Radiation Oncology   

Questions discussed in this category


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...

If the patient had PSC and baseline atrophy preventing brachytherapy boost (received SBRT boost instead), would this change your threshold for stentin...

Is there sufficient data to justify the routine use of GammaTile in the treatment of primary CNS malignancy or brain metastases?

When would you use 5-fluorouracil instead of, or in addition to, cisplatin during chemoradiation? When, if ever, would you offer adjuvant hysterectomy...

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...

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?

Patient with active rheumatoid arthritis, on escalating dose of Rituxan and Methotrexate, also has antisynthetase syndrome and Hashimoto's thyroiditis...

Tumor factor: Large axillary soft tissue sarcoma with involvement of the brachial plexus Other factor: Surgery would like to pursue upfront surgery t...

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...

My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...

Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...

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...

Do you think this has potential to become standard of care?

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 biopsy the metastatic lesion? Would you treat prostate definitively and monitor closely? Would you treat prostate and oligosites?

Would you add a sequential boost to the node? If so, what dose would you recommend? If surgery is advised, how you would you time it with chemoradiat...

If the patient is amenable to adjuvant chemotherapy alone, but is worried about chronic diarrhea/urgency after radiation, how would you counsel them?

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical prac...

Would you consider empiric SRS if biopsy/resection is not feasible? When would you consider liquid biopsy?

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?

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...

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...

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. 

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 ...

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...

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...

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...

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

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...

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...

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...

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...

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...

If a patient with endometrial stromal sarcoma managed with fulverstrant has a single oligoprogressive lung nodule, is there any contraindication to tr...

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...

If a patient calls you after hours with a headache following SRS and have not been given steroids, what is your preferred regimen? 

How does your counseling about side-effects change when offering short vs long course radiation?

If a patient with prostate or bladder cancer has irritative  bladder symptoms during IGRT and urinalysis reveals microscopic hematuria, WBCs, but...

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...

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...

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

If 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 adjuvant RT for subtotal resection of a parietal lobe hemangiopericytoma? How would histologic grade affect your decision making?

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?

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...

Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?

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 there a limit to the number of adjacently involved vertebrae where you would instead treat with conventionally fractionated palliation?

Do you use CT, MRI or PET/CT to create GTV volumes? What margins do you use for your CTV/PTV? 

If considering systemic therapy, would you consider standard chemotherapy or use biomarker-directed therapy (e.g., imatinib if ckit+, larotrectinib/en...

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?

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...

Does the MGMT status change your decision-making? Should we be routinely testing MGMT for elderly patients?

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 ...

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...

Do you take this into consideration when recommending treatment?

What contraindications or concerns do you have in this scenario beyond assessing the Child Pugh Score?

For example: radiation fractionation schedule, modality (proton, MRI linac, cyberknife, etc), risk categorization, prostate size, history of IBS, hist...

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?

What level of PNI is considered "large nerve" in this disease?

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?

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...

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...

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 ...

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...

Does this ever affect your decision for treatment of current disease (eg likely radiation-associated sarcoma vs likely unrelated new oropharynx cancer...

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?

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...

For example, would you modify your SBRT dose next to the azygous vein? While we talk frequently about OAR constraints for the great vessels, it seems ...

Do you take this into consideration when recommending treatment?

Is the radiation therapy management equivalent to similarly-staged squamous cell carcinoma? Is there a preferred concurrent chemotherapy regimen? ...

If the patient were of young age with high grade and ER+ disease without LVI, do these factors sway you one way or another?

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

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 ...

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...

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.  

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 the patient is outpatient and coming into clinic each day, at what point would you initiate a C. diff workup?

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...

A recent NCBD analysis (Rusthoven et al., PMID 27325855) suggests that the addition of prostate RT significantly improves survival compared to AD...

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...

Contreras et al., Phase II results suggests that elimination of PORT to the pN0 adequately dissected neck may be safe for some head and neck primary s...

Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?

Is there any particular reason to include or not include this in the treatment volumes?

The patient has no risk factors and would have been stage IB if it were not for the small nodule

What factors influence whether you treat an elective nodal volume vs gross nodal volume (plus a small margin) in the setting of oligometastatic or oli...

