Questions discussed in this category
Have you encountered this scenario?
Of note, there is ~150 cc small bowel left and no further surgery was offered.
There seems to be a wide variety of palliative doses used in clinical practice (8 Gy x1, 2 Gy x2, and 20 Gy in 10 fx). Do you have a preferred dose? D...
Per the NCCN guideline for HR HD, if treated per OEPA-COPDAC, you can omit ISRT. This patient received treatment per AHOD1331, which recommends ISRT f...
Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g., skin can...
I am not sure there is much efficacy for a regimen that does not include asparaginase. The patient received 2 cycles of P-GemOx, then was admitted for...
What would be your RT volumes and dose?
Al-Ibraheem et al., PMID 33731050
The patient has a history of a lymphoplasmacytic lymphoma with a CR after chemotherapy but presented with a large frontal lobe mass that was biopsied ...
For example, would you offer 4 Gy x 5 fx (vs 24 Gy/12 fx) in a patient with isolated recurrent follicular lymphoma of the breast after RCHOP and maint...
Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?
Would you offer palliative (4 Gy) radiation therapy to the stomach mass vs. definitive doses (24 - 30 Gy) encompassing all of the disease?
In which situations or patient populations do you find this useful? How is it sterilized?
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
If so, how long would you hold? This medication is given for migraines as q3 month infusions and some data suggest that CGRP plays a role in immune-mo...
Given pelvic RT is likely to induce ovarian dysfunction/menopause, would you consider systemic options?
Would you provide pentoxyphylline and vitamin E prophylactically after treatment? Is there a role for Boswellia? ACE inhibitor?
Would you consider observation following surgical resection with negative margins? Would you recommend WBRT and/or ISRT? What would be your preferred ...
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
Are there any skin care products you would avoid in this population?
Complete response was achieved after cycle 3. What extent of bone would you include?
Would you follow an algorithm such as the one proposed by Hall et al., PMID 29940062?How do you decide between intrathecal chemotherapy vs systemic th...
In what situations would you feel comfortable omitting RT to bulky disease in stage III/IV Hodgkin's lymphoma?
Initial tumor size:18 cm. Partial response was achieved after cycle 2 and cycle 6 of chemotherapy. Complete response (Deauville 2, size: 6 cm) was ach...
Is there benefit to radiation on top of systemic therapy?
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 ...
Would your management be different in node + vs. node - patients? What would be your radiation volume and dose?
Are you concerned about cases where radiation has to be started urgently before leukapheresis?
What is the best treatment management of low grade early stage follicular lymphoma of the mesentery?
If the mesentery is widely involved with small lesions would this change your management? What if the patient was symptomatic?
Would you offer WBRT + boost vs WBRT vs focal treatment/SRS.
Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?
Is there an optimal bridging radiation dose for aggressive B-cell NHL undergoing CAR T-cell therapy?
What influences your decision to proceed with palliative vs. definitive, and standard vs. hypofractionation dosing regimens?
Do you give RT before or after systemic therapy?
Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...
Does the fact that the patient is on methotrexate alter your choice?
How many cycles of systemic therapy is recommended? is XRT needed and what XRT dose is recommended?
How do you pursue fertility preservation in younger females with this presentation?
How would these expansions differ based on the anatomic site being treated?
What XRT dose do you use? Does the location of the disease (e.g., mediastinum) affect your decision when taking toxicity into account? would you offer...
Is this considered a sanctuary site from systemic therapy?
Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?
This is an adult patient that is status-post orchiectomy and R-CHOP now requiring prophylactic contralateral testicular radiation. Would you recommend...
How can these interactions be improved?
Good performance score, 7 cm in size, CSF cytology is negative, MRI complete spine is negative. Would you consider any additional systemic therapy mod...
Elderly patient with large fungating necrotic breast mass positive for high grade BCL and a solitary hypermetabolic ipsilateral axillary node. Medical...
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor p...
Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...
Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...
She was on surveillance after lumpectomy. No prior radiation therapy. What dose/fractionation?
When would you treat the entire orbit versus partial orbit? One patient has medial rectus involvement and another has only conjunctival involvement. I...
Imaging studies (MRI and PET) show bilateral disease
If so, how long before/after radiation?
If a patient clearly has N1 disease with high SUV on PET, do you routinely recommend EBUS or mediastinoscopy to evaluate for N2 disease?
