Radiation Oncology
Questions discussed in this category
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 ...
Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?
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...
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...
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?
What volumes would you encompass? Anything different than standard nodal basins for high risk prostate cancer?
Especially as the study was done before the adoption of total neoadjuvant therapy
Patient with circumferential thoracic spine tumor on imaging, with appearance of hemangioma. Surgical pathology demonstrated glomus tumor.
Woul...
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...
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?
Would you cover the chest wall alone or would it be chest wall plus regional nodes?
Patient factors: no prior radiation therapy
Would postmastectomy radiotherapy ever be indicated in a young patient with close margins and a massive (14 cm) DCIS breast tumor interspersed with le...
If so - how long?
Does your constraint differ based on region of the spinal cord?
Relevant pathology features: positive margin
Total dose prescription: 66 Gy
Patients are understandably concerned about the risks and benefits of radiation to an oozing, bleeding, ulcerated breast.
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?
How do the results affect your recommendations for workup and management?
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...
Size: 3 cm, cN0
Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?
Do you prefer SpaceOAR vs Barrigel and why?
If so, when and to what extent?
Do you proceed with sequential, concurrent, or sandwich treatment?
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?
My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...
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...
How does age, grade, hormone receptors play into your decision?
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?
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...
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?
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...
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...
Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.
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...
Imaging of breast and systemic imaging is all negative.
Would you give adjuvant radiation and Her2 based therapy like any other Her2 + breast cancer?
What margins do you use for each cancer for photons vs electrons?
If your margins differ between cBCC and cSCC, why?
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...
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
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
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?
Would you cover the entire prostate?
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...
Is standard chemoradiation the standard of care or conventional fractionation dose-escalated (>60 Gy) radiotherapy without chemotherapy or some for...
Prior tumor was adenocarcinoma, new primary is squamous cell carcinoma.
If you would offer reirradiation, what dose constraints would you apply to th...
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?
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 would you consider when thinking about your boost?
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...
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...
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.
After the randomized Phase IIb showed decreased mucositis, are you incorporating this agent? Please share your regimen and any tips.
How would it change your risk group or management? Does Decipher help further inform treatment?
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).
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...
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...
The patient is in her 40s with BRCA-2 mutation who underwent bilateral prophylactic nipple sparing, skin sparing mastectomy. No sentinel nodes were ta...
Ipsilateral V20? MLD?
In light of the recently published GY-018 and RUBY trial, how would you treat an advanced stage/recurrent uterine cancer?
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?
Is there benefit to radiation on top of systemic therapy?
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?
Do your post-operative treatment recommendations differ for benign vs. malignant phyllodes tumors of the breast?
Is phyllodes tumor size ever a crite...
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...
How does margin positive influence your decision?
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?
NRG-BR002 (Chmura et al.)
CURB (Tsai et al.)
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...
Is there a preferred duration of ADT? Do you give abiraterone/prednisone or other novel hormone therapy?
If doing radiation, would you just do SBRT t...
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?
Patient with active rheumatoid arthritis, on escalating dose of Rituxan and Methotrexate, also has antisynthetase syndrome and Hashimoto's thyroiditis...
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...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
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...
Aside from suctioning, what are other measures could be helpful?
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?
Data for SBRT for RCC is promising but there is increasing literature on microwave ablation, radio frequency, and cryoablation. Are there any distinct...
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?
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...
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...
RADICALS-HD trial (ESMO 2022) demonstrated metastasis free survival benefit with 24 months compared to 6 months of ADT.
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)?
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...
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, how long do you continue medication and when do you discontinue?
Does treatment with surgical resection versus radiation alone change your man...
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?
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...
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 so, how do you accelerate?
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...
The patient had a prior right-sided ER+ HER2-ve breast cancer, treated with neoadjuvant chemotherapy, MRM with ALND, and PMRT
They recently developed...
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?
Does the MGMT status change your decision-making? Should we be routinely testing MGMT for elderly patients?
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...
Current NCCN guidelines recommended not combining relugolix with these agents until more data is available.
Any drug interaction concerns or ot...
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...
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...
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?
What pathologic factors would you use to make your recommendation?
In patients <50y/o, would you a favor a surgical approach in cervical malignancies that have pre-operative borderline Sedlis criteria indications f...
What dose, fractionation, and volume would you choose?
Would you electively cover the vagal nerve(s) and associated recurrent laryngeal nerves?
Does...
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?
Are there any skin care products you would avoid in this population?
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...
Complete response was achieved after cycle 3. What extent of bone would you include?
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?
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...
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?
Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...
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 77Gy in 35 fractions boosting MRI defined nodule to 95Gy. Would you consider a 20 fraction or 28 fracti...
Have you noted significant diarrhea until the ileostomy is reversed?
Would you offer standard ChemoRT or favour APR given the risks associated with RT?
What total heart dose and LAD dose do you typically utilize to justify the DIBH technique?
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?
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
Have you found Trendelenburg positioning helpful for situations in which small bowel falls into a high dose target volume?
What would your approach be in a patient with a mid-esophageal squamous cell carcinoma treated with chemoradiation therapy followed by surgery, with P...
Are there any medications that you can prescribe? Diet changes? Does this typically resolve on its own after time?
Hypothetically not an ideal surgical candidate due to weight loss. Both cancers are non-metastatic and resectable if disregarding other cancer and com...
Would you delay salvage surgery for a stage I primary vaginal cancer with partial response but no new disease at 3 months after radiation (EBRT + brac...
My experience has been that patients can be neurologically devastated years out from WBRT. In Medical Oncology practice at my institution, we do not r...
For T2N0 anal squamous cell carcinoma, RTOG 0529 used 50.4/42Gy in 28 fractions. However, for nodal disease >3cm, 54Gy in 30 fractions is used (and...
What is your radiotherapy approach? How large is your treatment field, and for the leukoplakia/in situ disease, what is your dose?
How often are you scanning the brain and what is your trigger to treat?
For example, when palliating rectal or gynecologic bleeding in 5 fractions?
What structures do you contour and what dose constraints do you utilize?
