Questions discussed in this category
Are there any subgroups that would still benefit from RNI?
Would it matter if the patient did or did not have a pathologic CR in the breast?
This boost would be in addition to the standard regional nodal irradiation delivered post-op.
Isn't there a tradeoff of increased lung dose?
Disease is not responding to systemic therapy.
Would you expect a difference in skin reaction?
When treating nodes in the post mastectomy setting, what dose/coverage do you find acceptable to the nodal regions versus to the chest wall/reconstruc...
Are you routinely offering a 16-fraction course of hypofractionated PMRT for patients undergoing breast reconstruction versus a traditional 25-fractio...
Patient with pT2 N2a (6/9 LN+, 5 with macromets, 1 with focal ENE) ER/PR+, Her2- s/p mastectomy.
Is there compelling reason to start PMRT prior...
If no enlarged lymph nodes on imaging, and no other high risk features. Would your opinion change if the patient has had prior breast radiation?
Given the very low lymphedema rates associated with these procedures, does it impact your choice for axillary management?
Should the answer differ for cN1 luminal disease vs. cN0 TNBC?
How should ECE influence radiotherapy in breast cancer?
For T1-2 patients with N1 disease after sentinel node biopsy alone and upfront mastectomy (gr...
Would you treat with curative intent (neoadjuvant chemotherapy, surgery, and radiation to include the sternum)?
Would you cover the chest wall alone or would it be chest wall plus regional nodes?
Patient factors: no prior radiation therapy
For instance, would you incorporate use of Oncotype DX in this patient population to guide decision making on the use of regional nodal irradiation?
The patient is an elderly female with a good KPS who presented with a cT2N1 triple-negative breast cancer.
The patient refused chemotherapy and immun...
Such as breast plans with < 200 cGy mean heart dose
For example, when would you recommend clinical exam for surveillance versus imaging with MRI, CT or PET?
Would you feel confident in omission for residual disease in the breast and only 1 LN removed during SLNB, which is the same node that was biopsied up...
The SOUND trial looked at sentinel node versus observation in patients of any age with breast cancer up to 2 cm and a negative preoperative axillary u...
Would prior RT (>30 years ago in this case) to the breast or ATM mutation alter your recommendations?
Any pitfalls to be aware of?
In what circumstances would you offer or avoid APBI in a woman with an oncoplastic closure after lumpectomy?
In my experience, high tangents are commonly used for patients with pN1mic disease, and occasionally for higher risk patients with pN0 disease. The re...
How do you use 105%, 107% and max dose metrics differently compared with non-reconstructed cases?
Can adjuvant radiation therapy compensate for the potential increased local recurrence risk?
What would you consider when thinking about your boost?
Due to multiple complicating factors including travel distance of ~1 hour each way, this patient (mid-60s) refuses to come any more often than 2 days ...
If a patient is found to have 2 lymph nodes positive with ECE s/p mastectomy, axillary dissection, tissue reconstruction, and lympho-venous bypa...
Any concern for increased risk of radiation recall?
Would you consider administering Keytruda (pembrolizumab) concurrently with radiation therapy for the treatment of a patient with an ER-negative, PR-n...
Z0011 population, cN0 with 1-2 SLN involvement with a low likelihood for additional non SLN metastases?
The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) trial was a prospective noninferiority phase 3 randomized clinical trial suggestin...
For standard tangential radiation would you pull the field edge forward to avoid radiation dose to the entire implant?
Would your recommendation change if the patient had a high Oncotype and received adjuvant chemotherapy?
What are the current criteria in 2023 for selection to complete sentinel node biopsy or skipping of sentinel node biopsy specific to age, grade, clini...
If a patient had a stage I contralateral breast cancer and received bilateral mastectomies with implant reconstruction 2 decades ago and now has ...
Is there a role for loco-regional treatment in this scenario? If a young patient with ER/PR positive cT2N2M1 IDC presents with a single bone metastasi...
What dose constraints do you use for the left anterior descending artery (LAD) for breast radiation?
Is there data to support those constraints?
If so, what dose-fractionation do you utilize? What other factors do you take into consideration?
For additional reading, see JCO OGR (11/2021) by Drs. @Warren and @Bellon reviewing the landscape of adjuvant treatment after lumpectomy for DCIS and ...
Would you do a tumor bed boost in the absence of other risk factors?
Do young, early-stage breast cancer patients with pCR to chemoimmunotherapy still benefit from PMRT?
If a patient in her 30s with a cT2N0 triple negative breast cancer has a pathologic complete response (pCR) after chemo/immunotherapy at the time of m...
Would you ever consider any of the following?
Discontinue the bolus after brisk reaction
Moderate hypofractionation to the chest wall instead of c...
Controlled extracranial disease on trastuzumab+pertuzumab for 2 years. Treatment options include Enhertu or WBRT. Not a candidate for SRS or neurosurg...
The patient had a high-grade DCIS with necrosis, but a 0.9 DCSionRT score
The patient is an otherwise healthy patient in her 60s with an ER-positive, PR-positive, HER2 negative grade 3 pT1N0 invasive ductal carcinoma followi...
If so, what dose would you utilize for the SIB? When utilizing a boost with ultra-hypofractionated whole breast RT, would you favor adding a single fr...
The patient had ER/PR positive, early-stage recurrent disease superficial to the prior RT site involving the nipple and dermis without ulceration, tot...
Would you recommend this for a focally +, diffusely +, grossly + margin? What would you expect local recurrence rate for diffusely (+) microscopic mar...
My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...
This patient had a T1N0, ER/PR negative, HER2 negative breast cancer
In a young patient <30 years old with large pre-chemotherapy, multifocal disease with pCR following mastectomy, would you consider extrapolating th...
Would you consider pentoxifylline and vitamin E to mitigate fibrosis?
Good risk DCIS as per RTOG 9804
The patient had a prior right-sided ER+ HER2-ve breast cancer, treated with neoadjuvant chemotherapy, MRM with ALND, and PMRT
They recently developed...
Are there any skin care products you would avoid in this population?
In a patient who had a wide local excision and radiotherapy 10 years ago and now recurs with cT4 disease, would you repeat radiation after neoadjuvant...
How does age, grade, hormone receptors play into your decision?
Would postmastectomy radiotherapy ever be indicated in a young patient with close margins and a massive (14 cm) DCIS breast tumor interspersed with le...
Assume each lesion would have been suitable for partial breast radiation
In an asymptomatic patient, would this be safe?Is there any reason to withhold radiation such as in the case of T1N0 breast cancer advising the patien...
For example, if a patient is otherwise a candidate for APBI with a 1.5 cm primary tumor but has 2 cm of associated DCIS would the patient be ineligibl...
Would you still treat the chest wall with standard dose and give the patient the benefit of the doubt in the absence of pathological confirmation of m...
