Questions discussed in this category
The patient is a male in his 60s who underwent inguinal orchiectomy and spermatic cord resection of a 5 cm malignant fibrous histiocytoma of the sperm...
Would you cover the chest wall alone or would it be chest wall plus regional nodes?
Patient factors: no prior radiation therapy
S/P neoadjuvant chemotherapy and followed by oncologic surgical resection but with positive margins.
How do we approach patients with rare tumors given the paucity of data?
The patient is in their 40s with right arm rhabdomyosarcoma s/p amputation. Path shows embryonal rhabdomyosarcoma 6.5 cm, margins neg. 11 of 19 lymph ...
If so, what dose/fractionation?
Pathology: High grade spindle cell sarcoma
Relevant pathology features: 7.5cm, grade 3 with a 5mm bronchial margin, negative nodes.
Relevant pathology features: positive margin
Total dose prescription: 66 Gy
If there were negative margins, what other factors would you consider to add adjuvant RT? Size of the tumor or depth of invasion?
Angiosarcoma is invading the brachial plexus and thoracic vertebral bodies.
Prior radiation therapy: Radiation to the left chest wall and regional no...
Patient initially achieved CR with VAC-IE with resolution of presumed lung mets and 100% necrosis in LLE primary tumor on BKA. Then was NED again afte...
How would you add radiation in your treatment paradigm? No clinical trials available due to age.
No lymph node dissection. cN0
Tumor factor: Large axillary soft tissue sarcoma with involvement of the brachial plexus
Other factor: Surgery would like to pursue upfront surgery t...
The patient presented with spinal cord compression, had subtotal resection and instrumentation with metallic hardware. Main concern is that post op su...
No evidence of distant disease elsewhere. Surgical resection is not possible. Would you recommend metastasis direct therapy to the liver (i.e. SBRT or...
This was resected over 2 years ago with reconstruction of the IVC with a PTFE graft. No preop or postop RT given and the recurrence is in the area whe...
What dose would you use? For negative margins do you offer 50-50.4 Gy/25-28 fractions? What target volume margins do you typically recommend on t...
This patient is young and active but refuses palliative chemotherapy
Is there a role for pre-operative RT?
50+ yo F. Mastectomy, chemo, and RT in 2016 for primary breast angiosarcoma, not RT induced. Had longstanding cyst on wrist, biopsied, and positive fo...
Prior treatment: GTR in 2020, adjuvant radiation 63Gy
Patient factors: Medically inoperable and not fit for chemotherapy
The recurrence is within th...
What is the role for post-operative irradiation?
Would you change your management based on location, such as a sensitive area like the groin? What volumes do you recommend? Does age influence y...
Would you go beyond a traditional palliative regimen such as 30Gy in 10 fractions?
This is particularly relevant for patients with extensive delays due to wound healing issues.
The pulmonary metastases are planned to be addressed with a combination of surgical resection and SBRT.
Would you off more radiation if the prior pre-op radiation was within a few cm to the recurrence? If there a time interval you would wait before offer...
40 yo adult patient with a~6cm mass with concern for skull base bony involvement (group III and stage III, no nodal involvement )
When do you offer preop RT (50Gy) before the re-excision? When do you offer post-op RT after the re-excision?
Individuals often cite ARST0332 to justify radiation omission in high grade R0 resections, but R0 was defined as > 5 mm margins.
If a staging RPLND is NOT performed, is there a role for prophylactically irradiating the lymph nodes, even in the setting of a negative PET/CT at dia...
What would be your radiation volumes/dose and choice of chemotherapy?
Would you offer adjuvant RT or chemotherapy? If so, what chemotherapy would you prefer?
If so, what dose and treatment fields would you use?
No sarcomatous overgrowth seen.
These tumors are often low grade, but have a propensity for local recurrence.
Performance status is excellent. Second surgical opinion has also confirmed need for amputation, as the recurrence is now breaching intra and extra ar...
What margin would you consider to be necessary to omit radiation?
This patient had resection of the primary, requiring multiple resections to obtain an R0 resection, followed by adjuvant radiation to the primary. The...
Is chemoradiation a viable strategy in osteosarcoma?
Would you consider doing a pre-op RT prior to possible re-excision? If yes, what dose would you give? If the location is between L4-L5 spine.
How do you interpret the results from the recently published EORTC-62092: STRASS study that showed no benefit to preop RT+surgery vs surgery alone and...
In this patient dermatofibrosarcoma protuberans of the thoracic spine, which originally caused a cord compression and has since been debulked, gross r...
If post-op with clear margins would you prefer adjuvant RT or close observation with surgery for optimal reduction of local recurrence? This particula...
What if the patient had also received HIPEC prior?
Would you consider adjuvant chemotherapy, radiation therapy, hormone therapy, or surveillance?
Final pathology showed grade 3 spindle cell sarcoma of thee vagina involving the anterior lateral cervix 5.6cm x 4.5 x 3.4cm, <0.1cm left lateral m...
Which Radiation modality, if any, would be preferred?
Typical chemotherapy does not work for SFT. In which circumstance would you use VEGF ( Temozolo...
Recent results from the STRASS trial suggest limited benefit from preoperative radiation therapy for retroperitoneal sarcomas.
https://pubmed.n...
If you do what dose and fractionation do you recommend?
Presented with mass projecting into right/left anterior ethmoid complex
More specifically there is no testicular invasion - would you cover the entire scrotal sac? What lymph node stations if any would you cover?