Do you use a cutoff of 10 cm? Do you measure the size of the largest node or measure the largest conglomerate or measure the total length of the entir...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice...
If a patient has been treated sucessfully for Graves but has persistent symptoms of diplopia, is radiation therapy helpful? Or is this just a dry and ...
No additional systemic therapy is planned. Would you consider consolidative radiation therapy? If so, what dose?
Do you treat on consecutive days or more protracted interfraction intervals? Does tumor type (benign vs malignant) or size influence your choice?
Is prior Ra-223 a contraindication for treatment?
Is there any available therapy?
Patient has ED unresponsive to cialis/viagra; would you recommend testosterone replacement therapy?
If a weekly schedule is chosen, what would be the appropriate weekly dose given that PORTEC-3 and GOG 258 used two cycles of cisplatin 50 mg/m2?
When treating intact bladder case to 63-64.8 Gy with shrinking fields, the max bowel dose is close to the rx dose. Old RTOG trials often just used V45...
If you do recommend adjuvant therapy, what regimen would you use?
In addition to scans, would you biopsy the prostate/SV?
Would radiation therapy to the untreated pelvic nodes with hormonal therapy be a consideratio...
Are you able to achieve the contralateral breast and lung V5 constraints from current protocols?
The said patient has been on Imatinib for 2.5 years and is In MMR. Last rt-PCR was 0.04.
How do the results of RTOG 0534 presented at ASTRO affect your decision making?
Juven protein powder is good for healing and helps with mucositis but has high amounts of antioxidants. Is that of concern while patients are undergoi...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
Assume oligometastatic site will receive treatment.
How do you take into account the following factors:
The degree of pain and/or ambulation impairment, the extent cortical destruction, and/or lytic vs...
Do you use BID treatments toward the end? Do you add additional daily treatments to exceed the prescription dose? Would you alter systemic t...
No prior brain radiation. Is full dose whole brain radiation mandated? Would you consider PCI dose or brain surveillance?
What dose-fractionation would you recommend?
Assume the dissection cannot be treated yet due to greater urgency of treating the tumor. What dose-fractionation would you select, and any additional...
Does the TURP defect in the prostate affect efficacy or toxicity or SBRT?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
Would you recommend concurrent chemoradiation (organ presrevation) vs. surgery (laryngectomy/pharyngectomy and extensive base of tongue resection) and...
Would superficial dehiscence along the incision delay you starting radiation?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
Is this a clinical/radiographic or strictly pathologic diagnosis?
Specifically, what is considered the superior/top border of LUS?
I recently saw a patient who had been treated with concurrent pembrolizumab-RT elsewhere. Is this an acceptable practice outside the setting of a clin...
Would you still take the primary to 60-70Gy?
Do you have a preference for bicalutamide? Can abiraterone be used instead?
After a diversion, would any other factors impact your recommendation (residual disease/response to chemoradiation, performance status)? Although brac...
What if Medical Oncology wants to give more systemic therapy and further delay XRT start date?What should we be telling the Breast/Plastic surgeon/Med...
What are the best references to help distinguish small and large bowel during contouring, if still unclear despite giving PO contrast?
Would you consider APBI despite younger age?
Do you typically aim to wait a certain amount of time to allow for healing? The range seems to be 4-6 weeks but 4 seems a bit early with potential ser...
At what PSA would you become suspicious for biochemical recurrence and pursue restaging? Is there a threshold value?
What imaging modality would you ...
Pleural fluid cytology is negative for malignancy but shows mesothelial cells. Would you use a PleurX or target with radiotherapy? From my understandi...
Does your surveillance schedule change dependent upon delivery of SRS vs conventional-fractionated RT?
Sodium alginate, an ingredient found in ice cream, is now being used in Japan to reduce RT-induced esophagitis. Anecdotally, a daily quart of ice crea...
Is there a specific brand or formulation you prefer?
The literature supporting the use of probiotics does not standardize the type or dose of probiot...
Would you use it for initial staging or at time of biochemical recurrence?
What do you tell men who want to know if their testosterone has recovered?
Assume non-enlarged pelvic lymph nodes, with a PSA of 4ng/ml.
If the diagnosis was made by an outside physicain, how do you confirm/refute the diagnosis? Would an alternative diagnosis like a thrombosed hemorrhoi...
The patient had been treated with conventional fractionation to bilateral breasts in the past as treatment for her synchronous IDC.She is currently in...
Would you consider this standard in asymptomatic patients for workup and treatment planning? Or do you reserve MRI for symptomatic patients only?
At what disease free interval is the safest to consider this?
For example, for a biochemically recurrent patient now with 4 PSMA PET+ nodes, if one of those PSMA+ pelvic nodes is within the prior field and adjace...
What dose/fractionation would you give to the liver lesion and node? Would you treat just the celiac node or all there regional lymphatics?
In a patient not receiving adjuvant chemotherapy who has a delayed consultation due to complications/personal issues, etc, is there a time delay ...
LVSI positive. No other high-risk features. Would you cover lymphatics?
ASTRO 2015 guidelines did not recommend coverage of stations 5/6/7 except for what is within 1 cm of the esophagus to limit lung dose. However, ARS 20...
In this case, initial tumor was 9.5 cm craniocaudal but hardware spans the entire femur.
Recent data from Spratt has suggested improved outcomes with concurrent vs neoadjuvant ADT. However, during the first 1-2 months there is expected pro...
If radiation, what type? EBRT or brachytherapy? Any other techniques you would recommend, such as rectal balloon?
Does the elapsed time from prior chemoradiotherapy impact your selection of dose/target volumes?
What role or experience is there for noninvasive bioimpedance spectroscopy (BIS) devices (SOZO)?
If a patient had prior breast conserving treatment and now has inflammatory breast disease, would you prophylactical send the patient to a cardiologis...
What dose/fractionation do you use and what elective nodal areas do you cover? What studies do you order to aide in treatment planning (PET/CT? MRI?) ...
Do you change your dose constraints for lung tissue in patients with poor pulmonary function test results?
Would you ever offer pre-operative radiotherapy in carefully selected patients before primary oncologic surgery off-trial, based on this Lancet Oncolo...