Do you cover the entire ipsilateral neck or limit the field to involved nodal level(s), (assuming not chasing nerve for PNI)? Do you ever cover the c...

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...

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...

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?

E.g. breast or H&N cancers when boosting the supraclav area.

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

Assuming patient is medically operable, would you always advocate for surgical dissection? If so, how to you approach post op radiation (and chemo). ...

Would you treat with ADT if no metastatic disease? Does absolute PSA (e.g. PSA<2) inform decision?

iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.

What are the pros and cons of using uterine artery embolization with regard to how it may affect the efficacy of radiation (+/- chemotherapy)?

If so, what dose and what would you include in your field? Would the pre-chemotherapy extent/burden of nodal recurrence influence your decision?

If negative margins can be obtained, would you consider breast conversation therapy? If so, would you recommend bolus placement over lumpectomy scar?I...

Would you treat as bulky or non-bulky? Is ISRT indicated? Biopsy was performed because there was concern for soft tissue sarcoma. 

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...

Assume for this discussion: ECOG 0-1, life expectancy > 10How would nodal status influence your recommendation? Reference: Hawkins et al., PMI...

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...

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...

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 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?

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...

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...

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...

Does the time interval between the intial RT and recurrence influence your decision? What time interval would you feel is appropriate? What dose would...

Please share your patient selection criteria and experience.A recent study in H&N patients showed superiority of the StrataXRT gel over standard o...

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 ...

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

What are the factors, if any, that would prompt you to recommend radiation? Low grade vs High grade? Dose/volume?

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?

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...

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...

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...

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?

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...

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?

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?

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?

Assume the dissection cannot be treated yet due to greater urgency of treating the tumor. What dose-fractionation would you select, and any additional...

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...

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...

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?  

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 ...

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...

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?

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

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

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 ...

ASTRO 2015 guidelines did not recommend coverage of stations 5/6/7 except for what is within 1 cm of the esophagus to limit lung dose. However, ARS 20...

Recent data from Spratt has suggested improved outcomes with concurrent vs neoadjuvant ADT. However, during the first 1-2 months there is expected pro...

If radiation, what type? EBRT or brachytherapy? Any other techniques you would recommend, such as rectal balloon? 

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?

The Intergroup 0162 trial did not demonstrate noninferiority, although OS difference only 5.1 vs. 5.8 yrs.  Would pattern of spread affect your d...

Can elective nodal RT be omitted for select patients with T2-4N1 head and neck cancers with multiple commodities and poor KPS with life expectancy <...

For example, in a patient recovering from COVID pneumonia who is no longer a surgical candidate due to decline in pulmonary status, and still has clin...

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

If so, what percent likelihood do you quote patients for this risk with SRS, SRT and fully fractionated therapy?

Less than 2cm in size and closest margin is 0.6mm. Would you consider re-excision or mastectomy? Would you offer radiotherapy? 

At our institution we often give 5.5 Gy x 4 fractions. There really does not appear to be a general consensus regarding timing. Interested in what oth...

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

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?

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?

Do you increase EBRT or brachy dose by a certain amount based on interval? 

How do you modify your adjuvant whole breast RT design (e.g., CTV_WB per RTOG 1005 volume-based or field-based approach) for patients with *prior* cos...

Would you change your management based on location, such as a sensitive area like the groin?  What volumes do you recommend? Does age influence y...

Weekly (20 mg/m2 D1, D2) and q 3 wks (70 mg/m2 x 3c or 100 mg/m2 x 3c) regimens have all been listed as acceptable.  For reference, RTOG 97&...

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

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

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

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...

E.g. buccal mucosa, maxillary vestibule tumors Particularly what do you levels of the contralateral neck do you include?  What factors (T stage...

For patients who are not surgical candidates and have MIBC involving a moderate to large bladder diverticulum, do you consider it safe to offer concur...

The RTOG consensus guidelines suggest to not exclude small bowel when it falls into the space occupied by the rectal mesentery. Meanwhile, prostate an...