The interval since prior resection is between 3-5 years. Additionally, there is some evidence of nodal involvement but no evidence of metastatic disea...
Re-excision would result in amputation. And the patient had attempted pre-operative RT but quit at 16Gy due to toxicity/social reasons. Would you trea...
>5cm. If so, what is your preferred regimen?
Would you use general sarcoma expansions or would smaller expansions like the ones in head and neck would be reasonable?
Would chemotherapy be a consideration? If yes, would you adjust margins or dose?
Specifically, when treating a tumor located in the head and neck region, would you consider treating closer to 64-66 Gy? Or would you be consistent wi...
When deciding to treat what would be your dose/volumes? And would a re-staging scan play a role in your treatment planning?
If a patient with a high grade sarcoma has gross residual/recurrent disease after resection and cannot undergo further surgery - would you boost this ...
What is your regimen? And long-term follow-up in these patients?
What if it was status post partial resection? And had bilateral level 2 lymph nodes?
For example, would you consider switching to an outpatient regimen in lieu of AIM for metastatic soft tissue sarcoma?
What dose schedule would you use to treat plantar fibromatosis? How soon after resection would you begin treatment? And how happy were you with the re...
MRI with intravaginal gel shows no gross residual disease.
The case in question is a radiation-induced spindle cell sarcoma at the thoracic spine previously treated for a plasmacytoma to a dose of 60 Gy in 30 ...
For both the primary and re-resection surgeries, resection was achieved via both scrotal and inguinal incisions. And margins were reported as negative...
Sometimes wound healing can delay adjuvant radiotherapy by several months. For aggressive histology, such as high grade sarcomas or skin cancers with&...
Adverse features include increased nuclear size, nuclear atypia, and mitotic activity up to 10/50 HPF.
i.e. doxorubicin, ifosfamide + RT. Do you worry about decreased locoregional control or increased toxicities with the use of G-CSF in combination with...
If so, would you treat the whole pelvis, cuff brachytherapy, or both?
Recurrence is in the radiation field right at the border of graft and scalp, and started to surface at about 20-24 Gy. It is visibly enlarging over se...
Would certain patient/disease characteristics make you choose RT therapy over chemotherapy or other locally ablative therapies? What dose/fraction wou...
Specifically concurrent ifosfamide? Induction AIM?
Did the publication earlier this year by Gundle et al. JCO 2018 (http://ascopubs.org/doi/pdf/10.1200/JCO.2017.74.6941) alter your concept of close mar...
What margins (if any) do you consider appropriate to not require adj RT? And would you ever consider neoadj RT?
Specifically the groin region? Or are there techniques or a change in the management style of radiation at these sites you would employ to minimize to...
If so, how do you choose your region of treatment? Dose? And elective nodal volume?
If margins are clear, would this tumor necessitate adjuvant radiotherapy? Synovial sarcomas often occur in a young patient subset, would this cause yo...
If so, what patients do you select for the boost? And what data do you give to adequately satisfy the insurance review and win approval?
In a patient, with multiple small volume lesions (5-25mm), would you offer pelvic RT?
After and extensive en bloc resection, is there further surgery that would be recommended? Is radiation alone sufficient?
Would you treat these sites to definitive or post-operative doses? If not, is there a dose constraint you use at these sites? Do you use tighter margi...
Is there a role for adjuvant radiation? Other chemotherapy options?
What things would you take into consideration for the simulation set-up? Specific instructions for treatment planning? If the PTV is confined to only ...
Is breast conserving surgery followed by radiation therapy an option?
Do you follow pediatric protocols or treat this more like a high grade soft tissue sarcoma? Specifically for paratesticular pleomorphic RMS, do you ad...
Is a margin of 5 cm on the GTV still standart?
What are some guidelines or principles that you use to recommend adjuvant radiation after complete resections of sarcoma?
For example, in the setting of a lack of pre-operative imaging, what CTV margin(s) would you utilize for the initial and boost phases of treatment?
How does grade, margin status, and previous radiation dose factor into the recommendation?
What time delay would make the benefit of adjuvant therapy likely no longer significant?
Would it differ if the tumor was high grade at the same location?
Do you offer neoadjuvant RT with resection and node dissection vs. definitive radiation? How extensive does the nodal disease have to be for you...
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 ...
Should such a case be treated like retroperitoneal sarcoma?
If so, how to you address the scar? Do you use bolus? Do you place a 2mm retraction from skin for the target contour?
With the high rates of recurrence postoperatively with angiosarcomas of the scalp, adjuvant radiation is often recommended. What margins would y...
Most guidelines discuss target delineation and contouring recommendations for extremity sarcomas, which generally suggest larger longitudinal than rad...
For example, a patient with liposarcoma of the lower extremity status post preoperative radiation to 50 Gy who then underwent resection and had focall...
Can you use SBRT for boost?
Would the dose change based if there was tumor adherent to bowel versus abdominal wall or muscle?
Would the histological grade or histology affect the dose? Would you consider dose escalating to the center of the tumor if this would not affect orga...
I am treating a resected high grade liposarcoma with positive surgical margins to 66Gy. I would prefer to use IMRT to spare the humerus, but ...
What is the risk of joint issues if you treat the epitrochlear nodes?
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...
And does your dose changes with positive margins? I can't seem to find a good answer in the literature.
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