How long do you wait to radiate post spinal separation surgery for multilecord compression if there is superficial dehiscence of proximal scar?
Would you recommend axillary dissection, axillary dissection followed by adjuvant radiation, or axillary radiation alone? Does the number of positive ...
Does esophageal cancer continue to respond up to 6 months on PET, like anal SCC or p16+ oropharyngeal cancers?
What is the role for post-operative irradiation?
Garcia-Aguilar J et al, JCO 2022
The Intergroup 0162 trial did not demonstrate noninferiority, although OS difference only 5.1 vs. 5.8 yrs. Would pattern of spread affect your d...
Signs/symptoms and echo/EKG consistent with pericardial effusion likely secondary to acute pericarditis
Can elective nodal RT be omitted for select patients with T2-4N1 head and neck cancers with multiple commodities and poor KPS with life expectancy <...
For example, in a patient recovering from COVID pneumonia who is no longer a surgical candidate due to decline in pulmonary status, and still has clin...
Does your recommendation change depending on the disease-free interval?
If so, what percent likelihood do you quote patients for this risk with SRS, SRT and fully fractionated therapy?
Less than 2cm in size and closest margin is 0.6mm. Would you consider re-excision or mastectomy? Would you offer radiotherapy?
Stage is cT4N2M0.
If so, what is timing after salvage radiation that you would recommend?
And does this differ by site (e.g. gyn vs head and neck)?
Would you avoid radiation/prefer surgical approach? Tighter pharyngeal constraints?
For additional reading, see JCO OGR 11/2021 by @Laura Warren and @Jennifer R. Bellon reviewing landscape of adjuvant treatment after lumpectomy for DC...
Do you routinely discontinue the device or continue if they are otherwise tolerating the treatment well?
Assume no evidence of regional or distant metastatic disease on imaging.
Are there situations in which you would recommend dilation of stenotic airways after radiation? Is there a concern for increased complications of dila...
Do you use the same or more generous PTV expansions as definitive prostate cases?
If a patient is not a surgical candidate, what it the most appropriate treatment?
While protocols describe using a D2% constraint, there is little description of what should happen to the DVH between 30-37.5 Gy. It would ...
Is there a certain energy beyond which you feel the acute or late toxicity to the skin/breast warrants a switch to photon techniques?
In a refractory DLBCL of entire circumference of leg below knee, how do you spare a tissue strip for lymph node drainage?
Final pathology showed pT3N0, 0/27 nodes, negative margins +perforation, +PNI, pMMR.
If you avoid parathyroid hormone-related protein analog drugs in patients with prior external beam radiation, what data is this based on?
In what clinical circumstances would bolus be indicated for this histology?
Do you increase EBRT or brachy dose by a certain amount based on interval?
How do you modify your adjuvant whole breast RT design (e.g., CTV_WB per RTOG 1005 volume-based or field-based approach) for patients with *prior* cos...
Would you change your management based on location, such as a sensitive area like the groin? What volumes do you recommend? Does age influence y...
Weekly (20 mg/m2 D1, D2) and q 3 wks (70 mg/m2 x 3c or 100 mg/m2 x 3c) regimens have all been listed as acceptable. For reference, RTOG 97&...
What if there was mediastinal nodal involvement?
If so, what dose would you recommend? What other management options would you consider?
If the patient has invasive breast carcinoma and close margins with no other risk factors for local recurrence, would you utilize a cavity boost?
Are bony landmarks used to guide patient placement?
What factors do you consider?Is your thought process at all different from your approach to boost with IDC? Do you apply TROG 7.01 data (age <...
If the only indication were the parotid mets (primary site resected with no high risk features) would you treat the parotid and neck (assuming skin ca...
Assuming no overlap with prior RT doses, would a history of necrosis cause you to hypofractionate rather than deliver single fraction SRS?
Treat as invasive disease with concurrent chemotherapy? Any non-radiation options for large in-situ disease? If RT, would you include at least inguina...
Is it better to sacrifice target coverage (reducing volume receiving 95-100% dose) or change to fSRS in order to meet cord constraints without having ...
What resection margins are required for pure DCIS with adjuvant RT? What resection margins are required for pure DCIS without RT? For additi...
Initial tumor size:18 cm. Partial response was achieved after cycle 2 and cycle 6 of chemotherapy. Complete response (Deauville 2, size: 6 cm) was ach...
Would you offer RT if there was bone invasion? If there was poor wound healing causing a 6 months delay, would you still offer RT?
Due to the use of 1-1.5 cm CTV expansions on the surgical bed, the CTV for PBI often closely approaches the skin surface. In such cases, do you apply ...
Do you recommend changing the chemotherapy regimen post-operatively? Do you recommend post-operative chemoradiation?
Is single node >3cm sufficient for you to offer radiation, or do you have a different size cutoff? What other factors (such as those listed in NCCN...
Is it reasonable to dose de-escalate since survival will likely depend on the metastatic lung cancer?
E.g. buccal mucosa, maxillary vestibule tumors
Particularly what do you levels of the contralateral neck do you include?
What factors (T stage...
For patients who are not surgical candidates and have MIBC involving a moderate to large bladder diverticulum, do you consider it safe to offer concur...
When contouring pelvic lymph nodes in rectal and anal carcinoma, do you exclude bowel from your CTV?
The RTOG consensus guidelines suggest to not exclude small bowel when it falls into the space occupied by the rectal mesentery. Meanwhile, prostate an...
Should it include the entire brain (normal brain + target) or just the normal brain (brain - target)? How does the V10 or V12 constraint change ...
Would you treat differently if it was hypofractionation? How would your treatment management change if the prior radiation was within 2 years of the r...
Would you go beyond a traditional palliative regimen such as 30Gy in 10 fractions?
Would you consider boosting the nodes? What dose? Would this change your recommendation for length of ADT?
What dose and fractionation? Would use a Spaceoar?
What if it was found on SLNB and no axillary dissection was performed? Any risk factors that would make you consider RNI vs CW only vs observation?
Do you utilize MRI to aid in planning for oropharyngeal primaries?
