Radiation Oncology
Questions discussed in this category
Should external beam radiation be 'maxed out' before use of lutetium-177?
How should ECE influence radiotherapy in breast cancer?
For T1-2 patients with N1 disease after sentinel node biopsy alone and upfront mastectomy (gr...
Should lymph nodes ever be targeted? If bone invasion or erosion is present, and surgery is not feasible, is radiation appropriate, and to what dose?
Would you hypofractionate or be more conservative at 2 Gy per fraction? Would your management be affected knowing the patient is on hydroxyurea?
Specifically, after chemo and RT to 36.0 Gy/15 fx with stable to slight progression of disease at 6 months, what (if any) regimen of reirradiation wou...
Specifically, will the higher rate of local failure in the TNT (short-course RT) arm lead you to consider a TNT approach with long-course CRT?Dijkstra...
Should external beam radiation be 'maxed out' before use of lutetium 177?
Assuming the recurrence is above the prior radiation field, would you cover the paraaortic region with an SIB or treat only the involved node? What do...
A series of 46 patients showed excellent local control with SBRT (91% at 9 years). Should SBRT only be offered to patients formally deemed inoper...
Any best evidence for a given schema?
How do you incorporate this into your follow-up care and how do you instruct the patient?
If a patient presents with de novo oligometastatic (i.e., meeting STAMPEDE low met burden criteria) prostate cancer with no prior history of primary t...
Disease is not responding to systemic therapy.
How do clinicopathologic factors affect your selection of dose-fractionation?
Would you treat with curative intent (neoadjuvant chemotherapy, surgery, and radiation to include the sternum)?
Would you be willing to treat an elderly patient on blood thinners who has PSMA+ PET, elevated PSA, and multiple urologists have deemed biopsy too ris...
If pursuing a sequential approach with boost to dominant prostate nodules as seen on MRI, what dosing and fractionation would you use in the initial a...
Is there data on neoadjuvant chemo-RT or chemo in this setting?
What were your “Top 3” Presentations/Studies from the meeting this year? How will it impact your clinical practice?
Treating to 12 to 16 Gy in 1 fraction, I based on the new ASTRO Clinical practice guideline, PRO April 2024
Would you cover the chest wall alone or would it be chest wall plus regional nodes?
Patient factors: no prior radiation therapy
Using arthritis regimens such as 0.5 Gy x 6 fractions
Guidelines support standard fractionation when tumors are large or have brainstem compression but what would indications be for moderate hypofractiona...
Al-Ibraheem et al., PMID 33731050
Surgical data suggests improved survival with pelvic lymphadenectomy and is recommended by NCCN guidelines, however the same is not seen with RT data....
The patient has a history of a lymphoplasmacytic lymphoma with a CR after chemotherapy but presented with a large frontal lobe mass that was biopsied ...
NCCN states that all operable NSCLC patients should be evaluated for pre-op therapy with strong consideration of nivolumab + chemotherapy for those wi...
Some consider T4N3 Stage IIIC to be a borderline case. None of these patients were included in either PACIFIC or KEYNOTE-024 for example. Would y...
How about for non-UIP vs UIP? Non-improvement of ILD with steroids? Specifically in O2-dependent patients? Does the volume of ILD sway your decision (...
What is ideal timing between radiation and surgery? Would you recommend implant first and then radiosurgery? Any additional constraints to the acousti...
Assume the patient is young and active.
For instance, would you incorporate use of Oncotype DX in this patient population to guide decision making on the use of regional nodal irradiation?
If delivering 300 cGy per fraction to the DIL, what urethra dose constraints to you use for 26 and 28 fraction regimens?
Specifically, in the case of a complete response following chemotherapy, do you approach with resection or radiation? If you are treating with RT, wha...
The patient is an elderly female with a good KPS who presented with a cT2N1 triple-negative breast cancer.
The patient refused chemotherapy and immun...
What dose would you give for ECE in this setting?
More specifically, the patient had a single, positive, 3 cm inguinal LN (no ECE, negative margins) removed at the time of APR. If offering RT, would y...
In patients with bone metastases and osteoarthritis, if it is unclear if the pain is from cancer or OA, how do you decide on the radiation dose/fracti...
The Mayo Clinic protocol recommends initial fields -1.5 Gy BID initially to 45 Gy followed by a Brachytherapy boost. If HDR /LDR is not available, wha...
If so, what safety precautions would you have?
Would you consider standard definitive chemoRT (EBRT + HDR brachytherapy)?
With the advent of PSMA PET/CT, this is my study of choice for high risk prostate cancer. Are there scenarios where standard FDG PET is useful? For ex...
Patient is not a candidate for ablation or resection. Would you consider induction systemic therapy to hopefully shrink the disease away from the pace...
Would you consider 36 Gy in 6 once-weekly fractions?
What dose constraints are you most worried about in the re-irradiation setting with such high doses prior?
Are there any subgroups that would still benefit from RNI?
Such as breast plans with < 200 cGy mean heart dose
For example, when would you recommend clinical exam for surveillance versus imaging with MRI, CT or PET?
E.g. higher central hotspot in solid lesions? Any data on differences in toxicity?
Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...
Cervical cancer FIGO stage IIIC2. Bloodwork shows elevated ESR and CRP.
No LN dissection was performed as it was for a suspected CIN III. Final pathology showed +LVSI, -margins (>10mm), -parametrial extension, and 1.2mm...
Would you feel confident in omission for residual disease in the breast and only 1 LN removed during SLNB, which is the same node that was biopsied up...
The patient has extensive disease, and requires palliative radiation to the scapular area (proximal to the brachial plexus) in a region overlapping wi...
Based on the recent guidelines, should prostate SBRT dose be no higher than 3625 cGy in 5 fractions?
The recently published executive summary from ASTRO/ASCO/AUA hypofractionated radiation therapy for localized prostate cancer states "Five-fracti...
I.e. would you offer additional radiotherapy and if so, what technique and dose would you use?
When treating intact bladder cases to 63-64.8 Gy with shrinking fields, the max bowel dose is close to the rx dose. Old RTOG trials often just used V4...
Would a combination of other adverse features such as PNI, GIII, close margin, multiple positive nodes, T4 disease and others make you recommend chemo...
How do you construct the caudal extent of your volume - for example, pelvic floor via RTOG/international consensus vs 4 cm below gross disease via RAP...
If so, what dose would you use?
Do you start neoadjuvantly? Concurrently?
Long-term ADT is deleterious to multiple organ systems (bone/sexual/psychiatric) and increases the risk of MACE. What level 1 evidence do we have to c...
How do you decide between ureteral stent and percutaneous nephrostomy for decompression?
Specifically, on re-staging imaging, would the tumor regression be strictly defined by reduction in cranio-caudal direction only, or would other measu...
For a non-metastatic head and neck cancer patient in his early 80s with an ECOG PS of 3 who has already lost about 20 pounds, how would you favor appr...
Bentzen et al., IJROBP 2023
On the EMBARK trial (Freedland et al., PMID 37851874), 25% of men had a prostatectomy and the publication states, "Patients were excluded … if ...
What fields? Would you treat the pelvis? What factors would help you determine this?
Would you offer radiation and chemotherapy, vorasidenib, or observation?
The patient has an asymptomatic metastasis in the left atrial appendage.
Would you start off with immunotherapy then add radiation later, or visa ver...
Particularly in the setting of "higher risk" features such as grade 3 and a negative, but close margin, would you still consider offering surveillance...
Are there any recent publications or resources regarding which immunotherapy agents are contra-indicated with the use of RT or that outline interactio...
Do you perform NGS on all specimens? If so, how much do you rely on that alone to determine clonality?
The SOUND trial looked at sentinel node versus observation in patients of any age with breast cancer up to 2 cm and a negative preoperative axillary u...
Would prior RT (>30 years ago in this case) to the breast or ATM mutation alter your recommendations?
Are there situations in which one imaging modality has clear advantages over the other?
PSMA or Flucyclovine defined focal nodule
This includes duodenum, stomach, small bowel, colon, kidney, liver, etc.
Should the recent publication of Chen et al. dose escalation study for inoperable SCC esophageal cancer patients treated with CCRT, showing an 8% 5-ye...
Would you continue it until progression of disease? Or would you switch immediately to next line systemic therapy?
NCCN, NRG contouring guidelines, and NRG-GU-009 all recommend treating non-metastatic high risk prostate cancer with dose escalation to involved gross...
Would you consider omitting local therapy?
Any pitfalls to be aware of?
Compared with other thyroid carcinomas, Hürthle cell cancer has a lower avidity for 131I; therefore, treatment with radioactive iodide has l...
She required an episiotomy intraoperatively just to perform an EUA/biopsy. She may not tolerate vaginal cylinder insertion and even if she can, I am u...
In what circumstances would you offer or avoid APBI in a woman with an oncoplastic closure after lumpectomy?
For example, would you offer 4 Gy x 5 fx (vs 24 Gy/12 fx) in a patient with isolated recurrent follicular lymphoma of the breast after RCHOP and maint...
In palliating a painful bone metastasis that abuts a joint and which is associated with a joint effusion, would you treat the entire joint space to ad...
RADICALS-HD trial (ESMO 2022) demonstrated metastasis free survival benefit with 24 months compared to 6 months of ADT.
Would chemoRT be preferred over surgery if there is LVI or PNI?
For example, do you recommend RT for close margins or focal trans-capsular invasion?
In my experience, high tangents are commonly used for patients with pN1mic disease, and occasionally for higher risk patients with pN0 disease. The re...
The NCCN lists concurrent chemoradiotherapy as a primary treatment option in these patients. If so, what total dose do you deliver to involved ly...
Which criteria/factors would you use to decide whether to de-intensify prostate bed/fossa treatment? For instance, surgical margin status or biochemic...
While ESOPEC excluded squamous cell carcinoma, the Japanese JCOG1109 NExT trial also showed superiority of fluoropyrimidine/platinum/taxane over chemo...
What is the expected rate of pneumonitis with this approach?
What dose/fractionation, and constraints would you use?
Or do you start with systemic therapy and then reassess?
Would you consider this stage IVA (spread to adjacent organ) or IVB (spread to distant organ)? For instance, would the presence of direct lumbar verte...
What volumes would you treat for the primary?
RTOG 0848 presented at ASCO 2024 in abstract form: Abrams et al., Journal of Clinical Oncology 2024
What pathologic factors if any would you use to m...
Especially if using an escalated dose such as 58 Gy in 29 fractions for a T3-T4 primary
Is there data supporting the idea that chemotherapy must be onboard prior to delivering radiation for maximal radiosensitization (particularly for hea...
STAMPEDE answer is yes, intuitively it seems there must be a line somewhere though.
For patients staged only with PET that is widely M1, should a CT ...
Would treatment be palliative (i.e. for ureteral obstruction) or definitive? Is there a role for chemotherapy or hypofractionation/SBRT?
Biphenotypic sinonasal sarcoma is a recently described malignancy showing dual differentiation with both myogenic and neural elements.
Current NCCN guidelines recommended not combining relugolix with these agents until more data is available.
Any drug interaction concerns or ot...
Found small reports using SRS or fractionated SRS, but not feeling comfortable with this approach due to limited data. Would you consider surgery + co...
How do the results affect your recommendations for workup and management?
How do you use 105%, 107% and max dose metrics differently compared with non-reconstructed cases?
Does performance status, age, or urinary incontinence after surgery affect your recommendations?
Assume the patient is a good surgical candidate, and the perforation happened prior to initiating any treatment. Is the stent enough reason to avoid c...
Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?
The 4 cm cuff recurrence occurred 3 years after definitive treatment with hysterectomy and vaginal cuff brachytherapy to 21 Gy. The recurrence had a c...
Would your management change given that this recurrent lesion is over 10 cm and the patient previously achieved complete response on immunotherapy 5 y...
Do you consider hypofractionation rather than a volume staged approach?
Should they be context/disease specific?
Should the use of chemotherapy before/after, or during radiotherapy modify these tolerances?
Contexts...
Would you offer palliative (4 Gy) radiation therapy to the stomach mass vs. definitive doses (24 - 30 Gy) encompassing all of the disease?
Do you increase the dosage of the TKI or switch to a different generation TKI? How does your answer differ for EGFR vs. ALK, and for discrete brain me...
With low #s of patients on the durvalumab PACIFIC trial with EGFR mutated disease, and LAURA trial design of osimertinib until progression, should we ...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
How does time since radiation, original PSA and grade group/gleason score inform your decision?
Do you use decipher, or other genetic testing to determine whether you will include pelvic lymph nodes when you give definitive EBRT? Can you comment ...
Can adjuvant radiation therapy compensate for the potential increased local recurrence risk?
No disease elsewhere. Previous history of treated rectal cancer a few years ago.
Based on results from Zhang et al., PMID 38631536. Would we select patients based on planned lung V20 to avoid excess toxicity? Any further considerat...
I have always used the RTOG standard 2 cm margins off the T2 Flair to 46 Gy and 2 cm off the T1post for the 14 Gy boost. However, recently I have hear...
For example, do you favor using different induction chemotherapy (gemcitabine/cisplatin or TPF) for endemic vs non-endemic disease?
Do you favor usin...
The patient is in her 70s, was first diagnosed with vulvar cancer two years ago, and underwent a radical vulvectomy with clear margins and negative ly...
Assume patient has normal renal function, is not a surgical candidate, and kidney is the only site of disease.
The patient has undergone a vulvectomy years ago. The disease now involves the vulva, perineum, and peri-anal regions.
Tumor is PD-L1 positive and HER2 positive
ESOPEC compared perioperative FLOT vs neoadjuvant chemoradiation per the CROSS trial, and showed superior OS with perioperative FLOT. What concerns do...
Patient has not received radiation therapy in the past. If not, what would you offer for palliation of pain?
Is there any data to suggest higher risk of malignant transformation with hypofractionation? Does concurrent Temozolomide change your approach?
Given that LU002 has failed to meet its progression free survival benefit in results presented at ASCO, will you offer consolidative radiotherapy for ...
