RTOG 1308 used 8 mm bu...
Why does this differ when treating extracranial sites (lung, pelvis) where we hold bevacizumab prior to RT?
If so, when and to what extent?
The FLAME trial demonstrated a significant improvement in 5-year DFS, without any significant changes in overall toxicities, when patients being treat...
Patient with active rheumatoid arthritis, on escalating dose of Rituxan and Methotrexate, also has antisynthetase syndrome and Hashimoto's thyroiditis...
What dose and fractionation do you utilize? Would your recommendations differ considering the site of disease is at the penile base/suprapubic region?
Does it ever differ from a standard rectal field? For example, do you always treat the entire rectum, mesorectum, and entire length of internal iliac ...
What if the patient is also quite elderly? SBRT was a few years ago.
Would you cover the entire prostate?
If a patient had a high dose of radiation to the spleen (10 Gy over 5 fractions) over a year ago but with increasing splenomegaly now, would you consi...
If a patient is found to have 2 lymph nodes positive with ECE s/p mastectomy, axillary dissection, tissue reconstruction, and lympho-venous bypa...
Do you modify your volumes? What dose constraints do you use? How would you determine your dose/fraction regimen?
Tumor measures 4 cm after STR. Is NF1 a contraindication for adjuvant RT?
For a woman with complete resection of serous intraepithelial carcinoma of the endometrium, would you recommend adjuvant radiation or chemotherapy? Wh...
Any particular considerations for +PNI, close 1mm margin and 0/29 LN?
If a patient had a PSA > 15, PI-RADS 5 and lesions on MRI, would you treat without a biopsy?
Any concern for increased risk of radiation recall?
Is there really a need to boost up to 50.4 Gy in this setting?
Does histology (radioresistant or radiosensitive) play into this decision?
This is a less common histology in the vulva.
Would you include a CTV, and if so, how would you account for proximity to the heart?
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
Per the NCCN guidelines and clinical trials, the patient does not fit the criteria for low metastatic burden, and therefore the benefit of radiation t...
How do you incorporate the considerations regarding the brachial plexus and proximity to the cord when treating to ~60 Gy?
Would you offer brachytherapy boost after EBRT? Is there concern for needle tract seeding with brachytherapy?
Are there any creams or suppositories that can be safely applied internally in the vagina to soothe burning?
Would you consider administering Keytruda (pembrolizumab) concurrently with radiation therapy for the treatment of a patient with an ER-negative, PR-n...
Z0011 population, cN0 with 1-2 SLN involvement with a low likelihood for additional non SLN metastases?
Are there clinical factors that go into your decision making?
Is there a preferred method and should any of the following be avoided: esophageal stent, nasogastric tube, PEG, J-tube, or TPN?
The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) trial was a prospective noninferiority phase 3 randomized clinical trial suggestin...
For standard tangential radiation would you pull the field edge forward to avoid radiation dose to the entire implant?
Such as those meeting the eligibility criteria for NRG HN002, <10 pack years, HPV+ T1-2N1-2b, T3N0-N2b
2020 ASTRO SCLC guidelines state under KQ1 Table 3. For postoperative patients with LS-SCLC and R1 or R2 resection, postoperative RT is conditionally ...
Anyone here doing 17 Gy in 2 fx?
NRG-CC001 excluded a patient like this, but it seems that if the lesion in the HA region is treated, it would be reasonable.
Would your recommendation change if the patient had a high Oncotype and received adjuvant chemotherapy?
Testicular imaging was negative for suspicious mass. Would you treat the bilateral testes with radiation in addition to the PA field? Would you treat ...
Can you explain the expansion cohorts into larger trials and the current amendments to the the protocol?
Are there ones beyond the limited constraints given on the CONVERT and RTOG protocols you routinely use?
What are the current criteria in 2023 for selection to complete sentinel node biopsy or skipping of sentinel node biopsy specific to age, grade, clini...
If a patient had a stage I contralateral breast cancer and received bilateral mastectomies with implant reconstruction 2 decades ago and now has ...
Is there a role for loco-regional treatment in this scenario? If a young patient with ER/PR positive cT2N2M1 IDC presents with a single bone metastasi...
Would you recommend neck dissection and adjuvant ipsilateral RT?
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...
What dose constraints do you use for the left anterior descending artery (LAD) for breast radiation?
Is there data to support those constraints?
How to treat Radiation Induced Sarcoma (RIS) of the spinal cord after 40 years of postoperative radiation therapy to lower dorsal/upper lumbar ependym...
Patient has multiple adverse features on pathology, however, PSA just became detectable one year after surgery. SPPORT included patients with PSA>0...
Or, to manage tenesmus and discomfort after any type of pelvic radiation.
Do you treat this similarly to IDH-Wildtype GBM with the STUPP regimen? Is there any role of less-intensive paradigms, such as 59.4 Gy/33 fx?
Would you ever consider this approach for an initially polymetastatic patient?
What is your volume and point dose constraint within the vertebrae itself when prescribed 1 fx, 3 fx, 5 fx SBRT spine to reduce incidence of ver...
Assume that the volume of the tumor is <10 cc (equivalent diameter of 2.7 cm). Assume there is not a significant amount of overlap of the PTV with ...
If so, what dose-fractionation do you utilize? What other factors do you take into consideration?
Does the volume of or recent progression of other non-spine disease influence your patient selection? Does the patient's performance status, eligibili...
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 ...
For additional reading, see JCO OGR (11/2021) by Drs. @Warren and @Bellon reviewing the landscape of adjuvant treatment after lumpectomy for DCIS and ...
Would you do a tumor bed boost in the absence of other risk factors?
For example, if mass is ulcerated and cannot be excised with polypectomy? Would you ever consider radiation and chemotherapy?
If so, do you modify your external beam dose?
How do we approach patients with rare tumors given the paucity of data?
Do young, early-stage breast cancer patients with pCR to chemoimmunotherapy still benefit from PMRT?
If a patient in her 30s with a cT2N0 triple negative breast cancer has a pathologic complete response (pCR) after chemo/immunotherapy at the time of m...
What is the role of adjuvant radiation therapy for stage III melanoma in the era of adjuvant Opdivo?
Burnmeister data from 2012 showed a local control benefit for radiation therapy in selected patients, but that was without immunotherapy. Is adjuvant ...
How would you manage a FIGO IA G3 endometrial cancer with no LVSI, lymph nodes not sampled but CT a/p negative for lymphadenopathy, yet 2 foci of canc...
“Recent evidence” suggesting this was brought up in tumor board to justify excluding whole pelvic RT for a IIIC1 patient but I can’t...
Would you ever consider any of the following?
Discontinue the bolus after brisk reaction
Moderate hypofractionation to the chest wall instead of c...
What techniques and doses would you prescribe to the primary and regional nodes?
Current NCCN guidelines do not include adjuvant chemotherapy for patients treated in this fashion; however, in the PROSPECT trial itself, an additiona...
Are there additional studies that could be done to assist with management decisions?
Is there a role for adjuvant chemotherapy or radiation?
If so, how long would you hold? This medication is given for migraines as q3 month infusions and some data suggest that CGRP plays a role in immune-mo...
Does the stage at diagnosis affect your decision?
Size: 3 cm, cN0
Would you consider radiation following surgical resection of an intramedullary benign nerve sheath tumor with a small amount of residual tumor (9 mm) ...
Given pelvic RT is likely to induce ovarian dysfunction/menopause, would you consider systemic options?
This would apply to gynecologic and GI cancers as well. And as long as the patient's partner is within the recommend age of <45 yo
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
The patient had a high-grade DCIS with necrosis, but a 0.9 DCSionRT score
Would you consider it for a patient with good PS but with limited metastatic disease? What dose fractionation would you prefer?
How would poor urinary or bowel function affect the recommendation?
Female in her 30s, L5-S2 tumor volume, treated in 2020. So far, L-S MRI q6 month shows no change in residual tumor.
The patient is an otherwise healthy patient in her 60s with an ER-positive, PR-positive, HER2 negative grade 3 pT1N0 invasive ductal carcinoma followi...
Do you consider dose escalating to 160 mg or do you add chemotherapy to osimertinib?
Would you provide pentoxyphylline and vitamin E prophylactically after treatment? Is there a role for Boswellia? ACE inhibitor?
For example, a patient that received an MRI after biopsy that demonstrates a PIRADS 5 lesion in anterior TZ which likely was not sampled on biopsy. Wo...
What field design and dosing is most appropriate? Would you use ISRT or a more extended field?
I have an interesting case of gentleman in his 40s, HIV+ but viral count undetectable and CD4 1000+. He had prior diagnosis of Kaposi’s sarcoma ...
The patient had ER/PR positive, early-stage recurrent disease superficial to the prior RT site involving the nipple and dermis without ulceration, tot...
Data for SBRT for RCC is promising but there is increasing literature on microwave ablation, radio frequency, and cryoablation. Are there any distinct...
Would you wait until bowel symptoms are controlled or ever pursue diversion before starting treatment?
Would you recommend this for a focally +, diffusely +, grossly + margin? What would you expect local recurrence rate for diffusely (+) microscopic mar...
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...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical prac...
Are there other measures, pharmocologic or adjunctive, that can be used or are under investigation to mitigate cardiotoxicity related to chemo- or rad...
My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...
Would you still treat the primary site and to what dose?
This patient had a T1N0, ER/PR negative, HER2 negative breast cancer
Are you seeing this with increased BED regimens such as concurrent CRT to a dose of 60 Gy in 40 Fx BID?
Assume non regional nodes are non pathological by size. Patient also has pelvic nodes that are positive.
Would you consider this low metastatic burd...
Patient declined additional wider excision due to associated function morbidity as well as neck dissection. What would you estimate is the risk of cli...
The patient is in their 40s with right arm rhabdomyosarcoma s/p amputation. Path shows embryonal rhabdomyosarcoma 6.5 cm, margins neg. 11 of 19 lymph ...
In a young patient <30 years old with large pre-chemotherapy, multifocal disease with pCR following mastectomy, would you consider extrapolating th...
In light of the recent consensus contouring guidelines (Soliman et al., IJROBP 2017): 1) Are you routinely expanding along the dura up to 5-10 mm...
How would you treat a patient that had a T10 lytic lesion with extension to posterior 10th rib s/p cryoablation of the rib 4 months ago, but with resi...
When is SBRT appropriate? Do you approach dose and fractionation differently in this setting?
In the PORTEC LVSI grading system, 3 or more vessel are classified as extensive LVSI, while the FIGO 2023 Endometrial Cancer staging they reference WH...
Is standard chemoradiation the standard of care or conventional fractionation dose-escalated (>60 Gy) radiotherapy without chemotherapy or some for...
If so, what dose would you treat to the resection bed?
Is T4 disease a contraindication?
If CCRT is pursued, would you move forward with durvalumab consolidation? Assume the patient with ECOG PS 0 and no co-morbidities. How might this chan...
Would you offer consolidative brain SRS, SRS + consolidative RT to the primary (e.g. lung), consolidative RT to the primary alone?
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...
Would you consider observation following surgical resection with negative margins? Would you recommend WBRT and/or ISRT? What would be your preferred ...
Are the results superior to alternative treatment methods?
What dose, fractionation, and volume would you choose?
Would you electively cover the vagal nerve(s) and associated recurrent laryngeal nerves?
Does...
Would you consider pentoxifylline and vitamin E to mitigate fibrosis?
Does the site of treatment factor into your decision?
If so, what dose/volume is prescribed? How do you account for motion?
Good risk DCIS as per RTOG 9804
This post refers to the recently published RCT by Chang et al., PMID 37478883 investigating lung SBRT with vs. without 4 months of nivolumab for early...
Do you recommend adjuvant chemotherapy after radiation treatment?
Do you have a standard reporting format with specific doses?
At what point does the benefit of either post-operative vaginal cuff brachytherapy, or vaginal cuff brachytherapy boost following EBRT for endometrial...
Or would a typical prescription, such as 7 Gy x 3 Fx to 5 mm depth be reasonable for typical sizes 2.5-3.5 cm? Per ABS guidelines, they specify that t...
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
Specifically, with respect to sequencing of chemotherapy, dosing and target delineation- would you cover elective areas like standard NPC fields or gr...
Would you consider VBT alone vs EBRT and/or offer chemo?
This is a female in her late 60s with FIGO 2023 IIB disease given substantial LVSI+ (>5 v...
The patient had a prior right-sided ER+ HER2-ve breast cancer, treated with neoadjuvant chemotherapy, MRM with ALND, and PMRT
They recently developed...
If so, would you recommend adjuvant chemotherapy and PCI after?
How would it change your risk group or management? Does Decipher help further inform treatment?
Are there any skin care products you would avoid in this population?
Specifically, do you offer closer follow-up for certain patients after local radiation?
The patient has a primary breast cancer with a single progressive metastasis in liver.
Are there any patient characteristics that make you change fractionation when treating per STAMPEDE?
What characteristics? TURP? AUA? Size of prostate? How do you change your fractionation?
Many options for vasomotor symptoms of menopause do not work well for men on ADT. However, fezolinetant is a neurokinin B blocker, so theoretically, s...
In a patient who had a wide local excision and radiotherapy 10 years ago and now recurs with cT4 disease, would you repeat radiation after neoadjuvant...
Assume slowly rising PSA in a low risk prostate cancer patient with negative PSMA PET CT. If so, what dose and what would you cover? If not, when woul...
How does age, grade, hormone receptors play into your decision?
Would postmastectomy radiotherapy ever be indicated in a young patient with close margins and a massive (14 cm) DCIS breast tumor interspersed with le...
Assume each lesion would have been suitable for partial breast radiation
Would you use either as monotherapy or boost in appropriate candidates (favorable IPSS, safe for anesthesia)? Assuming IPSS < 15 or 20 and minimal ...
Have you been able to deliver standard of care treatment?
Complete response was achieved after cycle 3. What extent of bone would you include?
I have a pair of patients with MRI+ and biopsy+ disease who have staging PSMA PET/CT that do not show disease within the prostate (or anywhere else).&...
Does the entire bilateral BOT & ipsilateral tonsil need to be included in the elective CTV?
Plan to give adjuvant chemotherapy.
With the recent publication in IJROBP showing a greater than 50% response rate, have you started integrating this into your practice?
What dose and how would you treat this? Would you include periaortic nodal field?
Given this histology, does the groin need to be covered? Would you add chemotherapy?
Intravesical therapy was delivered two years prior, and last cystoscopy was negative. One-third of the bladder would otherwise be included in the plan...
In an asymptomatic patient, would this be safe?Is there any reason to withhold radiation such as in the case of T1N0 breast cancer advising the patien...
For example, if a patient is otherwise a candidate for APBI with a 1.5 cm primary tumor but has 2 cm of associated DCIS would the patient be ineligibl...
Do you treat the whole gland or the lesion only?
What is the role of additional imaging (MRI, PET/CT) to delineate disease?
What e...
In general, how does an esophageal stent affect what you might consider in terms of radiation dose and volume?
Assume this is a male, treating to 55 Gy in 20 fx.
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 a patient with a pT1-2 oral tongue cancer resected with negative margins and with a fully negative ipsilateral neck dissection, but with indication...
For radiation oncologists, how do you ameliorate the risk for radiation-related injury to epicardial coronaries during treatment sessions?
A patient had limited metastatic prostate cancer several years ago and was treated with orchiectomy only, and recently had Xtandi added. PSA remains d...
Does this option need to be added to NCCN guidelines? How does the type of brachytherapy, HDR vs LDR, influence your recommendations? Does ADT play a ...
Would you still treat the chest wall with standard dose and give the patient the benefit of the doubt in the absence of pathological confirmation of m...
NRG-BR002 (Chmura et al., JCO 2022)
CURB (Tsai et al., IJROBP 2022)
Additionally, would you give elective nodal coverage or just the postop bed?
Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...
Do your post-operative treatment recommendations differ for benign vs. malignant phyllodes tumors of the breast?
Is phyllodes tumor size ever a crite...
What is the risk of renal artery stenosis causing malignant hypertension and at what dose does this become an issue?
Does the MGMT status change your decision-making? Should we be routinely testing MGMT for elderly patients?
Oftentimes the needles were inadvertently pulled. Without using a template, are there any methods to mitigate this risk of compromising implant qualit...
Would you follow an algorithm such as the one proposed by Hall et al., PMID 29940062?How do you decide between intrathecal chemotherapy vs systemic th...
Do you typically recommend SBRT? What dose? Or do you ever recommend surgery or surgery followed by XRT?
If so, for how long afterwards do you think the patient needs to continue the exercises?
Is there high quality data to support debulking in terms of oncologic outcomes? Does HPV/p53 status impact your decision?
What factors might play into this decision?
For example, if preoperative imaging indicates T3 disease (non-mass enhancement extending over 5cm) but final pathology s/p mastectomy shows multiple ...
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. Assuming...
Do you use SIB regimen (40/48 Gy) per RTOG 1005 for whole breast radiation in scenarios not included on trial? For example: a patient who has received...
Should Y90 be offered before or after TACE (based on the Northwestern phase 2 study) or sorafenib (based on the SARAH trial)?
At 2023 ASTRO, PACE-B reported very low 5-year RTOG grade 2+ rectal toxicity with SBRT (1/363) and conventionally or moderately fractionated radiother...
E.g. esophagus? If you crop the esophagus out of the ITV, then your ITV would not fully encompass the iGTV.
How do you counsel patients and caregivers? Do you prescribe medications (''appetite stimulants'') with the goal to improve appetite even if they do n...
Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.
In what situations would you feel comfortable omitting RT to bulky disease in stage III/IV Hodgkin's lymphoma?
If a patient has thoracic metastases being managed with EGFR TKI, do you refrain from SBRT treatment, do you hold the TKI, or can you treat the patien...
What would you recommend for a patient in their 60s with stage IB grade 1 endometrial cancer without LVSI? How would this differ for a patient with st...
Do you proceed with sequential, concurrent, or sandwich treatment?
Would you advise against concurrent ozone during head neck radiotherapy for a locally advanced tumor?
Would you ever treat with definitive intent in a "curative" patient who has a stent placed, or only palliatively? Does the addition of chemotherapy or...
Initial tumor size:18 cm. Partial response was achieved after cycle 2 and cycle 6 of chemotherapy. Complete response (Deauville 2, size: 6 cm) was ach...
Assuming duodenum constraints are met, could there be any benefit to boosting a positive celiac node to 61.6 Gy in 28 fractions?
Do you treat pre-neoadjuvant volumes to full RT dose, or do you modify treatment volumes if there is tumor shrinkage?
Consider some stalk invasion, but no deep submucosal extent and negative margins by 9 mm.
Should 4 Gy x 5 be the standard of care for spinal cord compression in patients with poor prognosis?
The randomized SCORE-2 trial demonstrated equivalent survival (median 3 vs 3.7 months), response rates (72% vs 74% ambulatory at 1 month), and du...
Especially as the study was done before the adoption of total neoadjuvant therapy
How would you counsel the patient on wound healing and potential complications in this region?
If so, how do you accelerate?
The patient is not pacemaker dependent.
Patient with a locally advanced, node-positive vulvar cancer status post inguinal node dissection with persistent output in drain (for about 8 weeks) ...
In prior ASTRO guidelines, it was mentioned as a cautionary group for IDC but not in the 2023 updated guidelines.
For a patient with pT2N0 oral tongue cancer and no other adverse risk features (no LVI or PNI), would WPOI 4 or 5 be enough to offer adjuvant radiatio...
Has this recent retrospective analysis published in Lancet Oncology changed your practice?
Based on Mill et al. paper showing increased IBTR rates with ILC vs IDC (Mills et al., PMID 34516030)
Does it depend on treatment site? If you apply bolus after sim, how do you account for differences in bolus conformality between the virtual and actua...
Surgery would be very extensive and would not be likely to clear the disease. Do you divert these patients if treated with CRT?
Is there benefit to radiation on top of systemic therapy?
How would your management change in an elderly patient with no surgery verus superficial parotidectomy or total parotidectomy?
Do you recomment MRI, CT with contrast or CT angiogram? And at what time intervals post-treatment do you perform surveillance scans?
If a patient has a genetic mutation, but not necessarily the classic ones where we avoid radiation (ATM, BRCA, p53, etc.), does this change your treat...
If so, how many days before and after? Does this change if delivering SRS?
GOG 205 treated vulvar cancer patients to a dose of 57.6 Gy to sites of gross disease, which is somewhat less than what is suggested in cases of defin...
How does margin positive influence your decision?
What is the maximum time that can be used (given the complexities with patient being in the hospital or needing rehab)?
In an otherwise healthy patient with no contributory PMH, medications and without any evidence of disease.
Can this be done right away or do you wait for the cavity to involute before you plan postop SRS to cavity?
The patient is in her 40s with a BRCA-2 mutation and underwent bilateral prophylactic nipple-sparing, skin-sparing mastectomy. No sentinel nodes were ...
In other words, if offered wedge or segmentectomy, should SBRT be preferred? Does size matter ie if the lesion is < 3 vs < 2 vs < 1 cm? Does ...
Additionally, when evaluating margin status for APBI IMRT 30 Gy in 5 fractions which specifies at least 5 mm margins, do you look at the DCIS margin o...
Does the ENE of 1 mm or less versus >1 mm as in ECOG 3311 affect your decision?
Patients are understandably concerned about the risks and benefits of radiation to an oozing, bleeding, and ulcerated breast.
ABS APBI guidelines are much more permissive relative to the newer ASTRO Guidelines.
Would you change your recommendations for APBI vs whole-breast RT for this reason?
Do you preferentially use Ra-223 first given the RALU study?
For patients who fall into the E3311 intermediate risk category s/p TORS, do you routinely treat to 50 Gy? Or do you continue to treat to 60 Gy?
Do you routinely obtain a spine MRI prior to treatment for all cases, even for non-SBRT candidates (e.g., 30 Gy in 10 fractions) or do you ever rely s...
In a patient with metastatic cancer to the lumbar spine and epidural disease on CT who presents back pain and leg weakness:
Is a whole spine MRI in...
If so, what would be your approach to radiation? Could SBRT be an option?
Would your management be different in node + vs. node - patients? What would be your radiation volume and dose?
Does tumor size, age, or performance status play a role in your decision-making?
NSABP B-51 recommends V3<10% or a variation acceptable of V5<10% for contralateral breast. Is there a limit needed for contralateral chest wall/...
Do you advocate for completion ALND? If so, would you radiate the dissected axilla?
Would you especially consider RT omission in the setting of low-grade, small-volume disease with no underlying DCIS or invasive disease component on p...
Example: in a patient with a non-resectable pelvic mass involving the vagina but without evidence of distant disease, would you favor pelvic RT (as on...
How would you approach a young woman (under the age of 50) with DCIS with favorable disease (ER+, low grade, small size <5mm, negative margins)?
Consider a patient who prioritizes fertility preservation, for whom one of three suspicious nodes approaches the CRM, and is <1 mm from the mesorec...
Are you concerned about cases where radiation has to be started urgently before leukapheresis?
Do anticipated fields affect whether extractions are required i.e., limited field glottic larynx could forego?
Particularly, would you have concerns about OAR constraints or cumulative dose? Patient has excellent performance status and no neuro deficits post op...
Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?
Do you take it to 66 Gy even in the situation of negative margins/resection of that region of bone? For example, if there is a focal bony invasion tha...
Did your treatment inclinations change with the results of the recent FABREC trial (NCT03422003) presented at ASTRO?
What is the best way to counsel families in regards to their child's risk of infertility and need for fertility preservation?
Would you consider eliminating radiation to the chest wall in a patient greater than 50 years of age with a T3N0M0 grade 2, ER+/PR+ Her2 negative inva...
Aside from suctioning, what are other measures could be helpful?
What is considered the optimal interval from time of excision, partial, or radical vulvectomy and/or nodal dissection to initiation of post-op RT?
I.e., the IDC was completely removed during biopsy, but DCIS was present on post-lumpectomy specimen with close anterior margin
What is the best treatment management of low grade early stage follicular lymphoma of the mesentery?
If the mesentery is widely involved with small lesions would this change your management? What if the patient was symptomatic?
Do you prefer surgery (i.e. exenteration) given the radioresistant histology or would you attempt to manage with EBRT and brachytherapy?
A female in her 60's was simultaneously diagnosed with stage I triple-negative left breast cancer and stage I NSCLC of the left lung.
The patient had...
In which particular patient cases or clinical scenarios would you consider preferentially treating a patient with protons over photons?
Nodal staging changes radiation fields, but given increasing pertinent null findings of a positive SLNBx with regards to outcomes, I wonder if ypN0 is...
The patient also declines any brachytherapy treatment.
If so, what dose/fractionation?
Pathology: High grade spindle cell sarcoma
I have seen some patients who may undergo large complex closures (sometimes as a separate procedure) for smaller lesions with resulting scars that sig...
What factors influence your decision?
How do you manage these cases differently than HPV positive cases?
What total heart dose and LAD dose do you typically utilize to justify the DIBH technique?
Her primary disease is too large for any brachytherapy; if substantial residual disease remains, how would you approach external beam boost?
Relevant pathology features: 7.5cm, grade 3 with a 5mm bronchial margin, negative nodes.
MASTER analysis showed 30 - 40% perisalvage ADT use. What group of patients do you consider for ADT? And for what duration?
Do you treat in this scenario if mild/moderate infiltration? What are your thoughts on the article by Fischer-Valuck et al., PRO, 2017 (PMID 28089528)...
This is a patient in her 70s who previously received 5040 cGy adjuvant EBRT alone to the pelvis.
If a patient was noted to have poorly differentiated histology with two tumor foci in the breast, positive LVSI, and isolated tumor cells in 1/3 senti...
Some loss of tissue planes after 3 months of ADT.
Aside from limit due to extent of her hysterectomy, the patient's disease does not otherwise satisfy Peters' criteria
Does your constraint differ based on region of the spinal cord?
How will you translate treatment recommendations from older studies to the new staging system?
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 ...
Do your recommendations differ between appendiceal, colorectal, and gastric cancer? If radiation is offered, would you boost the unresectable/gross re...
The patient is a female in her 50s with luminal B pT1b pN1(sn) invasive ductal carcinoma with 2/2 nodes, 5 mm ECE, and extensive LVI. No preoperative ...
Does an EGFR mutation in a never-smoker change your radiation treatment recommendations for ES-SCLC?
Do you recommend that standard 30/10 TRT approach or a more aggressive non-small cell like approach (e.g. CRT of locally advanced thoracic disease or ...
Would you offer WBRT + boost vs WBRT vs focal treatment/SRS.
For example, would you consider treating part of the humeral head if required to adequately cover the axillary nodal volume CTV/PTV?
Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?
Patient in question had PMRT 20 years ago.
Would you consider APBI for an ER/PR/HER2 negative pT1-2 N0 with pathologic complete response after neoadjuvant chemotherapy? Would the presence...
Is there an optimal bridging radiation dose for aggressive B-cell NHL undergoing CAR T-cell therapy?
What influences your decision to proceed with palliative vs. definitive, and standard vs. hypofractionation dosing regimens?
In what scenarios do the benefits of local control with PMRT outweigh the risks?
How would systemic therapy and/or the number of bone metastases impa...
How would you approach a recurrent, cutaneous SCC of the face with high-risk features s/p resection?
Definitive radiation therapy > 5 years ago. Positive margins, PNI of 0.1 mm. What volume would you cover? Dose/fractionation?
Can chemoradiation be curative without maximal debulking TURBT?
For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...
A patient presents with clinically node-positive cT2 grade 3 invasive breast cancer in the upper outer quadrant. The patient had breast RT to 50 Gy wi...
Do all patients with brain metastases get started on anticonvulsants?
Do you decide based on extent of edema, tumor size, or something else?&nb...
The patient's current PET scan showed no systemic disease. Due to his age, there is a concern of whether the patient would tolerate dual immunotherapy...
Would you treat both at the same time? Does one need to be prioritized over the other?
Does Xeloda have any efficacy against Merkel cell cancer?
How...
How would you treat the primary tumor (located in the chest)? Would you treat the regional lymph nodes?
What constraints would you use for ribs, lungs, and heart?
How do you prioritize treatment? Would you move forward with radiation to the larynx, and if so, any modification to your treatment plan?
Multiple disease sites have studies showing time from surgery to post operation therapy impacts clinical outcomes. Is there any evidence to suggest th...
With trials like PROSPECT and FOWARC showing no statistically significant improvement in locoregional control and survival outcomes when comparing rad...
Especially consider a situation where surgical excision alone is not appropriate.
What if the radiation was LDR or HDR brachytherapy?
Severe lymphopenia can develop during treatment and increase the risk of Candida/HSV superinfection, along with potential challenges for any procedure...
A patient in her 70s initially underwent TAHBSO + LNB with Stage I, G1 cancer, No LVSI. 18 months later with very small mucosal recurrence (5mm). HDR ...
Does the presence of parametrial or cervical involvement impact your decision?
How do you sequence treatment modalities?
What volumes would you encompass? Anything different than standard nodal basins for high risk prostate cancer?
If utilizing an 8-12 fraction regimen, would daily fractionation be appropriate?
The CROSS trial showed a survival benefit with 4140 cGy and concurrent carbo/taxol, but I was always trained to treat to 5040 cGy. Is anyone de-escala...
What would be your preferred treatment technique and dose/fractionation?
For example, consider a patient who has had previous hepatectomy and total liver volume is only slightly greater than 700 cc.
This case involves an impressive ‘high volume’ vaginal recurrence and patient was not originally planned for adjuvant therapy. Concerned t...
NCCN cervical cancer guidelines added a new statement - Patients who have received prior pelvic radiation therapy and have osteoporosis may benef...
Would the extent of nodal involvement sway you one way or another (i.e., a micromet in a single sentinel node)?
Do you give RT before or after systemic therapy?
How would you utilize radiation to address a 10 cm-sized tumor with rib erosion and tumor expanding past ribs? How do you manage pain? What is the rol...
What workup do you typically recommend?
How are you approaching patients with rectal cancer who meet PROSPECT criteria but have other higher risk features, such as >4 lymph nodes with sus...
How do you choose between Avastin, hyperbaric O2 and other therapies?
The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...
Does the St. Jude's Experience (NEJM 2009, PMID: 19553647) provide sufficient justification for routine omission in high risk patients?
Is this degree of hypogonadism sufficient to omit leuprolide?
Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...
If a patient has a small luminal A invasive tumor resected to negative margins with admixed high-grade DCIS, does the high-grade DCIS component influe...
Does the fact that the patient is on methotrexate alter your choice?
How would you integrate RT with molecular agents?
Patient with circumferential thoracic spine tumor on imaging, with appearance of hemangioma. Surgical pathology demonstrated glomus tumor.
Woul...
Consider treatment of stage IVB cervical cancer with systemic therapy and local pelvic radiation therapy as in Perkins et al., PMID 31810653.
Do you feel comfortable stopped abiraterone after 2 years?
What prophylactic strategies you use to mitigate the risk?
In the setting of EBRT alone, a "FLAME"-style boost may increase bPFS. Does anyone have experience with increasing the EBRT dose in combination EBRT+L...
When starting HN radiation, which start day do you prefer to add most value to the treatment course?
Would you rather postpone treatment start to the following week if unable to accommodate your preferred start day?
What approach do you take to determine dose constraints for SBRT reirradiation of the head and neck?
Do you have formal constraints and evaluate cumulative doses on the composite plan? Do you use traditional constraints but account for repair?
What dose and fractionation do you use?
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.?
After initial induction chemo, how do you choose between radiation alone or concurrent CRT?