There are many cases where patient has cord compression in 1-2 vertebral levels, but surgery was done with hardware encompassing 5-7 levels. Are you c...
What medications (ibuprofen, steroids, muscle relaxers) due you use?
Are there any non-medication management options?
How do you sequence/integrate radiotherapy relative to high risk chemotherapy?
When would you consider cranial/craniospinal radiotherapy?
Would you follow the same guideline recommendations for adenocarcinoma if the adenoma component is invading miscle wall?
Does this change depending on stage?
The patient has metastatic NSCLC with painful metastases of the cervical spine, and is in between cycles of chemotherapy
What maximum dose do you allow to “connect” adjacent metastatic lesions receiving SRS/SRT?
What is this value for one-, three-, and five-...
If pCR in lumpectomies would you boost both sites?
Is biopsy necessary to confirm disease?
Would you include the entire parotid in the intermediate risk volume?
Some patients will go on to develop asymptomatic intermittent hematuria which can persist... In patients with scant hematuria, what's your routine car...
How would you approach management? If a low oncotype score was obtained, would this change your management?
The tumor was initially 5.5 cm in size.
Mastectomy and ALND revealed a grade 2, ER/PR positive HER-2 negative tumor with negative surgical marg...
The patient has a lesion of the manubrium.
Do you only recommend ADT in patients with Gleason 4+3?
Do you treat in this scenario if mild/moderate infiltration? What are your thoughts on the article Fischer-Valuck, et al, PRO, 2017 (PMID: 280895...
If pathology review is done and all imaging scans including CT scan, PET scan and MRI have come back without a primary site, is it reasonable to close...
How would you approach the treatment of a single vertebral body involved with multiple myeloma (MM)?
What dose/fractionation scheme and treatment volumes are most appropriate?
Could you consider treating a single vertebral level with SBRT if do...
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
Specifically, for high grade T1 bladder cancer, is there evidence that definitive radiation yields similar control rates compared to cystectomy?
If so, what dose/fractionation and constraints would you recommend?
Do you require neurosurgical evaluation first? Do you require any patients to wear a neck brace?
If a patient presents with ER/PR positive, HER-2 negative pT1cN1 invasive ductal carcinoma with micropapillary features s/p lumpectomy, how would you ...
How does this affect management?
Are you doing more TNT to prolong time to surgery? If so, do are you starting with CRT or chemotherapy?
Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...
This is particularly relevant for patients with extensive delays due to wound healing issues.
The pulmonary metastases are planned to be addressed with a combination of surgical resection and SBRT.
For example V70<10cc? Or do you stick with % of organ volume dose constraints?
The patient is not amenable to re-resection.
What pathologic features and/or margin status would preclude the need for additional irradiation?
Such as those meeting the eligibility criteria for NRG HN002, <10 pack years, HPV+ T1-2N1-2b, T3N0-N2b
From my review of literature, the rate of contralateral neck failures with ipsilateral radiotherapy for lateralized tonsil T1-2 N2a disease is very lo...
For example, what is the minimal acceptable distance between the medial tangents?
For example, a two week break halfway through a course of hypofractionation for early stage breast cancer.
When treating a NSCLC with extensive bilateral mediastinal disease +/- supraclavicular nodes, would you recommend exceeding certain tissue constrains ...
Would you consider radiation therapy? What dose/fractionation?
Do you utilize both therapies? Which should come first?
How does a diagnosis of active RA inform your treatment approach for patients with breast cancer, if at all?
Would you off more radiation if the prior pre-op radiation was within a few cm to the recurrence? If there a time interval you would wait before offer...
For example a power outage. While highly dependent on clinical scenario, is there some general guidance on whether to add another fraction or how else...
Given that FCCC trial (Pollack et al., PMID 24101042) showed worse late GU toxicity with IPSS >12.
Were patients with mixed histology included in the omission trials?
If radiation has a role in treatment, what is the recommended dose? Would SpaceOAR placement be helpful?
E.g. One NSCLC with N2 disease, and additional ipsilateral small nodule that is a biopsy-proven second primary. When do you consider SBRT to a nodule ...
The patient was treated with neoadjuvant cisplatin/etoposide followed by mastectomy and SLNB with a 4 cm primary and negative nodes. LVI was noted on ...
What is you decision making process in terms of the various hypofractionated regimens for WBRT supported by different trials?
When do you favor APBI?...
What constraints do you use for the contralateral breast and what will you accept?
What is the role for surgery vs RT?
What clinical and pathologic features - if any - would necessitate conventional fractionation?
Would the rate of growth, number of nodes involved, size of nodes, ENE etc. affect your decision?
What volume and dose would you recommend?
How does the PSA change differ (if at all) compared to IMRT. Do you still use the Phoenix definition?
What do you do if PSA is slow to decline?
Would you recommend whole pelvis as well as vaginal cuff brachytherapy?
This is one of the available options in the NRG-BR007 DEBRA trial
In what scenarios do the benefits of local control with PMRT outweigh the risks?
How would systemic therapy and/or the number of bone metastases impa...
Given multidisciplinary discussion has occurred and SBRT has been agreed upon as local therapy, how do you approach the presence of moderate/significa...
Do you do fluoroscopy first, match motion of diaphragm or fiducials? CBCT? Repeat Fluoro/CBCT? Do you use breath hold or gaiting or compression? Do yo...
Which sequences/protocols do you find most useful for target delineation (primary? nodes?). Do you use contrast? If you had to choose a few to limit t...
What would be the indications for doing so?
Would you proceed with APBI, or hypofractionated whole breast RT?
Do you recommend upfront diversion? Are there unique planning considerations such as the inability to use bladder filling? How do you boost? What are ...
VC brachy, pelvic RT, +/- chemo?
Does your management change if it is confined to the endometrium without myometrium invasion or if it is only ...
Are you offering patients beta-emitters (Samarium-153 lexidronam, strontium-89) to any patients?
If there is no pain relief after 9 months, is additional radiation reasonable? What dose/fractionation would be safe and likely to be effective?