If using adjuvant chemotherapy, should the patient receive carboplatin or use a more intensive regimen because of the positive margin status?
In which situations or patient populations do you find this useful? How is it sterilized?
What would you consider when thinking about your boost?
Due to multiple complicating factors including travel distance of ~1 hour each way, this patient (mid-60s) refuses to come any more often than 2 days ...
NCCN guidelines allow the heart to get 105% of PTV prescription for 5 fractions to 55 Gy, but Timmerman tables from 2021 state the heart should be bel...
Would a specific Gleason score, age, pathological feature, or PSA be an indication for covering the pelvic nodes? Would giving concurrent ADT affect y...
For higher risk patients, eg PSA >0.5 or high risk gleason score, etc, would you consider dose escalation still? Prior data had suggested benefit t...
Would you recommend post operative radiation in an adult patient with a thoracic spine osteosarcoma?
S/P neoadjuvant chemotherapy and followed by oncologic surgical resection but with positive margins.
Are GTV, CTV, PTV expansions adopted from pediatric studies? Given our ability to treat the craniospinal axis with accuracy, what would the "mode...
How would your treatment change for definitive vs post-surgical RT?
Does approach differ depending on the anatomic (distal vs proximal and dorsal vs ...
Some references and papers suggest 8 mm for adenocarcinoma and 6 mm for squamous cell carcinoma (Giraud et al., PMID 11072158). RTOG 1308 used 8 mm bu...
Why does this differ when treating extracranial sites (lung, pelvis) where we hold bevacizumab prior to RT?
If so, when and to what extent?
The FLAME trial demonstrated a significant improvement in 5-year DFS, without any significant changes in overall toxicities, when patients being treat...
Patient with active rheumatoid arthritis, on escalating dose of Rituxan and Methotrexate, also has antisynthetase syndrome and Hashimoto's thyroiditis...
What dose and fractionation do you utilize? Would your recommendations differ considering the site of disease is at the penile base/suprapubic region?
Does it ever differ from a standard rectal field? For example, do you always treat the entire rectum, mesorectum, and entire length of internal iliac ...
What if the patient is also quite elderly? SBRT was a few years ago.
Would you cover the entire prostate?
If a patient had a high dose of radiation to the spleen (10 Gy over 5 fractions) over a year ago but with increasing splenomegaly now, would you consi...
If a patient is found to have 2 lymph nodes positive with ECE s/p mastectomy, axillary dissection, tissue reconstruction, and lympho-venous bypa...
Do you modify your volumes? What dose constraints do you use? How would you determine your dose/fraction regimen?
Tumor measures 4 cm after STR. Is NF1 a contraindication for adjuvant RT?
For a woman with complete resection of serous intraepithelial carcinoma of the endometrium, would you recommend adjuvant radiation or chemotherapy? Wh...
Any particular considerations for +PNI, close 1mm margin and 0/29 LN?
If a patient had a PSA > 15, PI-RADS 5 and lesions on MRI, would you treat without a biopsy?
Any concern for increased risk of radiation recall?
Is there really a need to boost up to 50.4 Gy in this setting?
When using hypofractionated RT (i.e., 67.5 Gy in 15 fractions), can chemotherapy be delivered concurrently?
Options for systemic therapy in NCC...
Does histology (radioresistant or radiosensitive) play into this decision?
This is a less common histology in the vulva.
Would you include a CTV, and if so, how would you account for proximity to the heart?
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
Per the NCCN guidelines and clinical trials, the patient does not fit the criteria for low metastatic burden, and therefore the benefit of radiation t...
How do you incorporate the considerations regarding the brachial plexus and proximity to the cord when treating to ~60 Gy?
If so, will you recommend it universally or only for certain patient population(s)?
Would you offer brachytherapy boost after EBRT? Is there concern for needle tract seeding with brachytherapy?
Surgical pathology found negative pelvic/inguinal nodes, but revealed also focal LVI/PNI
Are there any creams or suppositories that can be safely applied internally in the vagina to soothe burning?
Would you consider administering Keytruda (pembrolizumab) concurrently with radiation therapy for the treatment of a patient with an ER-negative, PR-n...
Z0011 population, cN0 with 1-2 SLN involvement with a low likelihood for additional non SLN metastases?
Are there clinical factors that go into your decision making?
Is there a preferred method and should any of the following be avoided: esophageal stent, nasogastric tube, PEG, J-tube, or TPN?
The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) trial was a prospective noninferiority phase 3 randomized clinical trial suggestin...
For standard tangential radiation would you pull the field edge forward to avoid radiation dose to the entire implant?
Such as those meeting the eligibility criteria for NRG HN002, <10 pack years, HPV+ T1-2N1-2b, T3N0-N2b
2020 ASTRO SCLC guidelines state under KQ1 Table 3. For postoperative patients with LS-SCLC and R1 or R2 resection, postoperative RT is conditionally ...
Is 80 Gy/40 Fx + ADT the new standard of care for definitive radiation of high risk prostate cancer?
GETUG-AFU 18 has shown a survival benefit over 70 Gy. There is much pressure to hypofractionate, but this is the first study showing a survival benefi...
Anyone here doing 17 Gy in 2 fx?
NRG-CC001 excluded a patient like this, but it seems that if the lesion in the HA region is treated, it would be reasonable.
Would your recommendation change if the patient had a high Oncotype and received adjuvant chemotherapy?
Testicular imaging was negative for suspicious mass. Would you treat the bilateral testes with radiation in addition to the PA field? Would you treat ...
In light of the 4/2024 JCO publication by Peng et al., PMID 38215354
Can you explain the expansion cohorts into larger trials and the current amendments to the the protocol?
Are there ones beyond the limited constraints given on the CONVERT and RTOG protocols you routinely use?
What are the current criteria in 2023 for selection to complete sentinel node biopsy or skipping of sentinel node biopsy specific to age, grade, clini...
If a patient had a stage I contralateral breast cancer and received bilateral mastectomies with implant reconstruction 2 decades ago and now has ...
Is there a role for loco-regional treatment in this scenario? If a young patient with ER/PR positive cT2N2M1 IDC presents with a single bone metastasi...
Would you recommend neck dissection and adjuvant ipsilateral RT?
As we see more TORS being done, we sometimes run into the above scenario which could have been cured with RT alone.
Do you add concurrent chemotherap...
What dose constraints do you use for the left anterior descending artery (LAD) for breast radiation?
Is there data to support those constraints?
How to treat Radiation Induced Sarcoma (RIS) of the spinal cord after 40 years of postoperative radiation therapy to lower dorsal/upper lumbar ependym...
Patient has multiple adverse features on pathology, however, PSA just became detectable one year after surgery. SPPORT included patients with PSA>0...
Or, to manage tenesmus and discomfort after any type of pelvic radiation.
Do you treat this similarly to IDH-Wildtype GBM with the STUPP regimen? Is there any role of less-intensive paradigms, such as 59.4 Gy/33 fx?
Would you ever consider this approach for an initially polymetastatic patient?
What is your volume and point dose constraint within the vertebrae itself when prescribed 1 fx, 3 fx, 5 fx SBRT spine to reduce incidence of ver...
Assume that the volume of the tumor is <10 cc (equivalent diameter of 2.7 cm). Assume there is not a significant amount of overlap of the PTV with ...
If so, what dose-fractionation do you utilize? What other factors do you take into consideration?
Does the volume of or recent progression of other non-spine disease influence your patient selection? Does the patient's performance status, eligibili...
Have you utilized these gene-expression profiles in your practice?
Is there sufficient data for this test to be used for clinical decisions?
Would you treat just the gross tumor at recurrence or the entire initial operative bed? Do your volumes and dose differ from those treated adjuvantly ...
For additional reading, see JCO OGR (11/2021) by Drs. @Warren and @Bellon reviewing the landscape of adjuvant treatment after lumpectomy for DCIS and ...
Would you do a tumor bed boost in the absence of other risk factors?
For example, if mass is ulcerated and cannot be excised with polypectomy? Would you ever consider radiation and chemotherapy?
If so, do you modify your external beam dose?
How do we approach patients with rare tumors given the paucity of data?
Do young, early-stage breast cancer patients with pCR to chemoimmunotherapy still benefit from PMRT?
If a patient in her 30s with a cT2N0 triple negative breast cancer has a pathologic complete response (pCR) after chemo/immunotherapy at the time of m...
What is the role of adjuvant radiation therapy for stage III melanoma in the era of adjuvant Opdivo?
Burnmeister data from 2012 showed a local control benefit for radiation therapy in selected patients, but that was without immunotherapy. Is adjuvant ...
How would you manage a FIGO IA G3 endometrial cancer with no LVSI, lymph nodes not sampled but CT a/p negative for lymphadenopathy, yet 2 foci of canc...
“Recent evidence” suggesting this was brought up in tumor board to justify excluding whole pelvic RT for a IIIC1 patient but I can’t...
Re-staging is otherwise negative; patient's disease has FIGO grade 1 endometroid histology
Would you ever consider any of the following?
Discontinue the bolus after brisk reaction
Moderate hypofractionation to the chest wall instead of c...
What techniques and doses would you prescribe to the primary and regional nodes?
Current NCCN guidelines do not include adjuvant chemotherapy for patients treated in this fashion; however, in the PROSPECT trial itself, an additiona...
Are there additional studies that could be done to assist with management decisions?
Is there a role for adjuvant chemotherapy or radiation?
If so, how long would you hold? This medication is given for migraines as q3 month infusions and some data suggest that CGRP plays a role in immune-mo...
Does the stage at diagnosis affect your decision?
Size: 3 cm, cN0
Do you offer observation for POLE mutated tumors?
Controlled extracranial disease on trastuzumab+pertuzumab for 2 years. Treatment options include Enhertu or WBRT. Not a candidate for SRS or neurosurg...
Would you consider radiation following surgical resection of an intramedullary benign nerve sheath tumor with a small amount of residual tumor (9 mm) ...
Given pelvic RT is likely to induce ovarian dysfunction/menopause, would you consider systemic options?
This would apply to gynecologic and GI cancers as well. And as long as the patient's partner is within the recommend age of <45 yo
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
The patient is a female in her 40s. No mucosal changes were evidenced on clinical exam. Chemo-RT is recommended by GynOnc at an academic center. ...
The patient had a high-grade DCIS with necrosis, but a 0.9 DCSionRT score
Would you consider it for a patient with good PS but with limited metastatic disease? What dose fractionation would you prefer?
How would poor urinary or bowel function affect the recommendation?
If so, how long do you continue medication and when do you discontinue? Does treatment with surgical resection versus radiation alone change your mana...
Female in her 30s, L5-S2 tumor volume, treated in 2020. So far, L-S MRI q6 month shows no change in residual tumor.
The patient is an otherwise healthy patient in her 60s with an ER-positive, PR-positive, HER2 negative grade 3 pT1N0 invasive ductal carcinoma followi...
Do you consider dose escalating to 160 mg or do you add chemotherapy to osimertinib?
Would you provide pentoxyphylline and vitamin E prophylactically after treatment? Is there a role for Boswellia? ACE inhibitor?
For example, a patient that received an MRI after biopsy that demonstrates a PIRADS 5 lesion in anterior TZ which likely was not sampled on biopsy. Wo...
What field design and dosing is most appropriate? Would you use ISRT or a more extended field?
I have an interesting case of gentleman in his 40s, HIV+ but viral count undetectable and CD4 1000+. He had prior diagnosis of Kaposi’s sarcoma ...
If so, what dose would you utilize for the SIB? When utilizing a boost with ultra-hypofractionated whole breast RT, would you favor adding a single fr...
The patient had ER/PR positive, early-stage recurrent disease superficial to the prior RT site involving the nipple and dermis without ulceration, tot...
Data for SBRT for RCC is promising but there is increasing literature on microwave ablation, radio frequency, and cryoablation. Are there any distinct...
Would you wait until bowel symptoms are controlled or ever pursue diversion before starting treatment?
Would you recommend this for a focally +, diffusely +, grossly + margin? What would you expect local recurrence rate for diffusely (+) microscopic mar...
Would you treat the primary site alone, include the hand and arm lymphatics to the epitrochlear nodes (one continious treatment volume from hand to el...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical prac...
Are there other measures, pharmocologic or adjunctive, that can be used or are under investigation to mitigate cardiotoxicity related to chemo- or rad...
My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...
Would you still treat the primary site and to what dose?
This patient had a T1N0, ER/PR negative, HER2 negative breast cancer
Would you manage different whether ND was completed or not?
Are you seeing this with increased BED regimens such as concurrent CRT to a dose of 60 Gy in 40 Fx BID?
If so, what do you typically prescribe?
Assume non regional nodes are non pathological by size. Patient also has pelvic nodes that are positive.
Would you consider this low metastatic burd...
Patient declined additional wider excision due to associated function morbidity as well as neck dissection. What would you estimate is the risk of cli...
The patient is in their 40s with right arm rhabdomyosarcoma s/p amputation. Path shows embryonal rhabdomyosarcoma 6.5 cm, margins neg. 11 of 19 lymph ...
In a young patient <30 years old with large pre-chemotherapy, multifocal disease with pCR following mastectomy, would you consider extrapolating th...
In light of the recent consensus contouring guidelines (Soliman et al., IJROBP 2017): 1) Are you routinely expanding along the dura up to 5-10 mm...
How would you treat a patient that had a T10 lytic lesion with extension to posterior 10th rib s/p cryoablation of the rib 4 months ago, but with resi...
When is SBRT appropriate? Do you approach dose and fractionation differently in this setting?
Which patients specifically benefit from both mpMRI and PET-PSMA?
In the PORTEC LVSI grading system, 3 or more vessel are classified as extensive LVSI, while the FIGO 2023 Endometrial Cancer staging they reference WH...
Would you use 30/10, 20/5, or 8/1, and why?
Is standard chemoradiation the standard of care or conventional fractionation dose-escalated (>60 Gy) radiotherapy without chemotherapy or some for...