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
Would you treat as bulky or non-bulky? Is ISRT indicated? Biopsy was performed because there was concern for soft tissue sarcoma.
My experience has been that patients can be neurologically devastated years out from WBRT. In Medical Oncology practice at my institution, we do not r...
Do you use a cutoff of 10 cm? Do you measure the size of the largest node or measure the largest conglomerate or measure the total length of the entir...
The said patient has been on Imatinib for 2.5 years and is In MMR. Last rt-PCR was 0.04.
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
Is there a specific brand or formulation you prefer?
The literature supporting the use of probiotics does not standardize the type or dose of probiot...
In this case, initial tumor was 9.5 cm craniocaudal but hardware spans the entire femur.
Are there situations in which you would recommend dilation of stenotic airways after radiation? Is there a concern for increased complications of dila...
Does this change depending on stage?
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
Which systemic agents would you recommend holding during RT?
What dose/fractionation?
If re-irradiation, what dose would you use?
In situations when we are waiting for insurance clearance or due to other logistical reasons.
Plasmacytoma of 6th rib s/p resection. Negative multiple myeloma work-up.
If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...
Would chemotherapy be preferred over RT?
NCCN only recommends palliative ISRT for non-transplant eligible patients with refractory/relapsed DLBCL
The dosing in the literature has a huge range.
If so, what dose and fractionation would you recommend?
Would you move straight to second-line systemic therapy or first attempt consolidative ISRT/boost, or employ both? Assume node is biopsy-proven.
Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...
Would your recommendation change based on grade and/or location (weight-bearing vs non weight-bearing bone)?
Would your recommendations change if the mass were significantly smaller, say 1-2 cm, and was completely excised with negative margins?
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
What is your approach for a symptomatic inpatient with locally advanced NSCLC who cannot have a PET?
Would you consider treating the full mediastinum or any mildly enlarged nodes, even contralateral? Do you have a strategy that transitions from a pall...
Would inhaled steroids help reduce the PO dose and/or significantly accelerate tapering? If s, for what pneumonitis grade? What specific steroid...
Should patient be considered for definitive therapy or chemo alone if pleural cytology positive but no T4, N2, or sarcomatoid features?
There does not appear to be any guidance from the most recent published protocols on this topic. For individuals with dementia, recommendations call f...
How do you approach systemic therapy options? What are your recommended volumes?
Would you offer refractory doses (40-50 Gy) to the RPnodes and send for splenectomy? Or would you offer refractory doses to both RP nodes and spleen?&...
Would you reduce dose, e.g. from 30 Gy in 10 fractions to 20 Gy in 5 fractions, or hyperfractionate, e.g. 1.5 Gy bid to 20-30 Gy?
Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?
For example, a patient with a large (>3cm), spiculated, FDG-avid lung lesion, who has poor lung function and is refusing a CT-guided biopsy?
For instance, if the tissue came back SLL, Waldenstrom's, follicular lymphoma, or even nodular lymphocyte-predominant Hodgkin lymphoma, would any or a...
For example, in a young patient where standard fields would be very large and you want to minimize toxicity
For T2bN0 or T3N0 disease, you consider radiation alone, sequential radiation followed by chemotherapy, or concurrent chemoradiation?
Do you continue atezolizumab alone? Would you avoid anticoagulation?
After initiation of anti-TB treatment and 3 negative AFB smears, would you initiate concurrent chemoRT? Would you give sequential RT then chemo to giv...
In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?
What if it is a young patient?
In this scenario, is systemic treatment better given bilateral involvement? In a patient who has already had cataract surgery and is not at risk for c...
Does your dose recommendation change if a patient has cord compression or has undergone surgery? There is a range of doses in the ILROG guidelin...
In a patient with a large primary and a negative PET/CT for nodal disease, would you push for EUS for radiation planning? Or would this be an unnecess...
Would your practice change if the patient had N2 disease?
At what point would you recommend transfusion? At what point would you stop radiation?
I’ve noticed some patients develop worsening SOB and DOE months after RT and rather than interstitial diffuse pattern you would see with pneumon...
The patient received R-EPOCH followed by consolidative RT (36 Gy in 18 fractions) approximately one year ago and was subsequently salvaged with RICE.
Do you recommend TACE, RFA, radioembolization, systemic therapy or SBRT? What if the size is >5 cm?