Should it include the entire brain (normal brain + target) or just the normal brain (brain - target)?  How does the V10 or V12 constraint change ...

Would you treat differently if it was hypofractionation? How would your treatment management change if the prior radiation was within 2 years of the r...

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

What if it was found on SLNB and no axillary dissection was performed? Any risk factors that would make you consider RNI vs CW only vs observation?

There are many cases where patient has cord compression in 1-2 vertebral levels, but surgery was done with hardware encompassing 5-7 levels. Are you c...

What medications (ibuprofen, steroids, muscle relaxers) due you use? Are there any non-medication management options?

How do you sequence/integrate radiotherapy relative to high risk chemotherapy? When would you consider cranial/craniospinal radiotherapy? 

Would you follow the same guideline recommendations for adenocarcinoma if the adenoma component is invading miscle wall?

The patient has metastatic NSCLC with painful metastases of the cervical spine, and is in between cycles of chemotherapy

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

Some patients will go on to develop asymptomatic intermittent hematuria which can persist... In patients with scant hematuria, what's your routine car...

How would you approach management? If a low oncotype score was obtained, would this change your management?

The tumor was initially 5.5 cm in size.  Mastectomy and ALND revealed a grade 2, ER/PR positive HER-2 negative tumor with negative surgical marg...

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

If pathology review is done and all imaging scans including CT scan, PET scan and MRI have come back without a primary site, is it reasonable to close...

What dose/fractionation scheme and treatment volumes are most appropriate?  Could you consider treating a single vertebral level with SBRT if do...

What is the impact among patients and providers? Has your documentation been adjusted now that patients can readily review?

Specifically, for high grade T1 bladder cancer, is there evidence that definitive radiation yields similar control rates compared to cystectomy?

If so, what dose/fractionation and constraints would you recommend? 

Do you require neurosurgical evaluation first? Do you require any patients to wear a neck brace?  

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

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

Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...

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

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

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

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

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

How does a diagnosis of active RA inform your treatment approach for patients with breast cancer, if at all? 

Would you off more radiation if the prior pre-op radiation was within a few cm to the recurrence? If there a time interval you would wait before offer...

For example a power outage. While highly dependent on clinical scenario, is there some general guidance on whether to add another fraction or how else...

Given that FCCC trial (Pollack et al., PMID 24101042) showed worse late GU toxicity with IPSS >12.

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

E.g. One NSCLC with N2 disease, and additional ipsilateral small nodule that is a biopsy-proven second primary. When do you consider SBRT to a nodule ...

The patient was treated with neoadjuvant cisplatin/etoposide followed by mastectomy and SLNB with a 4 cm primary and negative nodes. LVI was noted on ...

What is you decision making process in terms of the various hypofractionated regimens for WBRT supported by different trials? When do you favor APBI?...

What clinical and pathologic features - if any - would necessitate conventional fractionation? 

Would the rate of growth, number of nodes involved, size of nodes, ENE etc. affect your decision?   What volume and dose would you recommend?

How does the PSA change differ (if at all) compared to IMRT. Do you still use the Phoenix definition? What do you do if PSA is slow to decline?

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

In what scenarios do the benefits of local control with PMRT outweigh the risks? How would systemic therapy and/or the number of bone metastases impa...

Given multidisciplinary discussion has occurred and SBRT has been agreed upon as local therapy, how do you approach the presence of moderate/significa...

Do you do fluoroscopy first, match motion of diaphragm or fiducials? CBCT? Repeat Fluoro/CBCT? Do you use breath hold or gaiting or compression? Do yo...

Which sequences/protocols do you find most useful for target delineation (primary? nodes?). Do you use contrast? If you had to choose a few to limit t...

What would be the indications for doing so? Would you proceed with APBI, or hypofractionated whole breast RT? 

Do you recommend upfront diversion? Are there unique planning considerations such as the inability to use bladder filling? How do you boost? What are ...

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

Are you offering patients beta-emitters (Samarium-153 lexidronam, strontium-89) to any patients?

If there is no pain relief after 9 months, is additional radiation reasonable? What dose/fractionation would be safe and likely to be effective?