If so, what dose would you treat to the resection bed?
Is T4 disease a contraindication?
If CCRT is pursued, would you move forward with durvalumab consolidation? Assume the patient with ECOG PS 0 and no co-morbidities. How might this chan...
Would you offer consolidative brain SRS, SRS + consolidative RT to the primary (e.g. lung), consolidative RT to the primary alone?
What dose-fractionation scheme do you utilize? Are there particular groups of patients this would not be a good option for (i.e. histologies of diseas...
Would you consider observation following surgical resection with negative margins? Would you recommend WBRT and/or ISRT? What would be your preferred ...
Are the results superior to alternative treatment methods?
What dose, fractionation, and volume would you choose?
Would you electively cover the vagal nerve(s) and associated recurrent laryngeal nerves?
Does...
Would you consider pentoxifylline and vitamin E to mitigate fibrosis?
Does the site of treatment factor into your decision?
If so, what dose/volume is prescribed? How do you account for motion?
Good risk DCIS as per RTOG 9804
This post refers to the recently published RCT by Chang et al., PMID 37478883 investigating lung SBRT with vs. without 4 months of nivolumab for early...
Do you recommend adjuvant chemotherapy after radiation treatment?
Do you have a standard reporting format with specific doses?
At what point does the benefit of either post-operative vaginal cuff brachytherapy, or vaginal cuff brachytherapy boost following EBRT for endometrial...
Or would a typical prescription, such as 7 Gy x 3 Fx to 5 mm depth be reasonable for typical sizes 2.5-3.5 cm? Per ABS guidelines, they specify that t...
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
Specifically, with respect to sequencing of chemotherapy, dosing and target delineation- would you cover elective areas like standard NPC fields or gr...
Would you consider VBT alone vs EBRT and/or offer chemo?
This is a female in her late 60s with FIGO 2023 IIB disease given substantial LVSI+ (>5 v...
The patient had a prior right-sided ER+ HER2-ve breast cancer, treated with neoadjuvant chemotherapy, MRM with ALND, and PMRT
They recently developed...
If so, would you recommend adjuvant chemotherapy and PCI after?
How would it change your risk group or management? Does Decipher help further inform treatment?
Are there any skin care products you would avoid in this population?
Specifically, do you offer closer follow-up for certain patients after local radiation?
The patient has a primary breast cancer with a single progressive metastasis in liver.
Are there any patient characteristics that make you change fractionation when treating per STAMPEDE?
What characteristics? TURP? AUA? Size of prostate? How do you change your fractionation?
Many options for vasomotor symptoms of menopause do not work well for men on ADT. However, fezolinetant is a neurokinin B blocker, so theoretically, s...
In a patient who had a wide local excision and radiotherapy 10 years ago and now recurs with cT4 disease, would you repeat radiation after neoadjuvant...
Assume slowly rising PSA in a low risk prostate cancer patient with negative PSMA PET CT. If so, what dose and what would you cover? If not, when woul...
How does age, grade, hormone receptors play into your decision?
Would postmastectomy radiotherapy ever be indicated in a young patient with close margins and a massive (14 cm) DCIS breast tumor interspersed with le...
Assume each lesion would have been suitable for partial breast radiation
Would you use either as monotherapy or boost in appropriate candidates (favorable IPSS, safe for anesthesia)? Assuming IPSS < 15 or 20 and minimal ...
What is the preferred dose, fractionation, and role of concurrent chemo?
Have you been able to deliver standard of care treatment?
Complete response was achieved after cycle 3. What extent of bone would you include?
I have a pair of patients with MRI+ and biopsy+ disease who have staging PSMA PET/CT that do not show disease within the prostate (or anywhere else).&...
Does the entire bilateral BOT & ipsilateral tonsil need to be included in the elective CTV?
Plan to give adjuvant chemotherapy.
With the recent publication in IJROBP showing a greater than 50% response rate, have you started integrating this into your practice?
In what circumstances would you offer adjuvant radiation after resection of vulvar mucosal melanoma?
If so, what would your target volumes and doses be? How would you sequence with immunotherapy (eg nivolumab)?
Do you find that starting with chemoradiation increases the risk of complete obstruction secondary to transient tumor inflammation, or do you favor st...
What dose and how would you treat this? Would you include periaortic nodal field?
Given this histology, does the groin need to be covered? Would you add chemotherapy?
Intravesical therapy was delivered two years prior, and last cystoscopy was negative. One-third of the bladder would otherwise be included in the plan...
In an asymptomatic patient, would this be safe?Is there any reason to withhold radiation such as in the case of T1N0 breast cancer advising the patien...
For example, if a patient is otherwise a candidate for APBI with a 1.5 cm primary tumor but has 2 cm of associated DCIS would the patient be ineligibl...
Do you treat the whole gland or the lesion only?
What is the role of additional imaging (MRI, PET/CT) to delineate disease?
What e...
In general, how does an esophageal stent affect what you might consider in terms of radiation dose and volume?
Assume this is a male, treating to 55 Gy in 20 fx.
Do you ever allow patients to receive a couple of cycles of systemic therapy first if there is high burden of disease? What is the maximum time after ...
In a patient with a pT1-2 oral tongue cancer resected with negative margins and with a fully negative ipsilateral neck dissection, but with indication...
For radiation oncologists, how do you ameliorate the risk for radiation-related injury to epicardial coronaries during treatment sessions?
A patient had limited metastatic prostate cancer several years ago and was treated with orchiectomy only, and recently had Xtandi added. PSA remains d...
Does this option need to be added to NCCN guidelines? How does the type of brachytherapy, HDR vs LDR, influence your recommendations? Does ADT play a ...
Would you still treat the chest wall with standard dose and give the patient the benefit of the doubt in the absence of pathological confirmation of m...
NRG-BR002 (Chmura et al., JCO 2022)
CURB (Tsai et al., IJROBP 2022)
Additionally, would you give elective nodal coverage or just the postop bed?
Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...
Do your post-operative treatment recommendations differ for benign vs. malignant phyllodes tumors of the breast?
Is phyllodes tumor size ever a crite...
What is the risk of renal artery stenosis causing malignant hypertension and at what dose does this become an issue?
Does the MGMT status change your decision-making? Should we be routinely testing MGMT for elderly patients?
Oftentimes the needles were inadvertently pulled. Without using a template, are there any methods to mitigate this risk of compromising implant qualit...
Would you follow an algorithm such as the one proposed by Hall et al., PMID 29940062?How do you decide between intrathecal chemotherapy vs systemic th...
Do you typically recommend SBRT? What dose? Or do you ever recommend surgery or surgery followed by XRT?
If so, for how long afterwards do you think the patient needs to continue the exercises?
Is there high quality data to support debulking in terms of oncologic outcomes? Does HPV/p53 status impact your decision?
What factors might play into this decision?
For example, if preoperative imaging indicates T3 disease (non-mass enhancement extending over 5cm) but final pathology s/p mastectomy shows multiple ...
I trained at a place where use of a bolus for chest wall irradiation PMRT was standard practice, but this is not so at my practice right now. Assuming...
Do you use SIB regimen (40/48 Gy) per RTOG 1005 for whole breast radiation in scenarios not included on trial? For example: a patient who has received...
Should Y90 be offered before or after TACE (based on the Northwestern phase 2 study) or sorafenib (based on the SARAH trial)?
At 2023 ASTRO, PACE-B reported very low 5-year RTOG grade 2+ rectal toxicity with SBRT (1/363) and conventionally or moderately fractionated radiother...
E.g. esophagus? If you crop the esophagus out of the ITV, then your ITV would not fully encompass the iGTV.
How do you counsel patients and caregivers? Do you prescribe medications (''appetite stimulants'') with the goal to improve appetite even if they do n...
Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.
In what situations would you feel comfortable omitting RT to bulky disease in stage III/IV Hodgkin's lymphoma?
If a patient has thoracic metastases being managed with EGFR TKI, do you refrain from SBRT treatment, do you hold the TKI, or can you treat the patien...
What would you recommend for a patient in their 60s with stage IB grade 1 endometrial cancer without LVSI? How would this differ for a patient with st...
Do you proceed with sequential, concurrent, or sandwich treatment?
Would you advise against concurrent ozone during head neck radiotherapy for a locally advanced tumor?
Would you ever treat with definitive intent in a "curative" patient who has a stent placed, or only palliatively? Does the addition of chemotherapy or...
Initial tumor size:18 cm. Partial response was achieved after cycle 2 and cycle 6 of chemotherapy. Complete response (Deauville 2, size: 6 cm) was ach...
Assuming duodenum constraints are met, could there be any benefit to boosting a positive celiac node to 61.6 Gy in 28 fractions?
Do you treat pre-neoadjuvant volumes to full RT dose, or do you modify treatment volumes if there is tumor shrinkage?
What is the harm of waiting for another recurrence after a second GTR to delay the toxicity of radiation and chemotherapy? The patient is a woman <...
Consider some stalk invasion, but no deep submucosal extent and negative margins by 9 mm.
Should 4 Gy x 5 be the standard of care for spinal cord compression in patients with poor prognosis?
The randomized SCORE-2 trial demonstrated equivalent survival (median 3 vs 3.7 months), response rates (72% vs 74% ambulatory at 1 month), and du...
Especially as the study was done before the adoption of total neoadjuvant therapy
How would you counsel the patient on wound healing and potential complications in this region?
If so, how do you accelerate?
The patient is not pacemaker dependent.
Patient with a locally advanced, node-positive vulvar cancer status post inguinal node dissection with persistent output in drain (for about 8 weeks) ...
In prior ASTRO guidelines, it was mentioned as a cautionary group for IDC but not in the 2023 updated guidelines.
For a patient with pT2N0 oral tongue cancer and no other adverse risk features (no LVI or PNI), would WPOI 4 or 5 be enough to offer adjuvant radiatio...
Has this recent retrospective analysis published in Lancet Oncology changed your practice?
Based on Mill et al. paper showing increased IBTR rates with ILC vs IDC (Mills et al., PMID 34516030)
Does it depend on treatment site? If you apply bolus after sim, how do you account for differences in bolus conformality between the virtual and actua...
Surgery would be very extensive and would not be likely to clear the disease. Do you divert these patients if treated with CRT?
Is there benefit to radiation on top of systemic therapy?
How would your management change in an elderly patient with no surgery verus superficial parotidectomy or total parotidectomy?
Do you recomment MRI, CT with contrast or CT angiogram? And at what time intervals post-treatment do you perform surveillance scans?
If a patient has a genetic mutation, but not necessarily the classic ones where we avoid radiation (ATM, BRCA, p53, etc.), does this change your treat...
If so, how many days before and after? Does this change if delivering SRS?
GOG 205 treated vulvar cancer patients to a dose of 57.6 Gy to sites of gross disease, which is somewhat less than what is suggested in cases of defin...
How does margin positive influence your decision?
What is the maximum time that can be used (given the complexities with patient being in the hospital or needing rehab)?
In an otherwise healthy patient with no contributory PMH, medications and without any evidence of disease.
Can this be done right away or do you wait for the cavity to involute before you plan postop SRS to cavity?
The patient is in her 40s with a BRCA-2 mutation and underwent bilateral prophylactic nipple-sparing, skin-sparing mastectomy. No sentinel nodes were ...
In other words, if offered wedge or segmentectomy, should SBRT be preferred? Does size matter ie if the lesion is < 3 vs < 2 vs < 1 cm? Does ...
Additionally, when evaluating margin status for APBI IMRT 30 Gy in 5 fractions which specifies at least 5 mm margins, do you look at the DCIS margin o...
Does the ENE of 1 mm or less versus >1 mm as in ECOG 3311 affect your decision?
Patients are understandably concerned about the risks and benefits of radiation to an oozing, bleeding, and ulcerated breast.
ABS APBI guidelines are much more permissive relative to the newer ASTRO Guidelines.
Would you change your recommendations for APBI vs whole-breast RT for this reason?
Do you preferentially use Ra-223 first given the RALU study?
For patients who fall into the E3311 intermediate risk category s/p TORS, do you routinely treat to 50 Gy? Or do you continue to treat to 60 Gy?
Do you routinely obtain a spine MRI prior to treatment for all cases, even for non-SBRT candidates (e.g., 30 Gy in 10 fractions) or do you ever rely s...
In a patient with metastatic cancer to the lumbar spine and epidural disease on CT who presents back pain and leg weakness:
Is a whole spine MRI in...
If so, what would be your approach to radiation? Could SBRT be an option?
Would your management be different in node + vs. node - patients? What would be your radiation volume and dose?
Does tumor size, age, or performance status play a role in your decision-making?
NSABP B-51 recommends V3<10% or a variation acceptable of V5<10% for contralateral breast. Is there a limit needed for contralateral chest wall/...
Do you advocate for completion ALND? If so, would you radiate the dissected axilla?
Would you especially consider RT omission in the setting of low-grade, small-volume disease with no underlying DCIS or invasive disease component on p...
Example: in a patient with a non-resectable pelvic mass involving the vagina but without evidence of distant disease, would you favor pelvic RT (as on...
How would you approach a young woman (under the age of 50) with DCIS with favorable disease (ER+, low grade, small size <5mm, negative margins)?
Consider a patient who prioritizes fertility preservation, for whom one of three suspicious nodes approaches the CRM, and is <1 mm from the mesorec...
Are you concerned about cases where radiation has to be started urgently before leukapheresis?
Do anticipated fields affect whether extractions are required i.e., limited field glottic larynx could forego?
Particularly, would you have concerns about OAR constraints or cumulative dose? Patient has excellent performance status and no neuro deficits post op...
Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?
The trial showed an overall survival benefit of 8% at 5 years with induction chemotherapy (80% vs 72%) utilizing at least 5 cycles of carboplatin-pacl...
Do you take it to 66 Gy even in the situation of negative margins/resection of that region of bone? For example, if there is a focal bony invasion tha...
Did your treatment inclinations change with the results of the recent FABREC trial (NCT03422003) presented at ASTRO?