Any differences in the risks between SBRT vs. conventionally fractionation? Concurrent immunotherapy?
If so, what dose would you recommend?
At what age would you treat an early stage hodgkins lymphoma patient with ABVD + RT (adult treatment) vs OEPA x 2 or AV-PC x 3 (pediatric paradigm)?&n...
Is there a certain age beyond which it is not safe to do SBRT?
How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?
The unfavorable risk factors for stage I-II Classic Hodgkin's Lymphoma differ depending on the cooperative group (GHSG, EORTC, NCCN), which criteria d...
Should staging and treatment decisions be made based on imaging alone?
Guidelines indicate RCHOPx3 +RT as category I and RCHOP x 6 below that; long term f/u for SWOG 8736 showed similar PFS and OS. Do you have and approac...
For a stage IAE DLBCL (in this case, of the oral cavity) that was completely excised, s/p R-CHOP, is the ISRT target volume just the preop volume plus...
How would your dose and/or volume change if the patient refuses chemotherapy?
Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...
Any experience treating patients prone with openings for both breasts, no minimize breast overlap with axilla and mediastinum?
The patient is not a transplant candidate due to multiple co-morbidities. Some of the sites in question have had a complete response and other have ha...
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
The patient has no bone marrow involvement.
Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?
Some specific questions:
Would you recommend repeat biopsy to confirm residual disease?
How would your recommendations vary if the patient had pre...
If the breast was previously radiated 15 years ago, would that change your decision?
If there was residual lymphoma on cytology of a chronic se...
Would you recommend RCHOP x 3-6 or RCHOP x 3 + ISRT? If you end up doing ISRT, would your target be any different than the principles that guide...
Is your scoring based on SUV uptake vs the subjective interpretation of the radiologist? How do you go about reconciling Deauville scoring when there ...
Is IO related pneumonitis in the radiation field or more diffuse?
Do you have any preferred dose fractionation schedules? What kind of margins do you use?
If clinically node negative, would you add elective nodal radiation?Does it depend on location (upper vs. lower trachea)?
Repeat EGD and additional biopsies of the stomach were all negative for MALT lymphoma and H. Pylori. A CT of the C/A/P was done showing no evidence of...
For example, would you go ahead with 20 Gy of ISRT if medical oncology has already treated a stage I-IIA patient with 2 cycles of ABVD meeting all oth...
If they are symptomatic do you relax that time interval? Do you ever consider partial brain radiation instead of whole brain to minimize neurotoxicity...
In a patient who absolutely cannot receive chemotherapy due to impaired performance status, what dose would you use for WBRT and what dose would you u...
Prior trials of systemic therapy including alkylating agents and rituximab have failed and the patient is medically inoperable with no history of Hepa...
The staging bone marrow biopsy was negative. The staging manual simply states "bone involvement is identified using appropriate imaging studies."...
Would you use a similar dose and fractionation as gastric MALT (30Gy in 1.5 Gy fractions)?
Should prechemo PET positive disease from bowel or other structures be carved out?
Does it factor into your decision making in the setting of restricted spirometry and normal lung volumes? Does this differ for SBRT v. chemoRT?
Do you generally always boost the scalp and/or soles even if those sites are not involved with disease?
The patient had a bilateral orchiectomy (pathology demonstrated no invasion of the tunica) followed by R-CHOP x 6 and IT Mtx with a PET CR in a para-a...
The patient is a 75 yo immunocompetent man who has a history of inverted papilloma of the sinuses and presented with a new lesion in the right maxilla...
Would you use 10 Gy in 1 Gy per fraction as mentioned in a litterature review in Pubmed?
What factors influence your choice to treat as well as dose and target?
The patient does have significant weight loss, drenching night sweats, but no evidence of other involved sites on PET, thorough skin exam, and has nor...
In the case of an excised groin node with no residual disease and no chemotherapy in a young adult patient, how large should the fields be? Is it requ...
I have a patient with low volume disease of Castleman's disease with cervical lymphadenopathy and tonsillar hyperplasia that is suspicious but not bio...
If a patient has an increase in PET avidity between the PET/CT done after 2 cycles of ABVD and after completion of chemo, how would you proceed? Would...
Does your follow-up differ depending on the dose you used (e.g. boom boom vs. 24 Gy)? Do you routinely image? If so, do you use MRI or PET...