If a patient is found to have multiple painful osseous lesions but is chemotherapy naive, do you typically wait for the patient to undergo treatment w...
If so, have you noticed differences in cognitive function post WBRT?
If so - how long?
Relevant pathology features: positive margin
Total dose prescription: 66 Gy
Would you offer definitive chemoradiation and include the non-regional nodal level in your plan?
Is anyone advising delaying COVID booster until after PET/CT to avoid false positive?
If a patient is <50 years old, would this change your recommendation?
Do you electively treat nodes and how does your approach change with intra- or extra-hepatic primaries?
Do you wait until chemotherapy completion, interdigitate between cycles 1-2 only when feasible, or between any cycle of chemotherapy?
What factors wo...
The patient is an otherwise healthy female in her 70s with an ER-positive, PR-negative, HER2-negative grade 3 invasive ductal carcinoma.
Lumpectomy r...
The patient was treated with neoadjuvant chemotherapy and had mastectomy with SLNBx about 6 months prior to being referred for adjuvant radiation.
In general: when would you recommend adjuvant radiation and capecitabine for a colon cancer?
Would you dose escalate areas of regrowth or boost the entire cavity?
If so, what dose of radiation dose would you use?
He cannot sense bladder fullness but has no incontinence. Intermittently he urinates by increasing intra-abdominal pressure resulting in a good stream...
Would you delay external beam?
How many cycles of systemic therapy is recommended? is XRT needed and what XRT dose is recommended?
Please comment on primary tumor size, extent of nodal involvement, and other adverse features.
Would it change if only one of the initially sampled positive stations was removed at surgery (eg both 4 and 7 positive pre-therapy, but only 7 sample...
How do you decide when to “pull the trigger” in these cases where the growth trajectory is slow?
The NCCN guidelines categorically recommend adjuvant XRT for a cT1-2N0 rectal adenocarcinoma upstaged to a pT3N0, yet there are multipl...
RADICALs used >0.1 and rising or 3 consecutive rising PSA levels regardless of absolute value. RAVES and GETUG-AFU 17 used >0.2.
If the dose to these OARs deviates from goal by a significant margin, how do you approach changing the treatment plan, accordingly?
Would it make a difference whether the patient was planned for chemoradiation followed by surgery or definitive nonoperative chemoradiation?
Does stage of the cervical cancer influence your decision? Does the amount of SUV uptake influence your decision? When does one biopsy? How long can o...
If so, what is the highest dose per fraction you would feel comfortable delivering?
If so, how do you determine which of the lesions constitutes the "dominant" lesion to boost?
Alternatively, do you treat all noted lesions with SIB, ...
Do you have a preference in ordering MRI, endoscopy, CT scan (chest, abdomen, pelvis), EUS, or other testing before starting any treatment, for re-sta...
Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?
Is it necessary to delay the start of radiation therapy for males planning on sperm banking for fertility preservation?
At our institution we often give 5.5 Gy x 4 fractions. There really does not appear to be a general consensus regarding timing. Interested in what oth...
Since there is no overlap between chemo regimens for these cancers, how would you sequence treatment?
For example do you use Prolaris, or other genetic tests to guide ADT decision making?
Assume recurrence is biopsy proven. Would you ever consider focal vs whole gland brachytherapy?
Do you factor in the time interval when deciding cumulative dose constraints?
If not, how do you sequence the therapies?
For a node positive, triple negative patient that underwent neoadjuvant chemotherapy followed by breast conservation with a complete pathologic respon...
What criteria do you use to determine the utility of using DIBH for planning after free breathing and DIBH CT scans?
Do you typically create a ...
How do you pursue fertility preservation in younger females with this presentation?
Any experience using phenytoin?
How would your neck coverage change (unilateral vs. bilateral, levels etc.)? Are there situations where you would cover bilateral neck for adenosquamo...
Assume this patient had resection with N2/N3 disease. Would you recommendations change if this was N1? Any other factors that weigh in on primary site...
The IMPORT-LOW and DBCG trials of 40 Gy in 15 fraction PBI utilized mini-tangents, which simplify planning but increase breast V40 Gy.The paper by Tho...
What systemic therapy is most appropriate, how would you sequence, and what RT dose fractionation would you use?
Considering this is stage IV disease, do your recommendations for definitive or adjuvant treatment (after surgery) change?
If an otherwise healthy male patient in his 70s has Gleason 4+4 disease in 7/12 cores and left sided internal iliac nodes, but refuses any form of end...
Is there diminished radiotherapy efficacy in tumor control after certain timeframe has passed for malignant meningiomas with no signs of recurrent dis...
If so, which substructures (LAD, left ventricle, etc.)?
Do you treat on the same days or sequentially? Any unique considerations regarding dose or planning?
For example, in a patient with an expected long-term prognosis?
For patients with painful SCLC vertebral metastases and no evidence of cord compression, would you recommend treating with immediate systemic therapy ...
Patients in their later 40s with favorable intermediate-risk prostate cancer s/p 7000cGy/28 EBRT only.
What clinical or radiographic factors would lean you in either direction - ie. time since index diagnosis, distribution or appearance of lung and noda...
In young adults (20-30), would you provide perioperative radiotherapy f if they have actually developed HO?
The GEPAR trials presented at ASCO 2015 showed increased LRR with the omission of RT in patients who had a pCR after neoadjuvant chemotherapy.
For a patient with an ER-positive, pT1c breast cancer who otherwise meets criteria for APBI, but has a BMI of 50 with pendulous breasts and N1mi disea...
Is there any role for RAI?
For example, reducing coverage to 95% of Rx within a large median lobe for an intermediate risk prostate cancer case with no gross disease near base t...
While I am encouraged by the results of the LUMINA trial with respect to identifying patients who are less likely to benefit from radiation therapy wh...
The patient is on a dose of 22 mg of methotrexate weekly for severe rheumatoid arthritis.
If you would discontinue the methotrexate, how long would y...
Assuming the patient had no prior radiation and has no evidence of metastatic disease, would you start with adjuvant radiotherapy or adjuvant systemic...
What is your GTV, CTV and PTV? If giving 30 Gy in 10 fx, does the contour need to extend all the way to the cut in the skull on both sides (is there a...
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...
Does fractionation (or location) influence this decision? What is your preferred steroid dose?
> 50-year-old woman with a pilocytic astrocytoma of the 4th ventricle (biopsy only). Caris shows BRAF intact and deleted CDKN2A/B.
Would you offer RT if persistent disease despite resections?
Would you prophylactically treat any lymph nodes due to risk of possible occult invasion...
If a patient had a remote history of pelvic radiation for another cancer and now has uterine cancer, what factors (grade, stage, KPS, LVSI, etc) would...
Would the location of the tumor (i.e. ultralow), symptoms (bleeding), or patient resistance to surgery play into this decision?
Might a prior SJ incident pre-dispose to SJ reaction to radiation?
Would you be more or less apt to treat with RT for grade 2 DCIS with refusal of pr...
If a patient had a partial mastectomy and radiation therapy 10 years ago and now has a large ipslateral breast cancer (different ER/PR/Her 2 markers n...
What constraints would you use for a 15 fraction regimen or other ablative regimen?
24 months ADT + abiraterone + definitive RT is indicated for cN1 disease but not for pN1 disease per NCCN. Can the data be extrapolated to this popula...
If so, what is your selection criteria? How long do they remain in place?
Do you have any dose constraints to the nasolacrimal duct?
How would these expansions differ based on the anatomic site being treated?
Would this change if the cancer was p16+ squamous cell carcinoma?
Notably, the patient presented with renal failure due to ureteral obstruction and hydronephrosis, receives hemodialysis, and has limited systemic opti...
NCCN suggests 2 - 4mm margins in DCIS, and no tumor on ink with invasive disease.
What agents have you found helpful? What agents have been proven to be effective/non-effective?
The patient is less than 35 years old, and received 21 Gy to the mantle and 10.5 Gy to the lungs >15 years ago as part of treatment for Hodgkins ly...
Please comment on how you view risk factors such as T-stage, tumor grade, P16 positivity, margin status PNI, LVI etc.
What dose/fractionation and vol...
For example: radiation fractionation schedule, modality (proton, MRI linac, cyberknife, etc), risk categorization, prostate size, history of IBS, hist...
I feel like it’s nearly impossible to take carafate QID and avoid food and medications for 1-2 hours before and after. How do you counsel patien...
If so, which checkpoint inhibitor would you use?
The patient has sustained a positive response for >1 year after diagnosis.
Would gene expression testing (e.g., Decipher, Prolaris, Oncotype DX) guide your management recommendations?
What XRT dose do you use? Does the location of the disease (e.g., mediastinum) affect your decision when taking toxicity into account? would you offer...
Would there be a survival advantage to pelvis RT with deep myometrial invasion, LVSI and ITC?
What volume and dose do you treat a bone met that has completely responded to chemo?
Did the EBCTCG meta-analysis change your practice?
For example a 1 or 2 mm brain metastasis? Would you consider waiting for these to enlarge slightly for reasons such as more certainty they are real, l...
The TROG 13.01 SAFRON-II trial used a single 28 Gy fraction. When is it appropriate to use this fractionation?
Patient has contraindication to MRI but otherwise has what seems to be a favorable intermediate risk prostate cancer
For patients who are otherwise eligible for CALGB 9343 and candidates for APBI who choose to proceed with partial breast RT, are you offering 26 Gy in...
Do you complete the originally prescribed RT course, add fractions, treat BID, offer no further TRT, or do something different?
Do you also give neoadjuvant, concurrent, and adjuvant ADT in the same manner as for non-SBRT EBRT?
Staging/pre-op MRI only showed mild non-specific thickening.
How would you sequence therapy, and what dose and volumes would you use for radiation? Prostate cancer is localized, Gleason 4+3, PSA 65.
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 ...
Do you routinely recommend TTF in the adjuvant setting for patients with glioblastoma?
Bone marrow preservation is important due to poor hematologic function. Chemotherapy is not possible as well.
If the radiation cystitis is hemorrhagic without clots how would you manage this?
What instructions do you give your radiation therapists - do you rely on OAR identification (ie. bladder and rectum filling) or soft tissue match to t...
If so what dose/fractionation would you use?
Do you give cuff and chemo or pelvic CRT or chemo alone?
Patient with h/o appendiceal carcinoma s/p surgery and HIPEC, now with endometrial cancer, IBG3, extensive LVSI, pNx, recommended for whole pelvic rad...
The patient is a woman in her 30s with a grade 2 T3N0 ER/PR+ Her2- invasive ductal carcinoma who was treated with mastectomy (margin negative, but LVI...
Would you offer pelvic RT or intracavitary brachytherapy?
Would you hypofractionate at all? Or use standard H&N doses of 70 Gy/35 fractions?
For example, initial imaging shows numerous bilateral nodal mets extending into the low neck but after induction gem/cis, originally involved nodes ar...
Angiosarcoma is invading the brachial plexus and thoracic vertebral bodies.
Prior radiation therapy: Radiation to the left chest wall and regional no...
Pretreatment PSA 25.3 with Gleason 4+3=7 and MRI suspicious for ECE. Eight months after pelvic nodal and prostate XRT to 79 Gy, PSA is 5.02 (down from...
Is concurrent chemoradiation reasonable or excessive in a patient with life expectancy <5 yrs? Should the standard be 5 Gy x 5, and will this provi...
I have a healthy 70+ year old man recently diagnosed with cT3N1M0 rectal adenoCA and GS 3+4=7 prostate cancer in 1/6 cores with a PSA of 25.
Is ...
Considering the ASTRO guidelines recommend against systemic therapy for patients with FIGO stage I-II endometrioid adenocarcinoma, would your recommen...
What sort of factors (post-op PSA level, time to biochemical failure, Gleason score, etc.) help guide your decision making?
In general, when do you c...
If so, how? The trial did not exclude patients who had prior radiation (except hemibody RT) but there is little information on how to estimate dose to...
Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...
Do biomarkers impact your decision-making? If you were to boost, what dose would you use?
MRI pelvis shows a 3.5 cm primary that appears infiltrative and without clear parametrial extension on MRI. Staging PET negative.
Is there any ...
Do you use CBCT or kV images? Do you match to the breast or the chest wall?
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...
Taking into account follow up from NEO, OPERA and other organ preservation trials?
Our patients seem to hate the 20% benzocaine spray (cherry) saying that it burns and causes their eyes to water. Looking for other options.
The patient had 0/2 sentinel lymph nodes involved, and mastectomy revealed pT3 disease with negative margins
Tumor factors: Neck mass, 6 cm in length, biopsy proven schwannoma. No extension into base of skull
Patient factors: No dysphagia, no dysphonia i.e. ...
Do you use the MIP to generate an ITV, contoured on the average scan, or do you contour on each time phase of the 4DCT and boolean the results togethe...
Is the patient permanently at elevated risk for rectourethral fistula with rectal biopsy? Do you have any threshold for the GI to biopsy a rectal lesi...
Mesonephric is described as a higher grade histology. For a superficially invasive IA (no LVSI, age < 60), would you consider vaginal brachytherapy...
Is there a practical way to quanitfy risk of LRR in patients with T1-2 N0 with multiple high risk factors in such as multifocal disease, high grade, L...
Is dose reduction needed? Would you still recommend hypofractionation?
Would you recommend PORT based on LVSI as the sole risk factor (i.e. pT1/T2N0 OP SCCa)?
If using cetuximab, would you recommend accelerated fractionation?
With molecular diagnosis taking several weeks to return for some institutions, how do you handle variations in dosing and contouring between different...
Does the time interval between the intial RT and recurrence influence your decision? What time interval would you feel is appropriate? What dose would...
Dose/fractionation? Concurrent v. sequential chemo? What literature do you use to backup PORT for a positive margin?
In patients with no apparent skin involvement but lymph-node showing basal cell carcinoma with extracapsular extension. Would this warrant radiation o...
A recent NCBD analysis (Rusthoven et al., PMID 27325855) suggests that the addition of prostate RT significantly improves survival compared to AD...
What margins do you use for each cancer for photons vs electrons?
If your margins differ between cBCC and cSCC, why?
Would you recommend this if we were treating level I/II?
The patient has locally advanced disease with chest wall invasion and extensive axillary/IMN lymphadenopathy
Is there a thickness cutoff you use?
What would you cover?
Assuming the patient is symptomatic and/or has compression of ventricles, what field design and dose-fractionation would you use?
If so, how long are they on degarelix before the switch?
Adult patient with suprasellar tumor, found to be AT/RT and unable to undergo GTR given encasement of optic structures.
The patient is >40 yo with Lynch syndrome and a history of endometrial hyperplasia status post R0 TAH/BSO with SLNBx for a 5.2 cm, grade 3 adenocar...
How does this strategy change depending on the acuity or chronicity of the symptoms?
Patient initially achieved CR with VAC-IE with resolution of presumed lung mets and 100% necrosis in LLE primary tumor on BKA. Then was NED again afte...
It's been 5+ years after the first course. If you decide to re-irradiate what dosing schema would you use?
Do you have a size cut-off in cases where OAR tolerances are not otherwise exceeded?
With targeted therapies available, is there a utility for post-op SRS to the resection cavity?
Is it 54 Gy or do we worry about hypoxia and need to go to 60 Gy? Does it change based on site (i.e., oral cavity versus a T4N0 larynx)?
There appear...
Please specify how your institution is allocating resources now or will be soon.
Do you take this into consideration when recommending treatment?
Majority of patients on the seminal trial (Gross et al., PMID 36094839) had tumors isolated to head & neck, what was the rationale for this?
Are there any concerns about increased acute or late toxicity in the context of more extensive surgery?
Do you base your decision on extent of residual disease?
Does the use of (neo)adjuvant immunotherapy have an impact on surgical site size or he...
Would you consider a 2x2 design incorporating immunotherapy?
The patient has metastatic ovarian cancer, currently on Avastin, with a large 13 cm pelvic mass with a fistula to large bowel.
Would you consider off...
Do you treat the whole bladder in the intial whole pelvic field to 45-50 Gy?
Margin status? Residual disease? Nodal status/ENE?
If so, what is included in that volume?
How does previous radiation pneumonitis impact your decision making and treatment planning for a new lung cancer or metastasis in a patient who is oth...
Would you consider treating with conventional fractionation to the entire staple line with a boost to the gross disease?
Would you offer adjuvant RT for subtotal resection of a parietal lobe hemangiopericytoma? How would histologic grade affect your decision making?
What do you utilize for patient immobilization and what are your PTV margins? What MRI sequences do you favor for target delineation?
The recurrence is mucosal and inferior to the prior field.
If only a few teeth, do you still wait to simulate until after the dental work?
Surgery remains an option. Given favorable response, would you recommend pre-op or definitive RT +/- chemo?
What is your approach to try to persuade her that photons would be a better option?
Retreatment? Pancreas? Ultracentral Lung?
Would you favor observation or adjuvant radiation? If so, what dose/fractionation would you consider?
Molecular findings that indicate a more aggressive WHO grade 2 meningioma would certainly support recommendations for adjuvant RT after GTR, but if th...
Prior tumor was adenocarcinoma, new primary is squamous cell carcinoma.
If you would offer reirradiation, what dose constraints would you apply to th...
Are you waiting until drug availability or changing to a preferred non-cisplatin radiosensitizer? If you're utilizing an alternative to cisplatin, wha...
Do you leave it in or out during sim and treatment? Any special instructions?
Close but negative radial margins? LVSI? What fractionation/dose do you use for your vaginal cuff boost if used?
Do you treat this as a higher grade tumor or alter your adjuvant recommendations?
Historically, chemotherapy has been delivered prior to radiation for breast cancer patients requiring it.
With the acceptance of shorter cour...
Would you biopsy lymph node to confirm recurrence/histology?
If confirmed, how do you decide between RT vs chemotherapy? If chemo - BEP x3 vs E...
If so, when do you resume?
Is this considered a sanctuary site from systemic therapy?
How much time is recommended to wait before? Does the dose or fractionation need to be modified given the flap? Does the scar need to have bolus?
E.g SCV and/or paratracheal nodes? If so, what dose do you prescribe for elective coverage?
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...
Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?
I have yet to see results from the SUPREMO trial investigating this question in Europe.
There is the EXPERT trial, NCT02889874 based in Australia/New...
For example, a pT4N0 oral cavity cancer with focally positive margins?
Would you boost involved lateral pelvic lymph nodes in this scenario?
The patient is not a candidate for re-resection or external beam radiotherapy
What do you consider valid reasons to deliver 39 or more fractions for prostate cancers, 25 or more fractions for breast cancers or 10 or more fractio...
In the phase III RTOG 0631 trial, patients with 1 to 3 vertebral metastases were randomized 2:1 to either SRS (16 or 18 Gy in 1 fraction) or cEBRT (8 ...
7 cm tumor limited to the cervix with no vaginal or parametrial invasion on exam and not lymphadenopathy or metastatic disease on imaging. Cystoscopy ...
Would you offer full dose adjuvant radiation?
Assume excellent performance status and inability to perform further surgery on margins without causing...
Is it safe to deliver palliative radiation to the spine with a spinal stimulator device with standard palliative dosing (8 Gy x 1 fx, 20 Gy/5 fx or 30...
If you do not use the PORTEC-3 regimen for p53 mutated IA endometrial cancer, what specific protocol or combination of chemotherapy and radiation ther...
Would you consider APBI so that less tissue is irradiated or do whole breast (hypofractionation vs conventional fractionation)?
If ADT +/- ARPI + RT, what duration of systemic therapy do you recommend?
The patient is in her 70s and had a prior breast recurrence 10 years ago treated with mastectomy and reconstruction; this most recent recurrence has t...
Is it necessary to repeat MRI a certain amount of time after surgical resection prior to starting radiation?
If there are no pre-op photos, what would your fields look like and dose/fractionation?
Assume the patient is not a candidate for surgery. What dose would you use? Would you recommend a lower dose to not damage the patient's kidney functi...
What patient factors do you consider to decide between 55 Gy/20 fx and 64 Gy/32 fx with or without nodal irradiation? What if your patient is younger ...
How would you add radiation in your treatment paradigm? No clinical trials available due to age.
For example, 5 PET-positive lesions, 2 lesions biopsied and both of the same histology.
Does not involve surface surface of the ovary, no gross disease elsewhere.
After the randomized Phase IIb showed decreased mucositis, are you incorporating this agent? Please share your regimen and any tips.
No lymph node dissection. cN0
Would you treat a smaller volume than the entire tongue for small, well lateralized tumor with indication for adjuvant radiation based on nodal status...
I've been prescribing sucralfate as first line symptom management but I sometimes see zero benefit. The randomized data doesn't support its use either...
How do you take into account pathologic factors like %clear cell histology, myometrial invasion, and LVSI?
I.e. based on the findings of ADAURA in surgically managed patients.
What special considerations or precautions would you keep in mind when considering re-irradiation? The prior radiation was post prostatectomy RT. ...
Patient with multiple comorbidities (childhood CNS cancer survivor, stroke with residual deficits).
The patient did not have radiation previously, but now has recurrent disease in Axillary levels 1-3, supraclavicular nodes, and IMN in the first inter...
Given the published results of the PRODIGE 23 trial where FOLFORINOX was used neoadjuvantly with FOLFOX post-op
The ASTRO consensus lists 2-3cm size as cautionary, while the ABS consensus lists 3cm or less as suitable, though acknowledges that most patients incl...
If, yes, what dose and fraction size did you use?
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...
Lately I have seen patients with a concurrent gynecologic (requiring chemoRT), head and neck (requiring surgery), and early stage NSCLC (requiring SBR...
Dose-escalation RT trials have had mixed results in the past for advanced rectal cancer, while in the early rectal stage there is a tendency towards a...
How do you weigh definitive chemoRT vs minimally invasive surgical approach with neoadjuvant chemo followed by transanal excision, in light of results...
Does a transperineal approach to prostate biopsy change your treatment plan compared to transrectal?
For example, transperineal biopsies may capture a higher volume of disease. Should this change risk stratification compared to transrectal biopsies? I...
Is there any reason that this is not commonly done, apart from lack of RNI coverage?
What factors influence your choice of SRS vs more fractionated regimens?
If the patient had no nodal sampling, would this influence your decision?
Since there is no overall survival benefit, does the local control benefit outweigh the increased risk for distant metastasis? How do you select patie...
For example pT4 and PNI, do you target the neck after a negative neck dissection?
What factors influence the decision to treat: - surgical bed alone ...
Medical Oncology did not recommend systemic therapy due to age/comorbidities. Would you consider radiation therapy? If so, what dose/fractionation?
The protocol for the James trial (NEJM 2012) states: "non-target tissue may be excluded at the discretion of treating physician." For gyn applications...
If there is partial response after chemoimmunotherapy in the primary, would you consolidate the primary? If there is complete response in the metastat...
Is it possible to do SBRT?
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...
Ipsilateral V20? MLD?
The patient had lumpectomy with standard radiotherapy to 50 Gy whole breast, followed by 10 Gy boost 11 years ago, and was recently found to have a sm...
Patient is refusing BID dosing as per RTOG 1014.
Would you recommend if there is only one uterine factor or do you typically require multiple to make this recommendation?
This same patient has Grade Group 5 disease with extraprostatic extension and a positive margin with pre-operative PSMA PET/CT negative for regional o...
Occult IB1 cervical SqCC found on simple extrafascial hysterectomy, with 4 mm deep stromal invasion and LVSI. Subsequent pelvic and para-aortic nodal ...
Please consider this National Cancer Database (NCDB) and Surveillance, Epidemiology, and End Results Program (SEER) registry study (Barrington et al.,...
What factors would push towards treatment? The patient had recurrence of a pT1bN0 vulvar SCC within a year of original surgery. Re-resection shows aga...
The patient has stage IV cervix cancer and was previously treated to 30 Gy in 10 fractions one year ago. Embolization for hemostasis was not successfu...
How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?
In patients with contraindications to receiving an MRI scan, are other imaging modalities sufficient to treat patients with SRS?
If so, is there a particular volumetric threshold you use before a patient gets onto the sim or treatment table?
Would you consider these as metastatic sites? Would you biopsy to confirm?
Patient developed pembrolizumab-related pneumonitis after ddAC followed by Taxol/Keytruda - what thresholds/constraints would you prioritize with rega...
Is your approach different than that to a primary essential tremor?
Would you offer adjuvant radiation? Dose/volume in postop setting?
Do you also use DIBH in these cases?
The idea would be to appropriately cover gross disease/lesions in/around the hippocampus, but then spare the rest of the hippocampus, with the rationa...
If so, how would you approach managing the increase in lung dose required to cover these? Would you consider this metastatic disease?
This is an adult patient that is status-post orchiectomy and R-CHOP now requiring prophylactic contralateral testicular radiation. Would you recommend...
For example, a patient with PSA < 10 and low volume Gleason 4+4=8 disease. Would you consider 6 months vs. 18 months vs. 2 years?
History of 4th ventricle choroid plexus papilloma s/p GTR, now with recurrent disease in the 4th ventricle and the left lateral ventricle (7 nodules i...
Are you more likely to consider a trans-anal resection?
Or would it change your decision on a boost in WBRT if negative surgical margins?
Why do the available guidelines restrict APBI to patients with lesion size <3cm? Is this purely from higher rates of necrosis noted in older brachy...
If so, when do you resume?
If records have been destroyed, how do you factor prior pelvic radiation for prostate cancer into your decision?
If so, are there any patient/pathology selection factors? What technique do you utilize?
What dose and margins would you use? The patient is s/p a liver transplant on immunosuppression.
How does your counseling about side-effects change when offering short vs long course radiation?
Is there a safe regimen that still delivers BED >100?
How can these interactions be improved?
Several articles report results with 0.5 -1 cm margins, and have suggested that with improved imaging and treatment planning, smaller margins such as ...
If radiation, what dose/fractionation and technique?
When would you use 5-fluorouracil instead of, or in addition to, cisplatin during chemoradiation? When, if ever, would you offer adjuvant hysterectomy...
The right obturator sentinel node had a 1.5mm metastasis with no ece. Additional right pelvic node and 6 left pelvic nodes are negative. The cervix ma...
Do you use CT, MRI or PET/CT to create GTV volumes? What margins do you use for your CTV/PTV?
There is evidence that parents do not adequately understand the purpose of phase I pediatric cancer trials (Cousino et al., PMID 23071225).
Is radiation effective in this case and if so, what dose would you use? Is there potential for perforation?
Good performance score, 7 cm in size, CSF cytology is negative, MRI complete spine is negative. Would you consider any additional systemic therapy mod...
Are there any resources comparing whichever value is more relevant for the various breast fractionation schedules (FAST, FAST-Forward, Canadian, UK, 3...
If a patient is found to have florid LCIS with with a 1 cm positive inferior margin s/p sentinel node biopsy (0/2 nodes involved) and mastectomy, is t...
Elderly patient with large fungating necrotic breast mass positive for high grade BCL and a solitary hypermetabolic ipsilateral axillary node. Medical...
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 boost dose?
I see the LungTECH trial dose constraints, but, they seem really conservative when you have something large and close the PBT resulting in use of 60 G...
How does 1p/19q co-deletion and IDH mutation status influence your decision?
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
Do you follow the breast NCCN guidelines to decide adjuvant radiation recommendations if a patient treated with neoadjuvant chemotherapy stops the che...
What are the factors, if any, that would prompt you to recommend radiation?
Low grade vs High grade?
Dose/volume?
If not constrained by field size, would you treat the entire hardware length?
Is there a certain amount of time that you prefer to have elapsed after the last infusion before delivering SRS? Do you avoid all subsequent Trastuzum...
Patients will frequently ask why they need treatment when there is no cancer left on the pathology specimen.
For example, if patient had Gleason 4+5 on biopsy but Gleason 4+3 with Tertiary Grade 5 on final pathology? Would you consider intensifying their horm...
Surgery has recommended against up-front diversion in order to avoid treatment delays. The patient has at least one suspicious internal iliac lymph no...
If the location of the biochemically evident cancer cannot be determined, would you re-irradiate the prostate despite absence of histologic proof of l...
In the absence of other high risk factors like positive/close margins, positive lymph nodes, T2/T3 disease, PNI, or LVI, would you offer postop RT?
The patient is now s/p neoadjuvant chemotherapy, mastectomy, and ALND for their ipsilateral recurrence, and pathology showing residual disease (ypT0N2...
Considering the high retropx drainage to be cranial to C1/hard palate.
Guideline statements recommend 30 Gy in 10 fractions postoperatively due to lack of evidence for other fractionation schemes. Would you consider 20/5 ...
Reference: TROG 05.01 Trial
What about a low lying rectal cancer with involved inguinal lymph nodes?
What if actively on immunosuppression or with active lupus? For this case, presume the patient is not a candidate for resection or IR guided therapies...
Ideally, treatment should be completed in 56 days (preferably < 50 days). If there has been a significant delay to brachytherapy (>2-3 months) d...
If so, would you also include the breast?
Sentinel lymph node assessment was negative and there are no other high risk features.
How long would you wait to see if the AVM obliterates? How would size or proximity to critical structures affect your decision i.e., would you choose ...
This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor p...
Female in her 60s who had presented originally with well-differentiated endometrioid adeno clinically and radiographically involving bilateral paramet...
Not a candidate for re-excision given proximity to the anal sphincter. Consider +PNI, -LVI.
Would you offer APBI if the DCIS was ER-?
Would you cover the lacrimal gland alone or the entire orbit?
Would you recommend standard definitive chemoradiation followed by adjuvant durvalumab? Would you treat pre- or post-systemic therapy volumes?
Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...
If a patient with early-stage breast cancer s/p lumpectomy is noted to have 1/3 SLNs positive for ITCs (and no other negative prognostic factors) woul...
Is this considered salvage or definitive since HIFU is not standard of care?
Does receipt of upfront HIFU impact ability to perform stand...
Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...
How does your approach differ for patients under age 60, between 60-70, and over age 70?
The patient is a woman in her 60s with a history of a grade 1 ER-positive, HER2 negative pT1bN0 invasive ductal carcinoma treated with lumpectomy, who...
Would you radiate concurrently with WBRT? How would you dose/fractionate in this situation?
If so, what is your dose constraint?
Do you have a number/volume threshold for SRS vs WBRT?
The Stanford report (Osmundson, IJROBP 2015) on central hepatobiliary tract toxicity recommended dose constraints to the cHBT that would limit dose to...
What treatment volumes do you target? What dose-fractionation scheme do you employ?
Would you biopsy the metastatic lesion?
Would you treat prostate definitively and monitor closely?
Would you treat prostate and oligosites?
Do you think these patients are appropriate for SBRT? Is endobronchial laser ablation or cryoablation a better treatment approach? Is there a role for...
How do you reconcile RAPIDO and OPRA trial results? OPRA was a Watch and Wait trial but the rectum preservation rate was much higher in that study tha...
Is there sufficient data to justify the routine use of GammaTile in the treatment of primary CNS malignancy or brain metastases?
Would you treat a knee?
If the patient had PSC and baseline atrophy preventing brachytherapy boost (received SBRT boost instead), would this change your threshold for stentin...
Consider negative margins and a patient refusing further surgery.
Do you have recommendations on timing of her implant placement with respect to radiation therapy?
For example, EGFR-mutated de novo metastatic disease, do you offer adjuvant RT vs observation with targeted therapy alone?
Do you assume some recovery since the prior course of RT? If so, how much over what time period?
Tumor factor: Large axillary soft tissue sarcoma with involvement of the brachial plexus
Other factor: Surgery would like to pursue upfront surgery t...
Masuda et al. NEJM 2017
If so, how do you sequence it with adjuvant radiotherapy?