What is the best way to counsel families in regards to their child's risk of infertility and need for fertility preservation?
Would you consider eliminating radiation to the chest wall in a patient greater than 50 years of age with a T3N0M0 grade 2, ER+/PR+ Her2 negative inva...
Aside from suctioning, what are other measures could be helpful?
What is considered the optimal interval from time of excision, partial, or radical vulvectomy and/or nodal dissection to initiation of post-op RT?
I.e., the IDC was completely removed during biopsy, but DCIS was present on post-lumpectomy specimen with close anterior margin
What is the best treatment management of low grade early stage follicular lymphoma of the mesentery?
If the mesentery is widely involved with small lesions would this change your management? What if the patient was symptomatic?
Do you prefer surgery (i.e. exenteration) given the radioresistant histology or would you attempt to manage with EBRT and brachytherapy?
A female in her 60's was simultaneously diagnosed with stage I triple-negative left breast cancer and stage I NSCLC of the left lung.
The patient had...
In which particular patient cases or clinical scenarios would you consider preferentially treating a patient with protons over photons?
Nodal staging changes radiation fields, but given increasing pertinent null findings of a positive SLNBx with regards to outcomes, I wonder if ypN0 is...
The patient also declines any brachytherapy treatment.
If so, what dose/fractionation?
Pathology: High grade spindle cell sarcoma
I have seen some patients who may undergo large complex closures (sometimes as a separate procedure) for smaller lesions with resulting scars that sig...
What factors influence your decision?
How do you manage these cases differently than HPV positive cases?
What total heart dose and LAD dose do you typically utilize to justify the DIBH technique?
Her primary disease is too large for any brachytherapy; if substantial residual disease remains, how would you approach external beam boost?
Relevant pathology features: 7.5cm, grade 3 with a 5mm bronchial margin, negative nodes.
MASTER analysis showed 30 - 40% perisalvage ADT use. What group of patients do you consider for ADT? And for what duration?
Do you treat in this scenario if mild/moderate infiltration? What are your thoughts on the article by Fischer-Valuck et al., PRO, 2017 (PMID 28089528)...
This is a patient in her 70s who previously received 5040 cGy adjuvant EBRT alone to the pelvis.
If a patient was noted to have poorly differentiated histology with two tumor foci in the breast, positive LVSI, and isolated tumor cells in 1/3 senti...
Some loss of tissue planes after 3 months of ADT.
Aside from limit due to extent of her hysterectomy, the patient's disease does not otherwise satisfy Peters' criteria
Does your constraint differ based on region of the spinal cord?
How will you translate treatment recommendations from older studies to the new staging system?
STAMPEDE arm H uses the CHAARTED definition for bone metastases in the axial skeleton. There is no mention of patients with non-regional nodes. Would ...
Do your recommendations differ between appendiceal, colorectal, and gastric cancer? If radiation is offered, would you boost the unresectable/gross re...
How do you advise patients who strongly desire chemotherapy?
The patient is a female in her 50s with luminal B pT1b pN1(sn) invasive ductal carcinoma with 2/2 nodes, 5 mm ECE, and extensive LVI. No preoperative ...
Does an EGFR mutation in a never-smoker change your radiation treatment recommendations for ES-SCLC?
Do you recommend that standard 30/10 TRT approach or a more aggressive non-small cell like approach (e.g. CRT of locally advanced thoracic disease or ...
Would you offer WBRT + boost vs WBRT vs focal treatment/SRS.
For example, would you consider treating part of the humeral head if required to adequately cover the axillary nodal volume CTV/PTV?
Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?
Patient in question had PMRT 20 years ago.
Would you consider APBI for an ER/PR/HER2 negative pT1-2 N0 with pathologic complete response after neoadjuvant chemotherapy? Would the presence...
Is there an optimal bridging radiation dose for aggressive B-cell NHL undergoing CAR T-cell therapy?
What influences your decision to proceed with palliative vs. definitive, and standard vs. hypofractionation dosing regimens?
In what scenarios do the benefits of local control with PMRT outweigh the risks?
How would systemic therapy and/or the number of bone metastases impa...
How would you approach a recurrent, cutaneous SCC of the face with high-risk features s/p resection?
Definitive radiation therapy > 5 years ago. Positive margins, PNI of 0.1 mm. What volume would you cover? Dose/fractionation?
In particular, in the modern era of multi-parametric prostate MRI and PSMA-PET, certain findings such as EPE, SVI, or pelvic lymphadenopathy may be no...
Can chemoradiation be curative without maximal debulking TURBT?
For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...
A patient presents with clinically node-positive cT2 grade 3 invasive breast cancer in the upper outer quadrant. The patient had breast RT to 50 Gy wi...
Do all patients with brain metastases get started on anticonvulsants?
Do you decide based on extent of edema, tumor size, or something else?&nb...
The patient's current PET scan showed no systemic disease. Due to his age, there is a concern of whether the patient would tolerate dual immunotherapy...
Would you treat both at the same time? Does one need to be prioritized over the other?
Does Xeloda have any efficacy against Merkel cell cancer?
How...
How would you treat the primary tumor (located in the chest)? Would you treat the regional lymph nodes?
What constraints would you use for ribs, lungs, and heart?
How do you prioritize treatment? Would you move forward with radiation to the larynx, and if so, any modification to your treatment plan?
If you recommend or use induction chemotherapy, what is your preferred chemotherapy regimen?
Multiple disease sites have studies showing time from surgery to post operation therapy impacts clinical outcomes. Is there any evidence to suggest th...
With trials like PROSPECT and FOWARC showing no statistically significant improvement in locoregional control and survival outcomes when comparing rad...
Especially consider a situation where surgical excision alone is not appropriate.
What if the radiation was LDR or HDR brachytherapy?
Severe lymphopenia can develop during treatment and increase the risk of Candida/HSV superinfection, along with potential challenges for any procedure...
A patient in her 70s initially underwent TAHBSO + LNB with Stage I, G1 cancer, No LVSI. 18 months later with very small mucosal recurrence (5mm). HDR ...
Does the presence of parametrial or cervical involvement impact your decision?
How do you sequence treatment modalities?
What volumes would you encompass? Anything different than standard nodal basins for high risk prostate cancer?
If utilizing an 8-12 fraction regimen, would daily fractionation be appropriate?
The CROSS trial showed a survival benefit with 4140 cGy and concurrent carbo/taxol, but I was always trained to treat to 5040 cGy. Is anyone de-escala...
What would be your preferred treatment technique and dose/fractionation?
For example, consider a patient who has had previous hepatectomy and total liver volume is only slightly greater than 700 cc.
This case involves an impressive ‘high volume’ vaginal recurrence and patient was not originally planned for adjuvant therapy. Concerned t...
NCCN cervical cancer guidelines added a new statement - Patients who have received prior pelvic radiation therapy and have osteoporosis may benef...
Would the extent of nodal involvement sway you one way or another (i.e., a micromet in a single sentinel node)?
Do you give RT before or after systemic therapy?
How would you utilize radiation to address a 10 cm-sized tumor with rib erosion and tumor expanding past ribs? How do you manage pain? What is the rol...
How are you approaching patients with rectal cancer who meet PROSPECT criteria but have other higher risk features, such as >4 lymph nodes with sus...
How do you choose between Avastin, hyperbaric O2 and other therapies?
The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...
Does the St. Jude's Experience (NEJM 2009, PMID: 19553647) provide sufficient justification for routine omission in high risk patients?
Is this degree of hypogonadism sufficient to omit leuprolide?
Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...
If a patient has a small luminal A invasive tumor resected to negative margins with admixed high-grade DCIS, does the high-grade DCIS component influe...
Does the fact that the patient is on methotrexate alter your choice?
How would you integrate RT with molecular agents?
Patient with circumferential thoracic spine tumor on imaging, with appearance of hemangioma. Surgical pathology demonstrated glomus tumor.
Woul...
Consider treatment of stage IVB cervical cancer with systemic therapy and local pelvic radiation therapy as in Perkins et al., PMID 31810653.
Do you feel comfortable stopped abiraterone after 2 years?
What prophylactic strategies you use to mitigate the risk?
In the setting of EBRT alone, a "FLAME"-style boost may increase bPFS. Does anyone have experience with increasing the EBRT dose in combination EBRT+L...
When starting HN radiation, which start day do you prefer to add most value to the treatment course?
Would you rather postpone treatment start to the following week if unable to accommodate your preferred start day?
What approach do you take to determine dose constraints for SBRT reirradiation of the head and neck?
Do you have formal constraints and evaluate cumulative doses on the composite plan? Do you use traditional constraints but account for repair?
What dose and fractionation do you use?
Is it safe to keep median dose to the brachial plexus to ≤69 Gy per NCCN guidelines and maximum D2cc <75 Gy per Amini et al.?
After initial induction chemo, how do you choose between radiation alone or concurrent CRT?
If a patient is found to have multiple painful osseous lesions but is chemotherapy naive, do you typically wait for the patient to undergo treatment w...
If so, have you noticed differences in cognitive function post WBRT?
If so - how long?
Relevant pathology features: positive margin
Total dose prescription: 66 Gy
Would you offer definitive chemoradiation and include the non-regional nodal level in your plan?
Is anyone advising delaying COVID booster until after PET/CT to avoid false positive?
If a patient is <50 years old, would this change your recommendation?
Do you electively treat nodes and how does your approach change with intra- or extra-hepatic primaries?
Do you wait until chemotherapy completion, interdigitate between cycles 1-2 only when feasible, or between any cycle of chemotherapy?
What factors wo...
The patient is an otherwise healthy female in her 70s with an ER-positive, PR-negative, HER2-negative grade 3 invasive ductal carcinoma.
Lumpectomy r...
If there were negative margins, what other factors would you consider to add adjuvant RT? Size of the tumor or depth of invasion?
The patient was treated with neoadjuvant chemotherapy and had mastectomy with SLNBx about 6 months prior to being referred for adjuvant radiation.
In general: when would you recommend adjuvant radiation and capecitabine for a colon cancer?
Would you dose escalate areas of regrowth or boost the entire cavity?
If so, what dose of radiation dose would you use?
He cannot sense bladder fullness but has no incontinence. Intermittently he urinates by increasing intra-abdominal pressure resulting in a good stream...
Would you delay external beam?
How many cycles of systemic therapy is recommended? is XRT needed and what XRT dose is recommended?
Please comment on primary tumor size, extent of nodal involvement, and other adverse features.
Would it change if only one of the initially sampled positive stations was removed at surgery (eg both 4 and 7 positive pre-therapy, but only 7 sample...
How do you decide when to “pull the trigger” in these cases where the growth trajectory is slow?
The NCCN guidelines categorically recommend adjuvant XRT for a cT1-2N0 rectal adenocarcinoma upstaged to a pT3N0, yet there are multipl...
RADICALs used >0.1 and rising or 3 consecutive rising PSA levels regardless of absolute value. RAVES and GETUG-AFU 17 used >0.2.
If the dose to these OARs deviates from goal by a significant margin, how do you approach changing the treatment plan, accordingly?
Would it make a difference whether the patient was planned for chemoradiation followed by surgery or definitive nonoperative chemoradiation?
Does stage of the cervical cancer influence your decision? Does the amount of SUV uptake influence your decision? When does one biopsy? How long can o...
If so, what is the highest dose per fraction you would feel comfortable delivering?
If so, how do you determine which of the lesions constitutes the "dominant" lesion to boost?
Alternatively, do you treat all noted lesions with SIB, ...
Do you have a preference in ordering MRI, endoscopy, CT scan (chest, abdomen, pelvis), EUS, or other testing before starting any treatment, for re-sta...
Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?
Do you prefer SpaceOAR vs Barrigel and why?
Is it necessary to delay the start of radiation therapy for males planning on sperm banking for fertility preservation?
At our institution we often give 5.5 Gy x 4 fractions. There really does not appear to be a general consensus regarding timing. Interested in what oth...
Since there is no overlap between chemo regimens for these cancers, how would you sequence treatment?
For example do you use Prolaris, or other genetic tests to guide ADT decision making?
Assume recurrence is biopsy proven. Would you ever consider focal vs whole gland brachytherapy?
Do you factor in the time interval when deciding cumulative dose constraints?
If not, how do you sequence the therapies?
For a node positive, triple negative patient that underwent neoadjuvant chemotherapy followed by breast conservation with a complete pathologic respon...
What criteria do you use to determine the utility of using DIBH for planning after free breathing and DIBH CT scans?
Do you typically create a ...
How do you pursue fertility preservation in younger females with this presentation?
Any experience using phenytoin?
How would your neck coverage change (unilateral vs. bilateral, levels etc.)? Are there situations where you would cover bilateral neck for adenosquamo...
Assume this patient had resection with N2/N3 disease. Would you recommendations change if this was N1? Any other factors that weigh in on primary site...
The IMPORT-LOW and DBCG trials of 40 Gy in 15 fraction PBI utilized mini-tangents, which simplify planning but increase breast V40 Gy.The paper by Tho...
What systemic therapy is most appropriate, how would you sequence, and what RT dose fractionation would you use?
Considering this is stage IV disease, do your recommendations for definitive or adjuvant treatment (after surgery) change?
If an otherwise healthy male patient in his 70s has Gleason 4+4 disease in 7/12 cores and left sided internal iliac nodes, but refuses any form of end...
Is there diminished radiotherapy efficacy in tumor control after certain timeframe has passed for malignant meningiomas with no signs of recurrent dis...
If so, which substructures (LAD, left ventricle, etc.)?
Do you treat on the same days or sequentially? Any unique considerations regarding dose or planning?
For example, in a patient with an expected long-term prognosis?
For patients with painful SCLC vertebral metastases and no evidence of cord compression, would you recommend treating with immediate systemic therapy ...
While the RTOG protocol defines central in relation to the PBT, should distance to the trachea above the PBT, esophagus, heart, spinal cord, etc. be t...
We have been receiving referrals for oligoprogressive SBRT for multiple primary tumors (NSCLC, Colorectal, Renal Cell, etc.) in the setting of diffuse...
