Palliation
Questions discussed in this category
Would you use 30/10, 20/5, or 8/1, and why?
What would you choose as the dose, fractionation and technique of following palliative scenarios with bone metastasis considering there are other visc...
If so, what are your typical treatment volumes in this scenario?
If a patient has a limited number of brain metastases (e.g., <3 total) but the additive volume of these intracranial metastases is high (e.g., each...
How would you manage a patient with a high-risk asymptomatic bone metastasis with a driver mutation?
For example, if the patient had an ALK+ NSCLC initiating targeted therapy, would you offer prophylactic radiotherapy as per Gillespie et al., PMID 377...
We have been receiving referrals for oligoprogressive SBRT for multiple primary tumors (NSCLC, Colorectal, Renal Cell, etc.) in the setting of diffuse...
My patient’s family has asked that I don’t tell her that she has metastatic cancer because it will devastate her. I am planning on palliat...
Treating to 12 to 16 Gy in 1 fraction, I based on the new ASTRO Clinical practice guideline, PRO April 2024
In patients with bone metastases and osteoarthritis, if it is unclear if the pain is from cancer or OA, how do you decide on the radiation dose/fracti...
The patient has extensive disease, and requires palliative radiation to the scapular area (proximal to the brachial plexus) in a region overlapping wi...
The patient has an asymptomatic metastasis in the left atrial appendage.
Would you start off with immunotherapy then add radiation later, or visa ver...
In palliating a painful bone metastasis that abuts a joint and which is associated with a joint effusion, would you treat the entire joint space to ad...
Patient has not received radiation therapy in the past. If not, what would you offer for palliation of pain?
Does histology (radioresistant or radiosensitive) play into this decision?
Anyone here doing 17 Gy in 2 fx?
If so, do you modify your external beam dose?
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
How would you treat a patient that had a T10 lytic lesion with extension to posterior 10th rib s/p cryoablation of the rib 4 months ago, but with resi...
What dose-fractionation scheme do you utilize? Are there particular groups of patients this would not be a good option for (i.e. histologies of diseas...
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...
Do you ever allow patients to receive a couple of cycles of systemic therapy first if there is high burden of disease? What is the maximum time after ...
How do you counsel patients and caregivers? Do you prescribe medications (''appetite stimulants'') with the goal to improve appetite even if they do n...
If a patient has thoracic metastases being managed with EGFR TKI, do you refrain from SBRT treatment, do you hold the TKI, or can you treat the patien...
Should 4 Gy x 5 be the standard of care for spinal cord compression in patients with poor prognosis?
The randomized SCORE-2 trial demonstrated equivalent survival (median 3 vs 3.7 months), response rates (72% vs 74% ambulatory at 1 month), and du...
What is the maximum time that can be used (given the complexities with patient being in the hospital or needing rehab)?
Do you routinely obtain a spine MRI prior to treatment for all cases, even for non-SBRT candidates (e.g., 30 Gy in 10 fractions) or do you ever rely s...
In a patient with metastatic cancer to the lumbar spine and epidural disease on CT who presents back pain and leg weakness:
Is a whole spine MRI in...
Do all patients with brain metastases get started on anticonvulsants?
Do you decide based on extent of edema, tumor size, or something else?&nb...
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...
If a patient is found to have multiple painful osseous lesions but is chemotherapy naive, do you typically wait for the patient to undergo treatment w...
If so, have you noticed differences in cognitive function post WBRT?
If not, how do you sequence the therapies?
For example, in a patient with an expected long-term prognosis?
For patients with painful SCLC vertebral metastases and no evidence of cord compression, would you recommend treating with immediate systemic therapy ...
Does fractionation (or location) influence this decision? What is your preferred steroid dose?
Notably, the patient presented with renal failure due to ureteral obstruction and hydronephrosis, receives hemodialysis, and has limited systemic opti...
In contrast to lung SBRT, rib lesions may not have a clear lesion on CT that can be delineated to create an ITV after 4DCT. Do you create an ITV, and ...
Does the time interval between the intial RT and recurrence influence your decision? What time interval would you feel is appropriate? What dose would...