Given the CALGB 9343 trial, as well as the recent "Choosing Wisely" recommendation (https://www.choosingwisely.org/clinician-lists/sso-sentinel-node-b...

Are there clinical features (post-op PSA, Decipher score, pN+, pT3, etc) that would inform your decision?

Given GU003 presented at ASTRO 2021- how does this impact your recommendations for adjuvant and salvage prostate RT?

Should definitive radiotherapy be used as a standard approach? If so, what are the dose and technique considerations in treating these complicated tum...

Is there any data to support it? What dose/fractionation would you consider?

Do you worry about false negatives on PET, CT, MRI if ADT is started before the scan? Scheduling scans can sometimes book 2-4 weeks out. 

Do you allow pre-RT treatment with the CDK 4/6i and hold during RT, vs. allow concurrent with breast/chest wall RT, vs. delay starting CDK 4/6i until ...

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

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

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

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

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

In this case, I have a patient with widely metastatic cutaneous melanoma (BRAF wild type, NRAS mutated) who is progressing through pembrolizumab and i...

Do you reduce the dose in such cases? Do you treat with six fractions per week similar to RTOG 1016 (w/ or without chemo)?

In the case of two fractions, would you complete two fractions one week apart? Or admit after the first and do the second fraction the next day? In p...

The patient has tissue expanders in place and is receiving ado-trastuzumab emtansine. Would you treat with PMRT? If so, would you target the CW and R...

Do you treat the inguinal lymph nodes prophylactically when using RAPIDO-style total neoadjuvant therapy (25 Gy in 5 fractions followed by CAPOX or FO...

Would 5000 cGy ISRT be appropriate?  Would you include the entire maxilla to 3000 cGy and cone down or just treat the post incisional biopsy site...

The tumor was 3.2 cm; post-op margins were negative, but <0.1 mm. The patient has excellent performance status.  She will not be receiving sys...

Resected small bilateral tonsil SCC & base of tongue SCC. The patient received 6 cycles of BEP 30 years ago for testicular cancer, and suffers fr...

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

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

Although these patients are included in the Danish trials, Taghian et al. & Floyd et al. both showed ~ 7% LRR in this group of patients witho...

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

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

Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate?  Is there a decent equatio...

Do the same concerns as post-mastectomy radiation of implants apply?There are some small case series' (https://www.ncbi.nlm.nih.gov/pubmed/21346535 DO...

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

How do you delineate your boost volume and to what dose? What dose would you use to boost suspicious remaining nodes and how are your doses impacted ...

Eg patient has been catching for years but now developing stenosis towards end of salvage RT course.

Would you treat the primary site only, include popliteal nodes, or include popliteal and inguinal nodes?

Our breast surgeons are increasingly using Wise-pattern mastectomy for improved cosmetic outcomes. Expanding the scars by 2 cm, especially along the i...

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

Given younger men have a longer period to live, are there concerns regarding long term side effects (GI, GU, secondary malignancy) between SBRT vs hyp...

If the plasmacytoma was originally limited to the femoral neck, is it necessary to cover the entire femur out of concern for marrow space involvement?

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

The patient was treated for left breast DCIS 5 years ago to a dose of 5040 cGy with a lumpectomy boost dose of 1600 cGy with conventional fractionatio...

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

For example, are PET Axumin or PSMA studies being ordered in the upfront setting? 

When patients have a single site of progression while on systemic therapy is it reasonable to consider stereotactic and/or conventional radiation to d...

If the patient has evidence of axillary lymphadenopathy on imaging, would that change your approach to treatment?  Would response to neoadjuvant...

If the tumor was excised but there is infiltration and encasement of the sciatic nerve, would you offer radiation? If numerous lines of chemotherapy h...

If yes, do you have an age cutoff and/or surgical margin cutoff?

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

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

Are there any concerns with using IMRT vs 3D? 

The patient is pT1c ER+/PR+/HER2- grade 1 IDC, LVSI-, N0(i+) with an upper outer cavity and a ~29cm breast separation If the cavity location is such ...