Patients in their later 40s with favorable intermediate-risk prostate cancer s/p 7000cGy/28 EBRT only.
What clinical or radiographic factors would lean you in either direction - ie. time since index diagnosis, distribution or appearance of lung and noda...
In young adults (20-30), would you provide perioperative radiotherapy f if they have actually developed HO?
The GEPAR trials presented at ASCO 2015 showed increased LRR with the omission of RT in patients who had a pCR after neoadjuvant chemotherapy.
For a patient with an ER-positive, pT1c breast cancer who otherwise meets criteria for APBI, but has a BMI of 50 with pendulous breasts and N1mi disea...
Is there any role for RAI?
For example, reducing coverage to 95% of Rx within a large median lobe for an intermediate risk prostate cancer case with no gross disease near base t...
While I am encouraged by the results of the LUMINA trial with respect to identifying patients who are less likely to benefit from radiation therapy wh...
The patient is on a dose of 22 mg of methotrexate weekly for severe rheumatoid arthritis.
If you would discontinue the methotrexate, how long would y...
Assuming the patient had no prior radiation and has no evidence of metastatic disease, would you start with adjuvant radiotherapy or adjuvant systemic...
What is your GTV, CTV and PTV? If giving 30 Gy in 10 fx, does the contour need to extend all the way to the cut in the skull on both sides (is there a...
SBRT vs more comprehensive nodal RT with SIB to involved node? Would you include the prostate bed in your treatment volume? ADT duration? What other f...
Does fractionation (or location) influence this decision? What is your preferred steroid dose?
> 50-year-old woman with a pilocytic astrocytoma of the 4th ventricle (biopsy only). Caris shows BRAF intact and deleted CDKN2A/B.
Would you offer RT if persistent disease despite resections?
Would you prophylactically treat any lymph nodes due to risk of possible occult invasion...
If a patient had a remote history of pelvic radiation for another cancer and now has uterine cancer, what factors (grade, stage, KPS, LVSI, etc) would...
Would the location of the tumor (i.e. ultralow), symptoms (bleeding), or patient resistance to surgery play into this decision?
Might a prior SJ incident pre-dispose to SJ reaction to radiation?
Would you be more or less apt to treat with RT for grade 2 DCIS with refusal of pr...
If a patient had a partial mastectomy and radiation therapy 10 years ago and now has a large ipslateral breast cancer (different ER/PR/Her 2 markers n...
What constraints would you use for a 15 fraction regimen or other ablative regimen?
24 months ADT + abiraterone + definitive RT is indicated for cN1 disease but not for pN1 disease per NCCN. Can the data be extrapolated to this popula...
If so, what is your selection criteria? How long do they remain in place?
Do you have any dose constraints to the nasolacrimal duct?
Eg 10-20 fraction regimens. And how (hot spot %, mean, D99) do you prescribe the dosage?
How would these expansions differ based on the anatomic site being treated?
Would this change if the cancer was p16+ squamous cell carcinoma?
Notably, the patient presented with renal failure due to ureteral obstruction and hydronephrosis, receives hemodialysis, and has limited systemic opti...
NCCN suggests 2 - 4mm margins in DCIS, and no tumor on ink with invasive disease.
What agents have you found helpful? What agents have been proven to be effective/non-effective?
The patient is less than 35 years old, and received 21 Gy to the mantle and 10.5 Gy to the lungs >15 years ago as part of treatment for Hodgkins ly...
Please comment on how you view risk factors such as T-stage, tumor grade, P16 positivity, margin status PNI, LVI etc.
What dose/fractionation and vol...
For example: radiation fractionation schedule, modality (proton, MRI linac, cyberknife, etc), risk categorization, prostate size, history of IBS, hist...
I feel like it’s nearly impossible to take carafate QID and avoid food and medications for 1-2 hours before and after. How do you counsel patien...
If so, which checkpoint inhibitor would you use?
The patient has sustained a positive response for >1 year after diagnosis.
Would gene expression testing (e.g., Decipher, Prolaris, Oncotype DX) guide your management recommendations?
What XRT dose do you use? Does the location of the disease (e.g., mediastinum) affect your decision when taking toxicity into account? would you offer...
Would there be a survival advantage to pelvis RT with deep myometrial invasion, LVSI and ITC?
What volume and dose do you treat a bone met that has completely responded to chemo?
Did the EBCTCG meta-analysis change your practice?
Interstitial implant was attempted under laparoscopic guidance (due to pre-brachy MRI showing potential bowel involvement). At the time of procedure, ...
For example a 1 or 2 mm brain metastasis? Would you consider waiting for these to enlarge slightly for reasons such as more certainty they are real, l...
The TROG 13.01 SAFRON-II trial used a single 28 Gy fraction. When is it appropriate to use this fractionation?
Patient has contraindication to MRI but otherwise has what seems to be a favorable intermediate risk prostate cancer
For patients who are otherwise eligible for CALGB 9343 and candidates for APBI who choose to proceed with partial breast RT, are you offering 26 Gy in...
Do you complete the originally prescribed RT course, add fractions, treat BID, offer no further TRT, or do something different?
Do you also give neoadjuvant, concurrent, and adjuvant ADT in the same manner as for non-SBRT EBRT?
Staging/pre-op MRI only showed mild non-specific thickening.
How would you sequence therapy, and what dose and volumes would you use for radiation? Prostate cancer is localized, Gleason 4+3, PSA 65.
In contrast to lung SBRT, rib lesions may not have a clear lesion on CT that can be delineated to create an ITV after 4DCT. Do you create an ITV, and ...
Do you routinely recommend TTF in the adjuvant setting for patients with glioblastoma?
Bone marrow preservation is important due to poor hematologic function. Chemotherapy is not possible as well.
If the radiation cystitis is hemorrhagic without clots how would you manage this?
What instructions do you give your radiation therapists - do you rely on OAR identification (ie. bladder and rectum filling) or soft tissue match to t...
If so what dose/fractionation would you use?
Do you give cuff and chemo or pelvic CRT or chemo alone?
Patient with h/o appendiceal carcinoma s/p surgery and HIPEC, now with endometrial cancer, IBG3, extensive LVSI, pNx, recommended for whole pelvic rad...
The patient is a woman in her 30s with a grade 2 T3N0 ER/PR+ Her2- invasive ductal carcinoma who was treated with mastectomy (margin negative, but LVI...
Would you offer pelvic RT or intracavitary brachytherapy?
Would you hypofractionate at all? Or use standard H&N doses of 70 Gy/35 fractions?
For example, initial imaging shows numerous bilateral nodal mets extending into the low neck but after induction gem/cis, originally involved nodes ar...
Angiosarcoma is invading the brachial plexus and thoracic vertebral bodies.
Prior radiation therapy: Radiation to the left chest wall and regional no...
Pretreatment PSA 25.3 with Gleason 4+3=7 and MRI suspicious for ECE. Eight months after pelvic nodal and prostate XRT to 79 Gy, PSA is 5.02 (down from...
Is concurrent chemoradiation reasonable or excessive in a patient with life expectancy <5 yrs? Should the standard be 5 Gy x 5, and will this provi...
I have a healthy 70+ year old man recently diagnosed with cT3N1M0 rectal adenoCA and GS 3+4=7 prostate cancer in 1/6 cores with a PSA of 25.
Is ...
Considering the ASTRO guidelines recommend against systemic therapy for patients with FIGO stage I-II endometrioid adenocarcinoma, would your recommen...
What sort of factors (post-op PSA level, time to biochemical failure, Gleason score, etc.) help guide your decision making?
In general, when do you c...
If so, how? The trial did not exclude patients who had prior radiation (except hemibody RT) but there is little information on how to estimate dose to...
Would a higher Decipher score, despite low risk for nodal disease based on MSKCC nomogram or Roach formula, encourage you to treat the pelvic lymph no...
Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...
Do biomarkers impact your decision-making? If you were to boost, what dose would you use?
MRI pelvis shows a 3.5 cm primary that appears infiltrative and without clear parametrial extension on MRI. Staging PET negative.
Is there any ...
Do you use CBCT or kV images? Do you match to the breast or the chest wall?
I can't convince the surgeons to refer their patients for adjuvant RT because the prospective data is messy and doesn’t seem to indicate a benef...
Taking into account follow up from NEO, OPERA and other organ preservation trials?
Our patients seem to hate the 20% benzocaine spray (cherry) saying that it burns and causes their eyes to water. Looking for other options.
The patient had 0/2 sentinel lymph nodes involved, and mastectomy revealed pT3 disease with negative margins
Tumor factors: Neck mass, 6 cm in length, biopsy proven schwannoma. No extension into base of skull
Patient factors: No dysphagia, no dysphonia i.e. ...
Do you use the MIP to generate an ITV, contoured on the average scan, or do you contour on each time phase of the 4DCT and boolean the results togethe...
Is the patient permanently at elevated risk for rectourethral fistula with rectal biopsy? Do you have any threshold for the GI to biopsy a rectal lesi...
Mesonephric is described as a higher grade histology. For a superficially invasive IA (no LVSI, age < 60), would you consider vaginal brachytherapy...
Please comment on toxicity profiles and the insufficient evidence regarding overall survival.
Is there a practical way to quanitfy risk of LRR in patients with T1-2 N0 with multiple high risk factors in such as multifocal disease, high grade, L...
Is dose reduction needed? Would you still recommend hypofractionation?
Would you recommend PORT based on LVSI as the sole risk factor (i.e. pT1/T2N0 OP SCCa)?
If using cetuximab, would you recommend accelerated fractionation?
With molecular diagnosis taking several weeks to return for some institutions, how do you handle variations in dosing and contouring between different...
Does the time interval between the intial RT and recurrence influence your decision? What time interval would you feel is appropriate? What dose would...
Dose/fractionation? Concurrent v. sequential chemo? What literature do you use to backup PORT for a positive margin?
In patients with no apparent skin involvement but lymph-node showing basal cell carcinoma with extracapsular extension. Would this warrant radiation o...
A recent NCBD analysis (Rusthoven et al., PMID 27325855) suggests that the addition of prostate RT significantly improves survival compared to AD...
What margins do you use for each cancer for photons vs electrons?
If your margins differ between cBCC and cSCC, why?
Would you recommend this if we were treating level I/II?
The patient has locally advanced disease with chest wall invasion and extensive axillary/IMN lymphadenopathy
Is there a thickness cutoff you use?
What would you cover?
Assuming the patient is symptomatic and/or has compression of ventricles, what field design and dose-fractionation would you use?
If so, how long are they on degarelix before the switch?
Adult patient with suprasellar tumor, found to be AT/RT and unable to undergo GTR given encasement of optic structures.
The patient is >40 yo with Lynch syndrome and a history of endometrial hyperplasia status post R0 TAH/BSO with SLNBx for a 5.2 cm, grade 3 adenocar...
How does this strategy change depending on the acuity or chronicity of the symptoms?
Patient initially achieved CR with VAC-IE with resolution of presumed lung mets and 100% necrosis in LLE primary tumor on BKA. Then was NED again afte...
It's been 5+ years after the first course. If you decide to re-irradiate what dosing schema would you use?
Do you have a size cut-off in cases where OAR tolerances are not otherwise exceeded?
Is axillary radiotherapy an acceptable alternative?
With targeted therapies available, is there a utility for post-op SRS to the resection cavity?
Is it 54 Gy or do we worry about hypoxia and need to go to 60 Gy? Does it change based on site (i.e., oral cavity versus a T4N0 larynx)?
There appear...
Please specify how your institution is allocating resources now or will be soon.
Do you take this into consideration when recommending treatment?
Majority of patients on the seminal trial (Gross et al., PMID 36094839) had tumors isolated to head & neck, what was the rationale for this?
Would you recommend elective nodal radiation and sequential boost to the node? What dose? Would you recommend treatment similar to OLIGOPELVIS-GETUG P...
Are there any concerns about increased acute or late toxicity in the context of more extensive surgery?
Do you base your decision on extent of residual disease?
Does the use of (neo)adjuvant immunotherapy have an impact on surgical site size or he...
Would you consider a 2x2 design incorporating immunotherapy?
The patient has metastatic ovarian cancer, currently on Avastin, with a large 13 cm pelvic mass with a fistula to large bowel.
Would you consider off...
Is a placebo-controlled trial anticipated?
Do you treat the whole bladder in the intial whole pelvic field to 45-50 Gy?
Margin status? Residual disease? Nodal status/ENE?
If so, what is included in that volume?
How does previous radiation pneumonitis impact your decision making and treatment planning for a new lung cancer or metastasis in a patient who is oth...
Would you consider treating with conventional fractionation to the entire staple line with a boost to the gross disease?
Would you offer adjuvant RT for subtotal resection of a parietal lobe hemangiopericytoma? How would histologic grade affect your decision making?
What do you utilize for patient immobilization and what are your PTV margins? What MRI sequences do you favor for target delineation?
The recurrence is mucosal and inferior to the prior field.
If only a few teeth, do you still wait to simulate until after the dental work?
Surgery remains an option. Given favorable response, would you recommend pre-op or definitive RT +/- chemo?
What is your approach to try to persuade her that photons would be a better option?
Retreatment? Pancreas? Ultracentral Lung?
Would you favor observation or adjuvant radiation? If so, what dose/fractionation would you consider?
Molecular findings that indicate a more aggressive WHO grade 2 meningioma would certainly support recommendations for adjuvant RT after GTR, but if th...
Prior tumor was adenocarcinoma, new primary is squamous cell carcinoma.
If you would offer reirradiation, what dose constraints would you apply to th...
Are you waiting until drug availability or changing to a preferred non-cisplatin radiosensitizer? If you're utilizing an alternative to cisplatin, wha...
Do you leave it in or out during sim and treatment? Any special instructions?
Close but negative radial margins? LVSI? What fractionation/dose do you use for your vaginal cuff boost if used?
Do you treat this as a higher grade tumor or alter your adjuvant recommendations?
