Lung Cancer   

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

Do you increase the dosage of the TKI or switch to a different generation TKI? How does your answer differ for EGFR vs. ALK, and for discrete brain me...

Anyone here doing 17 Gy in 2 fx?

If CCRT is pursued, would you move forward with durvalumab consolidation? Assume the patient with ECOG PS 0 and no co-morbidities. How might this chan...

Would you consider pentoxifylline and vitamin E to mitigate fibrosis?

Does the site of treatment factor into your decision? 

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 ...

Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?

For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...

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 ...

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

What clinical or radiographic factors would lean you in either direction - ie. time since index diagnosis, distribution or appearance of lung and noda...

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

With targeted therapies available, is there a utility for post-op SRS to the resection cavity? 

Would you consider treating with conventional fractionation to the entire staple line with a boost to the gross disease?

Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?

Would you recommend standard definitive chemoradiation followed by adjuvant durvalumab? Would you treat pre- or post-systemic therapy volumes?

Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...

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...

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...

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?

How does your approach change for same lung but now a different lobe v. different lung? How do you adjust your constraints?

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 ...

If a treatment machine is down for 3 days, would you do weekend treatment? Would you consider doing BID?

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

What dose/fractionation?

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...

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

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

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

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

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...

If so, what dose is appropriate?

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

When is the ideal window for delivering PCI for limited-stage SCLC?

Would close proximity to the heart/aorta affect your dose and fractionation?

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

Would you treat the nodes with margin, the nodal group, or the whole untreated mediastinum?

NCCN recommends annual CT surveillance indefinitely after year 5, but I’m curious how many physicians continue and for how long?

Would PDL-1 status impact your decision?

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?

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...

And at what intervals?

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...

Does the T stage or location of malignancy affect your decision?

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...

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)?

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

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?

Or would you rather treat with 3D-CRT in order to initiate chemoRT concurrently?

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...

Is another course of SBRT possible? If so, what are the important planning considerations?

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...

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 ...

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. 

What about patients who are still on steroids for radiation pneumonitis? 

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?

Will the NCCN guidelines change based on this study?

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...

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?

If so, how do you calculate the amount of fractions that are added?

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...

If so, what would you include in the target and what dose?

Would you treat initially involved contralateral supraclavicular nodes?

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...

Roughly what percentage of patients are treated without a biopsy?

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.

Should fractionated EBRT be administered or can repeat SBRT be used?

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?

In practice, do you send patients with N2/3 disease for mediastinal staging if not offered upfront?