No cord compression is present, and the patient remains symptomatic only with their upper extremity due to brachial plexopathy

MRI shows that it's not within the rectum or prostate but it does appear to be following the contour of the right peripheral zone down almost between ...

Per lutathera information, a patient who had previous treatment for describes an estimated radiation absorbed dose of 12.8 Gy to the bladder. Would yo...

In situations when we are waiting for insurance clearance or due to other logistical reasons. 

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

Plasmacytoma of 6th rib s/p resection. Negative multiple myeloma work-up.

If this is bothersome to the patient, are there any topic ointments or medications that can help if used? 

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

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

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

Is there a role of EBRT to the prostate with extended fields to cover the retroperitoneal nodes plus ADT (definitive therapy) or would you treat as ca...

For instance, are there 1. Specific Linac features, such as a certain MLC leaf width, 6-DOF couch, etc? 2. Requisite on board imaging/IGRT capabilit...

In light of updated monarchE trial data, it seems a SLNB would help delineate adjuvant treatment options in this population. However, Choosing Wisely ...

For example, would you treat the entire length of the femur after prophylactic intramedullary rod fixation for a femoral neck metastasis?

Dose recommendations for NSCLC are to use at least 60 Gy, but for SCLC  recommendations are for higher doses starting at 66 Gy.  Classicall...

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

 In which node positive patients will you omit the IMC when treating regional nodes?

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

What margin would you use? Does this differ based on free-breathing vs. motion-management techniques like abdominal compression? 

For stroke-like migraine attacks after radiation therapy (SMART syndrome), does your management of these patient's change with recurrent episodes? How...

Would you favor re-excision? If re-excision and surgery is not an option, would you proceed with radiation or observation? If the patient had prior ...

If the glottic cancer is T3 due to thyroid cartilage involvement, can nodal RT be omitted?

For example, if they were triple negative or had a poor response to neoadjuvant chemotherapy in the breast?

What dose/fractionation scheme is appropriate? Can SBRT be utilized? Can chemorRT with Xeloda be curative in this setting?

Based on the JCO 2020 paper, how are you using this information? I understand there is no data to change management and most of us will be hesitant t...

Recent Japanese guidelines recommend <10MV beams, heart rhythm society and AAPM suggest up to 10MV beams are safe, recommending ≤10MV beams. Giv...

The 2019 ASCO guideline suggests contralateral neck radiotherapy for T3-T4 oral tongue and/or floor of mouth primary sites or tumors approaching midli...

Does anyone have experience re-treating the axilla and what dose/fractionation would you recommend?

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

Knowing the OS benefit with the Slotman data in patients who did not have upfront MRIs, and the fact that the Takahashi data would not apply in his ca...

If so, how long after phototherapy (eg. NB-UVB) is it safe to proceed with RT? See: Systemic review of phototherapy for pruritic skin disorders

CheckMate 577 only included patients with R0 resection.For R1 resections, guidelines suggest observation vs re-resection only.  

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

Do you ever contour the normal pancreas, use any dose constraints, and/or counsel patients on any possible late effects such as pancreatic insufficien...

How do you stage? Like nasopharynx or p16+ oropharynx? Do you treat it like npx ca with chemo xrt + adj chemo or like opx p16+ with definitive chemo ...

While likely dependent on the case, do you ever view CTV coverage alone as sufficient in certain areas to meet an OAR constraint such as parotids? Thi...

What radiation doses would you use for the scar and axillary nodal regions? Should supraclavicular and/or IMNs be covered? 

NCCN only recommends palliative ISRT for non-transplant eligible patients with refractory/relapsed DLBCL

Is extranodal extension of pN1 node by itself an indication to offer adjuvant radiation if there are no additional risk factors like R1/R2 or pN2? Wha...

What constraints should be used for skin, thyroid and cricoid cartilage, and trachea when treating in 5 fractions? 

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

If using boost, how would you define the tumor bed? Would you consider resimulation for target localization? If so, what is the maximum interval of t...

Is there data to guide you? Is there any reason to believe that there is an increased risk of complications in patients with prior breast implant from...

In the adjuvant setting, what boost dose to vascular areas can be safely applied, assuming one has all the tech to reliably breath hold the patient an...

