For consideration of empiric lung SBRT without pathology, do you use a preferred nomogram to guide this decision?

I feel most comfortable offering empiric SBRT when the following criteria are met:

1. Growing
2. PET avid
3. Not likely a non-malignant condition
4. Compelling medical or patient-specific reason for no biopsy
5. Patient understands the implications of proceeding without a biopsy

This is an important and complicated topic. I have not depended heavily on nomograms to guide treatment decisions in my practice. Most nomograms describe the likelihood that a suspicious nodule is malignant. This does not exactly answer the question, “Is empiric SBRT the best option for my patient r...

No. This is because all models for lung nodule prediction are far from perfect.

Personally, I never deliver empiric lung SBRT without review by a pulmonologist. This is because they generally have >1,000x more experience evaluating radiographic nodules than any radiation oncologist I've ever met.

If obtaining a pathologic diagnosis is challenging for one of many reasons, consider performing a dual-phase PETCT imaging study on the lung nodule. Image the bed with the lung lesion, then repeat image acquisition after a 30-minute interval.

Considering neoplasm metabolism and the Warburg Effect, t...