NRG-BR002 (Chmura et al., JCO 2022)
CURB (Tsai et al., IJROBP 2022)
Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...
Do your post-operative treatment recommendations differ for benign vs. malignant phyllodes tumors of the breast?
Is phyllodes tumor size ever a crite...
For example, if preoperative imaging indicates T3 disease (non-mass enhancement extending over 5cm) but final pathology s/p mastectomy shows multiple ...
I trained at a place where use of a bolus for chest wall irradiation PMRT was standard practice, but this is not so at my practice right now. Assuming...
Do you use SIB regimen (40/48 Gy) per RTOG 1005 for whole breast radiation in scenarios not included on trial? For example: a patient who has received...
Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.
In prior ASTRO guidelines, it was mentioned as a cautionary group for IDC but not in the 2023 updated guidelines.
Based on Mill et al. paper showing increased IBTR rates with ILC vs IDC (Mills et al., PMID 34516030)
If a patient has a genetic mutation, but not necessarily the classic ones where we avoid radiation (ATM, BRCA, p53, etc.), does this change your treat...
The patient is in her 40s with a BRCA-2 mutation and underwent bilateral prophylactic nipple-sparing, skin-sparing mastectomy. No sentinel nodes were ...
Additionally, when evaluating margin status for APBI IMRT 30 Gy in 5 fractions which specifies at least 5 mm margins, do you look at the DCIS margin o...
Patients are understandably concerned about the risks and benefits of radiation to an oozing, bleeding, and ulcerated breast.
ABS APBI guidelines are much more permissive relative to the newer ASTRO Guidelines.
Would you change your recommendations for APBI vs whole-breast RT for this reason?
NSABP B-51 recommends V3<10% or a variation acceptable of V5<10% for contralateral breast. Is there a limit needed for contralateral chest wall/...
Do you advocate for completion ALND? If so, would you radiate the dissected axilla?
Would you especially consider RT omission in the setting of low-grade, small-volume disease with no underlying DCIS or invasive disease component on p...
How would you approach a young woman (under the age of 50) with DCIS with favorable disease (ER+, low grade, small size <5mm, negative margins)?
Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?
Did your treatment inclinations change with the results of the recent FABREC trial (NCT03422003) presented at ASTRO?
Would you consider eliminating radiation to the chest wall in a patient greater than 50 years of age with a T3N0M0 grade 2, ER+/PR+ Her2 negative inva...
I.e., the IDC was completely removed during biopsy, but DCIS was present on post-lumpectomy specimen with close anterior margin
A female in her 60's was simultaneously diagnosed with stage I triple-negative left breast cancer and stage I NSCLC of the left lung.
The patient had...
In which particular patient cases or clinical scenarios would you consider preferentially treating a patient with protons over photons?
Nodal staging changes radiation fields, but given increasing pertinent null findings of a positive SLNBx with regards to outcomes, I wonder if ypN0 is...
What total heart dose and LAD dose do you typically utilize to justify the DIBH technique?
If a patient was noted to have poorly differentiated histology with two tumor foci in the breast, positive LVSI, and isolated tumor cells in 1/3 senti...
The patient is a female in her 50s with luminal B pT1b pN1(sn) invasive ductal carcinoma with 2/2 nodes, 5 mm ECE, and extensive LVI. No preoperative ...
For example, would you consider treating part of the humeral head if required to adequately cover the axillary nodal volume CTV/PTV?
Would you consider APBI for an ER/PR/HER2 negative pT1-2 N0 with pathologic complete response after neoadjuvant chemotherapy? Would the presence...
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...
A patient presents with clinically node-positive cT2 grade 3 invasive breast cancer in the upper outer quadrant. The patient had breast RT to 50 Gy wi...
What constraints would you use for ribs, lungs, and heart?
The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...
If a patient has a small luminal A invasive tumor resected to negative margins with admixed high-grade DCIS, does the high-grade DCIS component influe...
What prophylactic strategies you use to mitigate the risk?
What dose and fractionation do you use?
If a patient is <50 years old, would this change your recommendation?
The patient is an otherwise healthy female in her 70s with an ER-positive, PR-negative, HER2-negative grade 3 invasive ductal carcinoma.
Lumpectomy r...
The patient was treated with neoadjuvant chemotherapy and had mastectomy with SLNBx about 6 months prior to being referred for adjuvant radiation.
If the dose to these OARs deviates from goal by a significant margin, how do you approach changing the treatment plan, accordingly?
For a node positive, triple negative patient that underwent neoadjuvant chemotherapy followed by breast conservation with a complete pathologic respon...
What criteria do you use to determine the utility of using DIBH for planning after free breathing and DIBH CT scans?
Do you typically create a ...
The IMPORT-LOW and DBCG trials of 40 Gy in 15 fraction PBI utilized mini-tangents, which simplify planning but increase breast V40 Gy.The paper by Tho...
The GEPAR trials presented at ASCO 2015 showed increased LRR with the omission of RT in patients who had a pCR after neoadjuvant chemotherapy.
For a patient with an ER-positive, pT1c breast cancer who otherwise meets criteria for APBI, but has a BMI of 50 with pendulous breasts and N1mi disea...
While I am encouraged by the results of the LUMINA trial with respect to identifying patients who are less likely to benefit from radiation therapy wh...
The patient is on a dose of 22 mg of methotrexate weekly for severe rheumatoid arthritis.
If you would discontinue the methotrexate, how long would y...
Assuming the patient had no prior radiation and has no evidence of metastatic disease, would you start with adjuvant radiotherapy or adjuvant systemic...
Might a prior SJ incident pre-dispose to SJ reaction to radiation?
Would you be more or less apt to treat with RT for grade 2 DCIS with refusal of pr...
If a patient had a partial mastectomy and radiation therapy 10 years ago and now has a large ipslateral breast cancer (different ER/PR/Her 2 markers n...
NCCN suggests 2 - 4mm margins in DCIS, and no tumor on ink with invasive disease.
What agents have you found helpful? What agents have been proven to be effective/non-effective?
The patient is less than 35 years old, and received 21 Gy to the mantle and 10.5 Gy to the lungs >15 years ago as part of treatment for Hodgkins ly...
Did the EBCTCG meta-analysis change your practice?
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...
The patient is a woman in her 30s with a grade 2 T3N0 ER/PR+ Her2- invasive ductal carcinoma who was treated with mastectomy (margin negative, but LVI...
Do biomarkers impact your decision-making? If you were to boost, what dose would you use?
Do you use CBCT or kV images? Do you match to the breast or the chest wall?
The patient had 0/2 sentinel lymph nodes involved, and mastectomy revealed pT3 disease with negative margins
Is there a practical way to quanitfy risk of LRR in patients with T1-2 N0 with multiple high risk factors in such as multifocal disease, high grade, L...
Would you recommend this if we were treating level I/II?