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

Have you treated anyone with an implanted sacral nerve stimulator and if so, what principles did you utilize with planning? Did you modify your fields...

RTOG 1010 has Lungs-PTV constraint of V10 < or = 40% (per protocol) to 50% (variation acceptable), but V10 is not often used in other thoracic mali...

Do you approach similar to pleomorphic adenoma since it is still non-invasive? If there are indications for treating the primary, do you also elective...

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

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

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

If a staging RPLND is NOT performed, is there a role for prophylactically irradiating the lymph nodes, even in the setting of a negative PET/CT at dia...

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

What dose/fractionation regimen is most appropriate?  -i.e. 12 Gy in 4 fractions, but would you modify that approach in a young patient? What i...

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

Do you treat just gross disease with margin or electively treat levels Ib-V?  What if the patient is elderly and there is a pacemaker in level IV...

Aside from symptomatic disease, is there a certain growth cutoff or other criteria that would be a trigger for treatment?

Do you try to keep Hb> 10 or 12? Or somewhere in between? 

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

The experience by Hsieh et al. from submandibular gland carcinoma shows an 11% contralateral nodal recurrence. If you had a parotid gland malignancy ...

Do you tend to do HDR before or after external beam? Is there more toxicity with one approach?

Are there specific dose constraints for the brainstem that you use?

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

Do you uniformly recommend adjuvant treatment or reserve SRS for a subtotal resection and/or recurrent disease?

For example, much of the data on treatment volumes treating the head and neck with an unknown primary  are from the pre-PETCT era. While the posi...

Would you offer external beam radiation if the prostatectomy specimen showed a high Gleason score with involved margins?

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

Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?

If yes, how do you modify your margins? How can you change the minds of community surgeons who refuse to place them citing patient discomfort and for...

BR-001 allows treatment of oligometastatic disease in cervical lymph nodes but provides few dose constraints for SBRT in the head and neck. (Most of t...

Do you routinely include elective nodes in your radiation volume? How, if at all, does your approach to NUT differ between various sinonasal carcinom...

Would your recommendation change if patient had complete response to neoadjuvant chemotherapy in breast and axillary nodes? Please include informatio...

Would you offer chemoradiation or radiation therapy to the primary?  Would you consider consolidation of oligometastatic sites?  What dose w...

Do you always radiate the elective neck in addition to the primary site? If they had one-sided neck dissection and radiation for their prior cancer, ...

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

Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...

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

What are the data for loco-regional and distant recurrence rates with and without local therapy? What is the OS advantage?

Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...

Do you treat all surgical hardware to a conventional palliative dose? Do you treat the metastasis with SBRT? Would you treat both with a simultaneous ...

Would you move straight to second-line systemic therapy or first attempt consolidative ISRT/boost, or employ both? Assume node is biopsy-proven. 

Would you be less likely to recommend in a patient? Are there any increased vascular, GI or GU risks? Any strategies you employ to mitigate risks?

Is it still necessary to treat to 50 Gy or can a lower dose safely be used as there is no gross disease (e.g., 42 Gy in 28 fractions to nodes and the ...

Do the multiple beam angles cover the skin adequately enough? Is full dose to the skin necessary? Do you take into account the amount of auto-bolus re...

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

What normalization do you choose, what is your preferred target volume coverage,  and how do you assess for homogeneity and heterogeneity?

How do you adequately balance treating a gross retropharngeal lymph node and limiting dose to the carotid? What would you quote the risk of carotid bl...

What dose and fractionation would you use, and would it differ from other types of H&N cancers? Would you consider Quadshot scheme?

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

The recommended concurrent chemotherapy regimens (cisplatin/paclitaxel and cisplatin/FU) in NCCN are based on BID fractionation of radiation as in RTO...

Do you favor systemic therapy for X cycles followed by restaging and then consolidative radiation (SBRT or CRT)? Or do you prefer up front thoracic di...

EBRT vs VB? She technically meets PORTEC2, but also meets GOG99 and GOG249 (for pelvic RT) and PORTEC4. NCCN recommends for IB grade 1 vaginal brachyt...

