Questions discussed in this category
In what circumstances would you offer adjuvant radiation after resection of vulvar mucosal melanoma?
If so, what would your target volumes and doses be? How would you sequence with immunotherapy (eg nivolumab)?
If so, what do you typically prescribe?
That nodal region has previously received 55 Gy in 25 fractions.
Do you offer observation for POLE mutated tumors?
Would you consider the addition of carboplatin/paclitaxel + dostarlimab to radiation as opposed to radiation alone?
Assume surgery is not an option. Would you encompass the entire involved muscle and treat with fractionated RT, or would you use SBRT to treat the dis...
What are your volumes and dose/fractionation for external beam boost in lieu of tandem and ovoid or tandem and ring implant?
Surgical pathology found negative pelvic/inguinal nodes, but revealed also focal LVI/PNI
Would you consider this stage IVA (spread to adjacent organ) or IVB (spread to distant organ)? For instance, would the presence of direct lumbar verte...
Re-staging is otherwise negative; patient's disease has FIGO grade 1 endometroid histology
Is there any evidence that variation in schedule (once weekly vs. every other day in between cycles) can affect outcome? Does this vary with dose pres...
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...
How do you advise patients who strongly desire chemotherapy?
How do you incorporate this into your follow-up care and how do you instruct the patient?
Would you consider standard definitive chemoRT (EBRT + HDR brachytherapy)?
Cervical cancer FIGO stage IIIC2. Bloodwork shows elevated ESR and CRP.
No LN dissection was performed as it was for a suspected CIN III. Final pathology showed +LVSI, -margins (>10mm), -parametrial extension, and 1.2mm...
She required an episiotomy intraoperatively just to perform an EUA/biopsy. She may not tolerate vaginal cylinder insertion and even if she can, I am u...
What volumes would you treat for the primary?
The 4 cm cuff recurrence occurred 3 years after definitive treatment with hysterectomy and vaginal cuff brachytherapy to 21 Gy. The recurrence had a c...
Would your management change given that this recurrent lesion is over 10 cm and the patient previously achieved complete response on immunotherapy 5 y...
The patient is in her 70s, was first diagnosed with vulvar cancer two years ago, and underwent a radical vulvectomy with clear margins and negative ly...
The patient has undergone a vulvectomy years ago. The disease now involves the vulva, perineum, and peri-anal regions.
Patient with active rheumatoid arthritis, on escalating dose of Rituxan and Methotrexate, also has antisynthetase syndrome and Hashimoto's thyroiditis...
For a woman with complete resection of serous intraepithelial carcinoma of the endometrium, would you recommend adjuvant radiation or chemotherapy? Wh...
This is a less common histology in the vulva.
If so, will you recommend it universally or only for certain patient population(s)?
Are there any creams or suppositories that can be safely applied internally in the vagina to soothe burning?
How would you manage a FIGO IA G3 endometrial cancer with no LVSI, lymph nodes not sampled but CT a/p negative for lymphadenopathy, yet 2 foci of canc...
“Recent evidence” suggesting this was brought up in tumor board to justify excluding whole pelvic RT for a IIIC1 patient but I can’t...
This would apply to gynecologic and GI cancers as well. And as long as the patient's partner is within the recommend age of <45 yo
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
The patient is a female in her 40s. No mucosal changes were evidenced on clinical exam. Chemo-RT is recommended by GynOnc at an academic center. ...
In the PORTEC LVSI grading system, 3 or more vessel are classified as extensive LVSI, while the FIGO 2023 Endometrial Cancer staging they reference WH...
If so, what dose would you treat to the resection bed?
If so, what dose/volume is prescribed? How do you account for motion?
At what point does the benefit of either post-operative vaginal cuff brachytherapy, or vaginal cuff brachytherapy boost following EBRT for endometrial...
Or would a typical prescription, such as 7 Gy x 3 Fx to 5 mm depth be reasonable for typical sizes 2.5-3.5 cm? Per ABS guidelines, they specify that t...
Would you consider VBT alone vs EBRT and/or offer chemo?
This is a female in her late 60s with FIGO 2023 IIB disease given substantial LVSI+ (>5 v...
Given this histology, does the groin need to be covered? Would you add chemotherapy?
Oftentimes the needles were inadvertently pulled. Without using a template, are there any methods to mitigate this risk of compromising implant qualit...
Is there high quality data to support debulking in terms of oncologic outcomes? Does HPV/p53 status impact your decision?
How do you counsel patients and caregivers? Do you prescribe medications (''appetite stimulants'') with the goal to improve appetite even if they do n...
What would you recommend for a patient in their 60s with stage IB grade 1 endometrial cancer without LVSI? How would this differ for a patient with st...
Do you proceed with sequential, concurrent, or sandwich treatment?
Patient with a locally advanced, node-positive vulvar cancer status post inguinal node dissection with persistent output in drain (for about 8 weeks) ...
GOG 205 treated vulvar cancer patients to a dose of 57.6 Gy to sites of gross disease, which is somewhat less than what is suggested in cases of defin...
Example: in a patient with a non-resectable pelvic mass involving the vagina but without evidence of distant disease, would you favor pelvic RT (as on...
The trial showed an overall survival benefit of 8% at 5 years with induction chemotherapy (80% vs 72%) utilizing at least 5 cycles of carboplatin-pacl...
What is considered the optimal interval from time of excision, partial, or radical vulvectomy and/or nodal dissection to initiation of post-op RT?
Do you prefer surgery (i.e. exenteration) given the radioresistant histology or would you attempt to manage with EBRT and brachytherapy?
The patient also declines any brachytherapy treatment.