When do you consider observation?
Would you alter the esophagus, trachea, and cord constraint in any way?
Still do Tandem and Ring or opt for interstitial?
Patient will have diverting colostomy. Concern is whether the tandem will be stable enough with lar...
Are there specific patient populations in which you may feel comfortable with a patient selecting only one adjuvant therapy approach (tamoxifen vs RT)...
The patient was a >70-year-old with right-sided cT3N1M0, ypT0N0 TNBC s/p NAC pembro/taxol x 4 cycles followed by mastectomy w SLN (0/4); post-opera...
Assume SSD at isocenter is correct. When are you concerned about the dose to PTV or OARs? Article below appears to say minor effect. Zhang et al....
How would your decision differ if the patient was not on immunotherapy or other systemic therapy? Would your thinking differ depending on the timing o...
Is a FAST regimen reasonable in this circumstance, or should a more gentle fractionation (either the RTOG re-treatment regimen, IMPORT-LOW, or 45Gy in...
For a > 70-year-old female patient with 2 mm of ER+ PR+ HER2- grade 1 invasive ductal carcinoma in background of 1 cm of grade 3 DCIS, would you re...
The patient presented with spinal cord compression, had subtotal resection and instrumentation with metallic hardware. Main concern is that post op su...
Would you add a sequential boost to the node? If so, what dose would you recommend?
If surgery is advised, how you would you time it with chemoradiat...
If the patient is amenable to adjuvant chemotherapy alone, but is worried about chronic diarrhea/urgency after radiation, how would you counsel them?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical prac...
Would you consider empiric SRS if biopsy/resection is not feasible?
When would you consider liquid biopsy?
Does the time from prior RAI affect your decision?
How would you counsel the patient differently about the side effects, if at all?
How does histology and/or molecular testing change your approach? How does the length of the disease free interval change your approach?
Groomed facial hair is an increasingly common style for men. Accordingly, there are patients who require treatment of the head and neck who become ups...
Would you offer adjuvant hypofractionated radiation therapy over a graft in the HN region?
If you treat with SBRT, how would you constrain the heart given the significant prior involvement of the pericardium in this area in the PTV, assuming...
If not, what interval between the patient's last RT and IT chemo would you prefer?
The patient is BRCA2 positive and previously received 30 Gy in 5 fraction APBI to the right breast for an ER/PR+ pT2N0 IDC. She then developed multifo...
The prior recommendations were between 6-12 months, but also were based on chemotherapy after surgery.
Would you offer definitive radiation, and if so, to what volume and dose/fractionation? Would your recommendation differ depending on if repeat resect...
Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...
In a woman with high-grade, clinically node positive invasive ductal carcinoma who receives neoadjuvant chemotherapy and breast conserving surgery, wo...
Assume a mild but diffuse case of lichens sclerosis with involvement of the ipsilateral breast. If node negative disease, would you recommend she unde...
Is there data on efficacy or toxicity when chemotherapy is added to Proton beam therapy for head and neck cancer like there is data to support adding ...
Would you consider omitting contralateral neck radiation if this was a younger patient (i.e. <50 yo)?
Does that change if they received a skin sparing mastectomy?
For a cT2 triple negative breast cancer with indeterminate enlarged breast nodes s/p negative biopsies, and indeterminate findings on both MRI and PET...
In addition to positive margins, perineural/vascular/lymphatic invasion as listed by NCCN, would features such as close margins or high grade dysplasi...
Would anyone consider elective mediastinal XRT to 45-50Gy then boost involved LN to 60-66? Or treat involved lymph node only? The patient will r...
If so, would you favor 30 Gy/5 fraction accelerated partial breast irradiation?
According to the NCCN guidelines, there is a highly selected group of T4a glottic larynx patients that can undergo observation instead of postoperativ...
Encouraging aggressive PO intake in patients with swallowing dysfunction may place them at risk for aspiration pneumonia, especially risky if undergoi...
Would you treat the entire pelvis vs local recurrence? How would you approach the oligometastatic lesion? Would your treatment recommendation change i...
Cancer was with mesonephric features, and was originally within a urethral diverticulum. Would you consider RT vs chemoRT vs surveillance?
This may impact decisions on brachytherapy boost and/or use of ADT since MRI-guided samples may skew patients into the unfavorable risk category
This patient previously received hysterectomy with adjuvant vaginal cuff brachytherapy without pelvic RT. Colonoscopy demonstrated invasive disease, b...
The serum testosterone is minimally low at 250 and the patient has some fatigue.
If imaging is aligned at PTV despite exceeding tolerances do you accept/override, perform shift verification image, or reposition the patient?
Do you...
If so, what dose-fractionation regimen do you utilize? What are your target volumes?
The patient previously underwent resection with close margins, adjuvant radiation to 66 Gy/33 fractions.
Serial MRIs demonstrate progression with con...
If a patient with endometrial stromal sarcoma managed with fulverstrant has a single oligoprogressive lung nodule, is there any contraindication to tr...
PSMA PET vs Conventional imaging vs combined imaging?
How is your approach different from or similar to those who undergo surgical menopause?
For conventional fractionation, should one increase total dose above 60 Gy for either close or positive margin (invasive or DCIS). What about for acce...
NCCN recommends floropyrimidine-based chemoradiation (sandwiched by 5-FU or capecitabine), but many medical oncologists are utilizing multi-agent chem...
If a patient calls you after hours with a headache following SRS and have not been given steroids, what is your preferred regimen?
Patient is declining mastectomy.
Are there certain portions of the mandible that you constrain more than others?
If a patient with prostate or bladder cancer has irritative bladder symptoms during IGRT and urinalysis reveals microscopic hematuria, WBCs, but...
A021501 trial: mFOLFIRINOX vs mFOLFIRINOX with hypofractionated radiation (Katz et al., PMID 35834226)
She was on surveillance after lumpectomy. No prior radiation therapy. What dose/fractionation?
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...
E.g. If a patient had CR in the primary tumor but PR in the nodes, would you still treat the primary?
If electrons are unable to be used, or if the patient's anatomy precludes use of electron treatment, what is your general approach to using IMRT in th...
What is your preferred dose/fractionation following a previous course of radiotherapy?
What volume do you treat? Initial disease extended from paratracheal to celiac LN. Residual disease now is only in celiac LN.
No evidence of distant disease elsewhere. Surgical resection is not possible. Would you recommend metastasis direct therapy to the liver (i.e. SBRT or...
Would you consider hypofractionation? If so,what dose? Would you consider a boost if there were close margins?
Is there an extent of nodal involvement in prostate cancer above which you would not offer definitive XRT? With PSMA/PET we see some patients with inc...
I've noticed that these patients have been having greater than expected fatigue that persists for months after SBRT. This is very different than the f...
How do you decide if/when to treat the primary disease and when would you treat definitively?
How will you approach patients with diffuse metastases who you would have otherwise deferred treatment?
Prophylactic Radiation Therapy vs. Standard-o...
What are the expected outcomes if you were to irradiate the pelvis in someone on peritoneal dialysis?
In a large unresectable grade 2 astrocytoma of the temporal lobe, what dose and GTV margin should be used?
I have heard of long-term pentoxifylline and Vitamin E daily combination that can prevent and even reverse radiation fibrosis (Delanian et al., PMID 1...
If a patient presents with metastatic disease (by virtue of extensive PA nodal burden, mediastinal/SCV involvement, no solid organs) but received urge...
Would you recommend chemoRT and take the whole bladder to full dose or do you only boost the invasive disease?
Would you offer radiation therapy? If so, what dose and fractionation would you use?
If a patient with good PS who does not meet criteria for prophylactic rod stabilization has radiographic features consistent with metastasis (lytic ap...
In light of recent trials showing no difference in outcomes with RT+cetuximab vs RT+IO, does this potentially lead us to use immunotherapy in cisplati...
Assume a life expectancy of approximately 5-10 years. What factors would influence your consideration of intermittent ADT vs. watchful waiting?
Do you stop treatment? What if an abscess is also present?
This endometrial cancer was a fortuitous finding following vaginal hysterectomy.
This was resected over 2 years ago with reconstruction of the IVC with a PTFE graft. No preop or postop RT given and the recurrence is in the area whe...
With the recent WHO classification redefining IDHwt tumors as glioblastoma, more patients have imaging features that are historically consistent with ...
Does the previous dose of SRS or the fact the patient had prior surgery matter when planning WBRT?
In the study published by Slotman et al (Lancet 2015), nearly all the patients in the thoracic RT arm started with PCI. For patients with gross diseas...
Does your approach differ from p16 positive disease?
Assuming a biopsy shows active disease and the metastatic workup is negative, when would you off...
VS schwannoma size 16mm
Patient received FSRT 25 Gy in 5 fx more than 4 years ago
I.E., can a patient with a questionable 5 mm node (MRI T2N1) which is negative on pathology after short course radiation be staged T2N0 and receive no...
How significant does the moist desquamation need to be? Does the length of tretment remaining ( i.e. 1 v. 3 weeks) or use of medication effect your de...
How would you approach treatment if SBRT was not technically possible?
How would you opt to treat if SBRT was instead not covered by insurance, and w...
NGS without any actionable mutations and PD-L1 TPS 15%.
Would you offer chemotherapy, radiation, or immunotherapy and, if so, in what order?
Is a bra that can be worn during treatment and indexed ever advisable for patients with large breasts who are otherwise unable to do prone treatment?
...
Is this stage IS or IIA? Is chemotherapy or RT preferred?
How would you modify this based on endopredict or RT-PCR?
Is there a limit to the number of adjacently involved vertebrae where you would instead treat with conventionally fractionated palliation?
If considering systemic therapy, would you consider standard chemotherapy or use biomarker-directed therapy (e.g., imatinib if ckit+, larotrectinib/en...
Main concern is radiation induced thyroid cancer
What advantages/disadvantages are there between assays or over traditional clinical pathologic factors? What other concerns do you have?For additional...
Now that RTOG 0915 shows 5 year data with no difference in OS, DFS, and toxicity, should single tx be routinely offered? Are there specific pati...
If you use VMAT, do you take into account leaf interplay/leaves crossing PTV or potential overmodulation during planning?
How do you decide between downstaging chemotherapy or upfront concurrent chemoradiotherapy? Both are listed as NCCN options.
Would you do SIB to gross nodes in the pelvis and/or inguinal region? Would you do SIB to the primary unresected tumor?
Would you favor the use of any particular biologics over others?
In a non-surgical candidate, would you consider adding radiotherapy sequenced with chemotherapy at any point? Or do you reserve it for palliative purp...
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...
If you were to offer radiation, what dose and fractionation would you use?
Assume a young, fit patient who has not had prior pelvic RT before, and has been fully staged with molecular imaging (e.g., PSMA) with no evidence of ...
How would you treat such a patient?
When do you continue with treatment and when do you terminate the plan? What is your criteria?
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...
For nodes just inferior to the celiac/SMA axis and no other distant metastatic disease? Stage is formally M1, but just barely. The patient is otherwis...
When would you treat the entire orbit versus partial orbit? One patient has medial rectus involvement and another has only conjunctival involvement. I...
What contraindications or concerns do you have in this scenario beyond assessing the Child Pugh Score?
Assouline et al., PMID 24411632 recommend delivering 500cGy x 4 fractions = 2000cGy on days 1, 3, 8, 10. Do you follow this schedule, treat every othe...
In a patient who had BCS and adjuvant radiation to the breast and regional nodes, now several years later with extensive axillary recurrence s/p axill...
Specifically, in the TZ and PZ? What references do use for prostate nodule boost as done in FLAME trial?
Hypointensities are contoured on T2W M...
Does your management change if the primary tumor is radioresistant, such as renal cell carcinoma?
Based on recent ASTRO data, what is your selection criteria and size cutoffs?
Patient has declined endocrine therapy and is unfit for systemic therapy.
Imaging studies (MRI and PET) show bilateral disease
If borderline resectable, can the TOPAZ regimen be considered for downstaging effects?
What level of PNI is considered "large nerve" in this disease?
Assuming in-field recurrence.
The patient was in her 30s with a 2.8 cm benign phyllodes tumor with positive margin at the posterior fascia. Surgical resection is not considered ide...
What fractionation scheme would you use? Would you give SBRT to a hilar tumor that has N1 nodal involvement adjacent to the tumor but can be enc...
The lesion is still ulcerative despite wound care for two months. Would you treat immediately or wait for healing? Would hyperbaric oxygen to heal ful...
C diff infection ruled out and CT abdomen pelvis shows diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field.
Would the presence of perianal extension and a positive inguinal lymph node affect your recommendation and how?
Are there particular indications you use for RT? i.e. multiply recurrent, refractory to other therapies, near critical structures, unresectable (or re...
How does your approach change for same lung but now a different lobe v. different lung? How do you adjust your constraints?
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...
For a large pelvic mass that is causing abdomino-pelvic pain, can hysterectomy be considered?
Are there guidelines that dictate who in the department should be present for treatment delivery?
When tumors come close to chest wall, how do you define skin contour?
General recommendations on dose and management presuming unresectable.
How do you define an “adequate” axillary dissection, (i.e., would 8 lymph nodes dissection instead of 10 be “adequate”), or ch...
Is there any evidence to support the theory that this may cause worse skin reaction?
The patient has notable lip lesions from her discoid lupus erythematosus
In patients with small breasts and large lumpectomy cavities, is there a benefit to switching to whole breast if you can produce a very homogenous par...
If a patient has T2N0 disease without LVSI, but has a ~4 mm IMN node in the 4th or 5th intercostal space, would you be inclined to include the IMN cha...
The patient has disease in the S2/S3 region with an anterior soft tissue mass.
The patient previously received 50.4 Gy with treatment for rectal canc...
Traditionally these patients may have received chemotherapy prior to chemoRT.
This patient is young and active but refuses palliative chemotherapy
This is an elderly patient with a BCC/SCC over the shin who is not eligible for Mohs due to concern for wound-healing issues. Orthovoltage/superficial...
It is not clear from CREATE-X whether radiation was before or after capecitabine. Is there a preferred approach?
What is the potential risk of immunotherapy toxicity in combining palliative RT in a patient already on immunotherapy?
Is there a role for pre-operative RT?
Does this ever affect your decision for treatment of current disease (eg likely radiation-associated sarcoma vs likely unrelated new oropharynx cancer...
Would you consider repeating a biopsy?
50+ yo F. Mastectomy, chemo, and RT in 2016 for primary breast angiosarcoma, not RT induced. Had longstanding cyst on wrist, biopsied, and positive fo...
Would increased risks from concurrent intravitreal avastin preclude treatment? Would you recommend a waiting period in between the treatments?
Patient had significant GI side effects with Trental. (This particular case involved a second course of radiation for a secondary lung cancer 30+ year...
What dose/fractionation scheme do you use? Is SBRT a viable option?
How long after the first treatment should one wait?
Do you specific renal impairment or hydronephrosis/hydroureter criteria?
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 ...
If so, which nodal regions?
SCC measures 5.5 cm, 2.0 cm thickness, closest margin 0.2 cm (deep), high grade, PNI+, LVSI+. Lymphadenectomy was deferre...
Please share your institutional preference.
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 ...
Do you take this into consideration when recommending treatment?
Is the radiation therapy management equivalent to similarly-staged squamous cell carcinoma? Is there a preferred concurrent chemotherapy regimen? ...
If the patient were of young age with high grade and ER+ disease without LVI, do these factors sway you one way or another?
Pt with 1.3 cm Merkel cell (buttock) excised with negative margins. Two sentinel inguinal nodes sampled and one is IHC+.
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?
Would you treat it like an “endemic” NPX cancer with induction systemic therapy followed by CRT vs. CRT followed by adjuvant chemo vs CRT ...
How would your approach change given the prior RT?
The patient had previously recurred twice in the abdominal wall, and was treated with resection. The patient has developed AML since that time and is ...
In a setting of standard fractionation, we would sometimes consider going to 66Gy total dose to the boost cavity, so how would you "translate" this to...
There is involvement of posterior vagina, left puborectalis, and peritoneal reflection. No nodes are involved.
Does your decision change if a smit sleeve is being placed?
Do you sim and treat with their bladder as is? Or do you have patients who do urinate fill their bladder somewhat? Fluid overload is often a considera...
NSCLC-style regimen of 60Gy/30fx daily or SCLC-style regimen of 45Gy/30fxBID?
In patients with large areas of painful bone metastases, do you ever do hemibody? If so, what is the preferred dose?
Would you offer SBRT (42.5 Gy in 5 fraction regimen off trial with or without Cyberknife)?
What if the spillage is noted to be limited to the tumor bed, per the surgeon?
We have a lot of push from our surgeons to do IORT, do you use the ASTRO APBI criteria? Do you treat off-protocol? Do you use Xoft or Intrabeam?
With newly published long-term data of single fraction IOeRT (Intraoperative electron Radiation Therapy) for breast cancer on the ELIOT trial, does th...
The patient’s tumor spans 6 cm depth within the scrotum, with no skin involvement.
What is your preferred beam arrangement?
With photons, woul...
PSMA showed no distant or regional disease but did show a prostatic recurrence.
How long after grafting do you start radiation?
Is there an optimal/recommended fractionation to preserve the graft?
If so, how long before/after radiation?
If the patient is outpatient and coming into clinic each day, at what point would you initiate a C. diff workup?
Assume no contraindications to hypofractionation.
Is there a reason to choose Pylarify (piflufolastat F 18) or Gallium 68 PSMA-11? If so, are there different rates of detection? Are there logisti...
Any adjustments in terms of elective nodal coverage?
In patients <50y/o, would you a favor a surgical approach in cervical malignancies that have pre-operative borderline Sedlis criteria indications f...
Post-operative MRI focused on CN V was negative. There is a focal positive margin.
Contreras et al., Phase II results suggests that elimination of PORT to the pN0 adequately dissected neck may be safe for some head and neck primary s...
Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?
Is there any particular reason to include or not include this in the treatment volumes?
The patient has no risk factors and would have been stage IB if it were not for the small nodule
What factors influence whether you treat an elective nodal volume vs gross nodal volume (plus a small margin) in the setting of oligometastatic or oli...
Do you cover the entire ipsilateral neck or limit the field to involved nodal level(s), (assuming not chasing nerve for PNI)?
Do you ever cover the c...
Should the dose still be given after completion of RT?
For example, portion is seen above and below the mesorectal fascia. Do you feel comfortable treating as colon cancer with surgery upfront?
Prior treatment: GTR in 2020, adjuvant radiation 63Gy
Patient factors: Medically inoperable and not fit for chemotherapy
The recurrence is within th...
Would your recommendations change based on patient age (pediatric vs adult)?
If so, what dose constraint do you follow and how do you contour the bladder neck?
What if the patient has had a liver transplant?
Would you consider SBRT in this instance?
If so, then how would you approach this case if the patient's extent of disease was suboptimal for SBRT?
Are there clinical scenarios in which you have found chemotherapy first has been beneficial?
(i.e., advanced T stage, extra-mesorectal LN, anat...
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...
If a patient clearly has N1 disease with high SUV on PET, do you routinely recommend EBUS or mediastinoscopy to evaluate for N2 disease?
After multiple failed attempts with typical radonc trouble-shooting (ativan, cutting out mask, oxygen, etc)
What if the duration of neoadjuvant therapy has been less than 6 months?
Would you treat lung and HN at the same time vs sequentially?
E.g. breast or H&N cancers when boosting the supraclav area.
Is there certain information or practices that you find sets the day up for success?
Assuming patient is medically operable, would you always advocate for surgical dissection? If so, how to you approach post op radiation (and chemo).
...
Would you treat with ADT if no metastatic disease?
Does absolute PSA (e.g. PSA<2) inform decision?
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
What are the pros and cons of using uterine artery embolization with regard to how it may affect the efficacy of radiation (+/- chemotherapy)?
If so, what dose and what would you include in your field? Would the pre-chemotherapy extent/burden of nodal recurrence influence your decision?
If negative margins can be obtained, would you consider breast conversation therapy? If so, would you recommend bolus placement over lumpectomy scar?I...
Would you treat as bulky or non-bulky? Is ISRT indicated? Biopsy was performed because there was concern for soft tissue sarcoma.
Does ADT affect the results of a biopsy?
Louis et al., PMID 34185076
Which radiation doses would you use if there is a >4.5 cm LN?
Additional imaging of the potential lesions, biopsy or assume negative given normal PSMA PET/CT.
If not, then what is your preferred treatment and would you integrate SRS into it?
Does it matter if the patient has a history of WBRT?
Does the specific chemotherapy agent (MTX vs Topotecan vs Triple Intrathecal) change your recomm...
Adjuvant chemoradiation? Would you boost the positive parametrial margin? Would you also boost vaginal cuff with brachy?
What treatment margins/set-up/on-board imaging would you use?
Assume for this discussion: ECOG 0-1, life expectancy > 10How would nodal status influence your recommendation? Reference: Hawkins et al., PMI...
Would you consider re-excision and/or adjuvant RT? If RT, what margins on the scar and treatment volume would you use?
Should one do pleurectomy/decortication?
How long after hysterectomy would you consider delivering adjuvant radiation therapy? Would this differ for external beam versus brachytherapy?
Are t...
If radiation is indicated, what dose would you use?
Do you have formal constraints and evaluate cumulative doses on the composite plan? Do you use traditional constraints but account for repair?
FLAME used an atypical fractionation scheme of 77 Gy in 35 fractions boosting MRI defined nodule to 95 Gy. Would you consider a 20-fraction or 28-frac...
Have you noted significant diarrhea until the ileostomy is reversed?
Would you offer standard ChemoRT or favour APR given the risks associated with RT?
Is concurrent axitinib contraindicated if a patient is to be treated with conventionally-fractionated spinal RT (e.g., is not a candidate for spinal S...
Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? Are the results of the recently published negative phase II...
If so, how long?
If a patient develops a new erythematous macular rash in the exact area of the prior radiation portal months following completion of RT without new me...
The NCCN Breast guidelines specify that for a patient with Paget's disease of the NAC with a positive full-thickness skin biopsy of involved NAC but a...
If a treatment machine is down for 3 days, would you do weekend treatment? Would you consider doing BID?
Does the dosimetry of the plan (e.g. exceeding V20 constraints) impact your decision?
Would a history of immunosuppression impact your decision?
If a patient has a painful breast lesion in the setting of rapidly progressing systemic disease treated with weekly taxol (60 mg/m2), would you feel c...
If the inguinal node was previously treated with SBRT 30Gy/5fx and immunotherapy >6 months, what treatment would you recommend?
Do you ever add prophylactic Keppra (levetiracetam) for glioblastoma patients without a seizure history based on data such as this study (nature.com) ...
Do you allow this finding to change your management, or ignore it, as the "lesion" was not malignant?
Assuming additional workup including more extensive biopsy and nodal evaluation shows no evidence of invasive squamous cell carcinoma.
Would this cha...
E.g treating and SCLC after prior NSCLC.
Have a patient with a multi-year history of a growing substernal goiter. There is mass effect on the trachea, esophagus, and aorta. He is experiencing...
Would ypN1mi after neoadjuvant endocrine therapy cause you to recommend postmastectomy radiation? Or regional nodal coverage after breast conservation...
Assume patient had high volume of disease removed. Prostatectomy was in the very distant past.
Would you offer adjuvant radiation? (Dose? Target?) vs Salvage?
Would you add ADT? Would you add abiraterone?
Would the number of lymph nodes involv...
How close can a metastasis be to the PRV05 and still make hippocampal sparing feasible? Do you ever reduce the margin on the hippocampi to 3 mm, if yo...
The patient is a young female with a pT2N1a ER/PR positive, Her-2 positive invasive ductal carcinoma of the upper inner quadrant of the right breast s...
How soon is too soon after surgery to check PSA?
What precautions can be taken to limit infestation of the department?
Do you implement a treatment delay and if so how do you decide when...
Please share your patient selection criteria and experience.A recent study in H&N patients showed superiority of the StrataXRT gel over standard o...
Is there a risk of increased sphincter tone issues in these patients?
If a patient had 35 Gy in 5 fractions to a vertebral bone metastasis with SBRT two years ago, how much more can I give now to the whole vertebra with ...
Eg peri-tumoral fibrotic changes noted on cone beam midway through their treatment course?
For example, would you offer a patient SBRT with 3-4 lung SCC nodules? If so, how do you approach planning?
Have you found Trendelenburg positioning helpful for situations in which small bowel falls into a high dose target volume?
What would your approach be in a patient with a mid-esophageal squamous cell carcinoma treated with chemoradiation therapy followed by surgery, with P...
Are there any medications that you can prescribe? Diet changes? Does this typically resolve on its own after time?
Hypothetically not an ideal surgical candidate due to weight loss. Both cancers are non-metastatic and resectable if disregarding other cancer and com...
Would you delay salvage surgery for a stage I primary vaginal cancer with partial response but no new disease at 3 months after radiation (EBRT + brac...
My experience has been that patients can be neurologically devastated years out from WBRT. In Medical Oncology practice at my institution, we do not r...
For T2N0 anal squamous cell carcinoma, RTOG 0529 used 50.4/42Gy in 28 fractions. However, for nodal disease >3cm, 54Gy in 30 fractions is used (and...
What is your radiotherapy approach? How large is your treatment field, and for the leukoplakia/in situ disease, what is your dose?
How often are you scanning the brain and what is your trigger to treat?
For example, when palliating rectal or gynecologic bleeding in 5 fractions?
What structures do you contour and what dose constraints do you utilize?
Do you use a cutoff of 10 cm? Do you measure the size of the largest node or measure the largest conglomerate or measure the total length of the entir...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice...
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 ...
No additional systemic therapy is planned. Would you consider consolidative radiation therapy? If so, what dose?
Do you treat on consecutive days or more protracted interfraction intervals? Does tumor type (benign vs malignant) or size influence your choice?
Is prior Ra-223 a contraindication for treatment?
Is there any available therapy?
Patient has ED unresponsive to cialis/viagra; would you recommend testosterone replacement therapy?
If a weekly schedule is chosen, what would be the appropriate weekly dose given that PORTEC-3 and GOG 258 used two cycles of cisplatin 50 mg/m2?
If you do recommend adjuvant therapy, what regimen would you use?
In addition to scans, would you biopsy the prostate/SV?
Would radiation therapy to the untreated pelvic nodes with hormonal therapy be a consideratio...
Are you able to achieve the contralateral breast and lung V5 constraints from current protocols?
The said patient has been on Imatinib for 2.5 years and is In MMR. Last rt-PCR was 0.04.
How do the results of RTOG 0534 presented at ASTRO affect your decision making?
Juven protein powder is good for healing and helps with mucositis but has high amounts of antioxidants. Is that of concern while patients are undergoi...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
Assume oligometastatic site will receive treatment.
How do you take into account the following factors:
The degree of pain and/or ambulation impairment, the extent cortical destruction, and/or lytic vs...
Do you use BID treatments toward the end? Do you add additional daily treatments to exceed the prescription dose? Would you alter systemic t...
No prior brain radiation. Is full dose whole brain radiation mandated? Would you consider PCI dose or brain surveillance?
What dose-fractionation would you recommend?
Assume the dissection cannot be treated yet due to greater urgency of treating the tumor. What dose-fractionation would you select, and any additional...
Does the TURP defect in the prostate affect efficacy or toxicity or SBRT?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
Would you recommend concurrent chemoradiation (organ presrevation) vs. surgery (laryngectomy/pharyngectomy and extensive base of tongue resection) and...
Would superficial dehiscence along the incision delay you starting radiation?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
Is this a clinical/radiographic or strictly pathologic diagnosis?
Specifically, what is considered the superior/top border of LUS?
I recently saw a patient who had been treated with concurrent pembrolizumab-RT elsewhere. Is this an acceptable practice outside the setting of a clin...
Would you still take the primary to 60-70Gy?
Do you have a preference for bicalutamide? Can abiraterone be used instead?
After a diversion, would any other factors impact your recommendation (residual disease/response to chemoradiation, performance status)? Although brac...
What if Medical Oncology wants to give more systemic therapy and further delay XRT start date?What should we be telling the Breast/Plastic surgeon/Med...
What are the best references to help distinguish small and large bowel during contouring, if still unclear despite giving PO contrast?
Would you consider APBI despite younger age?
Do you typically aim to wait a certain amount of time to allow for healing? The range seems to be 4-6 weeks but 4 seems a bit early with potential ser...
At what PSA would you become suspicious for biochemical recurrence and pursue restaging? Is there a threshold value?
What imaging modality would you ...
Pleural fluid cytology is negative for malignancy but shows mesothelial cells. Would you use a PleurX or target with radiotherapy? From my understandi...
Does your surveillance schedule change dependent upon delivery of SRS vs conventional-fractionated RT?
Sodium alginate, an ingredient found in ice cream, is now being used in Japan to reduce RT-induced esophagitis. Anecdotally, a daily quart of ice crea...
Is there a specific brand or formulation you prefer?
The literature supporting the use of probiotics does not standardize the type or dose of probiot...
Would you use it for initial staging or at time of biochemical recurrence?
What do you tell men who want to know if their testosterone has recovered?
Assume non-enlarged pelvic lymph nodes, with a PSA of 4ng/ml.
If the diagnosis was made by an outside physicain, how do you confirm/refute the diagnosis? Would an alternative diagnosis like a thrombosed hemorrhoi...
The patient had been treated with conventional fractionation to bilateral breasts in the past as treatment for her synchronous IDC.She is currently in...
Would you consider this standard in asymptomatic patients for workup and treatment planning? Or do you reserve MRI for symptomatic patients only?
At what disease free interval is the safest to consider this?
For example, for a biochemically recurrent patient now with 4 PSMA PET+ nodes, if one of those PSMA+ pelvic nodes is within the prior field and adjace...
What dose/fractionation would you give to the liver lesion and node? Would you treat just the celiac node or all there regional lymphatics?
In a patient not receiving adjuvant chemotherapy who has a delayed consultation due to complications/personal issues, etc, is there a time delay ...
LVSI positive. No other high-risk features. Would you cover lymphatics?
ASTRO 2015 guidelines did not recommend coverage of stations 5/6/7 except for what is within 1 cm of the esophagus to limit lung dose. However, ARS 20...
In this case, initial tumor was 9.5 cm craniocaudal but hardware spans the entire femur.
Recent data from Spratt has suggested improved outcomes with concurrent vs neoadjuvant ADT. However, during the first 1-2 months there is expected pro...
If radiation, what type? EBRT or brachytherapy? Any other techniques you would recommend, such as rectal balloon?
Does the elapsed time from prior chemoradiotherapy impact your selection of dose/target volumes?
What role or experience is there for noninvasive bioimpedance spectroscopy (BIS) devices (SOZO)?
If a patient had prior breast conserving treatment and now has inflammatory breast disease, would you prophylactical send the patient to a cardiologis...
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?) ...
Do you change your dose constraints for lung tissue in patients with poor pulmonary function test results?
Would you ever offer pre-operative radiotherapy in carefully selected patients before primary oncologic surgery off-trial, based on this Lancet Oncolo...
How long do you wait to radiate post spinal separation surgery for multilecord compression if there is superficial dehiscence of proximal scar?
Would you recommend axillary dissection, axillary dissection followed by adjuvant radiation, or axillary radiation alone? Does the number of positive ...
Does esophageal cancer continue to respond up to 6 months on PET, like anal SCC or p16+ oropharyngeal cancers?
What is the role for post-operative irradiation?
Garcia-Aguilar J et al, JCO 2022
The Intergroup 0162 trial did not demonstrate noninferiority, although OS difference only 5.1 vs. 5.8 yrs. Would pattern of spread affect your d...