Given the CALGB 9343 trial, as well as the recent "Choosing Wisely" recommendation (https://www.choosingwisely.org/clinician-lists/sso-sentinel-node-b...
Are there clinical features (post-op PSA, Decipher score, pN+, pT3, etc) that would inform your decision?
Given GU003 presented at ASTRO 2021- how does this impact your recommendations for adjuvant and salvage prostate RT?
What factors and evidence would you use in your decision?
40 yo adult patient with a~6cm mass with concern for skull base bony involvement (group III and stage III, no nodal involvement )
Would you offer systemic therapy and/or radiation therapy to groin/pelvis?
Should definitive radiotherapy be used as a standard approach? If so, what are the dose and technique considerations in treating these complicated tum...
Is there any data to support it? What dose/fractionation would you consider?
Do you worry about false negatives on PET, CT, MRI if ADT is started before the scan? Scheduling scans can sometimes book 2-4 weeks out.
Do you allow pre-RT treatment with the CDK 4/6i and hold during RT, vs. allow concurrent with breast/chest wall RT, vs. delay starting CDK 4/6i until ...
Is there a benefit to EBRT/SBRT or would you choose observation until there is pathologic evidence of invasive pancreatic cancer?
If multi-agent systemic therapy, i.e. FOLFIRINOX, is also planned, is there a preferred sequence of therapies?
Does availability of surface imaging (visionRT) reduce your use of imaging for setup?
Prior treatment with ipsilateral breast RT was >10 years ago
If not, how should you select those cases that should be referred?
What is your threshold for irradiating a suspicious lung nodule?
Do you approve ports daily or less often? Do you ever use CBCT?
Do you always cover these areas of ipsilateral neck is positive? Does it depend on nodal level involved, primary site (oropharynx vs. larynx/hypophary...
Would you consider chemoradiation to the supraclavicular region?
In this case, I have a patient with widely metastatic cutaneous melanoma (BRAF wild type, NRAS mutated) who is progressing through pembrolizumab and i...
Do you reduce the dose in such cases? Do you treat with six fractions per week similar to RTOG 1016 (w/ or without chemo)?
Would you always radiate? If not, when do you feel comfortable with observation after surgery?
In the case of two fractions, would you complete two fractions one week apart? Or admit after the first and do the second fraction the next day?
In p...
https://www.ncbi.nlm.nih.gov/pubmed/33497252
The patient has tissue expanders in place and is receiving ado-trastuzumab emtansine.
Would you treat with PMRT? If so, would you target the CW and R...
Do you treat the inguinal lymph nodes prophylactically when using RAPIDO-style total neoadjuvant therapy (25 Gy in 5 fractions followed by CAPOX or FO...
A certain cm above the superior-most involved node? A certain number of vertebral body above? To the diaphragm and include retrocrural nodes?
Would 5000 cGy ISRT be appropriate? Would you include the entire maxilla to 3000 cGy and cone down or just treat the post incisional biopsy site...
The tumor was 3.2 cm; post-op margins were negative, but <0.1 mm. The patient has excellent performance status. She will not be receiving sys...
Resected small bilateral tonsil SCC & base of tongue SCC.
The patient received 6 cycles of BEP 30 years ago for testicular cancer, and suffers fr...
When/how often do you order imaging?
Which systemic agents would you recommend holding during RT?
What dose/fractionation?
Has your practice changed based on the randomized, phase 3 study showing prophylactic gabapentin is not effective?
Please share your thoughts and exp...
NCCN recommends perioperative FLOT or FOLFOX vs. neoadjuvant chemoRT with Carboplatin/Paclitaxel or FOLFOX.Does CM-577 and the approval of nivolumab p...
What dose would you recommend? Is SBRT needed?
Although these patients are included in the Danish trials, Taghian et al. & Floyd et al. both showed ~ 7% LRR in this group of patients witho...
Is there a role for SRS/fSRS?
What about for a patient with complete radiographic response who declines surgical management?
If the margins contain in situ disease, would you recommend further wide local excision?
Would chronic immunosuppressive disease affect your treatmen...
Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate? Is there a decent equatio...
Do the same concerns as post-mastectomy radiation of implants apply?There are some small case series' (https://www.ncbi.nlm.nih.gov/pubmed/21346535 DO...
If re-irradiation, what dose would you use?
Additionally, when evaluating margin status for APBI IMRT 30 Gy in 5 fractions which specifies at least 5mm margins, do you look at the DCIS margin or...
Pathology also notable for LVI +, PNI+, but with negative margins.
Is 30 Gy/10 fractions acceptable, or is another dose/fractionation scheme ideal?
How do you delineate your boost volume and to what dose?
What dose would you use to boost suspicious remaining nodes and how are your doses impacted ...
Eg patient has been catching for years but now developing stenosis towards end of salvage RT course.
For patients who were not neoadjuvantly on pembrolizumab, is it safe to initiate it concurrently with radiation?
MRI pre-op did not reveal suspicious lymph nodes. Margins were negative upon mastectomy.
Does severity of dementia play a factor in recommending ADT?
Would you treat the primary site only, include popliteal nodes, or include popliteal and inguinal nodes?
Our breast surgeons are increasingly using Wise-pattern mastectomy for improved cosmetic outcomes. Expanding the scars by 2 cm, especially along the i...
In the absence of the ability to use IGBT, would you continue to treat the target?
Would you treat per OPRA, or try for a higher dose?
When would you add steroids or consider Avastin?
Given younger men have a longer period to live, are there concerns regarding long term side effects (GI, GU, secondary malignancy) between SBRT vs hyp...
Will this study change your practice?
If the plasmacytoma was originally limited to the femoral neck, is it necessary to cover the entire femur out of concern for marrow space involvement?
Would you prefer APBI or mastectomy in this situation?
If biopsy is not feasible, should these patient be treated as cN+ with neoadjuvant chemotherapy or as cN0 with upfront surgery with axillary sent...
Is it possible that the dehiscent is radiation induced?
The patient was treated for left breast DCIS 5 years ago to a dose of 5040 cGy with a lumpectomy boost dose of 1600 cGy with conventional fractionatio...