The patient has locally advanced disease with chest wall invasion and extensive axillary/IMN lymphadenopathy
Is axillary radiotherapy an acceptable alternative?
Please specify how your institution is allocating resources now or will be soon.
Are there any concerns about increased acute or late toxicity in the context of more extensive surgery?
What is your approach to try to persuade her that photons would be a better option?
Historically, chemotherapy has been delivered prior to radiation for breast cancer patients requiring it.
With the acceptance of shorter cour...
I have yet to see results from the SUPREMO trial investigating this question in Europe.
There is the EXPERT trial, NCT02889874 based in Australia/New...
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...
Would you consider APBI so that less tissue is irradiated or do whole breast (hypofractionation vs conventional fractionation)?
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...
Patient with multiple comorbidities (childhood CNS cancer survivor, stroke with residual deficits).
The patient did not have radiation previously, but now has recurrent disease in Axillary levels 1-3, supraclavicular nodes, and IMN in the first inter...
The ASTRO consensus lists 2-3cm size as cautionary, while the ABS consensus lists 3cm or less as suitable, though acknowledges that most patients incl...
Is there any reason that this is not commonly done, apart from lack of RNI coverage?
The patient had lumpectomy with standard radiotherapy to 50 Gy whole breast, followed by 10 Gy boost 11 years ago, and was recently found to have a sm...
Patient is refusing BID dosing as per RTOG 1014.
Patient developed pembrolizumab-related pneumonitis after ddAC followed by Taxol/Keytruda - what thresholds/constraints would you prioritize with rega...
Do you also use DIBH in these cases?
Or would it change your decision on a boost in WBRT if negative surgical margins?
Why do the available guidelines restrict APBI to patients with lesion size <3cm? Is this purely from higher rates of necrosis noted in older brachy...
If so, are there any patient/pathology selection factors? What technique do you utilize?
Are there any resources comparing whichever value is more relevant for the various breast fractionation schedules (FAST, FAST-Forward, Canadian, UK, 3...
If a patient is found to have florid LCIS with with a 1 cm positive inferior margin s/p sentinel node biopsy (0/2 nodes involved) and mastectomy, is t...
For example, a heavy burden of nodal disease with diffuse ECE? Would you treat the axilla higher than 45-50 Gy? What would you use for a boost dose?
Do you follow the breast NCCN guidelines to decide adjuvant radiation recommendations if a patient treated with neoadjuvant chemotherapy stops the che...
Is there a certain amount of time that you prefer to have elapsed after the last infusion before delivering SRS? Do you avoid all subsequent Trastuzum...
Patients will frequently ask why they need treatment when there is no cancer left on the pathology specimen.
The patient is now s/p neoadjuvant chemotherapy, mastectomy, and ALND for their ipsilateral recurrence, and pathology showing residual disease (ypT0N2...
If so, would you also include the breast?
Would you offer APBI if the DCIS was ER-?
If a patient with early-stage breast cancer s/p lumpectomy is noted to have 1/3 SLNs positive for ITCs (and no other negative prognostic factors) woul...
The patient is a woman in her 60s with a history of a grade 1 ER-positive, HER2 negative pT1bN0 invasive ductal carcinoma treated with lumpectomy, who...
Would you radiate concurrently with WBRT? How would you dose/fractionate in this situation?
What if positive margin is felt to be from a DCIS skip lesion (initial DCIS margins widely negative but small focus DCIS found in additional tissue wi...
Do you have recommendations on timing of her implant placement with respect to radiation therapy?
Masuda et al. NEJM 2017
If so, how do you sequence it with adjuvant radiotherapy?
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...
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...
Would you boost a resected axilla if extra-nodal extension is found in a patient with breast cancer?
What are your volumes? What if the lymph node area was not clipped?
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 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...
Does that change if they received a skin sparing mastectomy?
For a cT2 triple negative breast cancer with indeterminate enlarged breast nodes s/p negative biopsies, and indeterminate findings on both MRI and PET...
If a patient with endometrial stromal sarcoma managed with fulverstrant has a single oligoprogressive lung nodule, is there any contraindication to tr...
For conventional fractionation, should one increase total dose above 60 Gy for either close or positive margin (invasive or DCIS). What about for acce...
Patient is declining mastectomy.
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...
Would you consider hypofractionation? If so,what dose? Would you consider a boost if there were close margins?
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...
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...
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?
...
How would you modify this based on endopredict or RT-PCR?
What advantages/disadvantages are there between assays or over traditional clinical pathologic factors? What other concerns do you have?For additional...
What is your rationale for your approach?
Does your treatment in any way depend on stage, extent of RT, and/or dose to OARs?
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...
Patient has declined endocrine therapy and is unfit for systemic therapy.
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...
How do you define an “adequate” axillary dissection, (i.e., would 8 lymph nodes dissection instead of 10 be “adequate”), or ch...
Is there any evidence to support the theory that this may cause worse skin reaction?
The patient has notable lip lesions from her discoid lupus erythematosus
In patients with small breasts and large lumpectomy cavities, is there a benefit to switching to whole breast if you can produce a very homogenous par...
If a patient has T2N0 disease without LVSI, but has a ~4 mm IMN node in the 4th or 5th intercostal space, would you be inclined to include the IMN cha...
It is not clear from CREATE-X whether radiation was before or after capecitabine. Is there a preferred approach?
Patient had significant GI side effects with Trental. (This particular case involved a second course of radiation for a secondary lung cancer 30+ year...
If the patient were of young age with high grade and ER+ disease without LVI, do these factors sway you one way or another?
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...
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...
Assume no contraindications to hypofractionation.
What if the duration of neoadjuvant therapy has been less than 6 months?
If negative margins can be obtained, would you consider breast conversation therapy? If so, would you recommend bolus placement over lumpectomy scar?I...
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 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...
Would ypN1mi after neoadjuvant endocrine therapy cause you to recommend postmastectomy radiation? Or regional nodal coverage after breast conservation...
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...
Are you able to achieve the contralateral breast and lung V5 constraints from current protocols?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
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...
Would you consider APBI despite younger age?
Do you typically aim to wait a certain amount of time to allow for healing? The range seems to be 4-6 weeks but 4 seems a bit early with potential ser...
The patient had been treated with conventional fractionation to bilateral breasts in the past as treatment for her synchronous IDC.She is currently in...
In a patient not receiving adjuvant chemotherapy who has a delayed consultation due to complications/personal issues, etc, is there a time delay ...
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...
Would you ever offer pre-operative radiotherapy in carefully selected patients before primary oncologic surgery off-trial, based on this Lancet Oncolo...
Less than 2cm in size and closest margin is 0.6mm. Would you consider re-excision or mastectomy? Would you offer radiotherapy?
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 what clinical circumstances would bolus be indicated for this histology?
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...