A recent NCBD analysis (Rusthoven et al., PMID 27325855) suggests that the addition of prostate RT significantly improves survival compared to AD...
Assuming the patient is symptomatic and/or has compression of ventricles, what field design and dose-fractionation would you use?
The patient has metastatic ovarian cancer, currently on Avastin, with a large 13 cm pelvic mass with a fistula to large bowel.
Would you consider off...
In the phase III RTOG 0631 trial, patients with 1 to 3 vertebral metastases were randomized 2:1 to either SRS (16 or 18 Gy in 1 fraction) or cEBRT (8 ...
Is it safe to deliver palliative radiation to the spine with a spinal stimulator device with standard palliative dosing (8 Gy x 1 fx, 20 Gy/5 fx or 30...
The patient has stage IV cervix cancer and was previously treated to 30 Gy in 10 fractions one year ago. Embolization for hemostasis was not successfu...
How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?
In patients with contraindications to receiving an MRI scan, are other imaging modalities sufficient to treat patients with SRS?
The idea would be to appropriately cover gross disease/lesions in/around the hippocampus, but then spare the rest of the hippocampus, with the rationa...
How can these interactions be improved?
Is radiation effective in this case and if so, what dose would you use? Is there potential for perforation?
If not constrained by field size, would you treat the entire hardware length?
Guideline statements recommend 30 Gy in 10 fractions postoperatively due to lack of evidence for other fractionation schemes. Would you consider 20/5 ...
Groomed facial hair is an increasingly common style for men. Accordingly, there are patients who require treatment of the head and neck who become ups...
If a patient calls you after hours with a headache following SRS and have not been given steroids, what is your preferred regimen?
How will you approach patients with diffuse metastases who you would have otherwise deferred treatment?
Prophylactic Radiation Therapy vs. Standard-o...
If a patient with good PS who does not meet criteria for prophylactic rod stabilization has radiographic features consistent with metastasis (lytic ap...
Does the previous dose of SRS or the fact the patient had prior surgery matter when planning WBRT?
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...
Is there a limit to the number of adjacently involved vertebrae where you would instead treat with conventionally fractionated palliation?
Does your management change if the primary tumor is radioresistant, such as renal cell carcinoma?
The patient has disease in the S2/S3 region with an anterior soft tissue mass.
The patient previously received 50.4 Gy with treatment for rectal canc...
What dose/fractionation scheme do you use? Is SBRT a viable option?
How long after the first treatment should one wait?
The patient had previously recurred twice in the abdominal wall, and was treated with resection. The patient has developed AML since that time and is ...
In patients with large areas of painful bone metastases, do you ever do hemibody? If so, what is the preferred dose?
The patient’s tumor spans 6 cm depth within the scrotum, with no skin involvement.
What is your preferred beam arrangement?
With photons, woul...
Would you consider SBRT in this instance?
If so, then how would you approach this case if the patient's extent of disease was suboptimal for SBRT?
Is concurrent axitinib contraindicated if a patient is to be treated with conventionally-fractionated spinal RT (e.g., is not a candidate for spinal S...
If a patient had 35 Gy in 5 fractions to a vertebral bone metastasis with SBRT two years ago, how much more can I give now to the whole vertebra with ...
For example, when palliating rectal or gynecologic bleeding in 5 fractions?
What structures do you contour and what dose constraints do you utilize?
How do you take into account the following factors:
The degree of pain and/or ambulation impairment, the extent cortical destruction, and/or lytic vs...
How long do you wait to radiate post spinal separation surgery for multilecord compression if there is superficial dehiscence of proximal scar?
And does this differ by site (e.g. gyn vs head and neck)?
While protocols describe using a D2% constraint, there is little description of what should happen to the DVH between 30-37.5 Gy. It would ...
Should it include the entire brain (normal brain + target) or just the normal brain (brain - target)? How does the V10 or V12 constraint change ...
There are many cases where patient has cord compression in 1-2 vertebral levels, but surgery was done with hardware encompassing 5-7 levels. Are you c...