If the pacemaker receives no dose, what dose are the leads allowed to receive and still function? Should interrogation(s) be done weekly?Does dose per...
Historically, chemotherapy has been delivered prior to radiation for breast cancer patients requiring it.
With the acceptance of shorter cour...
Would you biopsy lymph node to confirm recurrence/histology?
If confirmed, how do you decide between RT vs chemotherapy? If chemo - BEP x3 vs E...
If so, when do you resume?
Is this considered a sanctuary site from systemic therapy?
How much time is recommended to wait before? Does the dose or fractionation need to be modified given the flap? Does the scar need to have bolus?
E.g SCV and/or paratracheal nodes? If so, what dose do you prescribe for elective coverage?
What dose and field margins would you add? Is a 50% response rate realistic to counsel a patient? What would you quote as a realistic rate for seconda...
Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?
I have yet to see results from the SUPREMO trial investigating this question in Europe.
There is the EXPERT trial, NCT02889874 based in Australia/New...
For example, a pT4N0 oral cavity cancer with focally positive margins?
Are you more inclined to offer brachytherapy boost instead of EBRT boost?
Would you boost involved lateral pelvic lymph nodes in this scenario?
The patient is not a candidate for re-resection or external beam radiotherapy
What do you consider valid reasons to deliver 39 or more fractions for prostate cancers, 25 or more fractions for breast cancers or 10 or more fractio...
In the phase III RTOG 0631 trial, patients with 1 to 3 vertebral metastases were randomized 2:1 to either SRS (16 or 18 Gy in 1 fraction) or cEBRT (8 ...
7 cm tumor limited to the cervix with no vaginal or parametrial invasion on exam and not lymphadenopathy or metastatic disease on imaging. Cystoscopy ...
Would you offer full dose adjuvant radiation?
Assume excellent performance status and inability to perform further surgery on margins without causing...
Is it safe to deliver palliative radiation to the spine with a spinal stimulator device with standard palliative dosing (8 Gy x 1 fx, 20 Gy/5 fx or 30...
If you do not use the PORTEC-3 regimen for p53 mutated IA endometrial cancer, what specific protocol or combination of chemotherapy and radiation ther...
Would you consider APBI so that less tissue is irradiated or do whole breast (hypofractionation vs conventional fractionation)?
There is a recent publication that nicely summarizes the molecular/genetic tests for prostate cancer (Ross et al., PMID 26123120). What should be done...
If ADT +/- ARPI + RT, what duration of systemic therapy do you recommend?
The patient is in her 70s and had a prior breast recurrence 10 years ago treated with mastectomy and reconstruction; this most recent recurrence has t...
Is it necessary to repeat MRI a certain amount of time after surgical resection prior to starting radiation?
If there are no pre-op photos, what would your fields look like and dose/fractionation?
Assume the patient is not a candidate for surgery. What dose would you use? Would you recommend a lower dose to not damage the patient's kidney functi...
What patient factors do you consider to decide between 55 Gy/20 fx and 64 Gy/32 fx with or without nodal irradiation? What if your patient is younger ...
How would you add radiation in your treatment paradigm? No clinical trials available due to age.
For example, 5 PET-positive lesions, 2 lesions biopsied and both of the same histology.
Does not involve surface surface of the ovary, no gross disease elsewhere.
After the randomized Phase IIb showed decreased mucositis, are you incorporating this agent? Please share your regimen and any tips.
No lymph node dissection. cN0
Would you treat a smaller volume than the entire tongue for small, well lateralized tumor with indication for adjuvant radiation based on nodal status...
I've been prescribing sucralfate as first line symptom management but I sometimes see zero benefit. The randomized data doesn't support its use either...
How do you take into account pathologic factors like %clear cell histology, myometrial invasion, and LVSI?
I.e. based on the findings of ADAURA in surgically managed patients.
What special considerations or precautions would you keep in mind when considering re-irradiation? The prior radiation was post prostatectomy RT. ...
Patient with multiple comorbidities (childhood CNS cancer survivor, stroke with residual deficits).
The patient did not have radiation previously, but now has recurrent disease in Axillary levels 1-3, supraclavicular nodes, and IMN in the first inter...
Given the published results of the PRODIGE 23 trial where FOLFORINOX was used neoadjuvantly with FOLFOX post-op
The ASTRO consensus lists 2-3cm size as cautionary, while the ABS consensus lists 3cm or less as suitable, though acknowledges that most patients incl...
If, yes, what dose and fraction size did you use?
Would you add any additional dose or fractions?
If a patient has a metastatic lesion in close proximity to one hippocampus, would you offer sparing of the contralateral hippocampus? Do your dose con...
Lately I have seen patients with a concurrent gynecologic (requiring chemoRT), head and neck (requiring surgery), and early stage NSCLC (requiring SBR...
Dose-escalation RT trials have had mixed results in the past for advanced rectal cancer, while in the early rectal stage there is a tendency towards a...
How do you weigh definitive chemoRT vs minimally invasive surgical approach with neoadjuvant chemo followed by transanal excision, in light of results...
Does a transperineal approach to prostate biopsy change your treatment plan compared to transrectal?
For example, transperineal biopsies may capture a higher volume of disease. Should this change risk stratification compared to transrectal biopsies? I...
Is there any reason that this is not commonly done, apart from lack of RNI coverage?
What factors influence your choice of SRS vs more fractionated regimens?
If the patient had no nodal sampling, would this influence your decision?
Since there is no overall survival benefit, does the local control benefit outweigh the increased risk for distant metastasis? How do you select patie...
For example pT4 and PNI, do you target the neck after a negative neck dissection?
What factors influence the decision to treat: - surgical bed alone ...
Medical Oncology did not recommend systemic therapy due to age/comorbidities. Would you consider radiation therapy? If so, what dose/fractionation?
The protocol for the James trial (NEJM 2012) states: "non-target tissue may be excluded at the discretion of treating physician." For gyn applications...
If there is partial response after chemoimmunotherapy in the primary, would you consolidate the primary? If there is complete response in the metastat...
Is it possible to do SBRT?
If the patient had high risk features (for example age 60+ and LVI) do you treat with vaginal brachytherapy or WPRT? If you treat with whole pelvis ra...
Ipsilateral V20? MLD?
The patient had lumpectomy with standard radiotherapy to 50 Gy whole breast, followed by 10 Gy boost 11 years ago, and was recently found to have a sm...
Patient is refusing BID dosing as per RTOG 1014.
Would you recommend if there is only one uterine factor or do you typically require multiple to make this recommendation?
This same patient has Grade Group 5 disease with extraprostatic extension and a positive margin with pre-operative PSMA PET/CT negative for regional o...
Occult IB1 cervical SqCC found on simple extrafascial hysterectomy, with 4 mm deep stromal invasion and LVSI. Subsequent pelvic and para-aortic nodal ...
Please consider this National Cancer Database (NCDB) and Surveillance, Epidemiology, and End Results Program (SEER) registry study (Barrington et al.,...
What factors would push towards treatment? The patient had recurrence of a pT1bN0 vulvar SCC within a year of original surgery. Re-resection shows aga...
The patient has stage IV cervix cancer and was previously treated to 30 Gy in 10 fractions one year ago. Embolization for hemostasis was not successfu...
How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?
In patients with contraindications to receiving an MRI scan, are other imaging modalities sufficient to treat patients with SRS?
Could you discuss how you decide between IMRT or SBRT boost for a patient who is not able to receive intracavitary or interstitial HDR or LDR brachyth...
If so, is there a particular volumetric threshold you use before a patient gets onto the sim or treatment table?
Would you consider these as metastatic sites? Would you biopsy to confirm?
Patient developed pembrolizumab-related pneumonitis after ddAC followed by Taxol/Keytruda - what thresholds/constraints would you prioritize with rega...
Is your approach different than that to a primary essential tremor?
Would you offer adjuvant radiation? Dose/volume in postop setting?
Do you also use DIBH in these cases?
The idea would be to appropriately cover gross disease/lesions in/around the hippocampus, but then spare the rest of the hippocampus, with the rationa...
If so, how would you approach managing the increase in lung dose required to cover these? Would you consider this metastatic disease?
This is an adult patient that is status-post orchiectomy and R-CHOP now requiring prophylactic contralateral testicular radiation. Would you recommend...
For example, a patient with PSA < 10 and low volume Gleason 4+4=8 disease. Would you consider 6 months vs. 18 months vs. 2 years?
History of 4th ventricle choroid plexus papilloma s/p GTR, now with recurrent disease in the 4th ventricle and the left lateral ventricle (7 nodules i...
Are you more likely to consider a trans-anal resection?
Or would it change your decision on a boost in WBRT if negative surgical margins?
Why do the available guidelines restrict APBI to patients with lesion size <3cm? Is this purely from higher rates of necrosis noted in older brachy...
If so, when do you resume?
If records have been destroyed, how do you factor prior pelvic radiation for prostate cancer into your decision?
If so, are there any patient/pathology selection factors? What technique do you utilize?
What dose and margins would you use? The patient is s/p a liver transplant on immunosuppression.
How does your counseling about side-effects change when offering short vs long course radiation?
Is there a safe regimen that still delivers BED >100?
How can these interactions be improved?
Several articles report results with 0.5 -1 cm margins, and have suggested that with improved imaging and treatment planning, smaller margins such as ...
If radiation, what dose/fractionation and technique?
When would you use 5-fluorouracil instead of, or in addition to, cisplatin during chemoradiation? When, if ever, would you offer adjuvant hysterectomy...
The right obturator sentinel node had a 1.5mm metastasis with no ece. Additional right pelvic node and 6 left pelvic nodes are negative. The cervix ma...
Do you use CT, MRI or PET/CT to create GTV volumes? What margins do you use for your CTV/PTV?
There is evidence that parents do not adequately understand the purpose of phase I pediatric cancer trials (Cousino et al., PMID 23071225).
Is radiation effective in this case and if so, what dose would you use? Is there potential for perforation?
Good performance score, 7 cm in size, CSF cytology is negative, MRI complete spine is negative. Would you consider any additional systemic therapy mod...
Are there any resources comparing whichever value is more relevant for the various breast fractionation schedules (FAST, FAST-Forward, Canadian, UK, 3...
If a patient is found to have florid LCIS with with a 1 cm positive inferior margin s/p sentinel node biopsy (0/2 nodes involved) and mastectomy, is t...
Elderly patient with large fungating necrotic breast mass positive for high grade BCL and a solitary hypermetabolic ipsilateral axillary node. Medical...
For example, a heavy burden of nodal disease with diffuse ECE? Would you treat the axilla higher than 45-50 Gy? What would you use for a boost dose?
I see the LungTECH trial dose constraints, but, they seem really conservative when you have something large and close the PBT resulting in use of 60 G...
How does 1p/19q co-deletion and IDH mutation status influence your decision?
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
Do you follow the breast NCCN guidelines to decide adjuvant radiation recommendations if a patient treated with neoadjuvant chemotherapy stops the che...
What are the factors, if any, that would prompt you to recommend radiation?
Low grade vs High grade?
Dose/volume?
If not constrained by field size, would you treat the entire hardware length?
Is there a certain amount of time that you prefer to have elapsed after the last infusion before delivering SRS? Do you avoid all subsequent Trastuzum...
Patients will frequently ask why they need treatment when there is no cancer left on the pathology specimen.
For example, if patient had Gleason 4+5 on biopsy but Gleason 4+3 with Tertiary Grade 5 on final pathology? Would you consider intensifying their horm...
Surgery has recommended against up-front diversion in order to avoid treatment delays. The patient has at least one suspicious internal iliac lymph no...
If the location of the biochemically evident cancer cannot be determined, would you re-irradiate the prostate despite absence of histologic proof of l...
In the absence of other high risk factors like positive/close margins, positive lymph nodes, T2/T3 disease, PNI, or LVI, would you offer postop RT?
The patient is now s/p neoadjuvant chemotherapy, mastectomy, and ALND for their ipsilateral recurrence, and pathology showing residual disease (ypT0N2...
Considering the high retropx drainage to be cranial to C1/hard palate.
Guideline statements recommend 30 Gy in 10 fractions postoperatively due to lack of evidence for other fractionation schemes. Would you consider 20/5 ...
Reference: TROG 05.01 Trial
What about a low lying rectal cancer with involved inguinal lymph nodes?
What if actively on immunosuppression or with active lupus? For this case, presume the patient is not a candidate for resection or IR guided therapies...
Ideally, treatment should be completed in 56 days (preferably < 50 days). If there has been a significant delay to brachytherapy (>2-3 months) d...
If so, would you also include the breast?
Sentinel lymph node assessment was negative and there are no other high risk features.
How long would you wait to see if the AVM obliterates? How would size or proximity to critical structures affect your decision i.e., would you choose ...
This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor p...
Female in her 60s who had presented originally with well-differentiated endometrioid adeno clinically and radiographically involving bilateral paramet...
Not a candidate for re-excision given proximity to the anal sphincter. Consider +PNI, -LVI.
Would you offer APBI if the DCIS was ER-?
Would you cover the lacrimal gland alone or the entire orbit?
Would you recommend standard definitive chemoradiation followed by adjuvant durvalumab? Would you treat pre- or post-systemic therapy volumes?
Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...
If a patient with early-stage breast cancer s/p lumpectomy is noted to have 1/3 SLNs positive for ITCs (and no other negative prognostic factors) woul...
Is this considered salvage or definitive since HIFU is not standard of care?
Does receipt of upfront HIFU impact ability to perform stand...
Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...
How does your approach differ for patients under age 60, between 60-70, and over age 70?
The patient is a woman in her 60s with a history of a grade 1 ER-positive, HER2 negative pT1bN0 invasive ductal carcinoma treated with lumpectomy, who...
Would you radiate concurrently with WBRT? How would you dose/fractionate in this situation?
If so, what is your dose constraint?
And, for additional information, what are the differences in 5 year survival and disease specific survival for stage I NSCCA between lobectomy vs SBRT...
Do you have a number/volume threshold for SRS vs WBRT?