If the patient has invasive breast carcinoma and close margins with no other risk factors for local recurrence, would you utilize a cavity boost?
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 <...
What resection margins are required for pure DCIS with adjuvant RT? What resection margins are required for pure DCIS without RT? For additi...
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 ...
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?
If pCR in lumpectomies would you boost both sites?
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...
If a patient presents with ER/PR positive, HER-2 negative pT1cN1 invasive ductal carcinoma with micropapillary features s/p lumpectomy, how would you ...
The patient is not amenable to re-resection.
What pathologic features and/or margin status would preclude the need for additional irradiation?
For example, what is the minimal acceptable distance between the medial tangents?
For example, a two week break halfway through a course of hypofractionation for early stage breast cancer.
How does a diagnosis of active RA inform your treatment approach for patients with breast cancer, if at all?
Were patients with mixed histology included in the omission trials?
The patient was treated with neoadjuvant cisplatin/etoposide followed by mastectomy and SLNB with a 4 cm primary and negative nodes. LVI was noted on ...
What is you decision making process in terms of the various hypofractionated regimens for WBRT supported by different trials?
When do you favor APBI?...
What constraints do you use for the contralateral breast and what will you accept?
What clinical and pathologic features - if any - would necessitate conventional fractionation?
This is one of the available options in the NRG-BR007 DEBRA trial
What would be the indications for doing so?
Would you proceed with APBI, or hypofractionated whole breast RT?
Given the CALGB 9343 trial, as well as the recent "Choosing Wisely" recommendation (https://www.choosingwisely.org/clinician-lists/sso-sentinel-node-b...
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 ...
Does availability of surface imaging (visionRT) reduce your use of imaging for setup?
Prior treatment with ipsilateral breast RT was >10 years ago
Do you approve ports daily or less often? Do you ever use CBCT?
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...
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...
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...
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...
For patients who were not neoadjuvantly on pembrolizumab, is it safe to initiate it concurrently with radiation?
MRI pre-op did not reveal suspicious lymph nodes. Margins were negative upon mastectomy.
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 prefer APBI or mastectomy in this situation?
If biopsy is not feasible, should these patient be treated as cN+ with neoadjuvant chemotherapy or as cN0 with upfront surgery with axillary sent...
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...
If the patient has evidence of axillary lymphadenopathy on imaging, would that change your approach to treatment?
Would response to neoadjuvant...
If yes, do you have an age cutoff and/or surgical margin cutoff?
For example, if the lumpectomy specimen had low risk/low volume invasive disease?
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 ...
The lymph node is 4 cm and is the only site that is growing on her current systemic therapy regimen.
At what timepoint after surgery does prospective adjuvant radiation no longer become beneficial?
If this is bothersome to the patient, are there any topic ointments or medications that can help if used?
What if the patient is refusing chemotherapy?
In light of updated monarchE trial data, it seems a SLNB would help delineate adjuvant treatment options in this population. However, Choosing Wisely ...
In which node positive patients will you omit the IMC when treating regional nodes?
Assume no nodal involvement.
Would you favor re-excision? If re-excision and surgery are not an option, would you proceed with radiation or observation?
If the patient had prior ...
Do you boost when employing this regimen?
Would you recommend a re-excision?
Is radiation without re-excision appropriate; if so, should a boost be given?
For example, if they were triple negative or had a poor response to neoadjuvant chemotherapy in the breast?
Does anyone have experience re-treating the axilla and what dose/fractionation would you recommend?
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
Do you deflate to a specific volume?
If using boost, how would you define the tumor bed?
Would you consider resimulation for target localization? If so, what is the maximum interval of t...
Is the competing risk of a distant recurrence too high to justify doing radiation?
Is there data to guide you? Is there any reason to believe that there is an increased risk of complications in patients with prior breast implant from...
No tumor at ink? 1-2mm?
CNS recurrence occurred within two years of prior neoadjuvant therapy
If yes, how do you modify your margins?
How can you change the minds of community surgeons who refuse to place them citing patient discomfort and for...
NSABP B51 and B52 specifically prohibit this.
Would your recommendation change if patient had complete response to neoadjuvant chemotherapy in breast and axillary nodes?
Please include informatio...
The recently published SSO/ASTRO/ASCO consensus guideline on DCIS states that "a 2 mm margin minimizes the risk of IBTR compared with smalle...
Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...
What normalization do you choose, what is your preferred target volume coverage, and how do you assess for homogeneity and heterogeneity?
Would you use 10x and 15x in your fields?
Does skin reaction at the time of starting the boost guide the decision to bolus?
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
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...
Does the answer change on proximity/distance from breast (i.e. what if pelvis or lower extremity?)
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...
In what situations would you want to include regional nodes? Particular tumor size?
Assume patient has refused surgery and additional systemic therapy.
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.
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...
Is there a time frame for when you may not offer post-mastectomy radiation therapy to a patient who may otherwise benefit from treatment in a typical ...
No prior radiation. No evidence of chest wall, axillary, or supraclavicular disease.
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?
Do you use no tumor on ink for margin even if DCIS is the component close to the margin?
Chemotherapy is often de-escalated and omitted in this setting. Would you also consider de-escalating radiation and treating like more favorable histo...
Historically, IBC is traditionally treated with trimodality therapy to include PMRT with comprehensive regional nodal irradiation (RNI). However, give...
Given the difficulty in identifying the location of the positive margin, would you push to re-excise?
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?
Presuming that imaging does not show distant metastatic disease, what would you offer? What about if the patient were PD-L1 negative?
What is the best evidence available for the benefit of PAB in disease control?
As opposed to the every other day Florence regimen.
Would you use mini tangents, 3D conformal, IMRT?
Do you need the expander to be removed?
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 ...
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...
How does patient age, grade, histology (IDC vs. ILC) and ER status affect your recommendations
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 ...
Is the dose fractionation used in BR-001 (10Gyx3) appropriate for all osseous locations, for example humeral head metastases?
The IDC was felt to be a new primary arising from residual breast tissue given it was over 10 years from her initial DCIS.
i.e. 1/1 node with ECE
Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?
Would you offer RT to the axilla? Would you treat the breast?
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...
Would you include the regional nodes?
Comprehensice RNI? High tangents? Whole breast only? Does ER/PR/Her2 status influence your decision?
This is assuming they have other indications requiring post mastectomy radiation therapy.
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 consider/favor APBI given the negative normal breast if you can meet the brachial plexus constraints?
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...
Is breast conservation absolutely contraindicated? What is the true increase in risk of secondary malignancy? Is there a good reference?
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 ...
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 ...
What technique/schedule/material?
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...
What is "clinically significant" lymphvascular invasion? What are the standards for focal vs multifocal vs embolic vs extensive? How does this serve a...
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.
In the case of conventional fractionation or SBRT, would you constrain the implants? (No history of breast cancer.)