What medications (ibuprofen, steroids, muscle relaxers) due you use?
Are there any non-medication management options?
The patient has metastatic NSCLC with painful metastases of the cervical spine, and is in between cycles of chemotherapy
What maximum dose do you allow to “connect” adjacent metastatic lesions receiving SRS/SRT?
What is this value for one-, three-, and five-...
The patient has a lesion of the manubrium.
How would you approach the treatment of a single vertebral body involved with multiple myeloma (MM)?
What dose/fractionation scheme and treatment volumes are most appropriate?
Could you consider treating a single vertebral level with SBRT if do...
If so, what dose/fractionation and constraints would you recommend?
Do you require neurosurgical evaluation first? Do you require any patients to wear a neck brace?
Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...
Are you offering patients beta-emitters (Samarium-153 lexidronam, strontium-89) to any patients?
If there is no pain relief after 9 months, is additional radiation reasonable? What dose/fractionation would be safe and likely to be effective?
Is 30 Gy/10 fractions acceptable, or is another dose/fractionation scheme ideal?
For instance, are there
1. Specific Linac features, such as a certain MLC leaf width, 6-DOF couch, etc?
2. Requisite on board imaging/IGRT capabilit...
For example, would you treat the entire length of the femur after prophylactic intramedullary rod fixation for a femoral neck metastasis?
Is there evidence that supports/refutes the safety of concurrent use?
What constraints should be used for skin, thyroid and cricoid cartilage, and trachea when treating in 5 fractions?
Based on the SCORAD III trial, will you now be treating patients with spinal cord compression with single-fraction radiotherapy? Is there anyone ...
Do you treat all surgical hardware to a conventional palliative dose? Do you treat the metastasis with SBRT? Would you treat both with a simultaneous ...
Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?
Is there any alteration in approach from the medical, surgical, or radiation oncology perspective that can mitigate the risk of forming keloids withou...
If a patient has a large femoral metastasis that cannot be resected, but is to be stabilized with ORIF which will push tumor into the distal end of th...
Would you consider doses >4-10Gy?
In treating an oligometastatic lesion in the sacrum, is it reasonable to extrapolate from RTOG brachial plexus contraints (eg, 8 Gy/fx for a 3-fractio...
There are many delivery methods of cannabis, including smoking, ingesting it through food, or inhaling it. Is one method more effective than another?
How do you decide between supportive care v. chemoimmunotherapy? Is there a threshold of disease burden that would push you towards recommending hospi...
How does this differ in the de novo versus reirradiation setting?
If so, can these be administered concurrently?
How long do you continue high dose dexamethasone after radiotherapy? Does your tapering regimen depend on the clinical response to treatment?
How does this vary with dose-fractionation schedule or location of bone being palliated? What is the expected time frame for recovery?
Would your recommendation change based on disease extent? What other factors would you consider?
In a palliative setting, how long would you wait to initiate WBRT?
If progression is proven by imaging modality (MRI spectroscopy, perfusion and PET/CT), is there evidence for retreatment with a second course of SRS?&...
For treatments such as whole brain radiation or palliative spine radiation, is there a certain hotspot value you try to limit the plan to (i.e. <10...
These situations often arise in patients with a poor prognosis and the recovery time from such a procedure may not be trivial. In what cases would you...
The COMET trial excluded femur sites.
Is there a certain size threshold you use? Does location of the lesion (e.g. spine) matter? What other cases do you feel are not ideal candidates for ...
This assumes no current local pain symptoms or spinal cord compression. Does this recommendation change based on histology? Any other factors to consi...
Patient with stage IIB cervical cancer treated 8 years ago, now with large (>10cm), isolated, symptomatic recurrence involving the left SCL and med...
How would your recommendation change for a lesion within a non-radiated field versus a previously radiated field? What about an oligoprogressive lesio...
Do you hold Avastin before and after radiation therapy? Do you avoid radiation in these patients?
Is this different for de novo or reirradiation cases? Would you recommend avoidance of the nerve roots if there is gross disease present in these area...
Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...
