Radiation Oncology

Lung Cancer   

Questions discussed in this category



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

Much of this approach was designed with cytotoxic chemotherapy in mind -- wait "x" cycles, assess response, deliver radiation after chemotherapy. How ...

Medical inoperability is clearly defined, anatomical resectability is also pretty much clear (invasion of trachea/carina/esophagus, etc). But what abo...

If you are using a standard 30/10 fractionation, is there a benefit to keeping chemo on board for radio-sensitization?

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

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 ...

I am treating a left lower lobe NSCLC and my PTV is so close to the spleen that a small portion of the spleen is getting significant dose.  I can...

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

As a for instance, a centrally located primary tumor with mediastinal adenopathy that results in a TE fistula? Currently we would recommend esophagea...

What would you anticipate with regard to potential adrenal toxicity when the patient has only 1 functioning adrenal gland? There are no other sites of...

Does EGFR+ status influence your decision? What is the significance of this finding and its potential for progression? Is it simply occult disease con...

Since the randomized phase II data from Gomez et al presented at ASTRO 2018 showed a survival benefit, is there concern about randomizing patients to ...

Does it factor into your decision making in the setting of restricted spirometry and normal lung volumes? Does this differ for SBRT v. chemoRT?

There seem to be a lot of different fractionation schemes in the literature. Is there one that is most standard?

The Indiana report and RTOG published a "danger zone".  There was a catastrophic "case report" for 50 Gy in 5 fractions.  Are there alternat...

In patients with aberrant anatomy due to previous surgery with lung PTV overlapping the stomach, how much would you dose de-escalate? Even conventiona...

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

Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?

Is local control worse for SBRT when the tumor is invading into the bone (rib)?

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...

Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?

If so, what fields do you irradiate? The initially involved nodal regions? If not, do you consolidate at any point in the future (ie after a loca...

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...

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

When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?

These patients have been largely excluded from these trials.  What if the infection is well controlled?

If you are considering chemotherapy and radiation in the definitive, postoperative, or nodal failure scenarios, would you prefer sequential treat...

If so, 50 Gy / 5 fx? 7.5 Gy / 8 fx? If so what dose constraints would you use to help determine fractionation?

If you treat pre-chemotherapy volumes, is there a benefit to induction chemotherapy even in bulky disease. If so, how do you define disease that ...

What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?

Is there a role for SBRT to the primary site? Is it required to treat the ipsilateral hilum if no adenopathy was seen on EBUS or PET?

Given the multiple retrospective studies showing benefit to higher BED fractionation schedules (most recently, http://www.redjournal.org/article/S0360...

Given the lepidic growth pattern, do you use similar margins as with frankly invasive lung tumors? Are there any challenges localizing the target with...

Would you recommend chemo alone first?  Would you treat with definite chemo-RT to the lung then the head/neck or vice versa? How would this chan...

When treating lung tumors abutting the visceral pleura/chest wall with SBRT, chest wall or rib pain sometimes occurs. In these cases, I try to avoid i...

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

Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?

Are there any rules you follow? Do you shrink target volumes if you notice a significant response (via CBCT) in a bulky lung tumor with fractionated r...

What is the best evidence for what dose to use? When would you give it in relation to the checkpoint inhibitors? Which metastatic sites do you choose ...

Recently, while planning a patient for lung SBRT it was suggested by the physicist that we change the density of the PTV to higher density to improve ...

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

Would a postiive margin or extracapsular extension altar your recommendations? Does size play a role in your recommendation?

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage.  Is t...

How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation? 

The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib. 

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...

If a biopsy carries a high risk of morbidity what interventions would you recommend for the local failure?

The NCCN guidelines call for pathological mediastinal lymph node staging for all NSCLC except in solid tumors <1cm and non-solid lesions < ...

Is it reasonable to dose escalate beyond 60 Gy if meeting all dosimetric criteria and with some room to spare? RTOG 0617 would suggest 60 Gy should be...

Following lung RT, I have rarely seen patients present with pneumonia-like symptoms of radiation pneumonitis. I'm more likely to see a patient with wo...

As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?

Based on the European data published in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961085-0/abstract), are you s...

Do you treat the hilum and ipsilateral mediastinum?  Just the lymph node levels that were positive at surgery?  I have not found good guidel...

In other words, if offered wedge or segmentectomy, should SBRT be preferred? Does size matter ie if the lesion is < 3 vs < 2 vs < 1 cm? Does ...

The BED10 for 50 Gy in 5 fractions is 100, which is significantly lower then the BED of the 54 Gy in 3 fractions regimen (151). Since the Kestin/Grill...

Our dosimetrists rarely meet the RTOG constraint using a non-coplanar technique, especially for very small lesions. I haven't been able to find a corr...

Does IFRT include only the involved lymph nodes + margin or the entire involved lymph node station as specified by the Michigan Atlas?

Are your constraints different than the standard constraints used for patients who have not had surgery?

I am aware that chemotherapy can obviate the need for RT in patients with SVC syndrome, but I'm not sure if this can be extrapolated to spinal cord co...

Would you consider placing a stent in this patent graft to minimize closure of the graft after SBRT?

Should elective mediastinal irradiation still be avoided? For example, if you have a T2 RLL lesion, and let's say, a positive AP window node, do you n...

Is there any concern about hemorrhage from treatment effect on tumor? Would SABR worsen the chance of fatal hemorrhage/hemoptysis and if so, would you...

In the case where there is a PET avid subpleural nodule in the exact same location as needle biopsy 3 months prior, is this considered a chest wall me...

For small overall volumes (e.g. 0.5cm solid component, 1cm total lesion size when including GGO), I imagine treating the entirety of the abnormality i...

Do you define it as whole lungs (inc. tumor) or whole lungs minus GTV, CTV,  ITV, or PTV?

We've seen quite a few patients present with NSCLC with a single brain metastasis and a good performance status. Would you advocate for an aggressive ...

ASTRO 2014's lung session presented data from RTOG 0236, showing a 20% intralobar failure/recurrence despite only 7% local failure. How does one recon...

RTOG 0915 allows either technique, but I've heard people say that IMRT is not "technically" SBRT. Is there is a benefit to the non-coplanar 3D techniq...

The patient underwent lobectomy and nodal staging for a presumed non-small cell lung cancer.

Dose/Fractionation? Concurrent v. sequential chemo? What literature do you use to backup PORT for a positive margin?

In SBRT, it has been said that Pencil Beam dose calculation algorithm can overestimate the target dose and understimate the normal tiss...

I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...

I've found that very few patients have a regular breathing cycle, which makes respiratory gating very difficult. Any other solutions?


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