Radiation Oncology   

How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?

I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...

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...

Would you biopsy lymph node to confirm recurrence/histology?  If confirmed, how do you decide between RT vs chemotherapy? If chemo - BEP x3 vs E...

Is this an artifact of what agent prior clinical trials used or something to do with mechanism of action (ie less mineralocorticoid effect of dex)?

How do you sequence/integrate radiotherapy relative to high risk chemotherapy? When would you consider cranial/craniospinal radiotherapy? 

What is the impact among patients and providers? Has your documentation been adjusted now that patients can readily review?

Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...

This is particularly relevant for patients with extensive delays due to wound healing issues. 

If not, how should you select those cases that should be referred?

When/how often do you order imaging?

Is there a role for more advanced delivery techniques

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...

If so, what dose and fractionation would you recommend?

What dose/fractionation regimen is most appropriate?  -i.e. 12 Gy in 4 fractions, but would you modify that approach in a young patient? What i...

Would extent of surgical resection matter? Do these patients need CSI (like Pineoblastoma), just local radiation, or something in-between (say whole ...

The patient initially presented with an large renal tumor encasing the IVC and abutting the abdominal aorta. Given this, the patient received inductio...

To minimize the likelihood of asymmetrical growth, when is it of sufficient concern to necessitate altering planning objects? When planning paediatri...

In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients. 

What is the best way to counsel families in regards to their child's risk of infertility and need for fertility preservation?

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 ...

What is the timing and role of surgery and RT at salvage for a lung recurrence?  Patient initially presented with lung metastases, but achieved ...

Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?

How should the need for dose homogeneity be managed relative to the proximity of these target volumes to the spine?   Are AREN0321(HR), 0532(...

Is chemotherapy recommended for M+ germinoma? CR to chemo; Spine MRI negative; CSF negative Is CSI required or whole brain radiation is sufficient f...

What if there is residual soft tissue disease?  Would you treat a distant metastatic site if only 1 or 2 metastatic sites total with gross residu...

Have the RAPID or CALGB 5064 studies changed your treatment approach?

What volume and dose would you use?

Do you cone down to gross residual (and stop elective nodal coverage) after 36Gy or 41.4Gy? Parameningeal group III, stage III alveolar rhabdo.

Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?

Does tumor type matter? Are there issues are associated with overcorrecting anemia during radiation?

ARST 1431 indicated: 30Gy (PTV2=GTV2); 25Gy (PTV1=CTV2+2mm) in 5 fractions. With complete response to chemo, how do you defined GTV2?

FOXO1 translocation positive

AREN 0532 kidney constraint is whole kidney <14.4Gy and 50% kidney <19.8Gy. If treating whole abdomen to 21Gy for diffuse unresectable peritonea...

Is radiation always indicated? AREN 0532 specified 10.8Gy flank with 10.8Gy boost to gross residual in all recurrent Wilms patients. However, NWTS-5 ...

When the original tumor extent is substantial (displaces normal abdominopelvic organs), but responds well to therapy (i.e. as of week 12) - How would ...

What if the patient had also received HIPEC prior?

ACNS1123 classified patients as NGGCT if serum & CSF AFP >10 ng/mL or bHCG >100 mIU/ml irrespective of biopsy results & did not mandate ...

There are mixed recommendations about re-testing vs simply waiting for a quarantine period prior to resuming therapy. 

Are there other practical tips for improving the patient setup in this patient population to minimize potential acute and late effects?

Do you give RT to the entire extent of disease at presentation or just regions with slow early response? Is it necessary to irradiate all known extent...

Do you radiate the paraaortic chain to 10.8Gy then boost gross residual with 1cm block edge margin to 19.8Gy or simply treat the entire paraaortic cha...

Do you treat in a response adjusted fashion as per ACNS1123 Stratum 2: 18-24 Gy whole ventricle with 12 Gy boost? Are there any situations where you d...

Is there a role for dose escalation? Would you recommend sequential or SIB? Is there more of a role for surgery vs. dose escalated RT in EWSR1-non-ET...

-Are there settings where group II disease does not need RT?-Are there additional genetic alterations in fusion negative RMS patients that can be used...

What are the data supporting this?

If proton therapy is not available would you consider radiosurgery? How would your management differ if residual disease is present?