Signs/symptoms and echo/EKG consistent with pericardial effusion likely secondary to acute pericarditis
Can elective nodal RT be omitted for select patients with T2-4N1 head and neck cancers with multiple commodities and poor KPS with life expectancy <...
For example, in a patient recovering from COVID pneumonia who is no longer a surgical candidate due to decline in pulmonary status, and still has clin...
Does your recommendation change depending on the disease-free interval?
If so, what percent likelihood do you quote patients for this risk with SRS, SRT and fully fractionated therapy?
Less than 2cm in size and closest margin is 0.6mm. Would you consider re-excision or mastectomy? Would you offer radiotherapy?
Stage is cT4N2M0.
If so, what is timing after salvage radiation that you would recommend?
And does this differ by site (e.g. gyn vs head and neck)?
Would you avoid radiation/prefer surgical approach? Tighter pharyngeal constraints?
Do you routinely discontinue the device or continue if they are otherwise tolerating the treatment well?
Assume no evidence of regional or distant metastatic disease on imaging.
Are there situations in which you would recommend dilation of stenotic airways after radiation? Is there a concern for increased complications of dila...
Do you use the same or more generous PTV expansions as definitive prostate cases?
If a patient is not a surgical candidate, what it the most appropriate treatment?
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 ...
Is there a certain energy beyond which you feel the acute or late toxicity to the skin/breast warrants a switch to photon techniques?
In a refractory DLBCL of entire circumference of leg below knee, how do you spare a tissue strip for lymph node drainage?
Final pathology showed pT3N0, 0/27 nodes, negative margins +perforation, +PNI, pMMR.
If you avoid parathyroid hormone-related protein analog drugs in patients with prior external beam radiation, what data is this based on?
In what clinical circumstances would bolus be indicated for this histology?
Do you increase EBRT or brachy dose by a certain amount based on interval?
How do you modify your adjuvant whole breast RT design (e.g., CTV_WB per RTOG 1005 volume-based or field-based approach) for patients with *prior* cos...
Would you change your management based on location, such as a sensitive area like the groin? What volumes do you recommend? Does age influence y...
Weekly (20 mg/m2 D1, D2) and q 3 wks (70 mg/m2 x 3c or 100 mg/m2 x 3c) regimens have all been listed as acceptable. For reference, RTOG 97&...
What if there was mediastinal nodal involvement?
If the patient has invasive breast carcinoma and close margins with no other risk factors for local recurrence, would you utilize a cavity boost?
Are bony landmarks used to guide patient placement?
What factors do you consider?Is your thought process at all different from your approach to boost with IDC? Do you apply TROG 7.01 data (age <...
If the only indication were the parotid mets (primary site resected with no high risk features) would you treat the parotid and neck (assuming skin ca...
Assuming no overlap with prior RT doses, would a history of necrosis cause you to hypofractionate rather than deliver single fraction SRS?
Treat as invasive disease with concurrent chemotherapy? Any non-radiation options for large in-situ disease? If RT, would you include at least inguina...
Is it better to sacrifice target coverage (reducing volume receiving 95-100% dose) or change to fSRS in order to meet cord constraints without having ...
What resection margins are required for pure DCIS with adjuvant RT? What resection margins are required for pure DCIS without RT? For additi...
Would you offer RT if there was bone invasion? If there was poor wound healing causing a 6 months delay, would you still offer RT?
Due to the use of 1-1.5 cm CTV expansions on the surgical bed, the CTV for PBI often closely approaches the skin surface. In such cases, do you apply ...
Is single node >3cm sufficient for you to offer radiation, or do you have a different size cutoff? What other factors (such as those listed in NCCN...
Is it reasonable to dose de-escalate since survival will likely depend on the metastatic lung cancer?
E.g. buccal mucosa, maxillary vestibule tumors
Particularly what do you levels of the contralateral neck do you include?
What factors (T stage...
For patients who are not surgical candidates and have MIBC involving a moderate to large bladder diverticulum, do you consider it safe to offer concur...
When contouring pelvic lymph nodes in rectal and anal carcinoma, do you exclude bowel from your CTV?
The RTOG consensus guidelines suggest to not exclude small bowel when it falls into the space occupied by the rectal mesentery. Meanwhile, prostate an...
Should it include the entire brain (normal brain + target) or just the normal brain (brain - target)? How does the V10 or V12 constraint change ...
Would you treat differently if it was hypofractionation? How would your treatment management change if the prior radiation was within 2 years of the r...
Would you go beyond a traditional palliative regimen such as 30Gy in 10 fractions?
Would you consider boosting the nodes? What dose? Would this change your recommendation for length of ADT?
What dose and fractionation? Would use a Spaceoar?
Do you utilize MRI to aid in planning for oropharyngeal primaries?
There are many cases where patient has cord compression in 1-2 vertebral levels, but surgery was done with hardware encompassing 5-7 levels. Are you c...
What medications (ibuprofen, steroids, muscle relaxers) due you use?
Are there any non-medication management options?
How do you sequence/integrate radiotherapy relative to high risk chemotherapy?
When would you consider cranial/craniospinal radiotherapy?
Would you follow the same guideline recommendations for adenocarcinoma if the adenoma component is invading miscle wall?
Does this change depending on stage?
The patient has metastatic NSCLC with painful metastases of the cervical spine, and is in between cycles of chemotherapy
What maximum dose do you allow to “connect” adjacent metastatic lesions receiving SRS/SRT?
What is this value for one-, three-, and five-...
If pCR in lumpectomies would you boost both sites?
Is biopsy necessary to confirm disease?
Would you include the entire parotid in the intermediate risk volume?
Some patients will go on to develop asymptomatic intermittent hematuria which can persist... In patients with scant hematuria, what's your routine car...
How would you approach management? If a low oncotype score was obtained, would this change your management?
The tumor was initially 5.5 cm in size.
Mastectomy and ALND revealed a grade 2, ER/PR positive HER-2 negative tumor with negative surgical marg...
The patient has a lesion of the manubrium.
Do you only recommend ADT in patients with Gleason 4+3?
If pathology review is done and all imaging scans including CT scan, PET scan and MRI have come back without a primary site, is it reasonable to close...
How would you approach the treatment of a single vertebral body involved with multiple myeloma (MM)?
What dose/fractionation scheme and treatment volumes are most appropriate?
Could you consider treating a single vertebral level with SBRT if do...
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
Specifically, for high grade T1 bladder cancer, is there evidence that definitive radiation yields similar control rates compared to cystectomy?
If so, what dose/fractionation and constraints would you recommend?
Do you require neurosurgical evaluation first? Do you require any patients to wear a neck brace?
If a patient presents with ER/PR positive, HER-2 negative pT1cN1 invasive ductal carcinoma with micropapillary features s/p lumpectomy, how would you ...
How does this affect management?
Are you doing more TNT to prolong time to surgery? If so, do are you starting with CRT or chemotherapy?
Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...
This is particularly relevant for patients with extensive delays due to wound healing issues.
The pulmonary metastases are planned to be addressed with a combination of surgical resection and SBRT.
For example V70<10cc? Or do you stick with % of organ volume dose constraints?
The patient is not amenable to re-resection.
What pathologic features and/or margin status would preclude the need for additional irradiation?
From my review of literature, the rate of contralateral neck failures with ipsilateral radiotherapy for lateralized tonsil T1-2 N2a disease is very lo...
For example, what is the minimal acceptable distance between the medial tangents?
For example, a two week break halfway through a course of hypofractionation for early stage breast cancer.
When treating a NSCLC with extensive bilateral mediastinal disease +/- supraclavicular nodes, would you recommend exceeding certain tissue constrains ...
Would you consider radiation therapy? What dose/fractionation?
Do you utilize both therapies? Which should come first?
How does a diagnosis of active RA inform your treatment approach for patients with breast cancer, if at all?
Would you off more radiation if the prior pre-op radiation was within a few cm to the recurrence? If there a time interval you would wait before offer...
For example a power outage. While highly dependent on clinical scenario, is there some general guidance on whether to add another fraction or how else...
Given that FCCC trial (Pollack et al., PMID 24101042) showed worse late GU toxicity with IPSS >12.
Were patients with mixed histology included in the omission trials?
E.g. One NSCLC with N2 disease, and additional ipsilateral small nodule that is a biopsy-proven second primary. When do you consider SBRT to a nodule ...
The patient was treated with neoadjuvant cisplatin/etoposide followed by mastectomy and SLNB with a 4 cm primary and negative nodes. LVI was noted on ...
What is you decision making process in terms of the various hypofractionated regimens for WBRT supported by different trials?
When do you favor APBI?...
What constraints do you use for the contralateral breast and what will you accept?
What is the role for surgery vs RT?
What clinical and pathologic features - if any - would necessitate conventional fractionation?
Would the rate of growth, number of nodes involved, size of nodes, ENE etc. affect your decision?
What volume and dose would you recommend?
How does the PSA change differ (if at all) compared to IMRT. Do you still use the Phoenix definition?
What do you do if PSA is slow to decline?
Would you recommend whole pelvis as well as vaginal cuff brachytherapy?
This is one of the available options in the NRG-BR007 DEBRA trial
Given multidisciplinary discussion has occurred and SBRT has been agreed upon as local therapy, how do you approach the presence of moderate/significa...
Do you do fluoroscopy first, match motion of diaphragm or fiducials? CBCT? Repeat Fluoro/CBCT? Do you use breath hold or gaiting or compression? Do yo...
Which sequences/protocols do you find most useful for target delineation (primary? nodes?). Do you use contrast? If you had to choose a few to limit t...
What would be the indications for doing so?
Would you proceed with APBI, or hypofractionated whole breast RT?
Do you recommend upfront diversion? Are there unique planning considerations such as the inability to use bladder filling? How do you boost? What are ...
VC brachy, pelvic RT, +/- chemo?
Does your management change if it is confined to the endometrium without myometrium invasion or if it is only ...
Are you offering patients beta-emitters (Samarium-153 lexidronam, strontium-89) to any patients?
If there is no pain relief after 9 months, is additional radiation reasonable? What dose/fractionation would be safe and likely to be effective?
Given the CALGB 9343 trial, as well as the recent "Choosing Wisely" recommendation (https://www.choosingwisely.org/clinician-lists/sso-sentinel-node-b...
Are there clinical features (post-op PSA, Decipher score, pN+, pT3, etc) that would inform your decision?
Given GU003 presented at ASTRO 2021- how does this impact your recommendations for adjuvant and salvage prostate RT?
What factors and evidence would you use in your decision?
40 yo adult patient with a~6cm mass with concern for skull base bony involvement (group III and stage III, no nodal involvement )
Would you offer systemic therapy and/or radiation therapy to groin/pelvis?
Should definitive radiotherapy be used as a standard approach? If so, what are the dose and technique considerations in treating these complicated tum...
Is there any data to support it? What dose/fractionation would you consider?
Do you worry about false negatives on PET, CT, MRI if ADT is started before the scan? Scheduling scans can sometimes book 2-4 weeks out.
Do you allow pre-RT treatment with the CDK 4/6i and hold during RT, vs. allow concurrent with breast/chest wall RT, vs. delay starting CDK 4/6i until ...
Is there a benefit to EBRT/SBRT or would you choose observation until there is pathologic evidence of invasive pancreatic cancer?
If multi-agent systemic therapy, i.e. FOLFIRINOX, is also planned, is there a preferred sequence of therapies?
Does availability of surface imaging (visionRT) reduce your use of imaging for setup?
Prior treatment with ipsilateral breast RT was >10 years ago
If not, how should you select those cases that should be referred?
What is your threshold for irradiating a suspicious lung nodule?
Do you approve ports daily or less often? Do you ever use CBCT?
Do you always cover these areas of ipsilateral neck is positive? Does it depend on nodal level involved, primary site (oropharynx vs. larynx/hypophary...
Would you consider chemoradiation to the supraclavicular region?
In this case, I have a patient with widely metastatic cutaneous melanoma (BRAF wild type, NRAS mutated) who is progressing through pembrolizumab and i...
Do you reduce the dose in such cases? Do you treat with six fractions per week similar to RTOG 1016 (w/ or without chemo)?
Would you always radiate? If not, when do you feel comfortable with observation after surgery?
In the case of two fractions, would you complete two fractions one week apart? Or admit after the first and do the second fraction the next day?
In p...
https://www.ncbi.nlm.nih.gov/pubmed/33497252
The patient has tissue expanders in place and is receiving ado-trastuzumab emtansine.
Would you treat with PMRT? If so, would you target the CW and R...
Do you treat the inguinal lymph nodes prophylactically when using RAPIDO-style total neoadjuvant therapy (25 Gy in 5 fractions followed by CAPOX or FO...
A certain cm above the superior-most involved node? A certain number of vertebral body above? To the diaphragm and include retrocrural nodes?
Would 5000 cGy ISRT be appropriate? Would you include the entire maxilla to 3000 cGy and cone down or just treat the post incisional biopsy site...
The tumor was 3.2 cm; post-op margins were negative, but <0.1 mm. The patient has excellent performance status. She will not be receiving sys...
Resected small bilateral tonsil SCC & base of tongue SCC.
The patient received 6 cycles of BEP 30 years ago for testicular cancer, and suffers fr...
When/how often do you order imaging?
Which systemic agents would you recommend holding during RT?
What dose/fractionation?
Has your practice changed based on the randomized, phase 3 study showing prophylactic gabapentin is not effective?
Please share your thoughts and exp...
What dose would you recommend? Is SBRT needed?
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...
Is there a role for SRS/fSRS?
What about for a patient with complete radiographic response who declines surgical management?
If the margins contain in situ disease, would you recommend further wide local excision?
Would chronic immunosuppressive disease affect your treatmen...
Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate? Is there a decent equatio...
Do the same concerns as post-mastectomy radiation of implants apply?There are some small case series' (https://www.ncbi.nlm.nih.gov/pubmed/21346535 DO...
If re-irradiation, what dose would you use?
Pathology also notable for LVI +, PNI+, but with negative margins.
Is 30 Gy/10 fractions acceptable, or is another dose/fractionation scheme ideal?
How do you delineate your boost volume and to what dose?
What dose would you use to boost suspicious remaining nodes and how are your doses impacted ...
Eg patient has been catching for years but now developing stenosis towards end of salvage RT course.
For patients who were not neoadjuvantly on pembrolizumab, is it safe to initiate it concurrently with radiation?
MRI pre-op did not reveal suspicious lymph nodes. Margins were negative upon mastectomy.
Does severity of dementia play a factor in recommending ADT?
Would you treat the primary site only, include popliteal nodes, or include popliteal and inguinal nodes?
Our breast surgeons are increasingly using Wise-pattern mastectomy for improved cosmetic outcomes. Expanding the scars by 2 cm, especially along the i...
In the absence of the ability to use IGBT, would you continue to treat the target?
Would you treat per OPRA, or try for a higher dose?
When would you add steroids or consider Avastin?
Given younger men have a longer period to live, are there concerns regarding long term side effects (GI, GU, secondary malignancy) between SBRT vs hyp...
Will this study change your practice?
If the plasmacytoma was originally limited to the femoral neck, is it necessary to cover the entire femur out of concern for marrow space involvement?
Would you prefer APBI or mastectomy in this situation?
If biopsy is not feasible, should these patient be treated as cN+ with neoadjuvant chemotherapy or as cN0 with upfront surgery with axillary sent...
Is it possible that the dehiscent is radiation induced?
The patient was treated for left breast DCIS 5 years ago to a dose of 5040 cGy with a lumpectomy boost dose of 1600 cGy with conventional fractionatio...
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...
Is there a role for SRS in this situation?
For example, are PET Axumin or PSMA studies being ordered in the upfront setting?
When patients have a single site of progression while on systemic therapy is it reasonable to consider stereotactic and/or conventional radiation to d...
If the patient has evidence of axillary lymphadenopathy on imaging, would that change your approach to treatment?
Would response to neoadjuvant...
If the tumor was excised but there is infiltration and encasement of the sciatic nerve, would you offer radiation? If numerous lines of chemotherapy h...
If yes, do you have an age cutoff and/or surgical margin cutoff?
Or would you always aim to treat with combined chemotherapy and fractionated radiation?
In elderly patients (>70-75) with a good performance status, does the risk of neurocognitive decline outweigh the benefit of PCI?
For example, if the lumpectomy specimen had low risk/low volume invasive disease?
Are there any concerns with using IMRT vs 3D?
The patient is pT1c ER+/PR+/HER2- grade 1 IDC, LVSI-, N0(i+) with an upper outer cavity and a ~29cm breast separation
If the cavity location is such ...
No cord compression is present, and the patient remains symptomatic only with their upper extremity due to brachial plexopathy
MRI shows that it's not within the rectum or prostate but it does appear to be following the contour of the right peripheral zone down almost between ...
Per lutathera information, a patient who had previous treatment for describes an estimated radiation absorbed dose of 12.8 Gy to the bladder. Would yo...
The lymph node is 4 cm and is the only site that is growing on her current systemic therapy regimen.
At what timepoint after surgery does prospective adjuvant radiation no longer become beneficial?
In situations when we are waiting for insurance clearance or due to other logistical reasons.
When do you offer preop RT (50Gy) before the re-excision? When do you offer post-op RT after the re-excision?
Plasmacytoma of 6th rib s/p resection. Negative multiple myeloma work-up.
If this is bothersome to the patient, are there any topic ointments or medications that can help if used?
Would a complete pathologic response impact your dose or decision to treat in absence of studies?
Would your answer change in the postop setting for a tumor right above peritoneal reflection with positive pelvic nodes?
What if the patient is refusing chemotherapy?
What would be your preferred technique and dose/fractionation?
For those of us just transitioning over to hypofractionation, what are reasonable, but conservative, constraints that you use?
Is there a role of EBRT to the prostate with extended fields to cover the retroperitoneal nodes plus ADT (definitive therapy) or would you treat as ca...
Would you do consolidation radiation or active surveillance?
Would presence of variant histology change your recommendation?
For instance, are there
1. Specific Linac features, such as a certain MLC leaf width, 6-DOF couch, etc?
2. Requisite on board imaging/IGRT capabilit...
In light of updated monarchE trial data, it seems a SLNB would help delineate adjuvant treatment options in this population. However, Choosing Wisely ...
Do you use conventional fractionated RT, hypofractionated RT, or SBRT?
For example, would you treat the entire length of the femur after prophylactic intramedullary rod fixation for a femoral neck metastasis?
Dose recommendations for NSCLC are to use at least 60 Gy, but for SCLC recommendations are for higher doses starting at 66 Gy.
Classicall...
Is there evidence that supports/refutes the safety of concurrent use?
In which node positive patients will you omit the IMC when treating regional nodes?
How do you counsel patients on the benefit of adjuvant therapy who thought surgical resection was curative?
If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...
Assume no nodal involvement.
What margin would you use? Does this differ based on free-breathing vs. motion-management techniques like abdominal compression?
For stroke-like migraine attacks after radiation therapy (SMART syndrome), does your management of these patient's change with recurrent episodes? How...
Would you favor re-excision? If re-excision and surgery are not an option, would you proceed with radiation or observation?
If the patient had prior ...
Do you boost when employing this regimen?
Would you recommend a re-excision?
Is radiation without re-excision appropriate; if so, should a boost be given?
If so, when do you consider this?
If the glottic cancer is T3 due to thyroid cartilage involvement, can nodal RT be omitted?
For example, if they were triple negative or had a poor response to neoadjuvant chemotherapy in the breast?
What dose/fractionation scheme is appropriate? Can SBRT be utilized? Can chemorRT with Xeloda be curative in this setting?
Based on the JCO 2020 paper, how are you using this information?
I understand there is no data to change management and most of us will be hesitant t...
Recent Japanese guidelines recommend <10MV beams, heart rhythm society and AAPM suggest up to 10MV beams are safe, recommending ≤10MV beams. Giv...
The 2019 ASCO guideline suggests contralateral neck radiotherapy for T3-T4 oral tongue and/or floor of mouth primary sites or tumors approaching midli...
What would be the treatment duration if using oral TKI?
Does anyone have experience re-treating the axilla and what dose/fractionation would you recommend?
What clinical criteria would make you prefer TORS as the initial treatment approach?
Do you offer definitive treatment?
Systemic therapy alone since it's metastatic?
Additionally, what dose constraint(s) do you use to avoid issues with vision?
Would chemotherapy be preferred over RT?
Knowing the OS benefit with the Slotman data in patients who did not have upfront MRIs, and the fact that the Takahashi data would not apply in his ca...
Is there a role for more advanced delivery techniques
If so, how long after phototherapy (eg. NB-UVB) is it safe to proceed with RT?
See: Systemic review of phototherapy for pruritic skin disorders
CheckMate 577 only included patients with R0 resection.For R1 resections, guidelines suggest observation vs re-resection only.
Do you ever contour the normal pancreas, use any dose constraints, and/or counsel patients on any possible late effects such as pancreatic insufficien...
How do you stage? Like nasopharynx or p16+ oropharynx?
Do you treat it like npx ca with chemo xrt + adj chemo or like opx p16+ with definitive chemo ...
E.g. A patient with station 4 and 5 nodal disease and arterial grafts.
Is there increased toxicity in patients with duodenal stents receiving RT?
Is there a benefit of SBRT over Y90 or vice versa?
Or do you only treat to IA if the primary is in an oral cavity location?
While likely dependent on the case, do you ever view CTV coverage alone as sufficient in certain areas to meet an OAR constraint such as parotids? Thi...
What radiation doses would you use for the scar and axillary nodal regions? Should supraclavicular and/or IMNs be covered?
NCCN only recommends palliative ISRT for non-transplant eligible patients with refractory/relapsed DLBCL
Does your approach change based on risk group?
Is extranodal extension of pN1 node by itself an indication to offer adjuvant radiation if there are no additional risk factors like R1/R2 or pN2? Wha...
What constraints should be used for skin, thyroid and cricoid cartilage, and trachea when treating in 5 fractions?
Would involvement of the PA nodes be an indication?
What is your level of concern for chest wall toxicity? Any difference in your thought process between SCLC vs. NSCLC?
Do you deflate to a specific volume?
If using boost, how would you define the tumor bed?
Would you consider resimulation for target localization? If so, what is the maximum interval of t...
Is the competing risk of a distant recurrence too high to justify doing radiation?
Is there data to guide you? Is there any reason to believe that there is an increased risk of complications in patients with prior breast implant from...
The dosing in the literature has a huge range.
If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?
Have you treated anyone with an implanted sacral nerve stimulator and if so, what principles did you utilize with planning? Did you modify your fields...
RTOG 1010 has Lungs-PTV constraint of V10 < or = 40% (per protocol) to 50% (variation acceptable), but V10 is not often used in other thoracic mali...
Is there any additional benefit to radiation in addition to steroids in a patient who is not a surgical candidate?
Does this affect your subsequent imaging surveillance frequency?
Based on the SCORAD III trial, will you now be treating patients with spinal cord compression with single-fraction radiotherapy? Is there anyone ...
Individuals often cite ARST0332 to justify radiation omission in high grade R0 resections, but R0 was defined as > 5 mm margins.
Has the use of immunotherapy replaced the use of sequential chemo?
If RT/chemo is preferred, what is an acceptable final boost dose?
If a staging RPLND is NOT performed, is there a role for prophylactically irradiating the lymph nodes, even in the setting of a negative PET/CT at dia...
If so, what dose and fractionation would you recommend?
Would you choose re-treatment with electrons, photons, or brachytherapy?
What dose and fractionation scheme would you employ?
Would your answer change for favorable vs unfavorable intermediate risk disease?
What dose/fractionation regimen is most appropriate?
-i.e. 12 Gy in 4 fractions, but would you modify that approach in a young patient?
What i...
Would you consider external beam radiation vs HDR vs LDR? What dose, margins, and OAR constraints would you use given prior treatment?
If so, how can we accomplish this advocacy?
Do you treat just gross disease with margin or electively treat levels Ib-V? What if the patient is elderly and there is a pacemaker in level IV...
Is adjuvant RT necessary for a completely resected pT1/2 N0 disease with negative margins?
SBRT? Do you change dose fractionation?
Would you consider SBRT?
Aside from symptomatic disease, is there a certain growth cutoff or other criteria that would be a trigger for treatment?
Do you try to keep Hb> 10 or 12? Or somewhere in between?
Surgical path confirmed CK7(-), CDX2(+), CK20(+), consistent with prior colonic adenocarcinoma.
What would be your radiation volumes/dose and choice of chemotherapy?
No tumor at ink? 1-2mm?
The experience by Hsieh et al. from submandibular gland carcinoma shows an 11% contralateral nodal recurrence.
If you had a parotid gland malignancy ...
Do you tend to do HDR before or after external beam? Is there more toxicity with one approach?
E.g. disease burden causing airway or vascular compression.
Are there specific dose constraints for the brainstem that you use?
Would extent of surgical resection matter?
Do these patients need CSI (like Pineoblastoma), just local radiation, or something in-between (say whole ...
Are there other high or very high risk features that would also contribute to your decision making?
CNS recurrence occurred within two years of prior neoadjuvant therapy
Do you uniformly recommend adjuvant treatment or reserve SRS for a subtotal resection and/or recurrent disease?
For example, much of the data on treatment volumes treating the head and neck with an unknown primary are from the pre-PETCT era. While the posi...
Would you offer external beam radiation if the prostatectomy specimen showed a high Gleason score with involved margins?
E.g. right hemithorax disease from lung apex to diaphragm, no response s/p 3 cycles of cis/pem.
Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?
If yes, how do you modify your margins?
How can you change the minds of community surgeons who refuse to place them citing patient discomfort and for...
NSABP B51 and B52 specifically prohibit this.
For example, not placing superior border at L5/S1.
BR-001 allows treatment of oligometastatic disease in cervical lymph nodes but provides few dose constraints for SBRT in the head and neck. (Most of t...
Do you routinely include elective nodes in your radiation volume?
How, if at all, does your approach to NUT differ between various sinonasal carcinom...
Would your recommendation change if patient had complete response to neoadjuvant chemotherapy in breast and axillary nodes?
Please include informatio...
Would you offer chemoradiation or radiation therapy to the primary? Would you consider consolidation of oligometastatic sites? What dose w...
Do you always radiate the elective neck in addition to the primary site?
If they had one-sided neck dissection and radiation for their prior cancer, ...
Lymph node is 4.5cm with no reported ECE. Does the size of the LN or presence or absence of ECE affect your decision?
Would you offer adjuvant RT or chemotherapy? If so, what chemotherapy would you prefer?
Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...
The recently published SSO/ASTRO/ASCO consensus guideline on DCIS states that "a 2 mm margin minimizes the risk of IBTR compared with smalle...
What are the data for loco-regional and distant recurrence rates with and without local therapy? What is the OS advantage?
Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...
Do you treat all surgical hardware to a conventional palliative dose? Do you treat the metastasis with SBRT? Would you treat both with a simultaneous ...
Would you move straight to second-line systemic therapy or first attempt consolidative ISRT/boost, or employ both? Assume node is biopsy-proven.
Would you be less likely to recommend in a patient? Are there any increased vascular, GI or GU risks? Any strategies you employ to mitigate risks?
Is it still necessary to treat to 50 Gy or can a lower dose safely be used as there is no gross disease (e.g., 42 Gy in 28 fractions to nodes and the ...
Do the multiple beam angles cover the skin adequately enough? Is full dose to the skin necessary? Do you take into account the amount of auto-bolus re...
GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease. Prostate MRI pending.
What normalization do you choose, what is your preferred target volume coverage, and how do you assess for homogeneity and heterogeneity?
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...
What dose and fractionation would you use, and would it differ from other types of H&N cancers?
Would you consider Quadshot scheme?
The recommended concurrent chemotherapy regimens (cisplatin/paclitaxel and cisplatin/FU) in NCCN are based on BID fractionation of radiation as in RTO...
Do you favor systemic therapy for X cycles followed by restaging and then consolidative radiation (SBRT or CRT)? Or do you prefer up front thoracic di...
Would you use 10x and 15x in your fields?
EBRT vs VB? She technically meets PORTEC2, but also meets GOG99 and GOG249 (for pelvic RT) and PORTEC4. NCCN recommends for IB grade 1 vaginal brachyt...
If the patient has received the majority of treatment, such as 24 of 28 planned fractions (60/70 Gy), and then had a 1 - 2 week unexpected break, woul...
Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage?
Do you have a volume cutoff in which you would prefer a more fractionated approach?
Additionally, do you routinely add concurrent temozolomid...
Does skin reaction at the time of starting the boost guide the decision to bolus?
Patient previously had prostatectomy and salvage RT
The patient initially presented with an large renal tumor encasing the IVC and abutting the abdominal aorta. Given this, the patient received inductio...
They are known to have worse prognosis. For an adult with supratentorial G2 ependymomas s/p GTR, radiation is generally not indicated. Does this chang...
Is there any indication for ENI in early stage disease or in advanced stages, without pathologic confirmation or PET positivity or CT size criteria?
Would you recommend surgery first or neoadjuvant therapy such as concurrent cisplatin/RT or another regimen?
Is age ever a concern given the potential side effects of long term ADT?
The patient was initially observed after radical hysterectomy due to young age, FIGO IA grade 2 disease.
The patient had isolated, biopsy-proven vagi...
How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?
If so, what dose and treatment fields would you use?
Did you change your practice given the SRE results in the control arm of EORTC 1333 at ASCO 2021?
When using bisphosphonates or denosumab, what dosin...
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...
Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.
Are there any risks to future transplantation into the pelvic area that would outweigh the benefits?
Are there planning techniques that you can utilize to improve dose homogeneity?
Any role for surgical extirpation vs systemic treatment?
Patient is 38yo, has a history of narcotic abuse, and may have an undiagnosed personality disorder.
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
As a resident, I think about this every day. Any words of wisdom to share?
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...
Would you consider adding ADT?
Is there often discordance with LVI status in biopsy vs. mastectomy such that biopsy resulting as LVI negative is not reliable to decide on PMRT indic...
For the purpose of this question, please assume an initially undetectable post-prostatectomy PSA, no presence of positive margins, extracapsular exten...
If the patient has received RCHOPx3 and the post treatment PET is negative, what would your management be?
In a patient who would be otherwise fit for surgery +/- adjuvant RT, and the delay is caused by COVID-related OR staffing issues, what would be your a...
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...
Assuming re-resection is not feasible. The NCCN guidelines for post-operative RT for Stage I lung cancer with positive margins is PORT to 54-60 Gy (in...
What are the advantages and disadvantages or using films vs. CBCT? What are you looking for in each case?
How often should you CBCT, and what are the...
Patient previously had adjuvant radiation to the tumor bed only.
What is your radiation volume and dose?
Any elective nodal levels (ipsilateral vs. ...
How does grade affect your decision-making? If adjuvant radiation is indicated, should the initial extent of disease be included or only the post-oper...
Would you offer SBRT over standard fractionation of smaller tumors?
Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?
E.g. SBRT 9 months ago.
If so, what patients do you recommend get one and do you have concerns for patients who also may be receiving chemotherapy as the CDC guidelines recom...
Patient is <60 years old
If so, what dose fractionation would you recommend?
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...
E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.
One example of this scenario would be a patient receiving consolidative durvalumab after chemoRT for stage III NSCLC who develops a new peripheral lun...
In what situations would you advocate for orbital exenteration vs orbit sparing surgery with adjuvant radiation (particle therapy)?
Patient underwent SBRT without recurrence and now has symptomatic internal hemorrhoids causing intermittent fecal incontinence. His colorectal s...