TBI was 20 years ago, chest wall RT was 8 years ago. The solitary nodal recurrence in axilla was resected, but with ENE+, PNI+, with no further ...
For example, in a young high risk patient who completes less than half of her prescribed treatment and wants to resume after a period of months, how w...
For example, ultra-hypofractionated whole breast RT?
For breast patients being treated in prone position. The plans generally spare the skin more so than in the supine position. If a patient has a ...
Initial presentation was stage 1 treated with lumpectomy and whole breast radiation.
Would there be concern that the false negative rate be too high with a SLNB alone? Is this mitigated by having the clinically involved node clip...
Mini-tangents only? 3-4 fields including lightly weighed perpendicular to chest with some exit dose to lung?
Are there exercises, massage techniques, or support garments that are effective at preventing or reversing lymphedema of the breast?
If no surgical LN evaluation is performed, how do you determine what volumes to include in your radiation fields?
For example, in a woman who is post-mastectomy with early stage pleomorphic ILC with ITCs in a sentinel node, would the histology push you to recommen...
(e.g. bulky supraclavicular, internal mammary, as well as retrosternal lymph nodes)
Do you adjust dose/fractionation?
For example, would you consider high tangents in a patient who did not undergo SNB due to age and comorbidities, but has high risk features such as gr...
ACOSOG Z11102 mandated radiation with a boost. Hypofractionation was prohibited. This isn't how we practice nowadays and some women might otherwise me...
If the oligometastatic lesions are not longer PET avid after neoadjuvant chemotherapy, would you consider further treatment with local therapy or obse...
Do you contour cardiac vessels and/or heart substructures? If so, which one(s) and what dose tolerances do you assign them?
e.g. Gingras et al., JNCI 2017, a secondary analysis of the ALTTO trial?
If a SLN biopsy could not be performed and only a few lymph nodes were removed by ALND that were negative, would you treat the nodes? What facto...
Since only part of the breast was treated before, would you include treatment of the whole breast now, despite no detectable disease?
The treatment of ITC and micrometastases in lymph nodes in women with breast cancer is controversial. Given the rarity of male breast cancer, complex ...
High risk meaning LVI, triple negative, Grade 3, etc?
For intact breasts, should adjuvant radiation to the lymphatic drainage be added to breast radiation?
What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...
Is age solely indication for boost irrespective of other factors?
Has anyone omitted post path fracture radiation of pelvis/long bone in favor of starting endocrine treatment first? Or would one omit RT and start a C...
Should the VP shunt be moved prior to RT? Are there any complications of radiating a VP shunt?
Does margin width play a role in your decision making? Would no tumor on ink be acceptable? What if there was LCIS in the specimen as well with ...
Would implant reconstruction prior to radiation therapy change your recommendations? Would you ever treat just the nodes and omit the chest wall/recon...
If a patient meets all omission criteria per CALGB and PRIME except age would you consider omitting RT? Is there any evidence for such an approach?
Would you boost the area of positive margin? Would you include the expander?
Would you have CT surgery resect the mass, followed by adjuvant radiation?
Assuming the patient is otherwise a candidate for APBI.
Do you use a standard margin around the mastectomy scar (ie 2cm sup/inf), or do you extend the field to include the entire chest wall?
How do the recent results from E2108 impact your practice? Would you consider locoregional therapy in patients who are good responders, have oligets, ...
How about in the setting of treatment after recurrent resected disease if it didn’t involve the skin: would you push for coverage even though pl...
Or would you only irradiate the axilla?
Would you modify your dose if there was overlap from the prior treatment?
In a patient with early stage breast cancer that would otherwise require radiation, would you recommend treatment if the patient has active skin lupus...
What are the differences that a patient may expect with HDR vs LDR brachytherapy?
What if ALND reveals no residual disease?
Would you consider reirradiating the breast and regional nodes? Further axillary surgery? Partial breast radiation? Or other?
Would the degree of response (pCR vs no pCR) influence your decision making?
i.e. FAST-Forward: 26 Gy in five daily fractions?
If so, do you give RT before or after adjuvant chemotherapy?
Radiation in the setting of positive margins is sub-optimal and from my understanding high boost doses do not replace further surgery. Is it better to...
Many hormone positive patients are beginning hormone therapy until they can go to surgery. With a prolonged pause in routine procedures seeming very l...
Do you consider this regimen based on the 10 year results of the UK FAST trial?
Is it possible to get a good measurement with TLDs? TLDs can overestimate the surface dose by 10 - 40%. Do you use a skin diode measurement on the fir...
Would your practice vary based on hormone receptor or Her2 status?
When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...
i.e. T1, low grade, ER positive, margins negative, older age?
If a skin flap was required due to necrosis after the mastectomy, would you still provide PMRT assuming the patient is high risk?
Would you consider VMAT or protons?
Given the recent results of the NRG/RTOG 1014 trial, would you consider it reasonable to offer breast conservation for women who meet the trial entry ...
Assuming the patient is not a candidate for SRS
In a patient with a positive SLNBx, would triple negative or Her2+ status affect your decision on whether or not to proceed with a full ALNDx?
Is surgery preferable? What dose/fractionation would you recommend?
Would it be acceptable to treat a patient with locally advanced breast cancer (ex pT2N2a) s/p lumpectomy with a short course 4 week treatment ins...
Generally, the margins are uncertain in this scenario and re-excision is usually not possible.
Would your decision change based on the patient's clinical nodal stage?
Z11 and AMAROS tell us that in cN0 patients, an adequate ALND is considered definitive treatment, but what about patients who have low volume biopsy p...
Would you offer definitive radiation? If so, what dose and technique?
What size cut off or other factors (i.e. LVI) do you consider? Do you only treat IMN and medial SCV vs include entire axilla if only SLN?
Assuming there is no other locoregional or distant disease. Would you treat the entire contralateral chest wall? Nodes?
Due to respiratory motion and resolution of the lesions on re-staging imaging, targeting the lesions on CT sim is extremely difficult. Also, is consol...
Do age or margins factor into your decision making? What dose and fractionation would you use?
Would you recommend it for a mammographically occult primary or if the patient had dense breasts? What if a high risk patient decides not to hav...
Let's assume genetic testing will not be done.
What are the indications for local control of the breast in patients with metastatic breast cancer?
Do you still follow the atlas guidelines and contour the breast to the latissimus muscle laterally the the pectoralis muscle posteriorly or since the ...
Alliance Z-1071 cohort had 5% with cN2 and <1% fixed or matted and the current Alliance trial 011202 only allows cN1. ALND has never been shown to ...
If there is a pCR in the breast and nodes do you treat the breast/chest wall SCV and full axilla? IMNs? Would the type of surgery (lumpect...
Do you think about it in the same way as DCIS in terms of radiation decision making (i.e. grade, margins, age of patient)? Is Paget's disease le...