If the patient has received the majority of treatment, such as 24 of 28 planned fractions (60/70 Gy), and then had a 1 - 2 week unexpected break, woul...

Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage? 

Do you have a volume cutoff in which you would prefer a more fractionated approach?   Additionally, do you routinely add concurrent temozolomid...

Does skin reaction at the time of starting the boost guide the decision to bolus?

The patient initially presented with an large renal tumor encasing the IVC and abutting the abdominal aorta. Given this, the patient received inductio...

They are known to have worse prognosis. For an adult with supratentorial G2 ependymomas s/p GTR, radiation is generally not indicated. Does this chang...

Is there any indication for ENI in early stage disease or in advanced stages, without pathologic confirmation or PET positivity or CT size criteria?

Would you recommend surgery first or neoadjuvant therapy such as concurrent cisplatin/RT or another regimen?

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

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

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

For higher risk patients, eg PSA >0.5 or high risk gleason score, etc, would you consider dose escalation still? Prior data had suggested benefit t...

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

Did you change your practice given the SRE results in the control arm of EORTC 1333 at ASCO 2021? When using bisphosphonates or denosumab, what dosin...

Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...

Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.

Are there any risks to future transplantation into the pelvic area that would outweigh the benefits? 

Are there planning techniques that you can utilize to improve dose homogeneity?

Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?

As a resident, I think about this every day. Any words of wisdom to share?

In a patient being treated with a palliative course of radiation for a bony metastasis from lung cancer is it safe to start immunotherapy for POD or w...

Is there often discordance with LVI status in biopsy vs. mastectomy such that biopsy resulting as LVI negative is not reliable to decide on PMRT indic...

For the purpose of this question, please assume an initially undetectable post-prostatectomy PSA, no presence of positive margins, extracapsular exten...

If the patient has received RCHOPx3 and the post treatment PET is negative, what would your management be?

In a patient who would be otherwise fit for surgery +/- adjuvant RT, and the delay is caused by COVID-related OR staffing issues, what would be your a...

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

Assuming re-resection is not feasible. The NCCN guidelines for post-operative RT for Stage I lung cancer with positive margins is PORT to 54-60 Gy (in...

What are the advantages and disadvantages or using films vs. CBCT? What are you looking for in each case? How often should you CBCT, and what are the...

Patient previously had adjuvant radiation to the tumor bed only. What is your radiation volume and dose? Any elective nodal levels (ipsilateral vs. ...

How does grade affect your decision-making? If adjuvant radiation is indicated, should the initial extent of disease be included or only the post-oper...

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

If so, what patients do you recommend get one and do you have concerns for patients who also may be receiving chemotherapy as the CDC guidelines recom...

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

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

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

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

In what situations would you advocate for orbital exenteration vs orbit sparing surgery with adjuvant radiation (particle therapy)?

Patient underwent SBRT without recurrence and now has symptomatic internal hemorrhoids causing intermittent fecal incontinence.  His colorectal s...

Has the recently published interim analysis of the CATNON trial altered your utilization of temozolomide? Does IDH status change your treatment appro...

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

Do you decrease total dose, increase the number of fractions, or both? What factors, in addition to size and location, do you consider?

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

Does the answer change on proximity/distance from breast (i.e. what if pelvis or lower extremity?)

How would you approach the lung constraints in a patient that received definitive RT doses >2 years ago and develops a new primary amenable to SBRT...

With so many choices listed in NCCN guidelines ranging from 2-7 weeks, what considerations factor into your decision making? 

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

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

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

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

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

Would you offer SBRT for a functional adrenal adenoma (Cushings)? If so, what dose would you deliver and what are some contouring and planning pearls?

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

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

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

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

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

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

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

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

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

Assume patient is otherwise a suitable candidate.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you manage post radiotherapy onset of tensmus differently? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are there any circumstances that would necessitate treatment? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Specifically, for cT2N0M0 small cell bladder cancer without response to neoadjuvant cisplatin and etoposide on imaging, would you proceed with cystect...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you use specific tools or take into account certain factors when considering treatment options for older adults?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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