Has the recently published interim analysis of the CATNON trial altered your utilization of temozolomide?Does IDH status change your treatment approac...
Do you consider the small, but statistically significant, improvement in OS to outweigh the side effects of treatment?
Do you decrease total dose, increase the number of fractions, or both? What factors, in addition to size and location, do you consider?
Under what circumstances would you discontinue or alter therapy?
Length of temozolomide course when given with adjuvant radiotherapy
Would your recommendation change based on grade and/or location (weight-bearing vs non weight-bearing bone)?
Does the answer change on proximity/distance from breast (i.e. what if pelvis or lower extremity?)
How would you approach the lung constraints in a patient that received definitive RT doses >2 years ago and develops a new primary amenable to SBRT...
With so many choices listed in NCCN guidelines ranging from 2-7 weeks, what considerations factor into your decision making?
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?
Is there any alteration in approach from the medical, surgical, or radiation oncology perspective that can mitigate the risk of forming keloids withou...
Is the QuadShot a possible option?
Are there certain situations where a hydrogel spacer is most useful based on treatment modality (SBRT, protons, brachy, etc) or other factors?
Are there any anatomical changes that would make the placement impractical or hurtful for the patient?
Does it depend on the DMARD type (biologic, targeted synthetic, or conventional synthetic)?
Would your recommendations change if the mass were significantly smaller, say 1-2 cm, and was completely excised with negative margins?
Would you offer SBRT for a functional adrenal adenoma (Cushings)? If so, what dose would you deliver and what are some contouring and planning pearls?
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...
Should a bone scan and/or MRI of the pelvis be obtained as well?
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...
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 and constraints do you use?
These structures are mobile and their location changes depending on bowel filling, gas, patient set-up, etc. Is there an advantage to contouring small...
Assume patient has refused surgery and additional systemic therapy.
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?
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...
If so, at what interval? NCCN recommends annual CT/MRI.
Could EBRT lead to rupture of the cyst?
This patient has pulmonary nodules that are too small to characterize.
No sarcomatous overgrowth seen.
To minimize the likelihood of asymmetrical growth, when is it of sufficient concern to necessitate altering planning objects?
When planning paediatri...
Would you consider chemo only, XRT only, chemoRT or sequential treatment?
Would you consider SBRT as post-chemo consolidation for a patient with a single unresectable focus of metastatic adenocarcinoma at the celiac axis?&nb...
What dose/fractionation would you utilize?
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...
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...
Assume patient has a strong contraindication to ADT.
Would you recommend XRT? Would you simultaneously attempt to treat the bladder curatively?
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?
Is there a time frame for when you may not offer post-mastectomy radiation therapy to a patient who may otherwise benefit from treatment in a typical ...
(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...
Would you consider doses >4-10Gy?
No prior radiation. No evidence of chest wall, axillary, or supraclavicular disease.
The recent randomized Phase II Scandinavian trial (Gronberg et al.) showed a statistically significant increased 2-year and median overall survival in...
When do you start fluoride treatment?
What dose do you recommend for salvage radiotherapy after biochemical recurrence in prostate cancer?
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...
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
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...
What are your dose constraints for the cord in these situations?
What margin would you consider to be necessary to omit radiation?
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...
If so, what dose is appropriate?
Gleason 4+3=7 and PSA 4
Previously received pelvic EBRT and intracavitary brachytherapy. IORT was administered to the node-positive side wall at the time of exenteration.
Assume patient is older than 60.
What is your approach for a symptomatic inpatient with locally advanced NSCLC who cannot have a PET?
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...
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.
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?
Do you use no tumor on ink for margin even if DCIS is the component close to the margin?
Is local control with SBRT poorer in cystic lung tumors?
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...
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...
Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?
Do you have any reservations about the efficacy of SRS over surgery?
Are there other adverse features aside from seminal vesicle invasion, positive margins, or extraprostatic extension that you consider?
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...
Patient did not previously receive para-aortic radiation. Considering RT vs RT + chemo vs chemo alone
Are there any effective non-pharm or pharm interventions?
Would you use platinum/etoposide concurrent with radiation or would you opt for platinum only during radiation?
Would you use BID fractionation...
Is chemoradiation a viable strategy in osteosarcoma?
Would inhaled steroids help reduce the PO dose and/or significantly accelerate tapering? If s, for what pneumonitis grade? What specific steroid...
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...
Assume patient has had maximal TURBT
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...
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...
Eg T2N2 who required management of cardiac comorbidities leading to months-long delay but scans are still clear.
Histology 1st described 2010, and acknowledged by WHO 2017. Probably previously usually diagnosed as Acinic Cell Carcinoma. In one source (Chiosea SI ...
If so, for how long?
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...
The site of oligometastatic disease was to a supra-clavicular node and was biopsy proven.
Does your answer change for long course chemoradiation vs short course radiation therapy?
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?
Would you consider SBRT and continue osimertinib?
If so, would you treat to full dose or lower elective dose?
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...
The invasive component had depth of invasion 1.7 mm, horizontal extent 3.5 mm.
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...
Given the difficulty in identifying the location of the positive margin, would you push to re-excise?
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?
Presuming that imaging does not show distant metastatic disease, what would you offer? What about if the patient were PD-L1 negative?
Do you make any modifications to your dose or treatment technique?
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
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?
As opposed to the every other day Florence regimen.
Would you use mini tangents, 3D conformal, IMRT?
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?
Do you need the expander to be removed?
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...
Would you always/never include the initial tumor bed?
Is there a time interval or any other factors that would affect your management?
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 you consider doing a pre-op RT prior to possible re-excision? If yes, what dose would you give? If the location is between L4-L5 spine.
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)...
In particular, for frail patients to avoid toxicity or for those that do not want chemotherapy
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?
If so, do you allow a period of "washout" between immunotherapy and radiation?
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)?
If so, at which intervals do you re-image?
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...
To avoid disfiguring surgery, would you consider treating a 2 cm well lateralized tumor without surgery? If so, would you recommend concurrent chemoth...
If no, would your recommendation change if there is obvious extranodal extension with invasion of adjacent muscle? Does p16 status affect your d...
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 ...
Assuming all other factors are favorable (pT1-2, TME, negative margins).
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?
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?
What would you target and what doses would you use?
Is there a threshold of when you would use chemo/radiation?
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...
Is it essential to wait one week after loading dose of erbitux to start RT for head and neck cancer?
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...
The IDC was felt to be a new primary arising from residual breast tissue given it was over 10 years from her initial DCIS.
How does this differ in the de novo versus reirradiation setting?
i.e. 1/1 node with ECE
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 54 Gy or 60 Gy for level IV? Or do you always take...
Would it being non-bulky and along the right heart border impact your decision making?
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...
In primary surgical resection, ENE on surgical path would be indication to add adjuvant chemoradiation. After progression through definitive chemoradi...
Is chemotherapy recommended for M+ germinoma?
CR to chemo; Spine MRI negative; CSF negative
Is CSI required or whole brain radiation is sufficient f...
If so, do you take any additional precautions with planning?
Would you offer RT to the axilla? Would you treat the breast?
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...
How does dialysis affect PSA lab values?
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 do you approach systemic therapy options? What are your recommended volumes?
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...
Specifically, for cT2N0M0 small cell bladder cancer without response to neoadjuvant cisplatin and etoposide on imaging, would you proceed with cystect...
In this patient dermatofibrosarcoma protuberans of the thoracic spine, which originally caused a cord compression and has since been debulked, gross r...
Would you include the regional nodes?
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?
Would you deliver RT or not? If you would deliver RT, would you use PCI dosing or WBRT dosing?
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) ?
This is assuming they have other indications requiring post mastectomy radiation therapy.
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?
Would you consider PCI?
How would you factor in a patient with profound thrombocytopenia?
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...
Would you cover elective lymph nodes?
Concern about tolerability of treatment in adding radiation to the penis given primary mode of failure will be distant.
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 so, can these be administered concurrently?
Paraaortic nodes positive to left renal vein
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...
Would you consider/favor APBI given the negative normal breast if you can meet the brachial plexus constraints?
What techniques do you employ for motion management?
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...
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?
When is the ideal window for delivering PCI for limited-stage SCLC?
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 ...
What are some appropriate dose fractionations? What about dose constraints for bronchial tree that previously got 70Gy?
Would you add abiraterone or enzalutamide?
What is considered an acceptable dose to normal breast tissue? E.g. for thymoma, PMBCL, HL, etc.
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...
Is there concern for airway healing and hemorrhage if the area is irradiated too soon?
NCCN recommends chemoRT for unresectable, “locally advanced, advanced or recurrent disease” but is chemoRT necessary in a small (e.g. 2.5c...
Tumor felt to be technically unresectable due to extensive cervical/parametrial involvement.
ER/PR and HER2 testing are pending.
Assume they are undergoing systemic therapy (ADT, etc). At what time do you initiate SBRT?
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...
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.
What radiation dose should be used for definitive chemoradiation for an unresectable pancoast tumor?
What would be your brachial plexus and cord constraints?
What technique/schedule/material?
What strategies do you use to meet those constraints?
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.
Have the RAPID or CALGB 5064 studies changed your treatment approach?
What volume and dose would you use?
Do you cone down to gross residual (and stop elective nodal coverage) after 36Gy or 41.4Gy?
Parameningeal group III, stage III alveolar rhabdo.
Any experiences using 50/20 with a break, or 30/5 in the adjuvant setting?
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...
What about for patients with hiatal hernia?
Do you use specific tools or take into account certain factors when considering treatment options for older adults?
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?
Specifically, this patient was unable to tolerate immunotherapy due to severe side effects.
Consider 6 fractions weekly chemoRT? Add cetuximab to chemoRT? Proton boost? Induction chemo prior to chemoRT? Interstitial H&N brachytherapy boos...
How will you counsel patients receiving radiation therapy regarding COVID-19 vaccine administration?
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 ...
What constraints do you use if using IMRT/VMAT?
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 nodal areas would you treat? What dose would you recommend?
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 your management change if the prostate and lymph nodes were treated with radiation two years ago?
Would you ever de-escalate your prescription dose in order to reduce cochlear dose when treating younger patients with intact hearing?
Would you be confortable to give full dose CRT?
For instance, if the tissue came back SLL, Waldenstrom's, follicular lymphoma, or even nodular lymphocyte-predominant Hodgkin lymphoma, would any or a...
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...
How would treat the node? What dose?
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?
Pt is 73yo, Grade 1, 81% invasion, MELF like features, foci of LVSI, and 47 ITCs identified.
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?&...
Would you treat the involved site or involved field for definitive intent?
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...
FOXO1 translocation positive
For example, in a young patient where standard fields would be very large and you want to minimize toxicity
Pt is 69yo, tumor 1.4cm, negative LVSI, ER/PR +
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 ...
Does not technically meet high intermediate risk criteria.
If so what is the crietria?
Assume patient has no history of IBD, UC, etc.
What dose, fractionation and treatment fields would you use?
If on pembrolizumab or nivolumab, when would you escalate to ipilimumab/nivolumab?
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 ...
The COMET trial excluded femur sites.
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 is the risk of perforation / fistulization?
What method provides the best reproducibility? Abdominal compression? Inhale breath hold? Exhale breath hold?
Margins widely negative - 1cm, and full bilateral inguinofemoral lymphadenectomy performed.
ex. in a patient with pulmonary micronodules, inguinal, pelvic, PA nodes
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...
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.)
What if the patient had also received HIPEC prior?
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?
The concern being that if patient does not go to surgery, you have delivered lower BED with 36/15.
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 ...
Does nodal positivity at time of surgery affect your decision?
For example, ultra-hypofractionated whole breast RT?
Do you continue atezolizumab alone? Would you avoid anticoagulation?
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...
Margins negative. Discussion included adjuvant RT versus observation and/or repeat resection with recurrence.
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...
For example, meningiomas or pituitary adenomas?
Are they necessary? Any group of patients that you use them on (concurrent ADT, anemia, or use of whole pelvis, etc)?
Assume there are high risk factors such as recurrence or positive margins.
This patient has previously been treated with low dose total skin electron therapy.
What dose-fractionation schedule would you utilize?
Is there a possibility the wound could heal after radiation therapy under such circumstances?
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?
In the unfortunate setting where you cannot get an underinsured patient whose policy does not cover radiotherapy started on treatment without guarante...
Do you re-test patients who test positive for COVID-19 during or prior to starting cancer treatment?
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?
Initial presentation was stage 1 treated with lumpectomy and whole breast radiation.
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...
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...
What if it is a young patient?
What indications do you use to consider adjuvant radiation therapy for vaginal cancer s/p resection?
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...
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...
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...
Can you comment on fractionation schedules with and without chemotherapy or immunotherapy.
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?
If no surgical LN evaluation is performed, how do you determine what volumes to include in your radiation fields?
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...
When would you offer hypofractionated radiotherapy?
What would be you field and margins?
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...
What would you consider if the recurrence occurs multiple times in the prostate? Salvage surgery if a candidate? HIFU or cryo? ADT?
Have you seen worse toxicities in these patients?
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...
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...
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...
How would you treat an elderly, frail patient with a bulky penile SCC with bilateral inguinal nodes?
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?
What dose, fractionation and what elective coverage do you recommend?
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...
(e.g. bulky supraclavicular, internal mammary, as well as retrosternal lymph nodes)
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 ...
If you would elect for adjuvant therapy, which study helps guide your choice of regimen?
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...
Does the amount of time from 1st treatment change your management or thinking in this situation?
Recent results from the STRASS trial suggest limited benefit from preoperative radiation therapy for retroperitoneal sarcomas.
https://pubmed.n...
Particularly with IMRT when delineating volumes.
Do you adjust dose/fractionation?
-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...
What levels would you cover and to what dose?
What are the data supporting this?
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.
What dose/targets do you typically use?
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.
Would your practice change if the patient had N2 disease?
What is your general approach to this rare histology?
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...
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?
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?
Would you consider SBRT or brachytherapy?
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?
e.g. Gingras et al., JNCI 2017, a secondary analysis of the ALTTO trial?
How would you adjust your small bowel dose constraints? What other considerations would be pertinent?
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?
Would it matter the site of recurrence (ie lung nodule vs bone lesion)?
If you do what dose and fractionation do you recommend?
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 routinely cover the surgical tracts?
How does your setup differ from oral cavity cases?
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 ...
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?
...
The recurrence is several adjacent nodes above the prior fields.
Is it higher than the average person?
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
High risk meaning LVI, triple negative, Grade 3, etc?
For intact breasts, should adjuvant radiation to the lymphatic drainage be added to breast radiation?
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...
What dose and fracionation? Would you use SBRT?
Given the proximity of the optic chasm and risk of compromised hemianopsia, the lack of adequate central vision adds another layer of risk.
Presented with mass projecting into right/left anterior ethmoid complex
Does CBCT suffice for prostate SBRT?
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...
Is age solely indication for boost irrespective of other factors?
For example, status post resection of a 4 cm high rectal carcinoma that was believed to be in the sigmoid colon but found interoperatively to be below...
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...
If so, what sub-volumes and dose constraints do you use?
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?
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...
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...
In which situations would you consider 37.5 Gy / 15 fx or 20 Gy / 5 fx over 30 Gy / 10 fx?
Ie for patients who are inoperable due to comorbidities?
Would your recommendation change if the patient was HIV positive?
In a case with negative margins, T1-2 primary, no ECE, no perineural invasion, etc, is adjuvant radiotherapy indicated based on N2a stage?
Would you consider this a new primary or recurrent disease?
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?
What dose would you use? How do you counsel on risk of damage to j-pouch?
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...
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 ...
Is the approach similar to squamous cell carcinoma?
Would implant reconstruction prior to radiation therapy change your recommendations? Would you ever treat just the nodes and omit the chest wall/recon...
What are the differences between Decipher, Oncotype, Prolaris?
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...
If the patient is medically inoperable, is post-chemotherapy radiation therapy or SBRT advisable with no visible GTV?
Would you spare contralateral neck?
Does your recommendation change depending on p16 status?
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...
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 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...
Is there data and FDA approval for this indication?
What about for nodal failure after radiation?
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...
Do you alter treatment and/or fractionation?
Is diverticulosis in large bowel adjacent to a target a contraindication for SBRT? How would you manage?
Would you consider this refractory disease and go on to salvage regimen and auto-SCT, or is there a role for definitive XRT to the site of residual di...
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?
Would you have CT surgery resect the mass, followed by adjuvant radiation?
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?
>5cm. If so, what is your preferred regimen?
Would there be any indication for postoperative RT if cervical lymph nodes are negative?
If neurologic symptoms are absent or controlled, does that affect your treatment decision?
MRI? Endoscopy? Physical exam?
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, ...
Is there evidence for radiation therapy in this setting?
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...
E.g. a patient with progression of their primary cancer but still is testing COVID19+ over a month after infection?
What is the added benefit of Chemo-RT vs RT alone?
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...
Or would you only irradiate the axilla?
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...
How does your approach differ for patients with stage IIA versus IIB disease? Age?
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...
Would chemotherapy be a consideration? If yes, would you adjust margins or dose?
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?...
Would you consider reirradiation, including SBRT?
Any dental extraction of the mandible could lead to healing problems and thus delaying reirradiation.
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...
Does cisplatin need to be administered on the start date of radiation
NCCN guidelines recommend pelvic RT for N+, but what is the hard evidence for this?
Would you offer definitive or neo-adjuvant chemo-RT in the setting of a single lung or bone metastasis?
Based on recent data published suggesting an OS advantage to the addition of ADT vs. brachytherapy boost to EBRT (Jackson et al., PMID 32396488), it i...
What is the duodenal stump dose constraint?
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 so, would you consider it with monotherapy only or also with combined checkpoint blockade?
Any differences in the risks between SBRT vs. conventionally fractionation? Concurrent immunotherapy?
Would close proximity to the heart/aorta affect your dose and fractionation?
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...
Is there data to support every 3 week dosage v. weekly?
https://ascopost.com/news/march-2022/postoperative-weekly-vs-every-3-week-cisplatin-i...
If this upstages the patient, do you modify treatment recommendations?
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 of radiation, what type of chemo, and what indications?
If so, what dose would you recommend?
Would you proceed with definitive chemoRT to ~60 Gy in 30 fractions?
Discuss the role of mAb in DIPG.
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 ...
What are the alternatives to gonioscopy gel to protect the cornea when using internal eye shielding?
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?
In which clinical situations is there a good rationale for the use of proton therapy for GI cancers?
Should we give concurrent capecitabine?
For a patient not on dialysis? Outside of single agent 5FU, all other standard chemotherapeutic options would be contraindicated for nephrotoxicity.&n...
Does it change your treatment fields or dose?
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...
Would you consider the addition of chemotherapy to proton beam therapy?
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 modify your dose if there was overlap from the prior treatment?
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?
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...
When would you elect for surgery vs radiotherapy (SRS)?
Would you manage this histology any differently relative to other low grade gliomas? Is a STR a definite indication for postoperative XRT?
What if this recurrence is not resectable?
What is your regimen? And long-term follow-up in these patients?
When would you offer re-irradiation in the setting of prior RT and tumors not amenable to gross total resection?
What are the differences that a patient may expect with HDR vs LDR brachytherapy?
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)?
What if ALND reveals no residual disease?
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...
Is there an appropriate hypofractionated regimen for such a clinical scenario?
What is your preferred combination and order of therapy for a T4 rectal tumor invading the uterus leading to both rectal and vaginal bleeding?
...
What dose and volumes of radiation would you use?
When would you recommend SRS vs WBRT?
How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?
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...
Does the GOG 249 abstract guide you one way or the other?
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...
How do counsel patients regarding potential for cartilage necrosis?
What is your recommended dose/volume for large tumors s/p limited resection? What dose constraints do you use for the visual pathways?
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?
Do you recommend targeted fusion biopsy?
Do you have a maximum bowel dose constraint?
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...
Radiation in the setting of positive margins is sub-optimal and from my understanding high boost doses do not replace further surgery. Is it better to...
This applies to both de novo cases and patients who have previously received injectable agents.
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...
What would your dosing recommendation be?
Are there any prospective studies?
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?
Sentinel Lymph Nodes negative
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...
If so, what dose and volume would you treat?
Didn’t 0129 establish no difference between conventional vs Accelerated RT with the same Cisplatin regimen? Are there still thoughts of benefit ...
How are you modifying your current sarcoma-directed therapy in the setting of the COVID-19 pandemic?
For example, would you consider switching to an outpatient regimen in lieu of AIM for metastatic soft tissue sarcoma?
Is there data to guide treatment re: SBRT vs. concurrent chemoradiation vs. sequential therapy vs. systemic therapy alone? Does the nodal location imp...
Would you treat the inguinal nodes and how?
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?
Are there any complications to using LHRH agonists in patients using estrogen?
Acknowledging that there is no time for good trials yet in this setting
Assume MRI noted this on exam and patient is minimally symptomatic.
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?
What dose/fractionation would you recommend?
Do you consider this regimen based on the 10 year results of the UK FAST trial?
Would you use SBRT, hypofractionated or standard fractionated boost?
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...
Assume we are using 37.5Gy in 15 fractions
Would you get repeat invasive mediastinal staging to confirm response?
Do factors such as large tumor size and/or node positivity affect the decision?
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...
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?
Would your practice vary based on hormone receptor or Her2 status?
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 ...
If so, what dose fractionation do you prefer?
Also, how would you handle immune modulators for rheumatoid arthritis during their treatment?
Is there a threshold for WBC or platelets below which you would hold RT?
For those of us who are just starting out in practice, do the seasoned pros have any advice?
i.e. T1, low grade, ER positive, margins negative, older age?
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...
Would you consider VMAT or protons?
If so, what dose fractionation and field is recommended?
When would you request a biopsy of a meningioma?
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...
What factors do you use in deciding whether or not to electively cover the celiac axis?
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 ...
Please comment specifically on fillings, crowns, and implants.
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...
Assuming the patient is not a candidate for SRS
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...
Are there kidney issues in which you would omit IV contrast?
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...
Assume the patient is medically inoperable.
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?
Is surgery preferable? What dose/fractionation would you recommend?
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...
MRI with intravaginal gel shows no gross residual disease.
*What dose and fractionation do you recommend for metastases >4cm in favorable positions (ie. not abutting mucosal tissue)?
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...
Insurance authorization for protons is pending, but if the patient cannot have protons would you treat with standard fractionation to ~70Gy or conside...
How do you advise your patients on toxicity?
Would you offer SABR in the setting of only two lesions? How would your recommendation change if this was NSCLC?
Would your decision change based on the patient's clinical nodal stage?
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...
Would you offer RT? If so, shat dose fractionation do you recommend?
What concerns do you have about a colonoscopy?
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...
When do you consider re-irradiation?
Would you avoid WBRT or PCI if otherwise indicated?
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 ...
Do you offer WBRT or SRS? If you prefer SRS, do you follow up with WBRT?
How would a much higher risk cancer affect decision making? How would you treat him?
Are there exclusion criteria?
For both the primary and re-resection surgeries, resection was achieved via both scrotal and inguinal incisions. And margins were reported as negative...
Sometimes wound healing can delay adjuvant radiotherapy by several months. For aggressive histology, such as high grade sarcomas or skin cancers with&...
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 ...
Is neoadjuvant chemoradiation or perioperative chemotherapy preferred?
What fields would you cover and how much dose would you boost to the primary?
*Negative margins, <1cm in size, no LVI, negative SLNB, not immunocompromised, no prior surgery (as well as a negative PET/CT scan).
Would you offer definitive radiation? If so, what dose and technique?
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 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.
Would you offer adjuvant chemoRT?
Do you routinely include pelvic lymph nodes, prostatic urethra, and prostate?
Due to respiratory motion and resolution of the lesions on re-staging imaging, targeting the lesions on CT sim is extremely difficult. Also, is consol...
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...
Do you include the entire hemorrhage volume in your target?
If so, how do you address the Joint Commission's cleaning requirements? The Joint Commission recently inspected our hospital including the radiation o...
Is 1000 cGy x 3 fractions to a portion of glenohumeral joint safe?
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...
(ie. surgery vs SBRT)
Would your choice of concurrent chemotherapy be impacted by this histologic finding?
If you were to treat, what do you include in your treatment?
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...
What would be your preferred dose and treatment volume?
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.
For example, HPV+ SCC in a single level II node
For example, in a patient who is a poor surgical candidate with stage III NSCLC.
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...
Would you consider EBRT or brachytherapy boost to the nodes? what dose would you recommend?
Indefinitely seems to be a typical recommendation, but rarely done.
Let's assume genetic testing will not be done.
What field and dose would you recommend? Would you consider whole abdominal?
Would you transfuse platelets before holding RT?
How do you manage these?
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...
Which radiation modality for definitive prostate cancer has the lowest risk of erectile dysfunction?
How do you counsel the patient regarding his risk of ED?
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...
How would your dose and/or volume change if the patient refuses chemotherapy?
If so, would you treat the whole pelvis, cuff brachytherapy, or both?
Would you recommend radiation to the prostatic fossa and/or the oligometastatic site? How would you dose these areas? Would you recommend ADT?
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...
RTOG 1308 uses 5mm, but is standard practice the same? Do you do daily CBCT?
If so, what dose do you boost these nodes to?
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...
What constraints do you use for plan evaluation?
If so, how long should the medication be stopped prior to SRS?
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...
Any experience treating patients prone with openings for both breasts, no minimize breast overlap with axilla and mediastinum?
Would you treat this AP window node like small cell lung cancer with chemoRT?
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...
Would it matter if their PET axumin was negative?
The patient's urologist will not offer testosterone supplementation unless he undergoes definitive therapy of his early stage prostate cancer. Are the...
Would you be concerned about toxicity given that he has ulcerative colitis?
NCCN recommends annual CT surveillance indefinitely after year 5, but I’m curious how many physicians continue and for how long?
p16 positive vs negative?
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)?
Would tumor pathology affect your decision-making (e.g. angiosarcoma)?
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?
If so, what would be your recommended technique/dose?
Would you treat with definitive doses?
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...
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
The patient has no bone marrow involvement.
If the patient will be having a total colectomy, would up-front surgery be a better consideration?
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...
Would your answer depend on the response of the primary site?
Assuming a negative workup otherwise.
Further resection is not recommended, as the surgeon is worried about damaging hearing with additional surgery.
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?
What risk do you quote for contracture or failure? Does the type of implant or age of implants matter?
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 ...
Is there a role for additional treatment?
Assuming the answer is quite low, the next question is why?
Would you offer local therapy to the liver?
Would you offer repeat CSI or favor chemotherapy?
Does your recommendation change for women with HER2- disease?
Will your recommendation change if there is suspicious/confirmed locally recurrent nodule in the prostate bed?
Is there a role for surgery? Assume early stage with negative nodes on EBUS and PET.
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...
If so, would you give it concurrently with radiation and ADT or adjuvantly? Would you consider it in post-prostatectomy patients?
Do you recommend additional x-ray, CT scans, MRI or biopsy?
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...
Further surgery is not possible.
Would certain patient/disease characteristics make you choose RT therapy over chemotherapy or other locally ablative therapies? What dose/fraction wou...
The patient refuses surgery.
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 you recommend any planning techniques or dosimetric constraints in this scenario?
Is there any literature on the safety of giving radiation to patients with scleroderma in H&N setting?
Do you worry about migration or scatter dose from the metal?
Is there any role for SRS/FSRT?
Specifically concurrent ifosfamide? Induction AIM?
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...
Do you favor tongue depressor instead? Does this change based on what primary you're targeting (i.e. base of tongue)?
Is prostate bed radiation therapy safe in this setting? Would you modify your planned prescription dose?
If so, what dose and fractionation?
What dose and fractionation would you consider?
Given this rare histology, would you treat this patient as a skin cancer or as an anal adenocarcinoma with inguinal nodal coverage?
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?
Is it possible to spare and minimize kidney dose?
How long would you continue androgen deprivation after radiation?
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,...
Do you include a T1 post-contrast series?
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...
If so, which levels? Bilateral? What about parotids or submandibular gland?
Do you utilize fMRI or other advanced sequences (DTI, etc) in the planning process?
How do these change in the setting of previous radiotherapy/radiosurgery?
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 factors do you consider? Size, symptoms, etc?
What margins (if any) do you consider appropriate to not require adj RT? And would you ever consider neoadj RT?
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 alter or avoid radiation?
Custom devices with dentistry can be cost-prohibitive.
The initial treatment did not include any adjuvant chemotherapy or radiation therapy.
Should this be part of the follow up?
Would T stage, Oncotype or any other factor affect your decision?
For example, for T2N1a ER+ disease? Or would you offer PMRT and axillary nodal irradiation (as a replacement for ALND)?
Would PDL-1 status impact your decision?
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.
Or should total neoadjuvant therapy be reserved for bulkier disease (T4N2)?
If you do rechallenge is there anything that can be done to prevent the recall reaction from happening again?
Would you offer definitive chemoradiation?
Some specific questions:
Would you recommend repeat biopsy to confirm residual disease?
How would your recommendations vary if the patient had pre...
I understand the perioperative trials are not based on tumor regression in cancer cells.
Do you recommend definitive therapy? Would your approach change if there are more than 1 site of bone metastases, such as 2-3?
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?
Let's re-open the debate!
If you would include it, what would you anticipate in regards to the impact on this fistula?
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...
Do you offer consolidation chemotherapy prior to durvalumab in locally advanced, unresectable NSCLC?
In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial.Antonia et al., PMID 28885881...
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...
For a patient with vaginal adhesions/stenosis, do you recommend any other therapy besides a dilator?
Would estrogen cream be helpful in this scenario?
Is there any data to support delayed treatment?
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 enzalutamide and leuprolide and refuses docetaxe...
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?
Assume the patient had axillary lymph node dissection and taxane chemotherapy. How would you counsel the patient about risk of lymphedema?
CT or PET? If so, how often?
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...
What dose would you recommend? Any role for systemtic therapy?
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...
Do you utilize EQD2 rectal and bladder constraints?
Could these be subclinical metastases that responded to ADT? Do they require further workup?
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...
If so, what dose would you use for the elective inguinal areas?
Would you offer palliative radiation? Would you fractionate differently?
When do you decide to fractionate?
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...
If so, how should one approach it?
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?
https://www.nejm.org/doi/full/10.1056/NEJMoa1813181
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 ...
Is IO related pneumonitis in the radiation field or more diffuse?
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...
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...
Does the permanent implant change your dose?
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?
Is there a time cutoff where there is no longer a benefit to adjuvant radiation and you recommend reserving radiation only in case of recurrence?
Sim...
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?
Is there a size or number of metastasis cut-off where you would consider SRS vs. WBRT?
If so, how do you choose your region of treatment? Dose? And elective nodal volume?
Would you recommend observation? Whole breast irradiation? APBI?
Do you have any specific bowel constraints when treating patients with palliative radiation 3000/10?
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?
Do you boost the positive nodes beyond your standard pelvic dose?
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 so, how would you modify this regimen?
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 full dissection with no LN mets allow sparing PORT to the contralateral side?
What if this lesion was at the top of the hair bearing skin of the axilla?
What dose do you take the primary to?
Assuming that surgery and brachytherapy are not options.
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?
What is your typical treatment depth prescribed to? What length of vaginal mucosa do you typically treat?
If not, how long would you wait between chemotherapy cycles to give treatment?
These devices give off a significant amount of artifact on CT and some devices say they are a relative contraindication with adjuvant RT.
Do you have an SUV cutoff for physiologic activity of the ovary?
How do you sequence imaging and headframe placement? Do you fuse a 3D CTA to the planning CT?