For instance, would you be more inclined to treat a patient with T3N0 disease and no other risk factors? What if there were a small neighboring ...
What risk do you quote for contracture or failure? Does the type of implant or age of implants matter?
Does your recommendation change for women with HER2- disease?
For instance, in a woman with small volume disease in the breast, is your posterior border still the lung interface? Do you cover all drain site...
What high risk pathology factors would you consider in making your decision one way or another?Would it matter if this patient was elderly vs young? W...
Would T stage, Oncotype or any other factor affect your decision?
For example, for T2N1a ER+ disease? Or would you offer PMRT and axillary nodal irradiation (as a replacement for ALND)?
In a patient with their second cancer, with oligometastatic disease, do the risks of RT related second malignancies outweigh the benefits?
What techniques are most effective to minimize contralateral breast, heart, and lung dose? Do you recommend conventional fractionation?
Assume the patient had axillary lymph node dissection and taxane chemotherapy. How would you counsel the patient about risk of lymphedema?
Are there any quantitative measures that you use to help select patients such as breast size or heart dose? Or do you use a case-by-case qualita...
For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...
Does the permanent implant change your dose?
Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...
Would you recommend observation? Whole breast irradiation? APBI?
What is your preferred approach to PMRT with inflammatory breast cancer with adverse risk features (i.e. age <45, close/positive margins or poor re...
What if this lesion was at the top of the hair bearing skin of the axilla?
How would you dose?
These devices give off a significant amount of artifact on CT and some devices say they are a relative contraindication with adjuvant RT.
Do you use portal or orthogonal imaging or both?
What is an adequate dose to the skin?
If so, what clinical indications? Are there any advantages of VMAT? Thoughts on concerns regarding lung and heart dose constraints?
Or would you offer high tangents with hypofractionation?
Some oncologists wait 1 day, 1 week or 1 month? Is there a preferred waiting period?
What size of DCIS would make you concerned? Would you estimate the risk of recurrence with and without radiation?
Would a limited axillary dissection influence your decision? Any other risk factors that would sway your decision?
What's the minimum isodose coverage line you accept for coverage of higher level axillary lymph nodes?
Does the T stage influence your decision (for example, T1mic)? Would multiple positive nodes showing isolated tumor cells sway your decision? Would a ...
Do you always recommend treating breast cancer patients with getting reconstruction with their tissue expanders in place? Or is there a scenerio you w...
NSABP B-39/RTOG 0413 prescribed a dose of 38.5 Gy using two fractions of 3.85 each daily, but prescribed to the ICRU 50 reference point dose (usually ...
Is it necessary to irradiate the breast?
Patient will receive adjuvant xeloda.
An ASTRO APBI update readers are warned “the combination of IORT and WBI should be used only with caution and limited to women with higher risk ...
NCCN states that daily imaging is discouraged but in practice many radiation oncologists are doing daily cone beam for non-IMRT breast
There have been case series published on this topic (most recently, PMID:26853347) with reported depigmentation within the RT treatment field.
Assume you have good margins and the cavity abuts the implant. Are there any specialized techniques that you would recommend?
Do you use NRG/RTOG, IMPORT LOW, single institution data, or retrospective data?
An example of an air expander is located at:
https://www.airxpanders.com/index.php
How do you ensure accurate dosimetry with the use of air ...
Specifically, any data or experience regarding Ehlers Danlos syndrome?
E.g. for lobular, etc.
How would your radiation targets change? There are not recommendations for intramammary nodes in guidelines.
If the patient meets the CALGB criteria for the current cancer, are there situations where you would omit RT in a patient who has never had RT? What i...
Would you recommend mastectomy? What would you irradiate? What are your fields?
Updated NCCN guidelines say there is no data to support radiation for pleomorphic LCIS. Previous discussion recommended radiation for LCIS https:...
If planning standard fractionation, what factors would you consider in omitting a boost (ie age, LVSI, etc)?
Which do you favor, if so?
https://www.abstracts2view.com/sabcs18/view.php?nu=SABCS18L_568
Any concerns regarding toxicity with APBI?
Assume she refused enrollment on B51.
Do your recommendations differ if patients are pre or postmenopausal given the data?
What factors influence your recommendation?
If a patient is on rituximab for multiple sclerosis, do you recommend a particular fractionation to minimize chance of MS flare during treatment? If a...
Would you recommend a patient get mastectomy to avoid radiation? If treating a breast cancer patient with ILD, what lung dose constraint do you use?
rad50 is a key DNA repair protein.
If a patient is due for their yearly mammogram on the breast that has been diagnosed with cancer but is still undergoing active treatment (chemo or ra...
Hormonal therapy would not be tamoxifen.
Would you do anything different than usual regarding bolus, energies, skin dose desired for post-mastectomy chest wall radiation if a nipple-sparing m...
Is there concern for increased risk of chronic nipple pain with NAC in the boost field?
At what energy of electrons would it be better to use photons? How many fields and what field angles should be used for photon boosts?&nbs...
Assume patient cannot do DIBH. Would techniques would you use to meet dose constraints? What minimum dose would you recommend?
What techniques have you used to evaluate for field overlap given the different setups? We have used a thick wire placed at midline during the verific...
Assume each primary meets ASTRO 2018 guidelines
Per NCCN guidelines, SLNB after neoadjuvant chemotherapy is preferred.
Would multifocality, multicentricity, LVSI, N1mi, etc affect your decision making?
Results for oncotype Dx are not always available readily.
Assume the patient has bone only metastses and will be on hormonal therapy
If a patient has early stage disease with peau d'orange but does not meet criteria for inflammatory breast cancer, is PMRT indicated?
Should LVI be considered present in a patient with positive nodes? MSKCC showed that LVI is a risk for LRR with 1-3 positive nodes...
Would you treat both chest walls at the same time? What fields would you use for the contralateral side: chest wall and lymph nodes? or just lym...
What if CD4 count was low?
Particularly for patients too large for prone breast treatment, do you use a breast immobilization device or bra? Do you change your fractionat...
Several surgeons have asked this to reduce the time to reconstruction, complications like contracture, and the possibility of re-operation/failure of ...
Assume your patient did not receive radiation upfront and they had an axillary dissection due to recurrence. Would you recommend radiation? What would...
Would your decision change if the patient is getting chemotherapy and hormonal therapy?
In the absence of epidermal invasion and absence of dermal lymphatic invasion (DLI)
Any consideration on standard vs hypofractionation?
There has been shifting concerns with medication side effects (such as osteoporosis, blood clots), duration, and potential non-compliance.
What volumes and dose would you treat? Would you treat the regional nodes alone (including IMN)? Would you treat the chest wall?
Assume workup is otherwise negative and she will get XRT.
Would you consider traditional breast doses or higher? Would you consider treating only the axilla if the mastectomy specimen showed widely-negative m...