With the recently reported START (A and B) trial data from the UK, in which patients were allowed to receive hypfractionated doses to nodal regions, i...
Is there a role for SRS in this situation?
For example, are PET Axumin or PSMA studies being ordered in the upfront setting?
When patients have a single site of progression while on systemic therapy is it reasonable to consider stereotactic and/or conventional radiation to d...
If the patient has evidence of axillary lymphadenopathy on imaging, would that change your approach to treatment?
Would response to neoadjuvant...
If the tumor was excised but there is infiltration and encasement of the sciatic nerve, would you offer radiation? If numerous lines of chemotherapy h...
If yes, do you have an age cutoff and/or surgical margin cutoff?
Or would you always aim to treat with combined chemotherapy and fractionated radiation?
In elderly patients (>70-75) with a good performance status, does the risk of neurocognitive decline outweigh the benefit of PCI?
Have you utilized these gene-expression profiles in your practice?
Is there sufficient data for this test to be used for clinical decisions?
For example, if the lumpectomy specimen had low risk/low volume invasive disease?
Are there any concerns with using IMRT vs 3D?
The patient is pT1c ER+/PR+/HER2- grade 1 IDC, LVSI-, N0(i+) with an upper outer cavity and a ~29cm breast separation
If the cavity location is such ...
No cord compression is present, and the patient remains symptomatic only with their upper extremity due to brachial plexopathy
MRI shows that it's not within the rectum or prostate but it does appear to be following the contour of the right peripheral zone down almost between ...
Per lutathera information, a patient who had previous treatment for describes an estimated radiation absorbed dose of 12.8 Gy to the bladder. Would yo...
The lymph node is 4 cm and is the only site that is growing on her current systemic therapy regimen.
At what timepoint after surgery does prospective adjuvant radiation no longer become beneficial?
In situations when we are waiting for insurance clearance or due to other logistical reasons.
When do you offer preop RT (50Gy) before the re-excision? When do you offer post-op RT after the re-excision?
Plasmacytoma of 6th rib s/p resection. Negative multiple myeloma work-up.
If this is bothersome to the patient, are there any topic ointments or medications that can help if used?
Would a complete pathologic response impact your dose or decision to treat in absence of studies?
Based on Mill et al paper showing increased IBTR rates with ILC vs IDC (https://theoncologist.onlinelibrary.wiley.com/doi/10.1002/onco.13980)
Would your answer change in the postop setting for a tumor right above peritoneal reflection with positive pelvic nodes?
What if the patient is refusing chemotherapy?
What would be your preferred technique and dose/fractionation?
For those of us just transitioning over to hypofractionation, what are reasonable, but conservative, constraints that you use?
Is there a role of EBRT to the prostate with extended fields to cover the retroperitoneal nodes plus ADT (definitive therapy) or would you treat as ca...
Would you do consolidation radiation or active surveillance?
Would presence of variant histology change your recommendation?
For instance, are there
1. Specific Linac features, such as a certain MLC leaf width, 6-DOF couch, etc?
2. Requisite on board imaging/IGRT capabilit...
In light of updated monarchE trial data, it seems a SLNB would help delineate adjuvant treatment options in this population. However, Choosing Wisely ...
Do you use conventional fractionated RT, hypofractionated RT, or SBRT?
For example, would you treat the entire length of the femur after prophylactic intramedullary rod fixation for a femoral neck metastasis?
Dose recommendations for NSCLC are to use at least 60 Gy, but for SCLC recommendations are for higher doses starting at 66 Gy.
Classicall...
Is there evidence that supports/refutes the safety of concurrent use?
In which node positive patients will you omit the IMC when treating regional nodes?
How do you counsel patients on the benefit of adjuvant therapy who thought surgical resection was curative?
If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...
Assume no nodal involvement.
What margin would you use? Does this differ based on free-breathing vs. motion-management techniques like abdominal compression?
For stroke-like migraine attacks after radiation therapy (SMART syndrome), does your management of these patient's change with recurrent episodes? How...
Would you favor re-excision?
If re-excision and surgery is not an option, would you proceed with radiation or observation?
If the patient had prior ...
Do you boost when employing this regimen?
Would you recommend a re-excision?
Is radiation without re-excision appropriate; if so, should a boost be given?
If so, when do you consider this?
If the glottic cancer is T3 due to thyroid cartilage involvement, can nodal RT be omitted?
For example, if they were triple negative or had a poor response to neoadjuvant chemotherapy in the breast?
What dose/fractionation scheme is appropriate? Can SBRT be utilized? Can chemorRT with Xeloda be curative in this setting?
Based on the JCO 2020 paper, how are you using this information?
I understand there is no data to change management and most of us will be hesitant t...
Recent Japanese guidelines recommend <10MV beams, heart rhythm society and AAPM suggest up to 10MV beams are safe, recommending ≤10MV beams. Giv...
The 2019 ASCO guideline suggests contralateral neck radiotherapy for T3-T4 oral tongue and/or floor of mouth primary sites or tumors approaching midli...
What would be the treatment duration if using oral TKI?
Does anyone have experience re-treating the axilla and what dose/fractionation would you recommend?
What clinical criteria would make you prefer TORS as the initial treatment approach?
Do you offer definitive treatment?
Systemic therapy alone since it's metastatic?
Additionally, what dose constraint(s) do you use to avoid issues with vision?
Would chemotherapy be preferred over RT?
Knowing the OS benefit with the Slotman data in patients who did not have upfront MRIs, and the fact that the Takahashi data would not apply in his ca...
Is there a role for more advanced delivery techniques
If so, how long after phototherapy (eg. NB-UVB) is it safe to proceed with RT?
See: Systemic review of phototherapy for pruritic skin disorders
CheckMate 577 only included patients with R0 resection.For R1 resections, guidelines suggest observation vs re-resection only.
Do you ever contour the normal pancreas, use any dose constraints, and/or counsel patients on any possible late effects such as pancreatic insufficien...
How do you stage? Like nasopharynx or p16+ oropharynx?
Do you treat it like npx ca with chemo xrt + adj chemo or like opx p16+ with definitive chemo ...