Would you consider using radiotherapy for persistent malignant pericardial effusion? What dose-fractionation would you use, and what would your ...
Is there specific workup you perform? Are there preventive measures? Once established, are there non-pharmacological and pharmacological treatments yo...
For that occasional "single lymph node metastasis" referral in patients with no other sites of disease, is there a therapeutic dose below which you're...
Would you offer SABR in the setting of only two lesions? How would your recommendation change if this was NSCLC?
Is your size limit a function of OAR dose? If yes, is there a volume of bone that you will not exceed regardless of no dose-limiting OARs?
Is 1000 cGy x 3 fractions to a portion of glenohumeral joint safe?
Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...
Would tumor pathology affect your decision-making (e.g. angiosarcoma)?
Specifically, how do you explain potential cognitive decline in a way that explains what changes they can expect in their daily lives?
How about those with metastatic disease eager to maintain quality of life? Do you risk progression of disease if the TNF blocker is re-started?
What is your normal dose-fractionation in this scenario?
Do you change your dosing if the lesion is in a weight bearing structure (femoral head/neck,...
Do you include a T1 post-contrast series?
Is urgent whole brain radiotherapy indicated for certain histologies such as choriocarcinoma from GTN or testicular origin? If SRS is employed, how sh...
Would you offer palliative radiation? Would you fractionate differently?
If so, how would you approach your radiotherapeutic plan and what dose-fractionation would you utilize?
Would you treat Dupuytren’s contracture shortly after surgery or wait till patient develops new contracture? What dose and fractionation do you ...
Are you waiting for final publication of NRG CC-001?
If already routinely using, any challenges with insurance approval, plan turnaround time, or oth...
Would you consider treating 3-5mm lesions with SBRT or wait until they are a certain size? I am concerned I will not be able to see them adequately on...
What factors would you consider? What if this meant treatment of the full kidney? If treatment is recommended, would you utilize an SBRT approach...
Would you continue treating the patient (in spite of the risk of causing a frank perforation, sepsis, and subsequently devastating consequences), or w...
Do you have a "threshold" quantity/dose of opioids above which you are uncomfortable prescribing?
Is this recommended in a certain subset of patients (EGFR positive or 1 metastasis only)? Or should we await maturation of the MD Anderson/Colorado/On...
What factors do you consider when determining this constraint? For example, in a patient who was previously treated to 30 Gy in 10 fractions, how woul...
A case series from Colorado raises concern over significant radiation necrosis with SRS. However, there doesn't seem to be much additional negative li...
If you are treating a very large palliative spine field that encompasses several vertebral levels, would you consider splitting the field (treating ha...
Would this be any different for whole brain radiotherapy?
Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?
What is your recommended dose-fractionation when treating with SBRT for a non-spine bone metastasis?
For example, what is a safe dose for SBRT for a ~5 cm colorectal bone metastasis of the acetabulum?
How does your fractionation choice change if the lesion is abutting the pleura?
Would you use adjuvant radiotherapy after xiaflex injection or needle aponeurotomy?
Would you take any special precautions with dosing or care for fingernail toxicity?
If given options of liver, lung, spine, brain, axilla, or other lymph nodes which sites do you pick?
Would you treat if there is active infection? How much improvement would you expect?
Would you treat if the patient is asymptomatic? If you do treat with RT, what dose-fractionation would you use, and what volumes do you target?
If so, how would you approach treatment?
How do you decide between plaque brachytherapy and external beam approaches? What dose do you use for plaque brachytherapy? For external beam, what do...
Does your volume change based on fractionation (high-dose single fraction vs. 3-5 fractions)? Do you treat the entire circumference of long bones? Wha...
Would you feel comfortable treating with palliative radiation without neurosurgical assessment? Are these patients at increased risk for neurolog...
There are solid data from Emory, Korea and others suggesting that is as effective as single fraction SRS but has less complications.
Are carcinoid tumors of the GI tract more or less radiosensitive than typical solid tumors?
Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?
To what degree, if any, is a neurosurgeon involved in the planning of SRS for brain metastases?