The Stanford report (Osmundson, IJROBP 2015) on central hepatobiliary tract toxicity recommended dose constraints to the cHBT that would limit dose to...
What treatment volumes do you target? What dose-fractionation scheme do you employ?
Would you biopsy the metastatic lesion?
Would you treat prostate definitively and monitor closely?
Would you treat prostate and oligosites?
Do you think these patients are appropriate for SBRT? Is endobronchial laser ablation or cryoablation a better treatment approach? Is there a role for...
How do you reconcile RAPIDO and OPRA trial results? OPRA was a Watch and Wait trial but the rectum preservation rate was much higher in that study tha...
Is there sufficient data to justify the routine use of GammaTile in the treatment of primary CNS malignancy or brain metastases?
Would you treat a knee?
If the patient had PSC and baseline atrophy preventing brachytherapy boost (received SBRT boost instead), would this change your threshold for stentin...
Consider negative margins and a patient refusing further surgery.
What if positive margin is felt to be from a DCIS skip lesion (initial DCIS margins widely negative but small focus DCIS found in additional tissue wi...
Do you have recommendations on timing of her implant placement with respect to radiation therapy?
For example, EGFR-mutated de novo metastatic disease, do you offer adjuvant RT vs observation with targeted therapy alone?
Do you assume some recovery since the prior course of RT? If so, how much over what time period?
Tumor factor: Large axillary soft tissue sarcoma with involvement of the brachial plexus
Other factor: Surgery would like to pursue upfront surgery t...
Masuda et al. NEJM 2017
If so, how do you sequence it with adjuvant radiotherapy?
When do you consider observation?
Would you alter the esophagus, trachea, and cord constraint in any way?
Still do Tandem and Ring or opt for interstitial?
Patient will have diverting colostomy. Concern is whether the tandem will be stable enough with lar...
Are there specific patient populations in which you may feel comfortable with a patient selecting only one adjuvant therapy approach (tamoxifen vs RT)...
The patient was a >70-year-old with right-sided cT3N1M0, ypT0N0 TNBC s/p NAC pembro/taxol x 4 cycles followed by mastectomy w SLN (0/4); post-opera...
Assume SSD at isocenter is correct. When are you concerned about the dose to PTV or OARs? Article below appears to say minor effect. Zhang et al....
How would your decision differ if the patient was not on immunotherapy or other systemic therapy? Would your thinking differ depending on the timing o...
Is a FAST regimen reasonable in this circumstance, or should a more gentle fractionation (either the RTOG re-treatment regimen, IMPORT-LOW, or 45Gy in...
For a > 70-year-old female patient with 2 mm of ER+ PR+ HER2- grade 1 invasive ductal carcinoma in background of 1 cm of grade 3 DCIS, would you re...
The patient presented with spinal cord compression, had subtotal resection and instrumentation with metallic hardware. Main concern is that post op su...
Would you add a sequential boost to the node? If so, what dose would you recommend?
If surgery is advised, how you would you time it with chemoradiat...
Would you boost a resected axilla if extra-nodal extension is found in a patient with breast cancer?
What are your volumes? What if the lymph node area was not clipped?
If the patient is amenable to adjuvant chemotherapy alone, but is worried about chronic diarrhea/urgency after radiation, how would you counsel them?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical prac...
Would you consider empiric SRS if biopsy/resection is not feasible?
When would you consider liquid biopsy?
Does the time from prior RAI affect your decision?
How would you counsel the patient differently about the side effects, if at all?
How does histology and/or molecular testing change your approach? How does the length of the disease free interval change your approach?
Groomed facial hair is an increasingly common style for men. Accordingly, there are patients who require treatment of the head and neck who become ups...
Would you offer adjuvant hypofractionated radiation therapy over a graft in the HN region?
If you treat with SBRT, how would you constrain the heart given the significant prior involvement of the pericardium in this area in the PTV, assuming...
If not, what interval between the patient's last RT and IT chemo would you prefer?
The patient is BRCA2 positive and previously received 30 Gy in 5 fraction APBI to the right breast for an ER/PR+ pT2N0 IDC. She then developed multifo...
The prior recommendations were between 6-12 months, but also were based on chemotherapy after surgery.
Does it vary based on tumor site (oral tongue, FOM, gingiva, hard palate, etc.)?
Would you offer definitive radiation, and if so, to what volume and dose/fractionation? Would your recommendation differ depending on if repeat resect...
Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...
In a woman with high-grade, clinically node positive invasive ductal carcinoma who receives neoadjuvant chemotherapy and breast conserving surgery, wo...
Assume a mild but diffuse case of lichens sclerosis with involvement of the ipsilateral breast. If node negative disease, would you recommend she unde...
Is there data on efficacy or toxicity when chemotherapy is added to Proton beam therapy for head and neck cancer like there is data to support adding ...
Would you consider omitting contralateral neck radiation if this was a younger patient (i.e. <50 yo)?
Does that change if they received a skin sparing mastectomy?
For a cT2 triple negative breast cancer with indeterminate enlarged breast nodes s/p negative biopsies, and indeterminate findings on both MRI and PET...
In addition to positive margins, perineural/vascular/lymphatic invasion as listed by NCCN, would features such as close margins or high grade dysplasi...
Would anyone consider elective mediastinal XRT to 45-50Gy then boost involved LN to 60-66? Or treat involved lymph node only? The patient will r...
If so, would you favor 30 Gy/5 fraction accelerated partial breast irradiation?
According to the NCCN guidelines, there is a highly selected group of T4a glottic larynx patients that can undergo observation instead of postoperativ...
Encouraging aggressive PO intake in patients with swallowing dysfunction may place them at risk for aspiration pneumonia, especially risky if undergoi...
Would you treat the entire pelvis vs local recurrence? How would you approach the oligometastatic lesion? Would your treatment recommendation change i...
Cancer was with mesonephric features, and was originally within a urethral diverticulum. Would you consider RT vs chemoRT vs surveillance?
This may impact decisions on brachytherapy boost and/or use of ADT since MRI-guided samples may skew patients into the unfavorable risk category
This patient previously received hysterectomy with adjuvant vaginal cuff brachytherapy without pelvic RT. Colonoscopy demonstrated invasive disease, b...
The serum testosterone is minimally low at 250 and the patient has some fatigue.
If imaging is aligned at PTV despite exceeding tolerances do you accept/override, perform shift verification image, or reposition the patient?
Do you...
If so, what dose-fractionation regimen do you utilize? What are your target volumes?
The patient previously underwent resection with close margins, adjuvant radiation to 66 Gy/33 fractions.
Serial MRIs demonstrate progression with con...
If a patient with endometrial stromal sarcoma managed with fulverstrant has a single oligoprogressive lung nodule, is there any contraindication to tr...
PSMA PET vs Conventional imaging vs combined imaging?
How is your approach different from or similar to those who undergo surgical menopause?
For conventional fractionation, should one increase total dose above 60 Gy for either close or positive margin (invasive or DCIS). What about for acce...
NCCN recommends floropyrimidine-based chemoradiation (sandwiched by 5-FU or capecitabine), but many medical oncologists are utilizing multi-agent chem...
If a patient calls you after hours with a headache following SRS and have not been given steroids, what is your preferred regimen?
Patient is declining mastectomy.
Are there certain portions of the mandible that you constrain more than others?
If a patient with prostate or bladder cancer has irritative bladder symptoms during IGRT and urinalysis reveals microscopic hematuria, WBCs, but...
A021501 trial: mFOLFIRINOX vs mFOLFIRINOX with hypofractionated radiation (Katz et al., PMID 35834226)
She was on surveillance after lumpectomy. No prior radiation therapy. What dose/fractionation?
What doses do you typically utilize? How does your coverage differ from your recommendation if this was an HPV-negative squamous cell carcinoma of the...
E.g. If a patient had CR in the primary tumor but PR in the nodes, would you still treat the primary?
If electrons are unable to be used, or if the patient's anatomy precludes use of electron treatment, what is your general approach to using IMRT in th...
What is your preferred dose/fractionation following a previous course of radiotherapy?
What volume do you treat? Initial disease extended from paratracheal to celiac LN. Residual disease now is only in celiac LN.
No evidence of distant disease elsewhere. Surgical resection is not possible. Would you recommend metastasis direct therapy to the liver (i.e. SBRT or...
Would you consider hypofractionation? If so,what dose? Would you consider a boost if there were close margins?
Is there an extent of nodal involvement in prostate cancer above which you would not offer definitive XRT? With PSMA/PET we see some patients with inc...
I've noticed that these patients have been having greater than expected fatigue that persists for months after SBRT. This is very different than the f...
How do you decide if/when to treat the primary disease and when would you treat definitively?
How will you approach patients with diffuse metastases who you would have otherwise deferred treatment?
Prophylactic Radiation Therapy vs. Standard-o...
What are the expected outcomes if you were to irradiate the pelvis in someone on peritoneal dialysis?
In a large unresectable grade 2 astrocytoma of the temporal lobe, what dose and GTV margin should be used?
I have heard of long-term pentoxifylline and Vitamin E daily combination that can prevent and even reverse radiation fibrosis (Delanian et al., PMID 1...
If a patient presents with metastatic disease (by virtue of extensive PA nodal burden, mediastinal/SCV involvement, no solid organs) but received urge...
Would you recommend chemoRT and take the whole bladder to full dose or do you only boost the invasive disease?
Would you offer radiation therapy? If so, what dose and fractionation would you use?
If a patient with good PS who does not meet criteria for prophylactic rod stabilization has radiographic features consistent with metastasis (lytic ap...
In light of recent trials showing no difference in outcomes with RT+cetuximab vs RT+IO, does this potentially lead us to use immunotherapy in cisplati...
Assume a life expectancy of approximately 5-10 years. What factors would influence your consideration of intermittent ADT vs. watchful waiting?
Do you stop treatment? What if an abscess is also present?
This endometrial cancer was a fortuitous finding following vaginal hysterectomy.
This was resected over 2 years ago with reconstruction of the IVC with a PTFE graft. No preop or postop RT given and the recurrence is in the area whe...
With the recent WHO classification redefining IDHwt tumors as glioblastoma, more patients have imaging features that are historically consistent with ...
Does the previous dose of SRS or the fact the patient had prior surgery matter when planning WBRT?
In the study published by Slotman et al (Lancet 2015), nearly all the patients in the thoracic RT arm started with PCI. For patients with gross diseas...
Does your approach differ from p16 positive disease?
Assuming a biopsy shows active disease and the metastatic workup is negative, when would you off...
VS schwannoma size 16mm
Patient received FSRT 25 Gy in 5 fx more than 4 years ago
I.E., can a patient with a questionable 5 mm node (MRI T2N1) which is negative on pathology after short course radiation be staged T2N0 and receive no...
How significant does the moist desquamation need to be? Does the length of tretment remaining ( i.e. 1 v. 3 weeks) or use of medication effect your de...
How would you approach treatment if SBRT was not technically possible?
How would you opt to treat if SBRT was instead not covered by insurance, and w...
NGS without any actionable mutations and PD-L1 TPS 15%.
Would you offer chemotherapy, radiation, or immunotherapy and, if so, in what order?
Is a bra that can be worn during treatment and indexed ever advisable for patients with large breasts who are otherwise unable to do prone treatment?
...
Is this stage IS or IIA? Is chemotherapy or RT preferred?
How would you modify this based on endopredict or RT-PCR?
Is there a limit to the number of adjacently involved vertebrae where you would instead treat with conventionally fractionated palliation?
If considering systemic therapy, would you consider standard chemotherapy or use biomarker-directed therapy (e.g., imatinib if ckit+, larotrectinib/en...
Main concern is radiation induced thyroid cancer
What advantages/disadvantages are there between assays or over traditional clinical pathologic factors? What other concerns do you have?For additional...
Now that RTOG 0915 shows 5 year data with no difference in OS, DFS, and toxicity, should single tx be routinely offered? Are there specific pati...
If you use VMAT, do you take into account leaf interplay/leaves crossing PTV or potential overmodulation during planning?
How do you decide between downstaging chemotherapy or upfront concurrent chemoradiotherapy? Both are listed as NCCN options.
Would you do SIB to gross nodes in the pelvis and/or inguinal region? Would you do SIB to the primary unresected tumor?
Would you favor the use of any particular biologics over others?
In a non-surgical candidate, would you consider adding radiotherapy sequenced with chemotherapy at any point? Or do you reserve it for palliative purp...
If a patient who has undergone radical prostatectomy many years previously presents with biochemical failure and is found to have a nodule in the pros...
If you were to offer radiation, what dose and fractionation would you use?
Assume a young, fit patient who has not had prior pelvic RT before, and has been fully staged with molecular imaging (e.g., PSMA) with no evidence of ...
How would you treat such a patient?
When do you continue with treatment and when do you terminate the plan? What is your criteria?
What dose would you use? For negative margins do you offer 50-50.4 Gy/25-28 fractions? What target volume margins do you typically recommend on t...
For nodes just inferior to the celiac/SMA axis and no other distant metastatic disease? Stage is formally M1, but just barely. The patient is otherwis...
When would you treat the entire orbit versus partial orbit? One patient has medial rectus involvement and another has only conjunctival involvement. I...
What contraindications or concerns do you have in this scenario beyond assessing the Child Pugh Score?
What is your rationale for your approach?
Does your treatment in any way depend on stage, extent of RT, and/or dose to OARs?
Assouline et al., PMID 24411632 recommend delivering 500cGy x 4 fractions = 2000cGy on days 1, 3, 8, 10. Do you follow this schedule, treat every othe...
In a patient who had BCS and adjuvant radiation to the breast and regional nodes, now several years later with extensive axillary recurrence s/p axill...
Specifically, in the TZ and PZ? What references do use for prostate nodule boost as done in FLAME trial?
Hypointensities are contoured on T2W M...
Does your management change if the primary tumor is radioresistant, such as renal cell carcinoma?
Based on recent ASTRO data, what is your selection criteria and size cutoffs?