E.g. A patient with station 4 and 5 nodal disease and arterial grafts.
Is there increased toxicity in patients with duodenal stents receiving RT?
Is there a benefit of SBRT over Y90 or vice versa?
Or do you only treat to IA if the primary is in an oral cavity location?
While likely dependent on the case, do you ever view CTV coverage alone as sufficient in certain areas to meet an OAR constraint such as parotids? Thi...
What radiation doses would you use for the scar and axillary nodal regions? Should supraclavicular and/or IMNs be covered?
NCCN only recommends palliative ISRT for non-transplant eligible patients with refractory/relapsed DLBCL
Does your approach change based on risk group?
Is extranodal extension of pN1 node by itself an indication to offer adjuvant radiation if there are no additional risk factors like R1/R2 or pN2? Wha...
What constraints should be used for skin, thyroid and cricoid cartilage, and trachea when treating in 5 fractions?
Would involvement of the PA nodes be an indication?
What is your level of concern for chest wall toxicity? Any difference in your thought process between SCLC vs. NSCLC?
Do you deflate to a specific volume?
If using boost, how would you define the tumor bed?
Would you consider resimulation for target localization? If so, what is the maximum interval of t...
Is the competing risk of a distant recurrence too high to justify doing radiation?
Is there data to guide you? Is there any reason to believe that there is an increased risk of complications in patients with prior breast implant from...
The dosing in the literature has a huge range.
In the adjuvant setting, what boost dose to vascular areas can be safely applied, assuming one has all the tech to reliably breath hold the patient an...
If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?
Have you treated anyone with an implanted sacral nerve stimulator and if so, what principles did you utilize with planning? Did you modify your fields...
RTOG 1010 has Lungs-PTV constraint of V10 < or = 40% (per protocol) to 50% (variation acceptable), but V10 is not often used in other thoracic mali...
Do you approach similar to pleomorphic adenoma since it is still non-invasive? If there are indications for treating the primary, do you also elective...
Is there any additional benefit to radiation in addition to steroids in a patient who is not a surgical candidate?
Does this affect your subsequent imaging surveillance frequency?
Based on the SCORAD III trial, will you now be treating patients with spinal cord compression with single-fraction radiotherapy? Is there anyone ...
Individuals often cite ARST0332 to justify radiation omission in high grade R0 resections, but R0 was defined as > 5 mm margins.
Has the use of immunotherapy replaced the use of sequential chemo?
If RT/chemo is preferred, what is an acceptable final boost dose?
If a staging RPLND is NOT performed, is there a role for prophylactically irradiating the lymph nodes, even in the setting of a negative PET/CT at dia...
If so, what dose and fractionation would you recommend?
Would you choose re-treatment with electrons, photons, or brachytherapy?
What dose and fractionation scheme would you employ?
Would your answer change for favorable vs unfavorable intermediate risk disease?
What dose/fractionation regimen is most appropriate?
-i.e. 12 Gy in 4 fractions, but would you modify that approach in a young patient?
What i...
Would you consider external beam radiation vs HDR vs LDR? What dose, margins, and OAR constraints would you use given prior treatment?
If so, how can we accomplish this advocacy?
Do you treat just gross disease with margin or electively treat levels Ib-V? What if the patient is elderly and there is a pacemaker in level IV...
Is adjuvant RT necessary for a completely resected pT1/2 N0 disease with negative margins?
SBRT? Do you change dose fractionation?
Would you consider SBRT?
Aside from symptomatic disease, is there a certain growth cutoff or other criteria that would be a trigger for treatment?
Do you try to keep Hb> 10 or 12? Or somewhere in between?
What would be your RT volumes and dose?
Surgical path confirmed CK7(-), CDX2(+), CK20(+), consistent with prior colonic adenocarcinoma.
What would be your radiation volumes/dose and choice of chemotherapy?
No tumor at ink? 1-2mm?
The experience by Hsieh et al. from submandibular gland carcinoma shows an 11% contralateral nodal recurrence.
If you had a parotid gland malignancy ...
Do you tend to do HDR before or after external beam? Is there more toxicity with one approach?
E.g. disease burden causing airway or vascular compression.
Are there specific dose constraints for the brainstem that you use?
Would extent of surgical resection matter?
Do these patients need CSI (like Pineoblastoma), just local radiation, or something in-between (say whole ...
Are there other high or very high risk features that would also contribute to your decision making?
CNS recurrence occurred within two years of prior neoadjuvant therapy
Do you uniformly recommend adjuvant treatment or reserve SRS for a subtotal resection and/or recurrent disease?
For example, much of the data on treatment volumes treating the head and neck with an unknown primary are from the pre-PETCT era. While the posi...
Would you offer external beam radiation if the prostatectomy specimen showed a high Gleason score with involved margins?
What would be your preferred treatment technique and dose/fractionation?
E.g. right hemithorax disease from lung apex to diaphragm, no response s/p 3 cycles of cis/pem.
Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?
If yes, how do you modify your margins?
How can you change the minds of community surgeons who refuse to place them citing patient discomfort and for...
NSABP B51 and B52 specifically prohibit this.
For example, not placing superior border at L5/S1.
BR-001 allows treatment of oligometastatic disease in cervical lymph nodes but provides few dose constraints for SBRT in the head and neck. (Most of t...
Do you routinely include elective nodes in your radiation volume?
How, if at all, does your approach to NUT differ between various sinonasal carcinom...
Would your recommendation change if patient had complete response to neoadjuvant chemotherapy in breast and axillary nodes?
Please include informatio...
Would you offer chemoradiation or radiation therapy to the primary? Would you consider consolidation of oligometastatic sites? What dose w...
Do you always radiate the elective neck in addition to the primary site?
If they had one-sided neck dissection and radiation for their prior cancer, ...
Lymph node is 4.5cm with no reported ECE. Does the size of the LN or presence or absence of ECE affect your decision?
Would you offer adjuvant RT or chemotherapy? If so, what chemotherapy would you prefer?
Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...
The recently published SSO/ASTRO/ASCO consensus guideline on DCIS states that "a 2 mm margin minimizes the risk of IBTR compared with smalle...