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?
Most of the literature experiences seem to focus only in the recurrent settings.
How do the biopsy results guide your management? Would you still treat if the biopsy is negative?
If clinically node negative, would you add elective nodal radiation?Does it depend on location (upper vs. lower trachea)?
What is an adequate dose to the skin?
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...
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?...
Do you treat retroperitoneal sarcomas with a boost to the rind (or suspected close surgical margin)?
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?
Do you routinely adjust margins to account for internal target motion?
Do molecular factors (1p/19q, IDH status) influence your choice of dose/volumes?
If so, what would your target encompass?
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.
Do you use concurrent Xeloda?
Is there a benefit to one fractionation schedule v. the other?
What percentage of unresectable T4N0 pancreatic body adenocarcinomas with celiac axis involvement and no response to 6c chemo, will convert to resecta...
Or would you offer high tangents with hypofractionation?
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?
If so, what is your suggested dose/fractionation?
Would a limited axillary dissection influence your decision? Any other risk factors that would sway your decision?
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...
If so, does it differ from the assessment you would perform in men receiving long term ADT?
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? Would a ...
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...
What dose and fractionation would you use. What is your target volume?
What factors influence your decision?
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...
In a patient, with multiple small volume lesions (5-25mm), would you offer pelvic RT?
If they are symptomatic do you relax that time interval? Do you ever consider partial brain radiation instead of whole brain to minimize neurotoxicity...
Is it necessary to irradiate the breast?
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...
Do you cover common iliac nodes (L3/L4) or keep field edge at L4/L5 to reduce bone marrow toxicity?
Patient will receive adjuvant xeloda.
Would the results effect your decision to offer PCI?
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...
And at what intervals?
The disease involving the endocervix was felt to be separate and appeared like a drop metastases
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?
Is there a role for SBRT with or without the addition of systemic therapy?
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...
What would be your preferred dose/fractionation and cord constraints?
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...
Does this vary depending on the site you are treating, i.e. abdomen vs pelvis?
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)?
Would you recommend neoadjuvant chemotherapy to spare the stomach?
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 ...
E.g. for lobular, etc.
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?
If so, what dose do you use?
How would your radiation targets change? There are not recommendations for intramammary nodes in guidelines.
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...
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?
If so, what indications would you use other than Peters criteria?
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?
Which do you favor, if so?
https://www.abstracts2view.com/sabcs18/view.php?nu=SABCS18L_568
Any concerns regarding toxicity with APBI?
The patient has no evidence of lymph node involvement.
Assume she refused enrollment on B51.
What would be factors that would indicate the need to include the pelvic nodes?
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...
If you would recommend radiation therapy, what dose-fractionation would you utilize?
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.
Do you follow a routine imaging schedule such as regular FDG-PET scans?
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?...
Should prechemo PET positive disease from bowel or other structures be carved out?
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 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 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?
What dose would you use?
There is no primary and no distant disease seen on restaging PET. RTOG 0236 shows significant regional failure rate. Some have reported salv...
What factors influence your recommendation?
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...
What is your preferred dose/fractionation?
Detailed instructions regarding lymph node coverage have been published, but how do you think about coverage of the anastamoses from the gastrectomy?
What timing do you recommend? What drug and what dose do you use?
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...
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...
Does the T stage or location of malignancy affect your decision?
Do you prefer using MR perfusion, MR spectroscopy or brain PET?
rad50 is a key DNA repair protein.
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?
What are your thoughts on dose, avoidance structures, re-tx risk, etc?
Hormonal therapy would not be tamoxifen.
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...
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 ...
Are there any general principles you apply for how far to track along a given nerve in either direction?
Do we need to really worry about neutron contamination?
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?
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 ...
Assume patient cannot do DIBH. Would techniques would you use to meet dose constraints? What minimum dose would you recommend?
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...
Assume each primary meets ASTRO 2018 guidelines
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...
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 are your fields? Do you treat nodes electively?
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?
What doses do you use?
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?
Per NCCN guidelines, SLNB after neoadjuvant chemotherapy is preferred.
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...
Would multifocality, multicentricity, LVSI, N1mi, etc affect your decision making?
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?
Results for oncotype Dx are not always available readily.
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...
Assume the patient has bone only metastses and will be on hormonal therapy
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 have different preferences based on T-stage?
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?
Does this vary based on whether the patient had a lobectomy v. wedge resection?
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) ...
Or do you wait for platinum resistance?
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?
If so how would you select patients (ie. PS, histology, PD-L1 expression level)?
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?
If so, what dose would you use?
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...
Is there a role for adjuvant radiation? Other chemotherapy options?
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?
Would you be concerned about SBRT worsening rectal bleeding in this situation?
In a patient with a cavitated lesion with underlying chronic infection (identified as cocci) and SqCC, are there additional risks to SBRT? Should spec...
In patients with aberrant anatomy due to previous surgery with lung PTV overlapping the stomach, how much would you dose de-escalate? Even conventiona...
In particular, many guidelines suggest a max point dose of 50Gy for small bowel but in cases of extensive disease how do you reconcile loops of bowel ...
Would the translocation status influence your decision? Are there specific subsites where elective radiotherapy likely offers a higher therapeutic rat...
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...
How do performance status and comorbidities affect your recommendation?
What if CD4 count was low?
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...
Several surgeons have asked this to reduce the time to reconstruction, complications like contracture, and the possibility of re-operation/failure of ...
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...
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...
Is there a risk for anejaculation?
Any special considerations with RT dose or fields?
What dose and fractionation would you consider if surgery is not an option?
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...
What are your criteria for inclusion of the retropharyngeal LN in node negative H&N cancer patients?
Aside from Other nasopharyngeal ca patients and those with cancers of the posterior pharyngeal wall, how do you contend with risks of dysphagia w...
Would you use the same schedule as early stage NSCLC primary?
Would your decision change if the patient is getting chemotherapy and hormonal therapy?
The current NCCN guidelines reserves radiation for patients who are not resectable after induction chemotherapy. Does it make sense to offer concurren...
If the patient is refusing hormone therapy is there a contraindication to prostate RT with concurrent 5FU-based chemotherapy?
In the absence of epidermal invasion and absence of dermal lymphatic invasion (DLI)
Any consideration on standard vs hypofractionation?
How high would you extend your field? Would you treat differently if the patient had lower PET avid pelvic lymph nodes?
There has been shifting concerns with medication side effects (such as osteoporosis, blood clots), duration, and potential non-compliance.
What volumes and dose would you treat? Would you treat the regional nodes alone (including IMN)? Would you treat the chest wall?
What things would you take into consideration for the simulation set-up? Specific instructions for treatment planning? If the PTV is confined to only ...
Many patients are still able to orgasm but are disturbed by the loss of seminal fluid.
If you are treating a very large palliative spine field that encompasses several vertebral levels, would you consider splitting the field (treating ha...
Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?
Would this be any different for whole brain radiotherapy?
Assume workup is otherwise negative and she will get XRT.
Would you consider traditional breast doses or higher? Would you consider treating only the axilla if the mastectomy specimen showed widely-negative m...
Would you treat all cases or only select risk factors (T4, N+/ECE, margin+, LVI etc.)? What would you treat? Would a negative neck diseect...
Would you also radiate the ipsalateral external and/or common iliac nodes?
What techniques would you use to help meet that constraint?
Is local control worse for SBRT when the tumor is invading into the bone (rib)?
Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?
The patient is a 75 yo immunocompetent man who has a history of inverted papilloma of the sinuses and presented with a new lesion in the right maxilla...
The new AJCC staging factors in HPV status and can drastically alter a patients overall stage group, hence dramatically change definitive treatment re...
Do you use size criteria (i.e. bulky nodes over 3 cm), specific adverse histology (adenocarcinoma), or location (near small bowel), etc.
More recent Italian (Sozzi et al) and French data (Canlorbe et al) show associations of greater tumor size > 25-35mm with higher rates of local &am...
For example, for a squamous cell carcinoma of the forearm treated with Mohs surgery with negative margins, are there features that would lead you to e...
Per NCCN, only +/close margins and +PNI are given as indications for adjuvant RT. However, are the presence of other risks factors considered to guide...
The NCCN guidelines give the option of "consider systemic tx/RT" for "other factors," what do you consider as other factors? For example: close margin...
If the oropharyngeal cancer is operable (ex T1N1), would would your preference be upfront surgery?
Would you use chemoradiation therapy to bo...
Is MRI fusion is adequate for urethral delineation and sparing? Would you worry about prostate deformation by placement and removal of catheter ...
A recent phase III trial published in JCO describes the NVALT-11/DLCRG-02 study, evaluating PCI vs observation in patients with stage III NSCLC s/p co...
If so, what is your technique?
Specifically, does the Decipher score influence the incorporation and/or duration of ADT? Can it be used to better stratify intermediate risk patients...
Would you recommend only chemotherapy or would you offer chemotherapy followed by restaging and possible definitive CRT and surgery?
Specifically, in patients who have an undetectable PSA post-op, with high risk features such as seminal vesicle invasion, positive margins, or extrapr...
Are the treatment volumes the same as those for squamous cell carcinoma of the anal canal?
How much will you weigh the demonstrated disease-free survival, including distant disease-free survival, in your recommendations?
What bowel dose constraints do you use when treating bladder cancer with moderate hypofractionation?
Using the standard whole bladder dose fractionation used in BC2001, 55 Gy in 2.75 Gy fractions.
For instance: urologists who only refer for a rising PSA, even in a patient with high-risk features, those who use Decipher results to decide when to ...
Given risk of secondary malignancies do you make an effort to avoid/spare the prostate or give any specific dose constraints when treating young men w...
She has extensive colposcopic lesions at upper/mid vagina, but no palpable/visible lesions on standard pelvic exam. Pelvic MRI with 20cc US gel in vag...
I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...
V20 of 30% can be hard to attain if IMs are being treated.
Aside from steroids and PT, is there anecdotal evidence for warfarin, hyperbaric oxygen, bevacizumab etc. Any experience with these therapies?
Despite some supportive data, it seems few institutions use these routinely. What do you view as the barriers in their utilization?
PORTEC-3 assigned women with high risk stage I or stage II-III endometrial carcinoma to adjuvant external beam radiation vs adjuvant chemoradiation wi...
Would you offer 3-5 fractions for larger lesions instead or would you favor more traditional standard fractionation regimens?
Based on the updated results of the PCS IV trial is 18 months of ADT the new standard of care for men with high-risk prostate cancer treated with...
Is the total time of ADT or the length of adjuvant ADT more important?
Does it make sense to resect only the axillary nodes, but not the other involved nodal regions? Regional nodal radiation will be given.
Is this patient considered to have metastatic disease? Should definitive surgery be considered?
Would you consider radical cystectomy equivelant in terms of local control and how do you balance morbidity of radiation with morbidity of non-organ p...
If so, do you have specific dose constraints you find reasonably achievable given the difficulties in achieving some of the very low dose goals noted ...
Is there any information on how ADT affects the test operating characteristics?
Has your institution changed practice patters based on the findings of the LACC Trial (Pedro et al., SGO in 3/2018) showing worse outcomes with roboti...
Or would you wait to start coincident with the start of cycle 2? If a shorter time from the start of any therapy to the end of radiation (SER) is sign...
Are these patients better candidates for preop chemotherapy alone?
Do you routinely pause systemic therapy when administering SRS? Which agents do you view as relative or absolute contraindications with SRS?
Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?
In the context of the new staging systems and possible differences of HPV mediated vs smoking mediated oropharynx SCC, would you ever not recommend co...
Does histology, i.e. urothelial carcinoma versus squamous cell carcinoma, impact this decision?
Will you treat only the anastamosis and remnant stomach without elective nodal RT, or will you include elective nodal RT in your treatment fields, ass...
What factors would you use to determine? Age, triple negative, LVSI, etc?
The patient will be planned using IMRT and fiducial placement.
Would you include the entire original surgical cavity or only the region of recurrent disease?
Does the stage of the cancer affect this decision?
For example, a NSCLC of the LLL abutting and potentially involving the adventitia of the descending aorta?
If the cyst was encapsulated and completely removed and SCC was found incidentally on final pathology, what are some factors that would influence your...
Are there any other medications, outside of anticoagulation, that would be considered absolute or relative contraindications?
NCCN guidelines mention EBRT/vaginal brachytherapy as options in addition to chemotherapy in the adjuvant setting for high grade histologies, stages 1...
Do you make any modifications to your treatment field or dose?
If a patient is unable or unwillling to undergo dual or tri-modality therapy with chemotherapy or surgery, would you use a palliative radiation treatm...
What if this was an electron vs photon boost? What fractionation scheme would you use?
For a patient with a new contralateral primary or recurrence and previous pneumonectomy, what lung constraints do you prioritize (ex mean lung dose, V...
Is a single-fraction HDR boost appropriate following conventionally fractionated EBRT to 45-50.4Gy?
Pt clinically has inflammatory breast cancer making mastectomy a poor option.
By the definition this would be M1 disease, but would definitive treatment be appropriate? Is there clear data that a single pleural nodule has no cha...
NCCN lists only substantial perineural invasion. What about other high-risk adverse features such as histologic subtype, multiple recurrences, d...
Would you use 10 Gy in 1 Gy per fraction as mentioned in a litterature review in Pubmed?
If a patient has simple bony metastases and no neurologic compromise what are your criteria for recommending that a patient wear a collar for c-spine ...
Is there data to support this practice, which appears in the NCCN guidelines?
It seems that we have increasingly been seeing younger patients with breast and rectal cancers. What rates of radiation-caused secondary maligna...
Comments regarding risk of Moyamoya
Current NCCN guidelines seem to support a variety of approaches.
If so, what dosing amd fractionation would you use?
Should nodes always be covered for perineural invasion when that is the only risk factor?
Is breast conserving surgery followed by radiation therapy an option?
What is your recommended dose-fractionation when treating with SBRT for a non-spine bone metastasis?
For example, what is a safe dose for SBRT for a ~5 cm colorectal bone metastasis of the acetabulum?
How does your fractionation choice change if the lesion is abutting the pleura?
What factors influence your choice to treat as well as dose and target?
What is your treatment approach in a patient with small cell lung cancer and a pericardial effusion?
In a patient with newly diagnosed small cell lung cancer with disease limited only to the thorax would you treat with definitive chemoRT in the presen...
If so, how do you quantify this when making a decision about who may or may not be a candidate for SBRT?
Would you use adjuvant radiotherapy after xiaflex injection or needle aponeurotomy?
If treating the H&N first, would you anticipate some effect of chemo on the rectal cancer? Would you include 5FU in the H&N chemo for be...
The patient does have significant weight loss, drenching night sweats, but no evidence of other involved sites on PET, thorough skin exam, and has nor...
If the patient is responding to external beam and likely to be converted to resectable, what brachytherapy dose/fractionation do you prescribe and wha...
If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...
Is conventional fractionation acceptable, or would you use altered fractionation (DAHANCA, SIB, BID etc.)?
What dose would you use? Would your approach to elective nodal radiation be different in the preoperative setting?
In the case of an excised groin node with no residual disease and no chemotherapy in a young adult patient, how large should the fields be? Is it requ...
Would you recommend chemoradiation therapy or chemotherapy upfront?
Would you take any special precautions with dosing or care for fingernail toxicity?
Inflammatory breast cancer is a contraindication for immediate reconstruction at the time of surgery, but is there a disease free interval after all t...
For example, in a patient with prior colectomy. Would you consider using a spacer?
The reports I've read indicate a fairly high rate of local recurrence and wanted to see if any can give guidance on this fairly rare tumor.
Should any additional anatomical areas be intentionally included in CTV-P2 if it goes beyond the "5+5" expansion? The text (found here:https://www.ncb...
In a patient with high risk rhabdomyosarcoma with significant marrow involvement (Stage IV), who has responded completely on imaging to all known site...
Would you recommend PMRT for these patients if they did not undergo resection? Would you boost if they had other indications for PMRT?
Assuming no distant metastases, should this scenario be managed with "sequential" chemoradiation to the para-aortic region with an external beam boost...
Any role for surgery? What radiation volumes would be used?
Do you electively treat the tracheobronchial tree? Or a certain length of the trachea and bronchus? Does the volume and dose depend on location (...
If so, what fields would you treat? What dose/fractionation would you recommend?
If the two intermediate risk factors are on the lower end of intermediate risk (ex GS 3+4 and PSA 11) with a very small volume disease, can a more int...
If they return to nadir, when (if ever) are they considered to have failed?
What about lobular carcinoma?
Differenes in dose of ~3% can be seen between different dose calculation algorithms. What dose calculation algorithm is the best to use? AAA, Acu...
For HDR brachytherapy for cervical cancer do you use the dose optimization algorithm? Is there a standard dwell time distribution that should be...
Is pelvic radiation contraindicated?
Does your recommendation change if the patient has received prior standard fractionation radiotherapy vs SRS?
In particular, for men who have no strong indication for ADT?
After the publication of ACOSOG Z11 we are seeing these patients in increasing numbers.
Do you favor surgery or radiation in this setting?
How does it vary for patients with a history of hypertension, diabetes, CHF, and coronary artery disease?
For example, assuming an excellent performance status, would you consider local radiation to the primary and metastasis in someone with a single ...
Do patients > 60 years old with no high risk features have any significant benefit? Has the recent update of the EORTC boost trial affected your pr...
What about tumor subtype, ie luminal A/B, Her2 positive, triple negative?
When would you omit or include a boost for DCIS after whole breat irradiation?
Should hypofractionation be avoided in triple negative disease?
In START B ~ 23 % of women received some form of cytotoxic chemotherapy, and the trial was conducted in the trastuzumab era, but there is no ment...
The Canadian trial showed conventional fractionation might be better in the Grade 3 subset, but this was not shown in the START A/B update. What can e...
Do you offer hypofractionation to younger women?
Patient had a single 3cm node s/p excisional biopsy of the one node without nodal dissection. We have done anoscopy and a thorough GYN exam...
When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?
Do you follow pediatric protocols or treat this more like a high grade soft tissue sarcoma? Specifically for paratesticular pleomorphic RMS, do you ad...
How does your approach differ due to squamous cell carcinoma histology? What are your radiation fields?
Would you ever defer radiation in patients with primary brain tumors or would you manage these patients similarly to non-MS patients? How do you ...
What dose calculation algorithm to you utilize (eg AAA, Acuros, etc)? Do you prefer a particular algorithm for certain sites? Do you take in...
5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?
Is close margins <=1mm alone enough to warrant adjuvant radiation?
What about other factors such as p-Staging, PNI, LVI etc.?
Do you recommend 5FU/mitomycin chemoradiotherapy or radiotherapy alone?
What evidence is there for efficacy and toxicity differences between the two ...
Do you routinely screen for pituitary dysfunction after radiation therapy for nasopharyngeal cancer?
Studies have shown increased rate of endocrine dysfunction in these patients:
https://www.ncbi.nlm.nih.gov/pubmed/26011172
https://www.ncbi.nlm.nih....
I have a patient with low volume disease of Castleman's disease with cervical lymphadenopathy and tonsillar hyperplasia that is suspicious but not bio...
EBRT boost only? SBRT? If you recommend interstitial brachytherapy do you place needles freehand or with a template based approach?
What have your liked or disliked about these newer applicators?
If a patient has an increase in PET avidity between the PET/CT done after 2 cycles of ABVD and after completion of chemo, how would you proceed? Would...
Is there any data on safety of radiaiton with pertuzumab?
Is there any evidence to show that treating with a bellyboard is preferred?
These patients have been largely excluded from these trials. What if the infection is well controlled?
When elective nodal radiation is recommended, which nodes would you treat (i.e. facial, pre-auricular, peri-parotid, levels I-III, etc.)?
Assume no history of radiation, no evidence of distant disease and no nodal disease on dissection. Would you treat the chest wall or the&nbs...
Would a high result give you pause about omission of RT? If yes what level is sufficiently high?
if so, would you favor brachytherapy alone? What dose?
What data do you quote patients with implants after PMRT?
In our clinical experience, we have used the treatment planning system's auto-match method, and then manually fine tune adjustments checking skull, IA...
If you are considering chemotherapy and radiation in the definitive, postoperative, or nodal failure scenarios, would you prefer sequential treat...
Is a margin of 5 cm on the GTV still standart?
What dose and volumes would you use?
Does your follow-up differ depending on the dose you used (e.g. boom boom vs. 24 Gy)? Do you routinely image? If so, do you use MRI or PET...
Would you change your dosing or dosing fractionation (45/25 vs 50.4/28 vs 46/23)? Would you try to adjust your fields?
If the patient received neoadjuvant FOLFOX for 4 cycles then 50.4 Gy with concurrent capecitabine, is that enough treatment to omit surgery?
If so, 50 Gy / 5 fx? 7.5 Gy / 8 fx? If so what dose constraints would you use to help determine fractionation?
Do you refer all patients who are felt to be at high risk to a genetic counselor for testing or are you comfortable performing a MyRisk panel in your ...
What are some guidelines or principles that you use to recommend adjuvant radiation after complete resections of sarcoma?
Do you still treat with definitive radiation and counsel about the risk of osteoradionecrosis? Or consider a palliative approach?
Is it better to treat without hormone suppression? Or would this be reason enough to push the patient toward prostatectomy?
Assuming the patient has N2-3 disease, would you consider omitting IMN? What other techniques would you consider to limit lung exposure?
What would be the appropriate treatment for grade I endometrial cancer s/p TAH/BSO but with SLNB yielding negative nodes. The uterus contained a 2cm t...
If you treat pre-chemotherapy volumes, is there a benefit to induction chemotherapy even in bulky disease. If so, how do you define disease that ...
Would you treat this with whole-abdomen RT with a boost? What dose would you recommend? This would be Stage 1, Group 2 (R1 resection), low risk; but l...
Is curative intent surgery off the table?
What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?
Or would you rather treat with 3D-CRT in order to initiate chemoRT concurrently?
Is there a role for SBRT to the primary site? Is it required to treat the ipsilateral hilum if no adenopathy was seen on EBUS or PET?
Obviously the details matter a lot, but are there guiding tenets one should follow beyond expressing condolences to the family?
Is there a dose constraint you are using for LV-V5?https://www.ncbi.nlm.nih.gov/pubmed/28095159?dopt=Abstract
At what point would you decide to forego local control managment (RT or mastectomy) in favor of chemotherapy alone?
Given the multiple retrospective studies showing benefit to higher BED fractionation schedules (most recently, http://www.redjournal.org/article/S0360...
Assuming the early stage endometrial cancer was treated with TAH+BSO initially and no further treatment, what would your recommendations be for HGIL? ...
For example, in the setting of a lack of pre-operative imaging, what CTV margin(s) would you utilize for the initial and boost phases of treatment?
Surgery showed 1/5 and 1/4 LNs involved in the groins. What areas would you cover and with what corresponding doses?
What if the patient was not a candidate for additional chemotherapy? Would your answer change if the patient received the CROSS regimen with <...
In the case where patient history and pathology markers are uninformative to distinguish oral cavity vs oropharynx, do you tend to favor up front surg...
Is another course of SBRT possible? If so, what are the important planning considerations?
If so what dose/fractionation? This was reported here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918530/
Given the lepidic growth pattern, do you use similar margins as with frankly invasive lung tumors? Are there any challenges localizing the target with...
How often do you obtain routine imaging if there has been no documented growth after 5 years?
Is the approach chemoradiotherapy (Mitomycin-5FU) as for squamous carcinoma with surgery only for salvage or do you always perform surgery after neo-a...
Assuming you are treating whole bladder only with concurrent chemotherapy, when would you recommend hypofractionated radiation (20 fractions) vs stand...
If imaging is negative for other sites of dissemination within the CSF, do you treat with craniospinal RT or use more localized fields?
This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...
Would you recommend chemo alone first? Would you treat with definite chemo-RT to the lung then the head/neck or vice versa?
How would this chan...
How would you use the information regarding extent of ECE? What if the patient was HPV negative? What is the impact of systemic therapy on...
Assume patient had 15 nodes removed. What if 1 or 2 nodes were positive?
Would patient age factor into your decision, such as a patient <30 or 40? If you would not give RNI for a favorable pT3N0, are there other risk fac...
CALGB 9343 included ER positive patients but did not separate them out based on herceptin status. Does the study help inform their risk?
When treating lung tumors abutting the visceral pleura/chest wall with SBRT, chest wall or rib pain sometimes occurs. In these cases, I try to avoid i...
For women treated with IMRT, there are multiple ways to define the upper border of the field
1) contouring the PAs up to where the renal vessels exit...
For example, do you ever offer adjuvant RT for pT2N1 SCC of BOT without any of the above adverse features?
There have been some retrospective studies in the literature describing recurrences in the the site of a temporary trachoestomy for head and neck mali...
Should the patient be counseled to anticipate a worse skin reaction than normal?
Is your approach different for oligometastatic versus oligoprogressive disease? If there is concurrent locally advanced disease, would you treat simul...
Would you treat a T2N0 high grade neuroendocrine carcinoma of the nasal cavity after a R1 resection?
Would you prophylactically treat LNs as well?
Is so, what lymph node regions would you treat if it arose from the sphenoethmoidal recess?
Patient underwent a shave biopsy of a 6x5x2mm preauricular lesion that showed moderatley differentiated sebaceous carcinoma with deep and lateral marg...
Is it recommended in every pediatric patient? Are there any guidelines for organ-specific surveillance after XRT for children based on age, dose...
Would you recommend any imaging of the axilla before lumpectomy? Would you recommend standard breast fields vs high tangents to cover the lo...
Would you delay/defer adjuvant radiation and/or temozolomide until completion of IV antibiotics? Would you still treat with a significant skull defect...
Classical teaching is the sooner the better - but there are times that treatment gets delayed or adjustments need to be made after seeing the post-op ...
Would you recommend radiation and/or systemic therapy? If you would irradiate, what would your fields/volumes look like?
In the case of patients many years out from RP who have a slowly rising PSA, do you offer salvage RT while the PSA is still very low or follow the PSA...
When would you use EBRT? What dose should be used and what extent of nodal treatment should be included? Is there a tracheal dose constraint?
How does grade, margin status, and previous radiation dose factor into the recommendation?
For a lesion that appears radiographically consistent with a high grade glioma, would you treat empirically if there is hesitancy to perform a high ri...
If given options of liver, lung, spine, brain, axilla, or other lymph nodes which sites do you pick?
Is obtaining serial MRIs or other imaging appropriate?
If so, what regimen would you consider?
Type II endometrial cancers made up roughly 15% of GOG 249 the study population, but seemed to be balanced between both arms.
Single institutio...
Assume the patient had no radiation, what would your volumes be? Would you recommend radiation if the patient had whole breast/chest wall radiati...
What fields would you use for adjuvant RT? SBRT vs. whole brain?
When do you institute a treatment break for skin reaction for patients who receive breast radiation?
Do concerns about matching with 3D plans justify IMRT?
Per the NCCN guidelines, in this specific scenario, adjuvant radiation therapy to the locoregional lymph nodes after lymph node dissection is not indi...
In a patient who received upfront surgery and chemotherapy who later recurred in the regional nodes, s/p lymphadenectomy, would you offer RT? If...
Is any further imaging warranted or is clinical surveillance sufficient? Do you recommend a repeat PET at a year (PMID: 28854069) or beyond...
After whole pelvis radiation therapy, what would be the highest dose you would allow in a single fraction, versus the total course EQD2 for small bowe...
Would you treat if there is active infection? How much improvement would you expect?
In a clinical N0 patient with high risk (large, deeply invasive, poorly differentiated, +PNI, etc) cutaneous SCC of the head and neck, who do you...
Would you treat if the patient is asymptomatic? If you do treat with RT, what dose-fractionation would you use, and what volumes do you target?
Is a pleural effusion not oligometastatic by definition? The best evidence for consolidative RT was the MD Anderson/U Colorado/Western Ontario phase I...
Unlike in post-operative cases, you lack detailed pathologic information in this scenario. Do you base your decision on location, size, and/or patholo...
If so, how would you approach treatment?
There is anecdotal concern regarding history of estrogen replacement therapy causing stimulation of breast tissue and therefore potentially increased ...
In other words, if there are borderline indications for PMRT (ex initial T3N0 or T2N1 disease) with a pCR, would the suspicious IM nodes lead you to o...
What is the maximal amount of time you would allow between the surgery the start of adjuvant RT? What other factors would you consider when deciding w...
Is microscopically positive renal vein margin an indication?
The small series by Lowell et al (IJROBP 2011) suggests significant toxicity risks following SRS.
Do you use the typical indications for PMRT (nodal status, size of primary, LVSI, age, etc)? Or, do you recommended PMRT more frequently (...
For example, if there was a common iliac node, does external iliac nodal region also need to be included? When, if ever, do you include the exter...
When would you recommend that SLNB be performed prior to neoadjuvant chemotherapy? When would you recommend additional staging (completion axillary di...
Antacids? Anti-motlity agents? Dietary changes? Combination?
How do you deliver it safely? Even when there is adherence to other organs (T4) or positive margins, I'm hesitant to offer RT because the volumes are ...
What is your cavity size/volume cutoff in selecting hypofractionated SRT over SRS?
What dose/fractionation would yield the lowest risk of graft failure? Does your treatment management change based of location, ex the ear vs back?
Is there evidence of decreased toxicity in the lung, brain, pelvis, breast or abdomen with 1.8 Gy fractions to justify longer treatment schedules or w...
Would you consider this in a patient with a single omental metastasis found and no other distant spread after surgery?
If the patient had a CR by PET/CT after 2 cycles of ABVD and received 6 cycles of ABVD would you recommended consolidating only the bulky disease and ...
If Dynamic Sentinel Lymph Node biopsy is not available, would you refer the patient for node dissection, radiate, or observe? What nodal regions would...
Is there any evidence that this improves outcomes over a more simple and cost effective follow up of careful physical examination and checking a perio...
For patients who are not candidates for excision, have you effectively used radiation alone? There is a study using 7.5 Gy x5 in weekly doses (Malaker...
Is there strong evidence to guide this decision?
In a patient who has a rising PSA, palpable nodule, MRI findings etc., is it ethical to treat the patient with inadequate information and ri...
For example, a patient with cervical or anal SCC who has missed many treatments due to side effects, low blood counts, hospitalizations, or non-compli...
What fields would you treat?
Would you treat the regional nodes alone (not previously irradiated) or would you also re-treat the breast/chest wall?
For example, previous RT for seminoma several decades ago.
How about a more recently treated rectal cancer with pre-op chemoradiation?
What factors would help you make your decision? (Age, genetics of lung or breast cancer, triple negative, LVSI, T2, etc?)
For treatment of multiple brain metastases, the V12 can often exceed the traditional dose constraint of 10 cc, especially as the number of lesions bei...
What factors influence your decision? Does high grade histology or pathological stage play a role? If the patient received chemotherapy due to +LN, pa...
Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?
Any role for endotracheal brachytherapy? If so, how long after laser treatment would it be safe to use endotracheal brachytherapy and at what dose?
How do you prioritize alignment of bony anatomy, prostate and nodes?
Do you have varying PTV margins for different structures or as compared to prost...
ASCENDE-RT excluded these patients as well as those with a PSA > 40, but it seems these patients may stand to benefit as well.
For example, would you recommend treatment of the cervical and posterior occipital lymphatics for a 4 cm lesion deeply invading the posterior ridge of...
Any special dosing considerations or can you approach this like any other small peripheral NSCLC?
Are there any situations where a patient is a suitable candidate for ABPI but you still encourage standard whole breast hypofractionation?