What techniques would you use to help meet that constraint?
If so, what is your technique?
How much will you weigh the demonstrated disease-free survival, including distant disease-free survival, in your recommendations?
I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...
V20 of 30% can be hard to attain if IMs are being treated.
Does it make sense to resect only the axillary nodes, but not the other involved nodal regions? Regional nodal radiation will be given.
What factors would you use to determine? Age, triple negative, LVSI, etc?
The patient will be planned using IMRT and fiducial placement.
What if this was an electron vs photon boost? What fractionation scheme would you use?
Pt clinically has inflammatory breast cancer making mastectomy a poor option.
If so, what dosing amd fractionation would you use?
Is breast conserving surgery followed by radiation therapy an option?
Inflammatory breast cancer is a contraindication for immediate reconstruction at the time of surgery, but is there a disease free interval after all t...
Would you recommend PMRT for these patients if they did not undergo resection? Would you boost if they had other indications for PMRT?
If so, what fields would you treat? What dose/fractionation would you recommend?
What about lobular carcinoma?
After the publication of ACOSOG Z11 we are seeing these patients in increasing numbers.
How does it vary for patients with a history of hypertension, diabetes, CHF, and coronary artery disease?
Do patients > 60 years old with no high risk features have any significant benefit? Has the recent update of the EORTC boost trial affected your pr...
What about tumor subtype, ie luminal A/B, Her2 positive, triple negative?
When would you omit or include a boost for DCIS after whole breat irradiation?
Should hypofractionation be avoided in triple negative disease?
In START B ~ 23 % of women received some form of cytotoxic chemotherapy, and the trial was conducted in the trastuzumab era, but there is no ment...
The Canadian trial showed conventional fractionation might be better in the Grade 3 subset, but this was not shown in the START A/B update. What can e...
Do you offer hypofractionation to younger women?
How does your approach differ due to squamous cell carcinoma histology? What are your radiation fields?
What dose calculation algorithm to you utilize (eg AAA, Acuros, etc)? Do you prefer a particular algorithm for certain sites? Do you take in...
Is there any data on safety of radiaiton with pertuzumab?
Assume no history of radiation, no evidence of distant disease and no nodal disease on dissection. Would you treat the chest wall or the&nbs...
Would a high result give you pause about omission of RT? If yes what level is sufficiently high?
What data do you quote patients with implants after PMRT?
Assuming the patient has N2-3 disease, would you consider omitting IMN? What other techniques would you consider to limit lung exposure?
Is there a dose constraint you are using for LV-V5?https://www.ncbi.nlm.nih.gov/pubmed/28095159?dopt=Abstract
At what point would you decide to forego local control managment (RT or mastectomy) in favor of chemotherapy alone?
This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...
Assume patient had 15 nodes removed. What if 1 or 2 nodes were positive?
Would patient age factor into your decision, such as a patient <30 or 40? If you would not give RNI for a favorable pT3N0, are there other risk fac...
CALGB 9343 included ER positive patients but did not separate them out based on herceptin status. Does the study help inform their risk?
Should the patient be counseled to anticipate a worse skin reaction than normal?
Is your approach different for oligometastatic versus oligoprogressive disease? If there is concurrent locally advanced disease, would you treat simul...
Would you recommend any imaging of the axilla before lumpectomy? Would you recommend standard breast fields vs high tangents to cover the lo...
Assume the patient had no radiation, what would your volumes be? Would you recommend radiation if the patient had whole breast/chest wall radiati...
When do you institute a treatment break for skin reaction for patients who receive breast radiation?
Do concerns about matching with 3D plans justify IMRT?
There is anecdotal concern regarding history of estrogen replacement therapy causing stimulation of breast tissue and therefore potentially increased ...
In other words, if there are borderline indications for PMRT (ex initial T3N0 or T2N1 disease) with a pCR, would the suspicious IM nodes lead you to o...
What is the maximal amount of time you would allow between the surgery the start of adjuvant RT? What other factors would you consider when deciding w...
Do you use the typical indications for PMRT (nodal status, size of primary, LVSI, age, etc)? Or, do you recommended PMRT more frequently (...
When would you recommend that SLNB be performed prior to neoadjuvant chemotherapy? When would you recommend additional staging (completion axillary di...
What fields would you treat?
Would you treat the regional nodes alone (not previously irradiated) or would you also re-treat the breast/chest wall?
What factors would help you make your decision? (Age, genetics of lung or breast cancer, triple negative, LVSI, T2, etc?)
Are there any situations where a patient is a suitable candidate for ABPI but you still encourage standard whole breast hypofractionation?
Would you rather they delay the start of treatment so that it was >3 months from date of surgery or have a break of several weeks during XRT? Assum...
And does the fact that the breast is lactating affect radiation toxicity in anyway?
What factors would help aid your decision?
For hypofrac breast patient (such as 40 Gy in 15 fractions), what is the maximum hot spot that you will accept anywhere in the breast? 107-8%? 1...
When trying to eliminate dose heterogeneity during field in field planning for hypofractionated breast radiation with a large separation, the resultin...
The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.
If the patient meets CALGB criteria but has EIC would you lean towards giving RT? What other factors would lead you to give whole breast RT an elderly...
Is the risk of IBRT any greater than in non mutation carriers?
Does neoadjuvant chemotherapy with complete response in the axilla alter your management preferences?
If a male has early stage breast cancer and would otherwise meet criteria for the CALGB or PRIME II trials, would omission of radiation be an option? ...
Any recommendations on technique?
e.g. how does the tumor burden on axillary dissection, sentinel biopsy only, extracapuslar extension, and the size of hte metastasis play into your de...
Is it still acceptable to deliver hypofractionation for what was previously a Stage I TN breast cancer, now Stage IIIA? Should RNI be considered? Or e...
How do you best counsel their radiation risks?
The subquestion can be "Ex if you are offering PMRT for reasons like young age and Her2+?
Do you attempt to have the pacemaker moved? If the patient is non-dependent, would you ever treat with the pacemaker in field?
Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound? I...
Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...
E.g. someone with high grade and/or >2.5cm disease? If we use age as a cutoff in invasive disease to omit adjuvant radiation based on the...
Her2 status was not evaluated as part of the PRIME 2 or CALGB trials and luminal Her2 patients likely represent a small minority of those enrolle...
Would you recommend a mastectomy for her breast cancer in attempts to avoid RT? If the patient undergoes a lumpectomy or needs PMRT, would you a...
If not, are there certain dose constraints one considers?
Is it a factor you consider, especially in borderline cases?
For instance, are you more likely to offer PMRT to a man who is node negative but with several high risk features such as high grade, LVI, high oncoty...
This is rarely done, but recently came up in a tumor board discussion. Which chemotherapy would you consider using, and when?
Do you ever use BID fractionation? What patient factors do you use to individualize the treatment?