Patient has declined endocrine therapy and is unfit for systemic therapy.
Imaging studies (MRI and PET) show bilateral disease
If borderline resectable, can the TOPAZ regimen be considered for downstaging effects?
What level of PNI is considered "large nerve" in this disease?
Assuming in-field recurrence.
The patient was in her 30s with a 2.8 cm benign phyllodes tumor with positive margin at the posterior fascia. Surgical resection is not considered ide...
What fractionation scheme would you use? Would you give SBRT to a hilar tumor that has N1 nodal involvement adjacent to the tumor but can be enc...
The lesion is still ulcerative despite wound care for two months. Would you treat immediately or wait for healing? Would hyperbaric oxygen to heal ful...
C diff infection ruled out and CT abdomen pelvis shows diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field.
Would the presence of perianal extension and a positive inguinal lymph node affect your recommendation and how?
Are there particular indications you use for RT? i.e. multiply recurrent, refractory to other therapies, near critical structures, unresectable (or re...
How does your approach change for same lung but now a different lobe v. different lung? How do you adjust your constraints?
SIBs of 55-57.5 Gy in 25 fractions are frequently mentioned with bowel volume constraints at this dose, but assuming there is no bowel nearby (e.g., b...
For a large pelvic mass that is causing abdomino-pelvic pain, can hysterectomy be considered?
Are there guidelines that dictate who in the department should be present for treatment delivery?
When tumors come close to chest wall, how do you define skin contour?
General recommendations on dose and management presuming unresectable.
How do you define an “adequate” axillary dissection, (i.e., would 8 lymph nodes dissection instead of 10 be “adequate”), or ch...
Is there any evidence to support the theory that this may cause worse skin reaction?
The patient has notable lip lesions from her discoid lupus erythematosus
In patients with small breasts and large lumpectomy cavities, is there a benefit to switching to whole breast if you can produce a very homogenous par...
If a patient has T2N0 disease without LVSI, but has a ~4 mm IMN node in the 4th or 5th intercostal space, would you be inclined to include the IMN cha...
The patient has disease in the S2/S3 region with an anterior soft tissue mass.
The patient previously received 50.4 Gy with treatment for rectal canc...
Traditionally these patients may have received chemotherapy prior to chemoRT.
This patient is young and active but refuses palliative chemotherapy
This is an elderly patient with a BCC/SCC over the shin who is not eligible for Mohs due to concern for wound-healing issues. Orthovoltage/superficial...
Isn't there a tradeoff of increased lung dose?
It is not clear from CREATE-X whether radiation was before or after capecitabine. Is there a preferred approach?
What is the potential risk of immunotherapy toxicity in combining palliative RT in a patient already on immunotherapy?
Is there a role for pre-operative RT?
Does this ever affect your decision for treatment of current disease (eg likely radiation-associated sarcoma vs likely unrelated new oropharynx cancer...
Would you consider repeating a biopsy?
50+ yo F. Mastectomy, chemo, and RT in 2016 for primary breast angiosarcoma, not RT induced. Had longstanding cyst on wrist, biopsied, and positive fo...
Would increased risks from concurrent intravitreal avastin preclude treatment? Would you recommend a waiting period in between the treatments?
Patient had significant GI side effects with Trental. (This particular case involved a second course of radiation for a secondary lung cancer 30+ year...
What dose/fractionation scheme do you use? Is SBRT a viable option?
How long after the first treatment should one wait?
Do you specific renal impairment or hydronephrosis/hydroureter criteria?
Are there elective neck regions you would choose treat to high risk (ie. 60 Gy) instead of low risk (ie 54Gy) dose?
Are there risk favors that ...
If so, which nodal regions?
SCC measures 5.5 cm, 2.0 cm thickness, closest margin 0.2 cm (deep), high grade, PNI+, LVSI+. Lymphadenectomy was deferre...
Please share your institutional preference.
For example, would you modify your SBRT dose next to the azygous vein? While we talk frequently about OAR constraints for the great vessels, it seems ...
Do you take this into consideration when recommending treatment?
Is there a dose response between 4500 and 5040 cGy?
Is the radiation therapy management equivalent to similarly-staged squamous cell carcinoma? Is there a preferred concurrent chemotherapy regimen? ...
If the patient were of young age with high grade and ER+ disease without LVI, do these factors sway you one way or another?
Pt with 1.3 cm Merkel cell (buttock) excised with negative margins. Two sentinel inguinal nodes sampled and one is IHC+.
How high would you try to boost those involved nodes if they are in a favorable location with respect to his rectum and small bowel?
Would you treat it like an “endemic” NPX cancer with induction systemic therapy followed by CRT vs. CRT followed by adjuvant chemo vs CRT ...
How would your approach change given the prior RT?
The patient had previously recurred twice in the abdominal wall, and was treated with resection. The patient has developed AML since that time and is ...
In a setting of standard fractionation, we would sometimes consider going to 66Gy total dose to the boost cavity, so how would you "translate" this to...
There is involvement of posterior vagina, left puborectalis, and peritoneal reflection. No nodes are involved.
Does your decision change if a smit sleeve is being placed?
Do you sim and treat with their bladder as is? Or do you have patients who do urinate fill their bladder somewhat? Fluid overload is often a considera...
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.
NSCLC-style regimen of 60Gy/30fx daily or SCLC-style regimen of 45Gy/30fxBID?
In patients with large areas of painful bone metastases, do you ever do hemibody? If so, what is the preferred dose?
Would you offer SBRT (42.5 Gy in 5 fraction regimen off trial with or without Cyberknife)?
What if the spillage is noted to be limited to the tumor bed, per the surgeon?
We have a lot of push from our surgeons to do IORT, do you use the ASTRO APBI criteria? Do you treat off-protocol? Do you use Xoft or Intrabeam?
With newly published long-term data of single fraction IOeRT (Intraoperative electron Radiation Therapy) for breast cancer on the ELIOT trial, does th...
The patient’s tumor spans 6 cm depth within the scrotum, with no skin involvement.
What is your preferred beam arrangement?
With photons, woul...
PSMA showed no distant or regional disease but did show a prostatic recurrence.
How long after grafting do you start radiation?
Is there an optimal/recommended fractionation to preserve the graft?
If so, how long before/after radiation?
If the patient is outpatient and coming into clinic each day, at what point would you initiate a C. diff workup?
Assume no contraindications to hypofractionation.
Is there a reason to choose Pylarify (piflufolastat F 18) or Gallium 68 PSMA-11? If so, are there different rates of detection? Are there logisti...
Any adjustments in terms of elective nodal coverage?
In patients <50y/o, would you a favor a surgical approach in cervical malignancies that have pre-operative borderline Sedlis criteria indications f...
Post-operative MRI focused on CN V was negative. There is a focal positive margin.
Contreras et al., Phase II results suggests that elimination of PORT to the pN0 adequately dissected neck may be safe for some head and neck primary s...
Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?
Is there any particular reason to include or not include this in the treatment volumes?
The patient has no risk factors and would have been stage IB if it were not for the small nodule
What factors influence whether you treat an elective nodal volume vs gross nodal volume (plus a small margin) in the setting of oligometastatic or oli...
Do you cover the entire ipsilateral neck or limit the field to involved nodal level(s), (assuming not chasing nerve for PNI)?
Do you ever cover the c...
Should the dose still be given after completion of RT?
For example, portion is seen above and below the mesorectal fascia. Do you feel comfortable treating as colon cancer with surgery upfront?
Prior treatment: GTR in 2020, adjuvant radiation 63Gy
Patient factors: Medically inoperable and not fit for chemotherapy
The recurrence is within th...
This boost would be in addition to the standard regional nodal irradiation delivered post-op.
Would your recommendations change based on patient age (pediatric vs adult)?
If so, what dose constraint do you follow and how do you contour the bladder neck?
What if the patient has had a liver transplant?
Would you consider SBRT in this instance?
If so, then how would you approach this case if the patient's extent of disease was suboptimal for SBRT?
Are there clinical scenarios in which you have found chemotherapy first has been beneficial?
(i.e., advanced T stage, extra-mesorectal LN, anat...
Would you consider additional EBRT or vaginal cuff HDR in a patient with previous tx with EBRT (45Gy) + HDR (30Gy) for a R1 resection with a radial ma...
If a patient clearly has N1 disease with high SUV on PET, do you routinely recommend EBUS or mediastinoscopy to evaluate for N2 disease?
After multiple failed attempts with typical radonc trouble-shooting (ativan, cutting out mask, oxygen, etc)
What if the duration of neoadjuvant therapy has been less than 6 months?
Would you treat lung and HN at the same time vs sequentially?
E.g. breast or H&N cancers when boosting the supraclav area.
Is there certain information or practices that you find sets the day up for success?
If so, what dose/volume would you use? Would you cover any nodal regions electively?
Assuming patient is medically operable, would you always advocate for surgical dissection? If so, how to you approach post op radiation (and chemo).
...
Would you treat with ADT if no metastatic disease?
Does absolute PSA (e.g. PSA<2) inform decision?
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
What are the pros and cons of using uterine artery embolization with regard to how it may affect the efficacy of radiation (+/- chemotherapy)?
If so, what dose and what would you include in your field? Would the pre-chemotherapy extent/burden of nodal recurrence influence your decision?
If negative margins can be obtained, would you consider breast conversation therapy? If so, would you recommend bolus placement over lumpectomy scar?I...
Would you treat as bulky or non-bulky? Is ISRT indicated? Biopsy was performed because there was concern for soft tissue sarcoma.
Does ADT affect the results of a biopsy?
Louis et al., PMID 34185076
Which radiation doses would you use if there is a >4.5 cm LN?
Additional imaging of the potential lesions, biopsy or assume negative given normal PSMA PET/CT.
If not, then what is your preferred treatment and would you integrate SRS into it?
Does it matter if the patient has a history of WBRT?
Does the specific chemotherapy agent (MTX vs Topotecan vs Triple Intrathecal) change your recomm...
Adjuvant chemoradiation? Would you boost the positive parametrial margin? Would you also boost vaginal cuff with brachy?
What treatment margins/set-up/on-board imaging would you use?
Assume for this discussion: ECOG 0-1, life expectancy > 10How would nodal status influence your recommendation? Reference: Hawkins et al., PMI...
Would you consider re-excision and/or adjuvant RT? If RT, what margins on the scar and treatment volume would you use?
Should one do pleurectomy/decortication?
How long after hysterectomy would you consider delivering adjuvant radiation therapy? Would this differ for external beam versus brachytherapy?
Are t...
If radiation is indicated, what dose would you use?
Do you have formal constraints and evaluate cumulative doses on the composite plan? Do you use traditional constraints but account for repair?
FLAME used an atypical fractionation scheme of 77 Gy in 35 fractions boosting MRI defined nodule to 95 Gy. Would you consider a 20-fraction or 28-frac...
Have you noted significant diarrhea until the ileostomy is reversed?
Would you offer standard ChemoRT or favour APR given the risks associated with RT?
Is concurrent axitinib contraindicated if a patient is to be treated with conventionally-fractionated spinal RT (e.g., is not a candidate for spinal S...
Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? Are the results of the recently published negative phase II...
If so, how long?
If a patient develops a new erythematous macular rash in the exact area of the prior radiation portal months following completion of RT without new me...
The NCCN Breast guidelines specify that for a patient with Paget's disease of the NAC with a positive full-thickness skin biopsy of involved NAC but a...
If a treatment machine is down for 3 days, would you do weekend treatment? Would you consider doing BID?
Does the dosimetry of the plan (e.g. exceeding V20 constraints) impact your decision?
Would a history of immunosuppression impact your decision?
If a patient has a painful breast lesion in the setting of rapidly progressing systemic disease treated with weekly taxol (60 mg/m2), would you feel c...
If the inguinal node was previously treated with SBRT 30Gy/5fx and immunotherapy >6 months, what treatment would you recommend?
Do you ever add prophylactic Keppra (levetiracetam) for glioblastoma patients without a seizure history based on data such as this study (nature.com) ...
Do you allow this finding to change your management, or ignore it, as the "lesion" was not malignant?
Assuming additional workup including more extensive biopsy and nodal evaluation shows no evidence of invasive squamous cell carcinoma.
Would this cha...
E.g treating and SCLC after prior NSCLC.
Have a patient with a multi-year history of a growing substernal goiter. There is mass effect on the trachea, esophagus, and aorta. He is experiencing...
Would ypN1mi after neoadjuvant endocrine therapy cause you to recommend postmastectomy radiation? Or regional nodal coverage after breast conservation...
Assume patient had high volume of disease removed. Prostatectomy was in the very distant past.
Would you offer adjuvant radiation? (Dose? Target?) vs Salvage?
Would you add ADT? Would you add abiraterone?
Would the number of lymph nodes involv...
How close can a metastasis be to the PRV05 and still make hippocampal sparing feasible? Do you ever reduce the margin on the hippocampi to 3 mm, if yo...
The patient is a young female with a pT2N1a ER/PR positive, Her-2 positive invasive ductal carcinoma of the upper inner quadrant of the right breast s...
How soon is too soon after surgery to check PSA?
What precautions can be taken to limit infestation of the department?
Do you implement a treatment delay and if so how do you decide when...
Please share your patient selection criteria and experience.A recent study in H&N patients showed superiority of the StrataXRT gel over standard o...
Is there a risk of increased sphincter tone issues in these patients?
If a patient had 35 Gy in 5 fractions to a vertebral bone metastasis with SBRT two years ago, how much more can I give now to the whole vertebra with ...
Eg peri-tumoral fibrotic changes noted on cone beam midway through their treatment course?
For example, would you offer a patient SBRT with 3-4 lung SCC nodules? If so, how do you approach planning?
Have you found Trendelenburg positioning helpful for situations in which small bowel falls into a high dose target volume?
What would your approach be in a patient with a mid-esophageal squamous cell carcinoma treated with chemoradiation therapy followed by surgery, with P...
Are there any medications that you can prescribe? Diet changes? Does this typically resolve on its own after time?