Would you rather they delay the start of treatment so that it was >3 months from date of surgery or have a break of several weeks during XRT? Assum...
Are there any rules you follow? Do you shrink target volumes if you notice a significant response (via CBCT) in a bulky lung tumor with fractionated r...
In the new AJCC 8th edition, p16+ downstages many patients from what used to be stage IV. Should the adjuvant therapy for these patients be de-escalat...
Does the 1 year of ADT used in the ASCENDE-RT trial present a new option of the standard of care in timing ADT when combined with brachtherapy boost?
How does this approach change with mediastinal lymph node involvement? What are the indications for definitive or adjuvant radiotherapy +/- chemothera...
Are there treatment planning considerations that are different for a large cystic lesion as compared to a solid metastasis?
The current treatment for bladder adenoCA is surgery. However in non-surgical candidates, RT is an option. Would you consider adding chemo ? Also woul...
For patients with eGFR of < 30, there is a risk of irreversible nephrogenic systemic fibrosis with gadolinium. Would you prefer whole brain for the...
And does the fact that the breast is lactating affect radiation toxicity in anyway?
Would age or histology alter your decision if biospy proven N2 disease has a pCR after 4 cycles of chemotherapy?
How does it vary based on disease site, lymphatics involvement, emergent vs. non-emergent trach etc.?
The RTOG contouring atlas doesn't give a consensus on this issue.
Which imaging studies do you perform and what is the timing after treatment?
Our urologists routinely get these scans prior to definitive therapy and at times in the postprostatectomy setting. The high sensitivity makes f...
What is the best evidence for what dose to use? When would you give it in relation to the checkpoint inhibitors? Which metastatic sites do you choose ...
Do you modify your dose/fractionation depending on the amount of prior intrathecal therapy?
Do you add an IMRT boost with possibly vaginal brachytherapy?
What are your specific protocols for monitoring and for dosing narcotics and sedatives?
Would you also add EBRT and/or ADT?
What technique do you use (IMRT vs direct electrons w bolus)?
The ILROG paper on extranodal NHL says "For tumors confined to the conjunctiva or...
Is there any experience with radiation therapy?
What factors would help aid your decision?
For hypofrac breast patient (such as 40 Gy in 15 fractions), what is the maximum hot spot that you will accept anywhere in the breast? 107-8%? 1...
Do you routinely offer re-irradiation? If so, what is your preferred dose and technique?
How does your dose/fractionation vary for patients with and without prior radiation?
How do you decide on the treatment volume? In particular, how do...
What time delay would make the benefit of adjuvant therapy likely no longer significant?
Would you send the patient for a stent or do palliative RT?
Would you start radiation without temodar if there is a delay in temodar rx?
If you do treat both nerve roots, how long do you wait between fractions? Do you modify anything because you are treating bilaterally?
When trying to eliminate dose heterogeneity during field in field planning for hypofractionated breast radiation with a large separation, the resultin...
If salvage EBRT - what dose?
Specifically, what criteria do you use to quantify "low-volume" prostate cancer? What other criteria do you consider when defining low volume in...
http://ascopubs.org/doi/full/10.1200/JCO.2015.64.2710
A retrospective review of the use of adjuvant radiation in the recurrent setting for pleomorphic adenoma of the parotid gland reported a 20 year actua...
What would be the RT dose and what percentages would you quote for toxicities? Would you recommend consideration of surgery instead?
If you leave it in, do you still use bolus?
If a patient will receive a total of 4 cycles ABVD and has a CR by PET/CT after cycle 2, can RT be omitted to non-bulky sites to avoid toxicity?
How do you decide between plaque brachytherapy and external beam approaches? What dose do you use for plaque brachytherapy? For external beam, what do...
Would the risk of secondary malignancy affect the decision?
Fecal incontinence can be one indication. What are others?
Assuming CSF is negative for neoplastic cells would you:
Re-irradiate gross disease only?
Re-irradiate posterior fossa only?
Re-irradiate the entir...
Would it differ if the tumor was high grade at the same location?
What is the role of the 3T MRI mprage sequence? Is there any literature to support a certain approach?
Should radiation be offered as a bridge to transplant? Should this depend on whether SBRT is feasible (i.e. is fractionated IMRT an appropriate option...
Would a large number of peribronchial nodes but negative nodes at the hilum and mediastinum (LN stations 7-10) affect decision making or volumes? What...
If so, how do you manage counseling for someone with low health literacy?
Given lack of strong evidence supporting the benefits of adjvuant RT in resected pancreatic adenocarcinoma (with results of the ongoing RTOG 0848 unav...
What dose-fractionation schedule and treatment volumes would you utilize for adjuvant radiation therapy status-post total parotidectomy with negative ...
When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...
cT3 patients were a minority of patients in the data demonstrating superiority of tri-modality therapy. While cT3b patients have particularly poor out...
For pN2b disease after bilateral neck dissection, is PORT to the negative side of the neck indicated?
Do you have a KPS or other cutoffs that would deter you from using accelerated fractionation due to concern for toxicity?
Does your volume change based on fractionation (high-dose single fraction vs. 3-5 fractions)? Do you treat the entire circumference of long bones? Wha...
Would you feel comfortable treating with palliative radiation without neurosurgical assessment? Are these patients at increased risk for neurolog...
If so, what constraints would you use for central biliary and other normal structures and what dose/fractionation would you use?
Are there specific conformality parameters you prioritize (105% dose volume outside of PTV, conformality index, ratio of 50% isodose volume to PTV, an...
Recently, while planning a patient for lung SBRT it was suggested by the physicist that we change the density of the PTV to higher density to improve ...
The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.
How would you interpret this finding when MRI was not used in defining risk category for prostate cancer?
Should high risk prostate cancer patients be placed on more potent ADT in the upfront setting with definitive RT?
Do you offer neoadjuvant RT with resection and node dissection vs. definitive radiation? How extensive does the nodal disease have to be for you...
Does it matter whether the intracranial lesions have been treated with whole brain or SRS/SRT?
What factors would push you to consider using IMRT vs opposed lateral fields for a T2N0 glottic SCC?
Would having supraglottic extension lead you to use IMRT?
There are solid data from Emory, Korea and others suggesting that is as effective as single fraction SRS but has less complications.
Would you insist that they shave or cut the beard? Is there a way to make the simulation reproducible without removing the beard?
Can radium-223 be given to patients with progressive diffuse osseous mets if they have a history of visceral mets that resolved with previous treatmen...
In what situations is it appropriate to offer observation (rather than VBT) to patients with stage II endometrial carcinoma who have had a radical hys...
Although elective nodal irradiation is not standard, what you treat lymph node stations that are adjacent to involved lymph nodes? For example, i...
If the patient meets CALGB criteria but has EIC would you lean towards giving RT? What other factors would lead you to give whole breast RT an elderly...
Does the time interval to progression, current use of immunotherapy, KPS, etc influence your decision?
Is the risk of IBRT any greater than in non mutation carriers?
Does neoadjuvant chemotherapy with complete response in the axilla alter your management preferences?
If a patient has a gynecological cancer, how long should one wait after RT before a screening colonoscopy can be completed?
The plans appear so much more conformal. If not, what is the rationale?
Also, is there a maximum hotspot within the target volume?
Would you consider altered fractionation in a postop patient who has ECE or positive margins but is refusing chemotherapy?
If a male has early stage breast cancer and would otherwise meet criteria for the CALGB or PRIME II trials, would omission of radiation be an option? ...
In patients with new bone pain and without any evidence of bone metastases receiving GnRH agonists, how do you manage pain symptoms?
What dose and volumes would you use?
Similarly, would SBRT be an option for a small central persistent node? What maximum total BED would you accept before no longer recommending addition...
Do you have a max dose constraint for PTV? Volume receiving dose higher than prescription? There seems to be variation among RTOG protocols from max d...
What dose constraints would you use in planning?
If utilizing conventionally fractionated radiation, do you cover just the gross disease or do you cover the preoperative tumor volume? What if you are...
Would you treat the node alone, unilateral/bilateral inguinal nodal basins, or cover any possible primary locations such as the anal mucosa?
Does definitive or adjuvant setting effect your planned dose? For example, for a woman with IB2 cervical cancer status post hysterectomy, who wa...
Is it reasonable to go with surveillance instead and keep radiation as a salvage option?
Do you approach it similar to a de novo GBM? Would you be more inclined to offer hypofractionated radiation given the poorer prognosis?
Are the results of the STAMPEDE trial presented at ASCO 2017 practice changing?
Is better systemic control needed to make radiation therapy beneficial?
Is there a length of time that would be considered too long between TURBT and CRT? At what time point would you recommend another cystoscopy to evalua...
When should pelvic/inguinal lymph nodes be included?
Do you use the same constraints that you would for the rectum? Or perhaps employ a lower dose limit, such as not exceeding 65Gy to a small volume of t...
With biopsy-proven, negative systemic restaging disease, what dose and fractionation is appropriate if treating with IMRT? Should ADT generally b...
Do you consider this a positive margin? Would you boost this area to a higher dose? Would you recommend concurrent chemotherapy in the abs...
PET/CT/bone marrow biopsy negative for evidence of distant disease. Following 4 cycles of combination chemotherapy with no evidence of progressive dis...
What about bulky nodal disease?
Is there a minimum amount of nodes you would like to be removed before you omit radiation to the neck? Do you consider other factors when deciding whe...
What has been your preferred management?
Are carcinoid tumors of the GI tract more or less radiosensitive than typical solid tumors?
Is there any role for a trageted agent with CNS penetration (such as second generation ALK inhibitors) after completion of postoperative brain radiati...
After sublobar resection and well dissected mediastinum, would you soley focus on the area of the positive margin or would you include ipsilateral hil...
If not, what is your thyroid hormone withdrawal protocol? If so, would you still treat a patient with possibly metastatic disease?
Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?
Would you offer it for positive margins? NCCN says to consider adjuvant radiation for pT3-T4 or pN0-2. Is there sufficient evidence for adjuvant radia...
In a patient who already received 13 courses of radiation (with complete response), is there any other effective treatment?
Have you ever seen toxicity related to diaphragm dose with conventional fractionation?
When can you feel confident that the growth is from tumor vs. radionecrosis?
Any recommendations on technique?
Would you consider this an indication to treat lymph nodes, if you would typically not do so?
To what degree, if any, is a neurosurgeon involved in the planning of SRS for brain metastases?
The 2014 "Choosing Wisely" list, released this past September, includes the assertion that we should not "routinely add adjuvant whole brain radiation...
Does the site of oligometastasis matter (ex. brain v bone)? In this trial https://www.ncbi.nlm.nih.gov/pubmed/27789196 20% of patients were ...
In what situation, if ever, do you include mediastinal nodes?
In this age of IGRT, CBCT, and MRI imaging, is this practice needed?
Specifically, the cheek? If so, which nodes should be treated and to what dose?
e.g. how does the tumor burden on axillary dissection, sentinel biopsy only, extracapuslar extension, and the size of hte metastasis play into your de...
And at what intervals? The published trials/RTOG call for q3 month MRI follow-up. Is this appropriate outside a clinical trial setting?
Is it still acceptable to deliver hypofractionation for what was previously a Stage I TN breast cancer, now Stage IIIA? Should RNI be considered? Or e...
If surgical stabilization has been performed, do you go with SBRT dosing? If so, do you treat only the involved site and not the extent of hardware? D...
In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...
If the patient had RT 3 months prior and had a revision surgery, would you offer RT again? If so, which dose and fractionation would you use?
What is the average healing time? What medications and/or procedures do you recommend for pain control? Does management differ for those with chest wa...
Is there an upper limit to offer definitive RT? Is it possible to have a PSA of 100-500 and still have only local disease?
Do you specify an isodose line to prescribe to? Do you ask for a percent hot, and if so do you specify what percent or volume of the GTV/ITV should re...
How do you best counsel their radiation risks?
Do you use V5, V30 (as per Dess, JCO 2017)? V50 (Speirs, JTO 2017)? Mean (Wang JCO 2017)? What is the most evidence based criteria? How do you b...
To what extent do you worry about overlapping myelosuppression? Is there any advantage to overlapping therapy?
Should such a case be treated like retroperitoneal sarcoma?
If so, how to you address the scar? Do you use bolus? Do you place a 2mm retraction from skin for the target contour?
Standard RTOG constraints include guidelines for rectal v60, v65, v70, v75, but is there a relative or absolute volume constraint for rectal v80 that ...
Is there a role for salvage LN dissection or salvage RT to the node? And is there a role for systemic therapy (ADT or chemotherapy) in addition? If yo...
Would a postiive margin or extracapsular extension altar your recommendations? Does size play a role in your recommendation?
Should the workup change with the PSA level (for example, >2 vs <2 ng/ml post-op PSA)? Is there a PSA level for which salvage radiotherapy...
RTOG 0529 guidelines were 2.5cm margin from GTVA to CTVA (except bone or air), do you still follow this practice?
The subquestion can be "Ex if you are offering PMRT for reasons like young age and Her2+?
Two retrospective studies from Stanford showed that patients who received ADT had an increased risk of dementia and Alzheimer's. Is this finding ...
If a patient developed locoregional recurrence after initial chemoradiation, would resection of known disease followed by observation be preferred?
Under what clinical circumstances would you consider prescribing them?
Are patients with extracapsular extension at diagnosis good candidates for brachytherapy boost? If extracapsular disease that can't be effectively&nbs...
Please share your decision algorithm, if any (based on age, histology, KPS, lines of therapy already used, prognosis, etc.).
Would you utilize IMRT to provide a boost to gross disease? If so, how would you define your treatment volumes and what dose would try to achieve? Als...
If a patient has undergone wide local excision with residual disease, but negative margins, is it safe to observe? If adjuvant treatment is indicated,...
In particular, for patients without clinical symptoms, would you image the spine based on any histologic, molecular, or other risk factors?
There is some data that suggests PSA and EBV can flare early in radiation therapy treatment courses in prostate and nasopharyngeal patients, respectiv...
Aside from relocating the generators, does anyone have any experience or knowledge about tolerance of the devices?
How do you minimize these risks? If using local anesthesia only in the outpatient setting, how is pain control at the area of injection?
Do you attempt to have the pacemaker moved? If the patient is non-dependent, would you ever treat with the pacemaker in field?
Would you still consider this high risk? If so, would you recommend pelvic radiation AND chemotherapy?
Do you use a PSA threshold, PSA doubling time, or only evidence of metastatic disease to trigger ADT? For those without rapid doubling time, do you ev...
Is inguinal coverage always required?
For instance with isolated progression at one metastatic site, with all other disease stable and clinically doing well.
If so, what criteria do you use to guide your decision?
One study comparing these techniques (https://www.ncbi.nlm.nih.gov/pubmed/12873685) showed 75% hearing preservation in the single fraction group ...
How would the new data presented at ASCO GI 2021 from from Alliance A021501 influence your answer?
I've seen 15Gy quoted as an effective GK dose, and a variety of LINAC doses in the literature.
If there was true residual disease, do you offer whole brain RT, partial brain RT, SRS boost to the resection cavity, or observation?
There is increasing technology available (ie flattening filter-free beams) to substantially increase dose rate.
Are there dose-response studies establishing 70Gy is the optimal dose for gross tumor control, or is it simply thought to be the maximally tolerated d...
We learn about nuclear disasters and radiation emergencies for the radiation biology boards. Practically speaking, what role, if any, do radiation onc...
Is there any benefit to delaying start of RT or perhaps changing to complete adrogen blockage if maximal PSA response is not achieved in 2 mo?
...
Is there data to support that surgery works better than chemo-RT in p16 negative patients?
For example: would you treat the entire Waldeyer's ring? For a stage II patient who also has cervical lymph node involvement on one side, do you...
If so, when? There seems to be an increasing trend among urologists to offer surgery to high-risk prostate cancer patients despite the low probability...
Every physician and institution seems to take a different approach based on factors such as type of replacement and whether or not cement was used.&nb...
Specifically, are hilar nodes metastatic?
Does treatment of the pancreas with radiotherapy during an episode of acute pancreatitis increase the risk of acute and late side effects? Should one ...
What adjuvant treatment should be offered after a complete resection?
Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound? I...
For example, would you counsel against breast conserving therapy for a woman exposed to fallout from the Chernobyl disaster or a downwinder?
Are fiducials always necessary?
Does your answer differ if you're treating with standard vs. moderate vs. extreme hypofractionation?
Would you treat large/total scalp fields to definitive skin cancer doses? If the patient has a more limited KPS, would you treat sequentially in order...
Would your recommendations change if it was a partial vs complete radiographic response?
E.g. someone with high grade and/or >2.5cm disease? If we use age as a cutoff in invasive disease to omit adjuvant radiation based on the...
We are being referred more patients for salvage radiation after this procedure, not sure what the evidence is.
Would you include the hygroma in your cavity volume? Does your decision change if you are treating a low grade vs high grade glioma? Are there other c...
Would you add chemotherapy if there was gross residual disease, pN+ and/or ECE?
For example, a larynx primary with direct extension to medial pyriform sinus?
How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation?
We often counsel patients that they shouldn't take very high doses of antioxidants but taking a daily multivitamin with antioxidants is OK. Do you thi...
Is there a role for adjuvant nodal irradiation for early stage squamous cell carcinoma of the penis?
Specifically if sentinel node mapping and sampling has not been performed or refused?
Several radiation oncologists have switched from 6MV to 10MV for cranial IMRT plans to prevent alopecia. Is this theoretical or do we have data? And a...
Is there data demonstrating an advantage of one particular IGRT strategy over another?
We often see young women with favorable, early stage disease in the mediastinum who have had a complete response to chemotherapy. With current smaller...
Her2 status was not evaluated as part of the PRIME 2 or CALGB trials and luminal Her2 patients likely represent a small minority of those enrolle...
For example, in someone with a new diagnosis of hormone receptor positive breast cancer with a 10 cm lytic bone lesion extending out into the pelvis a...
What is your approach to deciding when to treat these patients? Or is it solely dependent on when surgeons refer them?
At other sites we consider locally advanced disease and high risk of recurrence a contraindication for organ preservation. Would surgery improve likel...
Do you have a cut off in terms of prostate size, IPSS score, post-residual void volume, or any other criteria?
How have the results of the UK RAPID study (Radford et al NEJM 2015) changed your practice?
Can the classic indications for post-hysterectomy radiation (eg. "Sedlis" and "Peter's" criteria) be applied? Does the histology change radiation dose...
If there is an operationally failed sentinel lymph node biopsy, do you always include RT to regional nodes?
If so, is there a role for IMRT?
I was taught to use the RTOG style ports with whole pelvis 4 field box and then boost field to entire bladder ...
Per NCCN, only well-differentiated T1 lesions (with 1cm surgical margins) should be excised (with no other treatment). Do you follow this at your inst...
Would you recommend a mastectomy for her breast cancer in attempts to avoid RT? If the patient undergoes a lumpectomy or needs PMRT, would you a...
In the recent 10 year update of the ARO (adjuvant pelvic RT versus observation) trial, their definition of PSA failure was 2 successive rise...
In the setting of recent craniotomy and a plan for SRS to the surgical cavity, which systemic therapy would you choose and when would you start it?
For example, there is a retrospective series out of MD Anderson (Kim, Acta Oncologica 2008) wherein 37 patients with gastric cancer were treated with ...
Especially in patients who are not candidates for chemotherapy, what dose and fractionation should be applied given the fact that hyperfractionation w...
The immediate response by patients in this situation seems almost universally to be, "But I'll starve to death!" Referencing literature about lack of ...
If so, what dose?
Is there evidence for SBRT for recurrent ovarian granulosa cell tumors?
How would you manage the small bowel/prostatic interface? Have you tried SpaceOAR in this context? SpaceOAR + protons? What dose would you escalate to...
If offering radiation therapy, would you treat extended field whole pelvis or just cover the para-aortic LNs with an involved field volume? Would your...
For a patient with a history of non-muscle invasive disease in the bladder, presenting with a prostatic urethra only recurrence, do you approach this ...
If so in what circumstances and what margin is acceptable? ACNS 0331 recently showed no difference in outcomes when comparing IFRTboost vs ...
How long would you typically wait between date of surgery and initiation of radiation therapy? What factors influence this decision?
There are varying reports in the literature which seem to suggest increased rates of Gr 4-5 pneumonitis in IPF patients. How do you manage these...
If not, are there certain dose constraints one considers?
What are the pros and cons of completing a simple hysterectomy versus aborting surgery followed by chemoRT?
Is it a factor you consider, especially in borderline cases?
For instance, are you more likely to offer PMRT to a man who is node negative but with several high risk features such as high grade, LVI, high oncoty...
For an N0 patient with locally advanced (T4a) SNUC of the ethmoid sinus, would you include elective cervical lymph node irradiation? If so, what...
Is it true that urinary obstruction can improve with HDR brachy, as it can have an ablative effect on the prostate?
Radium-223 has an overall survival benefit and lower hematologic toxicity, but at a significantly increased cost. Does the cost-effectiveness fa...
With stage I/II vaginal cancer and an excellent response to 4500cGy EBRT with <5mm residual thickness of tumor remaining, what is your dose/fractio...
For example, if a patient had severe lung obstruction or hemoptysis from a tumor would it be okay to treat with 3Gy per fraction BID? Or, if a pa...
If so, to what dose?
This is rarely done, but recently came up in a tumor board discussion. Which chemotherapy would you consider using, and when?
Would a minor adverse pathologic features such as capsular penetration (not SV or positive margins) influence the decision for radiation treatment?
W...
Would your recommendation change if the histology was adenocarcinoma (excluding GE junction tumors)?
More specifically, what do you classify as a situation that needs treatment within 24 hours?
Reference: https://www.ncbi.nlm.nih.gov/pubmed/23578724
If a holiday falls during the week do you treat all patients, a select subset of patients (i.e. cervix, head and neck) or give everyone the ...
If so, how large of a margin would you place on the primary lesion and would you incorporate any adjacent lymph node levels?
Do you ever use BID fractionation? What patient factors do you use to individualize the treatment?
Place the patient partially on the table? Treat them on a hospital bed? Simply deny treatment until weight is reduced?
Do you ever hold treatment? Would you consider any of the following: decongestants, anti-inflammatories (e.g. steroid burst), antibiotics, or myringot...
Is your approach similar in unresectable disease? Is there evidence to support one approach over the other?
In particular, would you offer memantine to those with WHO II or III gliomas and a good performance status but larger treatment volume?
What is an appropriate target volume for a chordoma or chondrosarcoma after a gross total resection?
Should the whole resection cavity be included?
If no, in what patients should axillary ultrasounds be performed?
Or is this just theoretical?
Would you give radiation after and if so would you give it with chemotherapy or alone?
These patients with brain metastases were excluded from the CREST study.
Would your management change if the patient had extensive DCIS?
Please respond as I am looking for as many responses as possible. At our institution, we are present for the first IGRT where we discuss alignment obj...
Do you routinely ask all women of childbearing potential to have a pregnancy test? If so, do you get a pregnancy test before their CT simulation or th...
Is MRI being considered the primary mode of imaging in multidisciplinary tumor boards, especially in light of the results of the MERCURY trial (JCO 20...
Specifically, is there still a role for dd RCHOP followed by ICE, or do you recommend DA-R-EPOCH for all patients?
How many intercostal spaces do you include? Do you vary these parameters based on the disease characteristics?
What is the best evidence to support or refute this?
What is the best treatment option when the PSA indicates occult metastatic disease? What is the benefit of salvage RT?
Does the site of palliative radiation therapy matter (i.e. femur, abdomen, pelvis vs base of skull)? How long should you wait to give palliative ...
Is there concern for erythema multiforme or Steven Johnsons?
Would your recommendations change based on stage? What factors would influence your decision to include presacral lymph nodes in a locally advanced en...
Does this differ if the primary is vaginal? Do you prescribe the same dose when using an intracavitary applicator for cervix cancer?
These patients were not eligible for Z0011 and represents less than 5% of the patient population in AMAROS. Thus, can you apply these two trials to ju...
Would you include the surgical scar? If so, what margin around the scar would suffice?
The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib.
For example, in a patient minimal brain and liver metastasis, would you treat all sites definitively?
Would you send the patient to a surgeon for consideration of a mastectomy? Would you then consider post mastectomy radiation when the risk of re...
For palliation of vulvar cancer, what fractionation due you typically use. Can some of the toxicity be avoided with a shorter course of treatmen...
Would you include one vertebral body above and below the involved vertebral body? Is IMRT appropriate in order to reduce dose to small bowel? What oth...
What about patients who are still on steroids for radiation pneumonitis?
Some prefer radiation alone, while others do chemotherapy followed by RT (possibly to lower dose vs. RT alone).
With the high rates of recurrence postoperatively with angiosarcomas of the scalp, adjuvant radiation is often recommended. What margins would y...
Prior to starting vaginal cuff brachytherapy, do you wait for a specificed period of time prior to vaginal cuff brachy after hysterectomy? Do y...
For example, if you had an octogenarian with a previously resected squamous cell carcinoma of the skin who presented with metastases to the parotid an...
In my experience, it seems like the post-SBRT area of fibrosis is more than I would have otherwise expected with GGOs. I have usually advised wa...
Published data show a mixed review of late toxicity with adjuvant radiation. What are guiding principles we should use as more patients are getting ge...
With the results of the EMBRACE protocol, how do you approach MRI planning? Do you plan with applicators in situ, or use preimplant (post EBRT) ...
What if a large portion of small bowel is located within PTV45?
Would taking the drug at a specific time point prior to their radiation appointment time to maximize blood levels of the drug be clinically beneficial...
How would your radiation treatment approach change in terms of dose and target definition?
Would the time interval between diagnosis affect the optio...
We have seen a lot of patients referred to oral surgeons who insist all their teeth are in poor shape, leaving these patients edentulous.
What do you...
What are indications for adjuvant radiation for a early stage well differentiated adenosquamous carcinoma of the breast? What is the best radiation th...
What if there was a pT1aN0 invasive adenocarcinoma that was separate from the focus of adenocarcinoma in situ which resulted in the positive margin. &...
If a patient has increasing FLAIR and T1 enhancing activity, should both be included in the treatment volume? What factors to you consider in making y...
Do you give a treatment break? Is so, how long should RT be held? Are there skin management techniques to use?
If so, what adjustments do you make? Does your recommendation change based upon how long the lobe has been collapsed and/or its presumed functionality...
What do you consider when making this decision (concurrent chemotherapy, amount of bone marrow in field, whether patient is already on antibiotics, et...
If a patient had recently completed R-EPOCH x 6 cycles, would you change your dose for a low grade follicular lymphoma?
Most guidelines discuss target delineation and contouring recommendations for extremity sarcomas, which generally suggest larger longitudinal than rad...
What is the role of PET?
There are retrospective data (i.e. PMID 15072456) that seem to associate posterior fossa location with increased risk of leptomeningeal disease a...
Would this recommendation change based on proximity to a joint?
What are the best options to treat a patient with brain metastasis confined to the posterior fossa if the patient is young, has a favorable cancer, gr...
Any up to date interventions? Which expectorants have been effective?
Do you have any rules of thumb regarding amount of weight loss, a percentage change in the size of the primary/node, or the fit of the mask?
What factors in particular guide your recommendation of PMRT for invasive lobular carcinoma?
Is surgery an adequate treatment for Stage IE DLBCL of the cervix?
Does this management depend on treatment site?
Or do you use standared involved nodal fields, as is done with concurrent chemoRT?
How does your fractionation change based on the time from the previous treatment, such as 6-12 months vs. greater than 12 months?
Would your management change if including the drain sites requiree treating more lung or adding separate electron fields?
There is limited data to guide us in this relatively uncommon situation (PMID 7853587, PMID 2836634). Would this presentation...
Does your recommendation change depending on the agents they received?
Following Mohs surgery and in the absence of other high risk features, do you offer RT for any PNI? A single nerve < 0.1 mm? A single ne...
Do other factors (i.e. Gleason score, pretreatment PSA, or pT stage) affect your decision?
Would you be comfortable with 55Gy in 20 fractions around the optic nerves and brainstem, or would you treat with a more protracted fractionation? Do ...
What factors do you consider when offering PMRT? Would you change your dose/fx and/or field size?
What is your interpretation of the recently published QUARTZ trial? Is there a population of patients that you would consider withholding radiation th...
If so, is the time different based on intermediate (T4, N+, LVI etc.) vs high (ECE, +Margin etc.) risk indications for adjuvant RT?"
When treating with radiation therapy, what dose-fractionation do you typically utilize?
What is the best management for recurrent basal cell carcinoma after prior radiation and vismodegib?
Would re-irradiation be an appropriate option? What dose/field would you incorporate? If treating with standard fractionation, would you take the enti...
The mid treatment cystoscopy has been standard, but treating with or without mid-RT cystoscopy are both included in the NCCN guidelines. Can the treat...
Our lung cancer screening program does not enroll anyone who has previously been deemed to be a nonsurgical candidate. I see that there is no ev...
Women with cN1 disease at diagnosis who are ypN0 after neoadjuvant chemo can be randomized on NSABP B-51, but not those with cN0 disease and treatment...
What about in cases of a tunneled lumpectomy cavity using a circumareolar incision?
If so, when? Although anemia is associated with worse local control in HN cancer, I don't know of any data that shows that blood transfusions can help...
What about Lv V and VI?
If the patient is a poor surgical candidate and is a symptomatic, can he or she live with this?
If not what radiation fractionation regimen is preferred for otherwise good KPS patient?
Given recent advancements in the understanding of biological differences in prostate cancer patients of African vs. other ancestry, does your manageme...
For instance, in a patient with Her2(+) breast cancer and 3x small newly diagnosed asymptomatic brain metastases, would you consider a trial of TDM-1 ...
Do you have a preference for specific steroids? Some practices may switch to prednisone during this time.
Patients with gliomas are often on d...
The forrest plot in the recent meta-analysis published in European Urology is rather impressive, even in the more recent high dose radiation series.&n...
For definitive vulvar ca, is 5940 cGy the minimum acceptable dose for gross disease? 5760cGy? Or should the dose be escalated beyond 60Gy?
Do you always stick with a conventional fracionation, or in some cases, are you comfortable hypofractionating? Do you ever use a wait and see approach...
For instance, would you treat an anal cancer in someone that has a healing perianal access? What do you look for when considering initiating treatment...
For example, is 8 Gy x 1 well tolerated in the setting of multi-level vertebral body radiation?
For example, a patient with liposarcoma of the lower extremity status post preoperative radiation to 50 Gy who then underwent resection and had focall...
Specifically, a non-brachytherapy fellowship? As a private practitioner, when hiring, seeing a fellowship immediately hurts the applicant in my eyes. ...
Do you treat patients who are clinically hypothyroid but biochemically euthyroid?
Should surgery followed by adjuvant chemotherapy and radiation be considered for non-bulky single station N2 disease?
Would you recommend re-excision of a positive margin containing only pleomorphic LCIS prior to radiation for BCS? Does the presence of ...
RTOG 0539 takes a dose painting approach for Group III to treat edema to 54Gy and lesion to 60Gy. However, this significantly increases target v...
How much do you factor in the possibility of radiation-induced second malignancies for the treatment of benign conditions in younger patients?
How would your recommendation change based on interval from previous radiation?
Is there an age where the patient would be considered "too young" to receive definitive radiation therapy as opposed to surgery?
Should it be routinely used for all patients? Or should it be used for specific risk groups such as unfavorable intermediate risk patients to rule out...
Are there any data to support whole breast RT, SBRT, or cryoablation?
Do you adjust your dose based on previous whole brain radiation? What time interval would you wait following whole brain or would you treat with upfro...