If no, in what patients should axillary ultrasounds be performed?
Would your management change if the patient had extensive DCIS?
How many intercostal spaces do you include? Do you vary these parameters based on the disease characteristics?
These patients were not eligible for Z0011 and represents less than 5% of the patient population in AMAROS. Thus, can you apply these two trials to ju...
Would you send the patient to a surgeon for consideration of a mastectomy? Would you then consider post mastectomy radiation when the risk of re...
What are indications for adjuvant radiation for a early stage well differentiated adenosquamous carcinoma of the breast? What is the best radiation th...
What factors in particular guide your recommendation of PMRT for invasive lobular carcinoma?
Would your management change if including the drain sites requiree treating more lung or adding separate electron fields?
Does your recommendation change depending on the agents they received?
What factors do you consider when offering PMRT? Would you change your dose/fx and/or field size?
Women with cN1 disease at diagnosis who are ypN0 after neoadjuvant chemo can be randomized on NSABP B-51, but not those with cN0 disease and treatment...
What about in cases of a tunneled lumpectomy cavity using a circumareolar incision?
Do you always stick with a conventional fracionation, or in some cases, are you comfortable hypofractionating? Do you ever use a wait and see approach...
Would you recommend re-excision of a positive margin containing only pleomorphic LCIS prior to radiation for BCS? Does the presence of ...
Are there any data to support whole breast RT, SBRT, or cryoablation?
What factors do you consider when adding post-lumpectomy radiation therapy for treatment of an intracystic papillary carcinoma?
Randomized trials in the 1980s demonstrated equivalent survival and disease control outcomes for lumpectomy + RT vs mastectomy, but several recent pop...
Do you have a formalized approach, or is it a case by case decision? Do you use bolus differently for a TRAM, tissue expanders, implants, etc?
Do you prioritize certain dosimetric parameters over others (e.g., considering the Darby report, mean dose to the heart vs. mean LAD dose?)
In a patient who recently completed NAC, TM/LND and PMRT for a hormone positive locally advanced breast cancer and is then found to have a contralater...
Assuming the patient is a candidate for either of these treatments?
If so, what fields should be used?
Are there any tips on how to best use this technique?
If there is a signifcant amount of breast tissue contacting the couch in the prone position, are there strategies that can be used to mitigate po...
Comparison of prone versus supine positioning showed that 85% of patients with left sided breast cancer benefit more from the prone versus supine posi...
Since we know that both the "Canadian" fractionation and partial breast irradiation work as treatment for early stage breast cancer in the same patien...
The Hughes study looked at women > 70 years of age. In light of the PRIME II results, can women aged 65 - 70 avoid RT or is longer follow up needed...
Would you change your management based on receptor status (ER/PR+/HER2 neg vs triple neg) or menopausal status (pre vs post menopausal)? Would you tre...
Would this be considered acceptable in an older woman with high grade disease?
Can it be avoided in patients with a microscopically positive lymph node?
Dose in many studies were often prescribed to a point rather than a volume and with 3D planning, we may be upping the breast dose. The D2eq dose...
If so, how do you target this boost?
Does the recent Danish Breast Cancer Group IMN study (JCO 11/23/15), showing a survival benefit to IM irradiation in patients with early stage no...
If not, do you have any experience with acceptable late toxicity and cosmesis with whole breast radiation in these patients?
Can the IMNs ever be spared, or would you consider it mandatory for all inflammatory breast cancers?
E.g. breast? I have found no literature on skin tolerance acutely or chronically.
Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.
Do you put more weight on specific CVDs such as scleroderma as contraindications for any RT?
Is your decision influenced by factors such as the location of the intramammary nodes and/or the mapping of sentinel nodes to the axilla?
There seem to be good prospective studies (Australian study and Canadian study) which debunk the thought that deodorants/antiperspirants increase skin...
If the patient has no pathologic risk factors that would ordinarily necessitate PMRT, do you omit it? Does triple negative subtype affect your decisio...
Would the risk of radiation-induced second malignancy outweigh the benefit of locoregional control for a young patient with high grade DCIS?
Do you have any concern for increased toxicity when you treat a patient with radiation therapy who has an autoimmune disorder? (hypofractiationation v...
With conventional RT, the dose to the brachial plexus should be no more than 50-55Gy max. One exception to this is the addition of PAB in conventional...
Do you look at pretreatment breast MRI or post surgical assessment of the tumor bed/treatment effect? How would you resolve discrepancies betwee...
Would triple negative disease effect your decision?
In a patient with a T1 breast cancer who underwent mastectomy and ALND and recurred in the axilla a year later, would you offer RT to the chest wall a...
i.e. are there any situations where you may recommend against using hypofractionation for a patient with left sided breast cancer such as dose constra...
What if the pre-chemo FNA of the suspicious node is negative?
Borderline cases such as patients that received NAC with a complete response or N1 disease with 1-3 positive nodes make me think frequently about this...
Would extensive residual DCIS (>5cm), hormone receptor negativity, Her2+ status, or age < 40 effect your decision?
Is there any literature supporting that a gentle fractionation/bid regimen (i.e., 1.5Gy bid x 30 = 45Gy) is safer than a standard fractionation ...
Does the axilla have to be addressed surgically or with RT, given that the AMAROS trial eligibility criteria were amended to address sentinel lymph no...
Or, as this is presumed metastatic disease, would you recommend systemic treatment and defer RT?
If so, how do you decide which patients to treat with breath hold vs. free breathing? Do you routinely perform 4D CTs?
A 40 year old patient receiving post-op RT for breast cancer asked me if there is any risk for her becoming pregnant after completing RT. Eric H...
In a patient with Stage IE DLBCL, is your treatment volume postchemo ISRT or whole breast? Would you consolidate if a lumpectomy was performed prior t...
Is it a function of the type of reconstruction contemplated?
The 2013 ASCO guidelines and current NCCN guidelines recommend yearly mammograms but our radiologists are still recommending mammograms every 6 m...
If the patient has negative axillary nodes and no other signs of high risk disease other then a local chest wall failure, do I still need to treat the...
They used to be given concomitantly now they are done sequentially. I can only find conflicting data to justify this trend.
If so, do you do this routinely or only in certain circumstances? Is there data to support routine mammogram before breast radiotherapy?
In a case-control study by Darby et al in the New England Journal of Medicine, patients treated for breast cancer with radiation were found to have an...
Or for that matter, offer PMRT on the basis of a patient having triple negative disease?
I'm not sure how to interpret the results of the study published in JNCI earlier this year.
My institution is considering a major investment/purchase of this technology to complement our existing array of breast radiotherapy options.
In other words, have the results of the MA.20 and EORTC trials changed your practice?
Has the recent 12-year ECOG update for surgical excision of DCIS without radiation therapy changed your practice management?
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