If you do what dose and fractionation do you recommend?

After optimizing symptoms and reversible factors, and attempting cognitive-behavioral interventions and exercise, do you recommend pharmacologic agent...

 Is it higher than the average person?

Presented with mass projecting into right/left anterior ethmoid complex

Are there general ages that you refer to in terms of risk of secondary malignancy or points dropped for IQ over time after treatment, or particular he...

Should they be context/disease specific?  Should use of chemotherapy before/after, or during radiotherapy modify these tolerances? Contexts: ex...

Stage 4/group 4 due to dissemination in peritoneal fluid. Translocation negative; treated per intermediate risk protocol on study arm ARST1431 VAC/VI ...

If so, what dose would you consider in the setting of complete and incomplete repeat surgical resection? How would you sequence this with salvage sys...

Should this be based off of the response? or the site of disease such as bone vs soft tissue?What data are there to dictate that the prior (response, ...

E.g. a patient with progression of their primary cancer but still is testing COVID19+ over a month after infection?

i.e. Should concurrent therapy be given?, Does MGMT matter? What are the current most promising therapeutic approaches? Should we always treat based o...

If so, what dose would you recommend? 

Discuss the role of mAb in DIPG.

Would you manage this histology any differently relative to other low grade gliomas? Is a STR a definite indication for postoperative XRT?

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...

Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...

Acknowledging that there is no time for good trials yet in this setting

How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...

Scanning beam only machines are being increasingly marketed, it could be problematic if you can't use them to treat the one site which is most appropr...

The more recent NWTS trials do not include these tumors, since rhabdoid are recognized to not be similar to Wilms, and the AREN0321 does not provide s...

Should the patient be admitted for observation which will risk exposing other immunocompromised patients to COVID-19, or should the patient be quarant...

How do you prevent early menopause in women? Please comment on freezing of eggs, oophopexy, supine vs prone position, vaginal dialator. 

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...

-The data on induction for adult H&N ca has been mixed (excluded NPX) but recent data suggest a benefit for adult NPX. -Given that this is standa...

When covering with radiation what dose and technique do you favor, electrons, IMRT, brachytherapy, protons?

Would you offer repeat CSI or favor chemotherapy?

Some emerging data of improved up front therapy shifting recurrence to CNS as sanctuary site, is focal RT approach (i.e. SRS) reasonable or is CSI a s...

With the recent publication of multi-institutional trial data, should this now become standard of care?

Is there a role for adjuvant radiation? Other chemotherapy options?

Would the translocation status influence your decision? Are there specific subsites where elective radiotherapy likely offers a higher therapeutic rat...

Would you consider radical cystectomy equivelant in terms of local control and how do you balance morbidity of radiation with morbidity of non-organ p...

Comments regarding risk of Moyamoya

In a patient with high risk rhabdomyosarcoma with significant marrow involvement (Stage IV), who has responded completely on imaging to all known site...

Would you treat this with whole-abdomen RT with a boost? What dose would you recommend? This would be Stage 1, Group 2 (R1 resection), low risk; but l...

Does the St. Jude's Experience (NEJM 2009, PMID: 19553647) provide sufficient justification for routine omission in high risk patients?

Is it recommended in every pediatric patient?  Are there any guidelines for organ-specific surveillance after XRT for children based on age, dose...

What fields would you use for adjuvant RT?  SBRT vs. whole brain?

For example, if there was a common iliac node, does external iliac nodal region also need to be included? When, if ever, do you include the exter...

Would the risk of secondary malignancy affect the decision?

Assuming CSF is negative for neoplastic cells would you: Re-irradiate gross disease only? Re-irradiate posterior fossa only? Re-irradiate the entir...

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 ...

We often see young women with favorable, early stage disease in the mediastinum who have had a complete response to chemotherapy. With current smaller...

 If so in what circumstances and what margin is acceptable? ACNS 0331 recently showed no difference in outcomes when comparing IFRTboost vs ...

Can you use SBRT for boost?

What is the risk of joint issues if you treat the epitrochlear nodes?

What dose do you recommend?

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...

What if there is a CR to chemo? 

Are the results of AHOD0031 practice changing?

AREN0533 schema requires knowledge of 1p16q status, though this test is not available off-protocol. How does this affect management for patients treat...

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...

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.