The 2014 "Choosing Wisely" list, released this past September, includes the assertion that we should not "routinely add adjuvant whole brain radiation...
In this age of IGRT, CBCT, and MRI imaging, is this practice needed?
If surgical stabilization has been performed, do you go with SBRT dosing? If so, do you treat only the involved site and not the extent of hardware? D...
Please share your decision algorithm, if any (based on age, histology, KPS, lines of therapy already used, prognosis, etc.).
For example, in someone with a new diagnosis of hormone receptor positive breast cancer with a 10 cm lytic bone lesion extending out into the pelvis a...
For example, there is a retrospective series out of MD Anderson (Kim, Acta Oncologica 2008) wherein 37 patients with gastric cancer were treated with ...
The immediate response by patients in this situation seems almost universally to be, "But I'll starve to death!" Referencing literature about lack of ...
Will higher doses per fraction increase the risk of fibrosis and cause permanent impediment to biliary flow?
For example, if a patient had severe lung obstruction or hemoptysis from a tumor would it be okay to treat with 3Gy per fraction BID? Or, if a pa...
More specifically, what do you classify as a situation that needs treatment within 24 hours?
What is the best evidence to support or refute this?
Does the site of palliative radiation therapy matter (i.e. femur, abdomen, pelvis vs base of skull)? How long should you wait to give palliative ...
For example, in a patient minimal brain and liver metastasis, would you treat all sites definitively?
What are the best options to treat a patient with brain metastasis confined to the posterior fossa if the patient is young, has a favorable cancer, gr...
How does your fractionation change based on the time from the previous treatment, such as 6-12 months vs. greater than 12 months?
When treating with radiation therapy, what dose-fractionation do you typically utilize?
If not what radiation fractionation regimen is preferred for otherwise good KPS patient?
For example, is 8 Gy x 1 well tolerated in the setting of multi-level vertebral body radiation?
How would your recommendation change based on interval from previous radiation?
Does your dose-fractionation approach change in such cases?
Can the drug continue during radiation therapy or should it be discontinued at a specified time prior to initiation of radiation?
We have a great palliative care clinic and I like to refer many patients with metastatic disease, even if I feel that they will live a year or two lon...
If the systemic agent is going to be held, how many days prior to starting radiation therapy should the agent be held and when can it be restarted aft...
Does your criteria change if you are considering SBRT?
Is there a hypofractionated dose regimen that would be suitable for palliation prior to the patient going to hospice?
For a patient who has completed 40 hyperbaric sessions with steroids with little improvement, what other options exist?
If so what dose-fractionation do you use and what constraints for brachial plexus?
The Canadian study presented at ASTRO 2015 showed a decrease in pain flare prior to single dose 8Gy RT, but steroids were given for 5 days prior to RT...
I know that some would argue that healthy patients with an excellent performance status may not need an early palliative care referral, but wouldn't i...
Specifically from a GI primary?
Do you handle a non-emergent indication such as palliation for pain vs cord compression differently in a patient unwilling to undergo a biopsy?
What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...
In a patient with multiple brain metastases from NSCLC, is this reasonable?
Any advice on how to safely incorporate it into our practice?
How do the number of lesions treated and histology affect your decision making?
The most frequent argument against whole brain RT is debilitating toxicity. However, I am having a hard time finding the most evidence based data on h...
Is heparin or warfarin routinely held prior to treatment?
In RTOG 9508, 4 cm was the cut-off size for WBRT followed by SRS.
In reading through the policy of one of my state's private insurance companies, I came across something with which I'm not familiar, namely treating p...
I'm aware of a number of publications that suggest that after 1-2 years, the cord should be able to handle about 50% of the original tolerance dose. &...
It is my impression that for brain metastases >3 cm it may be preferable to deliver fractionated SRT versus the RTOG dose of 15 Gy SRS, if WBRT is ...
I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...
What dose/fractionation is appropriate and does it differ between histology?
More specificlaly, in a non-emergent situation?
Do you hypofractionate or add any concurrent systemic therapy? What specific dose-fractionation regimens do you recommend?
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