Does it make a difference if you place the bolus above or below the mask?
In other words, how long after radiation therapy do you expect the palpable mass to completely resolve?
Does your dose-fractionation approach change in such cases?
Can the drug continue during radiation therapy or should it be discontinued at a specified time prior to initiation of radiation?
In keeping with prior randomized trials, Alliance N0574 demonstrated that SRS+WBRT provides superior intracranial disease control but w...
Specifically, what arguments can be made for or against upfront neck dissection in patients who present with necrotic neck nodes? How would the ...
And if so, in which situations do you offer differing doses?
For example, would you consider adjuvant chemotherapy alone to be sufficient in a patient with an isolated pelvic recurrence and positive margin after...
Would adjuvant chemotherapy suffice, or would you also consider RT in a patient with a PS of 0-1? Would your recommendations change if it was N0...
A recent gamma knife retrospective study from Cleveland Clinic (Mohammadi et al., PMID 27231978) argues for the RTOG dose of 24 Gy, although the ...
The textbook "Shaped Beam Radiosurgery" recommends MRI q 6 months x 2 years, then annually through year 5. "UpToDate" recommends annual MRIs thr...
Assuming other variables, such as number/volume of brain lesions, KPS, and extra-cranial disease status are equal, would HER2 status in a breast cance...
If a biopsy carries a high risk of morbidity what interventions would you recommend for the local failure?
Can you use SBRT for boost?
Are there specific subsets for whom these results should change management?
The NCCN guidelines call for pathological mediastinal lymph node staging for all NSCLC except in solid tumors <1cm and non-solid lesions < ...
What factors do you consider when adding post-lumpectomy radiation therapy for treatment of an intracystic papillary carcinoma?
Randomized trials in the 1980s demonstrated equivalent survival and disease control outcomes for lumpectomy + RT vs mastectomy, but several recent pop...
Do you have a formalized approach, or is it a case by case decision? Do you use bolus differently for a TRAM, tissue expanders, implants, etc?
In situations where there is a significant risk of either local or nodal persistence/recurrence post prostatectomy with a rising PSA, or nodal involve...
Specifically, what factors contribute to your dose-fractionation schedule? In what circumstances (if any) would you recommend 25 Gy in 5 fractions?
Do you prioritize certain dosimetric parameters over others (e.g., considering the Darby report, mean dose to the heart vs. mean LAD dose?)
In a patient who recently completed NAC, TM/LND and PMRT for a hormone positive locally advanced breast cancer and is then found to have a contralater...
Does the better prognosis associated with p16+ H&N cancers relate only to patients who are treated with RT +/- chemo? Or do they do better in...
Given the excellent results from the ASCENDE-RT trial, should we be combining EBRT and brachytherapy? What criteria do you use to determine when ...
Does the recommended frequency depend on the dose that the device is receiving?
Do you target the whole pelvis or a smaller "boost-like" field?
Assuming the patient is a candidate for either of these treatments?
If so, what fields should be used?
If a patient has only IR disease factors but "findings suspicious of extraprostatic extension" on biopsy or MRI or both, would this upstage the patien...
In this abstract the 5-year probability of survival without clinical/biochemical relapse was significantly improved with ADT.
If so, what is your preferred regimen?
We have a great palliative care clinic and I like to refer many patients with metastatic disease, even if I feel that they will live a year or two lon...
Is there any consensus regarding the optimal RT dose, fractionation, and timing to the best abscopal response? What is the optimal metastatic site to ...
Would the dose change based if there was tumor adherent to bowel versus abdominal wall or muscle?
If the systemic agent is going to be held, how many days prior to starting radiation therapy should the agent be held and when can it be restarted aft...
Is it reasonable to dose escalate beyond 60 Gy if meeting all dosimetric criteria and with some room to spare? RTOG 0617 would suggest 60 Gy should be...
If a patient had a recurrence that was pathologically proven despite negative idodine scans, what imaging scans would you follow up with for surveilla...
Should post-op RT be offered to patients after a recurrence in the cervical lymph nodes after a neck dissection?
Are there any tips on how to best use this technique?
In the case of a partial resection with focal perineural invasion, but no lymphadenectomy due to severe fibrosis from prior radio-ablation for hyperth...
For example, how do you decide between applicators such as tandem and ovoid versus tandem split ring insertion for cervical brachytherapy patients?&nb...
In a patient who is not a surgical candidate and has a negative PET/CT and EUS, would you include celiac lymph nodes in the radiation field?
There are a wide range of seemingly safe/effective regimens in the published literature, with an associated array of BED/EQDs and little more to guide...
If there is a signifcant amount of breast tissue contacting the couch in the prone position, are there strategies that can be used to mitigate po...
Does it differ for localized vs. node-positive?
In a patient with node positive disease, treated definitively with radiation, should continuous or intermittent ADT be administered? If a patien...
Following lung RT, I have rarely seen patients present with pneumonia-like symptoms of radiation pneumonitis. I'm more likely to see a patient with wo...
Recently, Epstein et al proposed using a Grade Group system of Groups 1 (GS < 6), 2 (GS 3+4=7), 3 (GS 4+3=7), 4 (GS 4+4=8), and 5 (GS 9-10). T...
Would the histological grade or histology affect the dose? Would you consider dose escalating to the center of the tumor if this would not affect orga...
Does your criteria change if you are considering SBRT?
In this trial, 6 months of concurrent LHRH agonist therapy improved 5-year progression-free survival from 62% to 80%, with similar benefit in low-risk...
For instance, RTOG 0418 did not allow clear cell or papillary serous histologies, but subsequent trials that allow IMRT have (GOG 0249, 0258, RTOG 120...
The NCCN guidelines recommend all patients receive 3 cycles RCHOP followed by ISRT unless they have bulky disease greater than 7.5 cm. However, are th...
Specifically - anus, pancreas, gastric?
What can be done prior to RT to prevent this? (Flomax/hormones not helping)
Do you treat to full dose or a lower dose with a cone down to the prostate PTV? Is there any data to support a particular dose?
For a recurrence after nephrectomy, the NCCN recommends surgery or, in inoperable patients, systemic therapy. There is no mention of SBRT in...
Would you do concurrent vs. sequential chemoradiation? What would be your preferred dose and fractionation?
Interstitial needles can result in hot spots in the bladder, but how well tolerated is that? On the other hand, intracavitary applicators usually don'...
Comparison of prone versus supine positioning showed that 85% of patients with left sided breast cancer benefit more from the prone versus supine posi...
With the field moving more toward ISRT/ INRT, and conformal radiation, would you generate separate PTV for initial nodal involvements that are within ...
Do you use any age limit to determine whether pancreatic SBRT is appropriate?
Does your postop dose change or use of chemo change if you have close margins?
How do you manage a patient a with a PET positive inguinal lymph node who has a typical anal cancer? If a biopsy is done and it is negative, is it is ...
In a case with negative margins, would you consider chemotherapy alone or sequence with chemoradiation?
Since we know that both the "Canadian" fractionation and partial breast irradiation work as treatment for early stage breast cancer in the same patien...
What dose would you boost to in each situation?
The Hughes study looked at women > 70 years of age. In light of the PRIME II results, can women aged 65 - 70 avoid RT or is longer follow up needed...
Would you change your management based on receptor status (ER/PR+/HER2 neg vs triple neg) or menopausal status (pre vs post menopausal)? Would you tre...
Does the presense of ulcerative colitis, now in remission, affect your dose and fields?
Would this be considered acceptable in an older woman with high grade disease?
How do you incorporate the pre-chemo vs post-chemo tumor volume into the treatment design?
I am treating a resected high grade liposarcoma with positive surgical margins to 66Gy. I would prefer to use IMRT to spare the humerus, but ...
In a man with castrate resistant disease invading into the bladder and rectum, I have been told that 30Gy/10 fractions to the prostate is inadequate, ...
Guidelines dont seem to account for this possibility. Could it just be normal prostate tissue growing back that is leading to PSA, why just assume it ...
When planning SBRT cases for primary liver cancers, it is very difficult to see the tumor on the non-contrast 4D scan. How do you use information from...
In my training, we used an abdominal compression paddle, but in my current practice, my physicist says that we cannot treat through multiple parts of ...
Is RAI sufficient in cases of +margin but negative post-op iodine scan? In cases where there was no pre-op radioactive iodine scan to ensure iodi...
What is the risk of joint issues if you treat the epitrochlear nodes?
What number of cores and what % cores involved do you look at to consider them low-intermediate risk for prostate SBRT?
What are the contraints you look for?
In this circumstance is their any evidence that indicates a locoregional control benefit to PORT?
Are there any precautions to prevent formation of a TE fistula?
Can it be avoided in patients with a microscopically positive lymph node?
Would your approach change if the histology were adenocarcinoma?
Dose in many studies were often prescribed to a point rather than a volume and with 3D planning, we may be upping the breast dose. The D2eq dose...
If so, how do you target this boost?
As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?
If so, what data should be presented to insurance companies to cover the cost?
If so, how? Or would you avoid SBRT in such a situation?
In a lesion <2.5 cm from anal verge arising in a tubulovillous adenoma, does the data from Taylor, et. al. Red Journal 2001 apply?
Are the interim results of EF-14 (Stupp et al) practice changing?
Do you offer RT if the patient is well controlled on medications?
What are the late effect risks in a patient status post a total colectomy if treated with IMRT for prostate cancer?
It seems that some high volume centers have expanded their selection of patients for both HDR monotherapy and boosts.
If you do have size or IP...
Does the recent Danish Breast Cancer Group IMN study (JCO 11/23/15), showing a survival benefit to IM irradiation in patients with early stage no...
In starting prostate SBRT at an instutution, what are issues with the treatment that one should pay special attention to?
Will the NCCN guidelines change based on this study?
The NCCN guidelines discourage the use of PET/CT surveillance but the recent analysis of RTOG 0235 found post-CRT PET uptake to be associated with wor...
In other words, is there a PSA value above which metastases are imminent?
Based on the European data published in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961085-0/abstract), are you s...
Is there a hypofractionated dose regimen that would be suitable for palliation prior to the patient going to hospice?
If so, what is your treatment volume?
If so, what dose should be used?
For a patient who has completed 40 hyperbaric sessions with steroids with little improvement, what other options exist?
For example, in an otherwise intermediate risk localized endometrial cancer (Grade 2, FIGO IB)?
What are the targets (tumor bed, positive margin, nodes etc.)?
If so what dose-fractionation do you use and what constraints for brachial plexus?
If not, do you have any experience with acceptable late toxicity and cosmesis with whole breast radiation in these patients?
Do you treat the hilum and ipsilateral mediastinum? Just the lymph node levels that were positive at surgery? I have not found good guidel...
Would you avoid any RT in these patients, including palliation for a portal vein thrombus? Or would you consider a short course of RT (like 20Gy/5fx)?
What dose do you recommend?
What clinicopathologic features do you typically consider?
The Canadian study presented at ASTRO 2015 showed a decrease in pain flare prior to single dose 8Gy RT, but steroids were given for 5 days prior to RT...
When nodal regions not amenable to biopsy but are enlarged without significant SUV uptake, should they be treated as involed and recieve RT?
I know that some would argue that healthy patients with an excellent performance status may not need an early palliative care referral, but wouldn't i...
Although the landmark randomized trials treated up to 64 Gy, there is data out of Italy suggesting that higher doses yield better biochemical control ...
In the setting of a negative lymph node sampling, would you treat a full pelvis or mini-pelvis to compensate for lack of the appropriate surgery? Is a...
Is it based on symptoms only? Every 3 months?
Can the IMNs ever be spared, or would you consider it mandatory for all inflammatory breast cancers?
Specifically from a GI primary?
E.g. breast? I have found no literature on skin tolerance acutely or chronically.
On what other factors should be considered in making a treatment recommendation for salvage radiation therapy?
The BED10 for 50 Gy in 5 fractions is 100, which is significantly lower then the BED of the 54 Gy in 3 fractions regimen (151). Since the Kestin/Grill...
Our dosimetrists rarely meet the RTOG constraint using a non-coplanar technique, especially for very small lesions. I haven't been able to find a corr...
In a patient with an R0 resection, would you routinely recommend postop chemoradiation, since these patients were included in the MacDo...
In patients who don't meet traditional criteria for adjuvant chemoradiation from Peters (GOG 109) and < 2 high risk factors from Rotman (GOG 92) fo...
For cases with positive margins, do you boost to 54 Gy? If so, do you boost the entire tumor bed or only the area of the positive margin?
Do you handle a non-emergent indication such as palliation for pain vs cord compression differently in a patient unwilling to undergo a biopsy?
Does IFRT include only the involved lymph nodes + margin or the entire involved lymph node station as specified by the Michigan Atlas?
Many centers seem to try to get at least 2 fractions in the week that patients begin treatment, is this something that is necessary to try to do? &nbs...
Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.
Do you favor a short palliative regimen, or a full course definitive treatment to 64.8Gy? How does your management change if the patient has a good pe...
Do you put more weight on specific CVDs such as scleroderma as contraindications for any RT?
After ABVE-PC X4 and Ifos/vinorelbine x 2 per AHOD 0831 (and is unable to have these sites biopsied), what dose would you treat to and what volume wou...
Should standard post operative radiation fields be used, treating up to the L5-S1 interspace? Or is it acceptable to treat a lower field, for ins...
What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...
For example: Initial primary of early stage completely resected oral cavity or oral tongue cancer with no adverse features and therefore did not get r...
With ultra-sensitive PSA, it's unclear to me whether a doubling from 0.01 to 0.02 or 0.02 to 0.04 is significant. Is there a certain value that you wo...
Are your constraints different than the standard constraints used for patients who have not had surgery?
For example, if a 5 x 5 cm squamaous cell carcinoma with deep invasion has been resected via Mohs with negative margins, will your PTV include the ent...
If a patient is deemed high risk enough to require hormones with RT in the salvage setting, how long would you maintain them on ADT? Would you extrapo...
Is your decision influenced by factors such as the location of the intramammary nodes and/or the mapping of sentinel nodes to the axilla?
In a patient with multiple brain metastases from NSCLC, is this reasonable?
Any advice on how to safely incorporate it into our practice?
Would you favor only offering salvage therapy if the PSA rises?
I am aware that chemotherapy can obviate the need for RT in patients with SVC syndrome, but I'm not sure if this can be extrapolated to spinal cord co...
What if there is a CR to chemo?
Would you consider placing a stent in this patent graft to minimize closure of the graft after SBRT?
Do people use it interchangeably with DMax or use the 2cmx2cm definition? I often get pushback from the dosimetrists for plans where the DMax is ...
If so, how do you calculate the amount of fractions that are added?
For example, in a demented, poor performance status, elderly patient?
Should elective mediastinal irradiation still be avoided? For example, if you have a T2 RLL lesion, and let's say, a positive AP window node, do you n...
When counseling patients with organ-confined prostate cancer, what rates of impotence, incontinence, rectal toxicity, and urethral stricture shou...
Is there any concern about hemorrhage from treatment effect on tumor? Would SABR worsen the chance of fatal hemorrhage/hemoptysis and if so, would you...
How do the number of lesions treated and histology affect your decision making?
We can always find individual cases from time to time in which the care deviated from the “standard of care” and these can be referred for...
Would a history of prior vasectomy in a stage IIA seminoma be an indication to include the inguinal nodes in the RT treatment field?
If so, what would you include in the target and what dose?
Is modern surgical/reconstruction treatment superior to radiation therapy?
If contact brachytherapy or superficial (orthovoltage) therapy isnt possib...
Is there any advantage to primary RT as opposed to just orchiectomy? Additionally, in order to confirm Tis, a biopsy is required, which is typica...
For elective target volumes it makes sense in most cases to pull in the PTV 3-5mm from the skin for planning, but for gross disease close to the skin ...
If the post-operative simulation films reveal a significant lymphocele secondary to pelvic lymph node sampling, is it imperative that the entire lymph...
There seem to be good prospective studies (Australian study and Canadian study) which debunk the thought that deodorants/antiperspirants increase skin...
The long term data indicating an OS and PFS benefit with the addition PCV with RT when compared to RT alone were reported in a NCI press release (http...
After a wide excision for a <3mm lesion, flap reconstruction and selective neck dissection and no initial PNI, residual tumor, or positive ymph nod...
The optimal timing of post-prostatectomy RT in high-risk patients is debatable and currently the question of prospective randomized trials; however, g...
Since the Bonner trial only found a benefit to the combination of cetuximab with the concomitant boost arm, do you routinely recommend this fractionat...
Is there a preferred low dose splenic irradiation regimine?
I've heard justification for treating the whole bladder to 60-64 Gy based on the UK MRC study (James et al. NEJM 2012 and Huddart et al. IJROBP 2013) ...
The most frequent argument against whole brain RT is debilitating toxicity. However, I am having a hard time finding the most evidence based data on h...
If the patient has no pathologic risk factors that would ordinarily necessitate PMRT, do you omit it? Does triple negative subtype affect your decisio...
Fore example for a T3N0 rectal cancer on EUS?
When radiation therapy is utilized, what should the radiation therapy treatment fields include and what imaging studies should be completed to assist ...
Would the risk of radiation-induced second malignancy outweigh the benefit of locoregional control for a young patient with high grade DCIS?
Is the surrounding erythema as part of the GTV so that the margin is placed around the erythema rather than around the gross lesion only?
If so, should involved site radiation thearpy (ISRT) or involved field radiation therapy (IFRT) be used for the radiation therapy treatment fields? Wo...
Assume all other options have been exhausted or are not feasible (e.g. systemic treatments, medically inoperable, etc.). Is there a BED or EQD2 that y...
In this case, the patient is currently on maintenance BCG.
While the Duke randomized study found similar rates of control with 1mm v. 3mm margins and higher radionecrosis with 3mm, it did not look at treating ...
If so, when is the right time to obtain this? Are there situations when you recommend postop MRI ( for example, for patients with a large reconstructi...
The gyn oncs at my institution sometimes will not perform lymphadenectomy if biopsy indicates low risk disease. Would LVSI as sole adverse risk factor...
Realistically, there will always be some (hopefully small) inconsistency with bladder filling, and thus some small bowel could easily receive &ge...
The literature does not seem to report on the rates of improvement of headaches.
Do you have any concern for increased toxicity when you treat a patient with radiation therapy who has an autoimmune disorder? (hypofractiationation v...
Is heparin or warfarin routinely held prior to treatment?
Are the results of AHOD0031 practice changing?
With conventional RT, the dose to the brachial plexus should be no more than 50-55Gy max. One exception to this is the addition of PAB in conventional...
Assuming a patient who could tolerate either, which is preferred? Does this depend on the choice for concurrent chemotherapy (5FU+mitomycin vs ci...
While there are clearly well-defined margin guidelines for GBM (which nonetheless differ between RTOG and other groups), little has been written about...
Do you look at pretreatment breast MRI or post surgical assessment of the tumor bed/treatment effect? How would you resolve discrepancies betwee...
Do you use SIB or sequential approach? Do size of lymph nodes influence your dose or decision?
Would triple negative disease effect your decision?
I would presume (perhaps incorrectly) that hospital-based centers might oppose this for whatever reason, but the proposal is at a minimum intriguing. ...
When the disease (in this case, lymphoma) involves almost all of the entire muscle compartment of the distal lower extremity, what is a safe dose? I'm...
In drawing the lung blocks approximately 1 cm in from the chest wall, diaphragm and mediastinum, should the blocks stop underneath the clavicle o...
The VA system has gotten some bad press the past few years. Is it a good first job after residency, if you are interested in academics? Are there oppo...
AREN0533 schema requires knowledge of 1p16q status, though this test is not available off-protocol. How does this affect management for patients treat...
If a patient with stage I, low grade follicular lymphoma achieves a complete response after rituxan and treanda is there any role for consolidative ra...
Would you treat initially involved contralateral supraclavicular nodes?
The Chung validation study did not find that size > 4cm or rete testis invasion are risk factors for relapse and the current NCCN guideline discour...
In the past, I haven't seen great results in palliating the presacral area. The pain is excruciating for many patients. Is there an effective option f...
In a patient with a T1 breast cancer who underwent mastectomy and ALND and recurred in the axilla a year later, would you offer RT to the chest wall a...
i.e. are there any situations where you may recommend against using hypofractionation for a patient with left sided breast cancer such as dose constra...
Should an agressive attempt at resection be made? Do factors like age, KPS, MGMT status play a role in how aggressive of a push for surgery you make?
I've recently found out about your work on diet and cancer, and am greatly intrigued. I am a big believer in the power of nutrition and think we as do...
Do you feel that it must start on day 1 with RT, as strict as even 4h prior to RT (recommended by some folks for maximal “Radiosensitization&rdq...
In the case where there is a PET avid subpleural nodule in the exact same location as needle biopsy 3 months prior, is this considered a chest wall me...
In RTOG 9508, 4 cm was the cut-off size for WBRT followed by SRS.
Conversely, should OARs be kept within contraints if it requires dose compromise on these high risk CTV structures?
Even if there is a gap, it is dosimetrically hard to spare that little strip.
Particularly the old T2b with sluggish cords and rather diffuse involvement? The data is mixed with regard to hyper- fractionation, vs. hypo-frac...
For small overall volumes (e.g. 0.5cm solid component, 1cm total lesion size when including GGO), I imagine treating the entirety of the abnormality i...
What dose and volume would you use?
Do you treat the enlarged PET negative nodes to the high risk dose as well?
In reading through the policy of one of my state's private insurance companies, I came across something with which I'm not familiar, namely treating p...
What if the pre-chemo FNA of the suspicious node is negative?
In a patient with recurrent SCC in the neck s/p ***remote*** partial glossectomy (R0, 6 months ago), who is now s/p neck dissection for gross disease ...
If so, what selection criteria do you use for such patients?
Borderline cases such as patients that received NAC with a complete response or N1 disease with 1-3 positive nodes make me think frequently about this...
The retrospective series quote a local control rate of 85-90% at one year and the current NCCN guidelines list this as an option following surgery for...
Would extensive residual DCIS (>5cm), hormone receptor negativity, Her2+ status, or age < 40 effect your decision?
Are there any open clinical trials testing this?
Is there any literature supporting that a gentle fractionation/bid regimen (i.e., 1.5Gy bid x 30 = 45Gy) is safer than a standard fractionation ...
Does the axilla have to be addressed surgically or with RT, given that the AMAROS trial eligibility criteria were amended to address sentinel lymph no...
We are in the process of implementing a BrainLab SRS program for intracranial sites. In my previous experience, all of the planning and set-up f...
If so, what technique and dose would you suggest?
Following a mini-pelvis field?
Do you use a particular cut-off? For example, someone in their 40's?
Or, as this is presumed metastatic disease, would you recommend systemic treatment and defer RT?
Roughly what percentage of patients are treated without a biopsy?
Specifically for marginal zone or follicle center?
Do you define it as whole lungs (inc. tumor) or whole lungs minus GTV, CTV, ITV, or PTV?
If so, how do you decide which patients to treat with breath hold vs. free breathing? Do you routinely perform 4D CTs?
Is it necessary to treat the whole orbit or is conformal treatment ok?
The patient has a positive bone scan (2 lesions), grade 4+5=9/10 prostate, and cancer cannot urinate without a catheter.
A 40 year old patient receiving post-op RT for breast cancer asked me if there is any risk for her becoming pregnant after completing RT. Eric H...
After a nerve sparing parotidectomy, would you offer postoperative radiotherapy? If so, what volume and dose? Would it change your management if the p...
I'm aware of a number of publications that suggest that after 1-2 years, the cord should be able to handle about 50% of the original tolerance dose. &...
I.e. Would you treat most of the normal esophagus to include a mediastinal lymph node?
We've seen quite a few patients present with NSCLC with a single brain metastasis and a good performance status. Would you advocate for an aggressive ...
In a patient with Stage IE DLBCL, is your treatment volume postchemo ISRT or whole breast? Would you consolidate if a lumpectomy was performed prior t...
ASTRO 2014's lung session presented data from RTOG 0236, showing a 20% intralobar failure/recurrence despite only 7% local failure. How does one recon...
RTOG 0915 allows either technique, but I've heard people say that IMRT is not "technically" SBRT. Is there is a benefit to the non-coplanar 3D techniq...
RTOG 9802 showed a large overall survival benefit for the addition of PCV to radiotherapy in patients with "high-risk" low grade glioma (eit...
Is it a function of the type of reconstruction contemplated?
The 2013 ASCO guidelines and current NCCN guidelines recommend yearly mammograms but our radiologists are still recommending mammograms every 6 m...
Do you prophylactically treat the entire parotid gland as well?
The patient underwent lobectomy and nodal staging for a presumed non-small cell lung cancer.
It seems that postoperative RT is indicated to help improve local control (based on small series from MD Anderson and Mayo Clinic). What areas s...
Do you pre-medicate with steroids?
For a T3N0 SCC of the larynx with PET/CT showing negative cervical nodes, but with CT neck showing a 1.5cm level II cervical node, to what dose to you...
If the patient has negative axillary nodes and no other signs of high risk disease other then a local chest wall failure, do I still need to treat the...
What exactly do you contour and what is your dose constraint to that volume?
What is the best management for a local recurrence for a stage I NSCLC treated previously with SBRT?
Should fractionated EBRT be administered or can repeat SBRT be used?
Our ENT surgeons often tell patients with evidence of matted nodes on imaging that their swallowing function will be much worse after 70Gy as compared...
Do you really feel the failure was because people crossed over to bev at progression, or is it simply that bev does not affect overall survival?
Does using something like a vienna applicator allow you to avoid dose escalation with more external beam? How do you recommend doing a classic pa...
They used to be given concomitantly now they are done sequentially. I can only find conflicting data to justify this trend.
Some classic references recommend the coverage of the entirety of the sacrum but the volume delineation guidelines for both seem to only cover the mos...
In the definitive setting, and would that change if cystecomy was planned if there was a complete response after CRT? (similar to TCC paradigm).
Do the level II lymph nodes need to be covered for T2 SCC of the retormolar trigone if it is completely resected but has close margins?
It is my impression that for brain metastases >3 cm it may be preferable to deliver fractionated SRT versus the RTOG dose of 15 Gy SRS, if WBRT is ...
While the Nigro/Wayne state regimen consisting of Mito C & 5FU is well stablished for squamous cell carcinoma of the anus/perianal tissue, a...
If so, what dose?
In SBRT, it has been said that Pencil Beam dose calculation algorithm can overestimate the target dose and understimate the normal tiss...
I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...
Definitive chemoradiation vs. surgery followed by adjuvant radiation/chemoradiation?
In contouring base of tongue, tonsil, larynx and other H+N tumors, the CTV and PTV will frequently encroach on the posterior pharyngeal wall. I'd appr...
Hoskin et al (Lancet Oncology 2014) suggest 24Gy/12fx is more effect RT dose compared to 4Gy.
Eight years after brachytherapy for a low risk prostate cancer, a patient has unresectable high grade squamous cell carcinoma of the bladder. Should I...
If so, do you do this routinely or only in certain circumstances? Is there data to support routine mammogram before breast radiotherapy?
Some people have compared medical missions to "placing a band-aid on a severed limb." How do radiation oncology missions go beyond the band-aid approa...
What regional lymph nodes do you include perigastric, portahepatic, periesophageal, celiac, splenic, pancreaticoduodenal, sup. mesenteric, paraesophag...
What dose/fractionation is appropriate and does it differ between histology?
More specifically, which cardiac risk factors do you look for? Diabetes? Previous MI? Dyslipidemia? Peripheral vascular disease? CHF?
In general how do you counsel patients with high risk prostate cancer when choosing radiation verse prostatectomy? What numbers do you quote for ...
More specificlaly, in a non-emergent situation?
Do you hypofractionate or add any concurrent systemic therapy? What specific dose-fractionation regimens do you recommend?
Our neurosurgeons have been pushing for definitive and postop SRS in patients with a poor performance status. Should I consider this or is it tot...
The patient failed previous excisions and medical therapy and is no longer a surgical candidate.
Even though data from TROG 02.01 showed 52% decrease in LR, I've heard some argue that toxicity is increased and that "it damages the blood vessels an...
We rarely treat grade III oligos with sequential PCV and RT, despite the positive results of phase III trials. We do TMZ alone until progression which...
What are the primary data that drove organ at risk and conformality dose constraints?
Is there a benefit to IMRT when we treat to relatively low doses (as compared to squamous cell cancers of the head and neck)?
Additionally, what lymph node levels do you typically treat?
This is a patient who would have been an appropriate candidate for radiation upfront, but was managed with androgen deprivation therapy instead. On th...
Does hydroureter and leg edema alter your opinion?
Is a biopsy needed? Do you consider treatment palliative or curative?
In a case-control study by Darby et al in the New England Journal of Medicine, patients treated for breast cancer with radiation were found to have an...
What dose and fractionation is appropriate for medullary thyroid carcinoma with extrathyroid extension, bilateral cervical lymph node levels 2-5 with ...
Brachytherapy, EBRT or both and what is the best dose?
Are there any indications to choose one over the other?
For example, for a tumor arising from the true cord and extending superiorly to false cord and inferiorly to subglottis with mobile vocal cords?
How should we counsel young women who are receiving treatment for GI/GYN malignancies?
Sometimes the scans don’t line up well because of differences in rectal and bladder fullness- any tips to optimize the fusion?
Do you plan every fraction, every other fraction, or use one plan for the whole treatment?
Or for that matter, offer PMRT on the basis of a patient having triple negative disease?
I ask this because I am seeing more and more patients who have had surgery despite presenting with high risk disease.
I've found that very few patients have a regular breathing cycle, which makes respiratory gating very difficult. Any other solutions?
The most recent ABS guidelines don't discuss a dose constraint for the small bowel.
For example, if there is extensive ipsilateral lymph node involvement and extracapsular extension for a submandibular gland tumor?
Even though we do not have the best data on the use of induction chemotherapy, what are current practices?
Is your practice different between HPV+ an...
I know many do not treat the pelvis at all, but for those who do, what criteria do you use? Risk? Gleason? PSA? T stage?
Or is it more appropriate for certain sites/stages/histologies?
I'm not sure how to interpret the results of the study published in JNCI earlier this year.
What schedule is best for preventing fibrosis and for patient compliance?
Does your strategy change if bladder invasion is present?
Is there a consensus on the MAGIC v. MacDonald debate?
Specifically, for a diffuse large B cell lymphoma of the femur?
Do you treat PAs if pelvic nodes are positive? If common iliacs are involved? Only if there are positive PA nodes?
And should special precautions be taken (such as dose reduction, prophylactic symptom management, etc)?
It seems that with the arms up, you get better lung blocking but with arms akimbo, you might have a lower dose to the humeral head.
In practice, do you send patients with N2/3 disease for mediastinal staging if not offered upfront?
Would you treat this as high risk?
And does your dose changes with positive margins? I can't seem to find a good answer in the literature.
My institution is considering a major investment/purchase of this technology to complement our existing array of breast radiotherapy options.
In other words, have the results of the MA.20 and EORTC trials changed your practice?
Has the recent 12-year ECOG update for surgical excision of DCIS without radiation therapy changed your practice management?
Do the urethral constraints used in prostate brachytherapy apply to women undergoing gyn brachy?
I recently had a patient with unresectable disease ask for a PET before starting RT but I’m not sure there is a benefit.
We use PET for esophageal, but not gastric cancer. GE junction seems like a grey area.
Does the advent of FLOT in gastric cancers, change your approach to GE adeno's? Would anyone consider FLOT followed by chemoradition followed by surge...
What techniques work best?
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