What are the data for loco-regional and distant recurrence rates with and without local therapy? What is the OS advantage?
Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...
Do you treat all surgical hardware to a conventional palliative dose? Do you treat the metastasis with SBRT? Would you treat both with a simultaneous ...
Would you move straight to second-line systemic therapy or first attempt consolidative ISRT/boost, or employ both? Assume node is biopsy-proven.
Would you be less likely to recommend in a patient? Are there any increased vascular, GI or GU risks? Any strategies you employ to mitigate risks?
Is it still necessary to treat to 50 Gy or can a lower dose safely be used as there is no gross disease (e.g., 42 Gy in 28 fractions to nodes and the ...
Do the multiple beam angles cover the skin adequately enough? Is full dose to the skin necessary? Do you take into account the amount of auto-bolus re...
GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease. Prostate MRI pending.
What normalization do you choose, what is your preferred target volume coverage, and how do you assess for homogeneity and heterogeneity?
How do you adequately balance treating a gross retropharngeal lymph node and limiting dose to the carotid? What would you quote the risk of carotid bl...
What dose and fractionation would you use, and would it differ from other types of H&N cancers?
Would you consider Quadshot scheme?
How would your management change in an elderly patient with no surgery verus superficial parotidectomy or total parotidectomy?
The recommended concurrent chemotherapy regimens (cisplatin/paclitaxel and cisplatin/FU) in NCCN are based on BID fractionation of radiation as in RTO...
Do you favor systemic therapy for X cycles followed by restaging and then consolidative radiation (SBRT or CRT)? Or do you prefer up front thoracic di...
Would you use 10x and 15x in your fields?
EBRT vs VB? She technically meets PORTEC2, but also meets GOG99 and GOG249 (for pelvic RT) and PORTEC4. NCCN recommends for IB grade 1 vaginal brachyt...
If the patient has received the majority of treatment, such as 24 of 28 planned fractions (60/70 Gy), and then had a 1 - 2 week unexpected break, woul...
Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage?
Do you have a volume cutoff in which you would prefer a more fractionated approach?
Additionally, do you routinely add concurrent temozolomid...
Does skin reaction at the time of starting the boost guide the decision to bolus?
Patient previously had prostatectomy and salvage RT
The patient initially presented with an large renal tumor encasing the IVC and abutting the abdominal aorta. Given this, the patient received inductio...
They are known to have worse prognosis. For an adult with supratentorial G2 ependymomas s/p GTR, radiation is generally not indicated. Does this chang...
Is there any indication for ENI in early stage disease or in advanced stages, without pathologic confirmation or PET positivity or CT size criteria?
Would you recommend surgery first or neoadjuvant therapy such as concurrent cisplatin/RT or another regimen?
Is age ever a concern given the potential side effects of long term ADT?
The patient was initially observed after radical hysterectomy due to young age, FIGO IA grade 2 disease.
The patient had isolated, biopsy-proven vagi...
For higher risk patients, eg PSA >0.5 or high risk gleason score, etc, would you consider dose escalation still? Prior data had suggested benefit t...
How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?
If so, what dose and treatment fields would you use?
Did you change your practice given the SRE results in the control arm of EORTC 1333 at ASCO 2021?
When using bisphosphonates or denosumab, what dosin...
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...
Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.
Are there any risks to future transplantation into the pelvic area that would outweigh the benefits?
Are there planning techniques that you can utilize to improve dose homogeneity?
Any role for surgical extirpation vs systemic treatment?
Patient is 38yo, has a history of narcotic abuse, and may have an undiagnosed personality disorder.
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
As a resident, I think about this every day. Any words of wisdom to share?
In a patient being treated with a palliative course of radiation for a bony metastasis from lung cancer is it safe to start immunotherapy for POD or w...
Would you consider adding ADT?
Is there often discordance with LVI status in biopsy vs. mastectomy such that biopsy resulting as LVI negative is not reliable to decide on PMRT indic...
For the purpose of this question, please assume an initially undetectable post-prostatectomy PSA, no presence of positive margins, extracapsular exten...
If the patient has received RCHOPx3 and the post treatment PET is negative, what would your management be?
In a patient who would be otherwise fit for surgery +/- adjuvant RT, and the delay is caused by COVID-related OR staffing issues, what would be your a...
Does patient age effect your approach?
Would you consider RPLND for any patients in light of the phase II SEMS trial presented at the 2021 ASCO GU Ca...
Assuming re-resection is not feasible. The NCCN guidelines for post-operative RT for Stage I lung cancer with positive margins is PORT to 54-60 Gy (in...
What are the advantages and disadvantages or using films vs. CBCT? What are you looking for in each case?
How often should you CBCT, and what are the...
Patient previously had adjuvant radiation to the tumor bed only.
What is your radiation volume and dose?
Any elective nodal levels (ipsilateral vs. ...
How does grade affect your decision-making? If adjuvant radiation is indicated, should the initial extent of disease be included or only the post-oper...
Would you offer SBRT over standard fractionation of smaller tumors?
Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?
E.g. SBRT 9 months ago.
If so, what patients do you recommend get one and do you have concerns for patients who also may be receiving chemotherapy as the CDC guidelines recom...
Patient is <60 years old
The CROSS trial showed a survival benefit with 4140cGy and concurrent carbo/taxol, but I was always trained to treat to 5040cGy. Is anyone de-escalati...
If so, what dose fractionation would you recommend?
Would there be any benefit to surgery in a healthy/good PS patient? There is so little data on pulmonary atypical carcinoid and radiation respons...
E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.
One example of this scenario would be a patient receiving consolidative durvalumab after chemoRT for stage III NSCLC who develops a new peripheral lun...
In what situations would you advocate for orbital exenteration vs orbit sparing surgery with adjuvant radiation (particle therapy)?
Patient underwent SBRT without recurrence and now has symptomatic internal hemorrhoids causing intermittent fecal incontinence. His colorectal s...
Has the recently published interim analysis of the CATNON trial altered your utilization of temozolomide?
Does IDH status change your treatment appro...