Would you treat if there is active infection? How much improvement would you expect?
If the patient had a CR by PET/CT after 2 cycles of ABVD and received 6 cycles of ABVD would you recommended consolidating only the bulky disease and ...
What technique do you use (IMRT vs direct electrons w bolus)?
The ILROG paper on extranodal NHL says "For tumors confined to the conjunctiva or...
If a patient will receive a total of 4 cycles ABVD and has a CR by PET/CT after cycle 2, can RT be omitted to non-bulky sites to avoid toxicity?
When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...
What dose and volumes would you use?
PET/CT/bone marrow biopsy negative for evidence of distant disease. Following 4 cycles of combination chemotherapy with no evidence of progressive dis...
Is there any role for consolidative RT/CRT to the lung and mediastinum after initial chemo? What dose and fractionation would be most appropriate for ...
For example: would you treat the entire Waldeyer's ring? For a stage II patient who also has cervical lymph node involvement on one side, do you...
We often see young women with favorable, early stage disease in the mediastinum who have had a complete response to chemotherapy. With current smaller...
How have the results of the UK RAPID study (Radford et al NEJM 2015) changed your practice?
There are varying reports in the literature which seem to suggest increased rates of Gr 4-5 pneumonitis in IPF patients. How do you manage these...
Specifically, is there still a role for dd RCHOP followed by ICE, or do you recommend DA-R-EPOCH for all patients?
What is the best evidence to support or refute this?
Would you include one vertebral body above and below the involved vertebral body? Is IMRT appropriate in order to reduce dose to small bowel? What oth...
What about patients who are still on steroids for radiation pneumonitis?
If a patient had recently completed R-EPOCH x 6 cycles, would you change your dose for a low grade follicular lymphoma?
Is surgery an adequate treatment for Stage IE DLBCL of the cervix?
When treating with radiation therapy, what dose-fractionation do you typically utilize?
The NCCN guidelines call for pathological mediastinal lymph node staging for all NSCLC except in solid tumors <1cm and non-solid lesions < ...
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...
The NCCN guidelines recommend all patients receive 3 cycles RCHOP followed by ISRT unless they have bulky disease greater than 7.5 cm. However, are th...
With the field moving more toward ISRT/ INRT, and conformal radiation, would you generate separate PTV for initial nodal involvements that are within ...
If so, what data should be presented to insurance companies to cover the cost?
What dose do you recommend?
When nodal regions not amenable to biopsy but are enlarged without significant SUV uptake, should they be treated as involed and recieve RT?
After ABVE-PC X4 and Ifos/vinorelbine x 2 per AHOD 0831 (and is unable to have these sites biopsied), what dose would you treat to and what volume wou...
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...
Is there a preferred low dose splenic irradiation regimine?
When radiation therapy is utilized, what should the radiation therapy treatment fields include and what imaging studies should be completed to assist ...
If so, should involved site radiation thearpy (ISRT) or involved field radiation therapy (IFRT) be used for the radiation therapy treatment fields? Wo...
Are the results of AHOD0031 practice changing?
When the disease (in this case, lymphoma) involves almost all of the entire muscle compartment of the distal lower extremity, what is a safe dose? I'm...
In drawing the lung blocks approximately 1 cm in from the chest wall, diaphragm and mediastinum, should the blocks stop underneath the clavicle o...
If a patient with stage I, low grade follicular lymphoma achieves a complete response after rituxan and treanda is there any role for consolidative ra...
Roughly what percentage of patients are treated without a biopsy?
Specifically for marginal zone or follicle center?
Is it necessary to treat the whole orbit or is conformal treatment ok?
After a nerve sparing parotidectomy, would you offer postoperative radiotherapy? If so, what volume and dose? Would it change your management if the p...
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...
Hoskin et al (Lancet Oncology 2014) suggest 24Gy/12fx is more effect RT dose compared to 4Gy.
Is there a benefit to IMRT when we treat to relatively low doses (as compared to squamous cell cancers of the head and neck)?
Are there any indications to choose one over the other?
Or is it more appropriate for certain sites/stages/histologies?
Specifically, for a diffuse large B cell lymphoma of the femur?
It seems that with the arms up, you get better lung blocking but with arms akimbo, you might have a lower dose to the humeral head.
In practice, do you send patients with N2/3 disease for mediastinal staging if not offered upfront?
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