Radiation Oncology   

Questions discussed in this category


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

If the diagnosis was made by an outside physicain, how do you confirm/refute the diagnosis? Would an alternative diagnosis like a thrombosed hemorrhoi...

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...

Would you offer adjuvant radiation? (Dose? Target?) vs Salvage? Would you add ADT? Would you add abiraterone? Would the number of lymph nodes involv...

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 ...

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...

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? 

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...

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)?

No prior brain radiation. Is full dose whole brain radiation mandated? Would you consider PCI dose or brain surveillance?

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...

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 ...

In patients with large areas of painful bone metastases, do you ever do hemibody? If so, what is the preferred dose? 

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...

Does esophageal cancer continue to respond up to 6 months on PET, like anal SCC or p16+ oropharyngeal cancers?

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...

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? 

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...

If so, what is timing after salvage radiation that you would recommend? 

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.

NGS without any actionable mutations and PD-L1 TPS 15%. Would you offer chemotherapy, radiation, or immunotherapy and, if so, in what order?

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?

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? 

Are there specific patient populations in which you may feel comfortable with a patient selecting only one adjuvant therapy approach (tamoxifen vs RT)...

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?

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&...

If so, what dose would you recommend? What other management options would you consider? 

If the patient has invasive breast carcinoma and close margins with no other risk factors for local recurrence, would you utilize a cavity boost?

Is this an artifact of what agent prior clinical trials used or something to do with mechanism of action (ie less mineralocorticoid effect of dex)?

The patient previously underwent resection with close margins, adjuvant radiation to 66 Gy/33 fractions. Serial MRIs demonstrate progression with con...

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? 

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...

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 ...

Do you recommend changing the chemotherapy regimen post-operatively? Do you recommend post-operative chemoradiation? 

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...

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...

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...

What advantages/disadvantages are there between assays or over traditional clinical pathologic factors? What other concerns do you have?

Would you consider boosting the nodes?  What dose?  Would this change your recommendation for length of ADT?  

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?

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?

What dose/fractionation scheme do you use? Is SBRT a viable option? How long after the first treatment should one wait?

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?

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-...

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...

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

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...

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?  

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

If a patient presents with ER/PR positive, HER-2 negative pT1cN1 invasive ductal carcinoma with micropapillary features s/p lumpectomy, how would you ...

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...

The patient is not amenable to re-resection. What pathologic features and/or margin status would preclude the need for additional irradiation? 

Do you treat this as a recurrence with comprehensive CW and RLN irradiation? Are there any patients who don't need RT? For example, would you recommen...

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

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, a two week break halfway through a course of hypofractionation for early stage breast cancer. 

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? 

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

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.

Ideally, treatment should be completed in 56 days (preferably < 50 days). If there has been a significant delay to brachytherapy (>2-3 months) d...

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 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?

This is one of the available options in the NRG-BR007 DEBRA trial

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...

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 is your rationale for your approach? Does your treatment in any way depend on stage, extent of RT, and/or dose to OARs?

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 ...

For example do you use Prolaris, or other genetic tests to guide ADT decision making? 

Is there certain information or practices that you find sets the day up for success? 

Is there a benefit to EBRT/SBRT or would you choose observation until there is pathologic evidence of invasive pancreatic cancer?

Does availability of surface imaging (visionRT) reduce your use of imaging for setup?

If not, how should you select those cases that should be referred?

Do you always cover these areas of ipsilateral neck is positive? Does it depend on nodal level involved, primary site (oropharynx vs. larynx/hypophary...

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)?

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...

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...

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...

If a patient presents with metastatic disease (by virtue of extensive PA nodal burden, mediastinal/SCV involvement, no solid organs) but received urge...

Has your practice changed based on the randomized, phase 3 study showing prophylactic gabapentin is not effective? Please share your thoughts and exp...

NCCN recommends perioperative FLOT or FOLFOX vs. neoadjuvant chemoRT with Carboplatin/Paclitaxel or FOLFOX.Does CM-577 and the approval of nivolumab p...

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...

If the margins contain in situ disease, would you recommend further wide local excision? Would chronic immunosuppressive disease affect your treatmen...

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...

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...

Additionally, when evaluating margin status for APBI IMRT 30 Gy in 5 fractions which specifies at least 5mm margins, do you look at the DCIS margin or...

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.

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...

Would you boost to >54Gy? 60Gy? Is there relevant literature/evidence for supporting a higher dose?

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...

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?

If biopsy is not feasible, should these patient be treated as cN+ with neoadjuvant chemotherapy or as cN0 with upfront surgery with axillary sent...

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...

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?

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

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

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...

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? 

Based on Mill et al paper showing increased IBTR rates with ILC vs IDC (https://theoncologist.onlinelibrary.wiley.com/doi/10.1002/onco.13980)

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

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...

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 ...

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?

If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...

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 is not an option, would you proceed with radiation or observation? If the patient had prior ...

Would you use it for initial staging or at time of biochemical recurrence?

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...

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?  

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...

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.  

Patient developed pembrolizumab-related pneumonitis after ddAC followed by Taxol/Keytruda - what thresholds/constraints would you prioritize with rega...

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 ...

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

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? 

What is your level of concern for chest wall toxicity? Any difference in your thought process between SCLC vs. NSCLC?

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 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...

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...

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...

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...

Is there any additional benefit to radiation in addition to steroids in a patient who is not a surgical candidate?

Based on the SCORAD III trial, will you now be treating patients with spinal cord compression with single-fraction radiotherapy? Is there anyone ...

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...

Individuals often cite ARST0332 to justify radiation omission in high grade R0 resections, but R0 was defined as > 5 mm margins.

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...

Would you choose re-treatment with electrons, photons, or brachytherapy?   What dose and fractionation scheme would you employ?

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...

I have seen small amounts of evidence for V4<20cc and V14<7cc, but overall it seems like there is little published on this issue.  

Would you consider external beam radiation vs HDR vs LDR? What dose, margins, and OAR constraints would you use given prior treatment?

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...

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? 

What would be your radiation volumes/dose and choice of chemotherapy?

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?

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 ...

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?

What would be your preferred treatment technique and dose/fractionation?

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...

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, ...

Would you treat the entire pelvis vs local recurrence? How would you approach the oligometastatic lesion? Would your treatment recommendation change i...

Lymph node is 4.5cm with no reported ECE. Does the size of the LN or presence or absence of ECE affect your decision?

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?

How would your management change in an elderly patient with no surgery verus superficial parotidectomy or total parotidectomy? 

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...

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?

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? 

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

The patient was initially observed after radical hysterectomy due to young age, FIGO IA grade 2 disease. The patient had isolated, biopsy-proven vagi...

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...

How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?

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...

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?

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...

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...

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

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

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...

The CROSS trial showed a survival benefit with 4140cGy and concurrent carbo/taxol, but I was always trained to treat to 5040cGy. Is anyone de-escalati...

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 appro...

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?

Would your recommendation change based on grade and/or location (weight-bearing vs non weight-bearing bone)? 

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

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...

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?

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

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 ...

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...

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?

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

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...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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? 

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

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

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

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

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

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are there any circumstances that would necessitate treatment? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

Assuming the patient is otherwise a candidate for APBI.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What fractionation scheme would you use?  Would you give SBRT to a hilar tumor that has N1 nodal involvement adjacent to the tumor but can be enc...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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