Her primary disease is too large for any brachytherapy; if substantial residual disease remains, how would you approach external beam boost?
This is a patient in her 70s who previously received 5040 cGy adjuvant EBRT alone to the pelvis.
Aside from limit due to extent of her hysterectomy, the patient's disease does not otherwise satisfy Peters' criteria
How will you translate treatment recommendations from older studies to the new staging system?
A patient in her 70s initially underwent TAHBSO + LNB with Stage I, G1 cancer, No LVSI. 18 months later with very small mucosal recurrence (5mm). HDR ...
Does the presence of parametrial or cervical involvement impact your decision?
How do you sequence treatment modalities?
This case involves an impressive ‘high volume’ vaginal recurrence and patient was not originally planned for adjuvant therapy. Concerned t...
NCCN cervical cancer guidelines added a new statement - Patients who have received prior pelvic radiation therapy and have osteoporosis may benef...
Would the extent of nodal involvement sway you one way or another (i.e., a micromet in a single sentinel node)?
Consider treatment of stage IVB cervical cancer with systemic therapy and local pelvic radiation therapy as in Perkins et al., PMID 31810653.
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...
Do you wait until chemotherapy completion, interdigitate between cycles 1-2 only when feasible, or between any cycle of chemotherapy?
What factors wo...
Does stage of the cervical cancer influence your decision? Does the amount of SUV uptake influence your decision? When does one biopsy? How long can o...
At our institution we often give 5.5 Gy x 4 fractions. There really does not appear to be a general consensus regarding timing. Interested in what oth...
Considering this is stage IV disease, do your recommendations for definitive or adjuvant treatment (after surgery) change?
If a patient had a remote history of pelvic radiation for another cancer and now has uterine cancer, what factors (grade, stage, KPS, LVSI, etc) would...
Would there be a survival advantage to pelvis RT with deep myometrial invasion, LVSI and ITC?
Interstitial implant was attempted under laparoscopic guidance (due to pre-brachy MRI showing potential bowel involvement). At the time of procedure, ...
Bone marrow preservation is important due to poor hematologic function. Chemotherapy is not possible as well.
If the radiation cystitis is hemorrhagic without clots how would you manage this?
What instructions do you give your radiation therapists - do you rely on OAR identification (ie. bladder and rectum filling) or soft tissue match to t...
Do you give cuff and chemo or pelvic CRT or chemo alone?
Patient with h/o appendiceal carcinoma s/p surgery and HIPEC, now with endometrial cancer, IBG3, extensive LVSI, pNx, recommended for whole pelvic rad...
Would you offer pelvic RT or intracavitary brachytherapy?
Considering the ASTRO guidelines recommend against systemic therapy for patients with FIGO stage I-II endometrioid adenocarcinoma, would your recommen...
Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...
MRI pelvis shows a 3.5 cm primary that appears infiltrative and without clear parametrial extension on MRI. Staging PET negative.
Is there any ...
Mesonephric is described as a higher grade histology. For a superficially invasive IA (no LVSI, age < 60), would you consider vaginal brachytherapy...
Please comment on toxicity profiles and the insufficient evidence regarding overall survival.
The patient is >40 yo with Lynch syndrome and a history of endometrial hyperplasia status post R0 TAH/BSO with SLNBx for a 5.2 cm, grade 3 adenocar...
Please specify how your institution is allocating resources now or will be soon.
Do you treat the whole bladder in the intial whole pelvic field to 45-50 Gy?
The recurrence is mucosal and inferior to the prior field.
Surgery remains an option. Given favorable response, would you recommend pre-op or definitive RT +/- chemo?
Close but negative radial margins? LVSI? What fractionation/dose do you use for your vaginal cuff boost if used?
The patient is not a candidate for re-resection or external beam radiotherapy
7 cm tumor limited to the cervix with no vaginal or parametrial invasion on exam and not lymphadenopathy or metastatic disease on imaging. Cystoscopy ...
If you do not use the PORTEC-3 regimen for p53 mutated IA endometrial cancer, what specific protocol or combination of chemotherapy and radiation ther...
Does not involve surface surface of the ovary, no gross disease elsewhere.
How do you take into account pathologic factors like %clear cell histology, myometrial invasion, and LVSI?
Since there is no overall survival benefit, does the local control benefit outweigh the increased risk for distant metastasis? How do you select patie...
If the patient had high risk features (for example age 60+ and LVI) do you treat with vaginal brachytherapy or WPRT? If you treat with whole pelvis ra...
Would you recommend if there is only one uterine factor or do you typically require multiple to make this recommendation?
Occult IB1 cervical SqCC found on simple extrafascial hysterectomy, with 4 mm deep stromal invasion and LVSI. Subsequent pelvic and para-aortic nodal ...
Please consider this National Cancer Database (NCDB) and Surveillance, Epidemiology, and End Results Program (SEER) registry study (Barrington et al.,...
What factors would push towards treatment? The patient had recurrence of a pT1bN0 vulvar SCC within a year of original surgery. Re-resection shows aga...
How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?
Could you discuss how you decide between IMRT or SBRT boost for a patient who is not able to receive intracavitary or interstitial HDR or LDR brachyth...
When would you use 5-fluorouracil instead of, or in addition to, cisplatin during chemoradiation? When, if ever, would you offer adjuvant hysterectomy...
The right obturator sentinel node had a 1.5mm metastasis with no ece. Additional right pelvic node and 6 left pelvic nodes are negative. The cervix ma...
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
In the absence of other high risk factors like positive/close margins, positive lymph nodes, T2/T3 disease, PNI, or LVI, would you offer postop RT?
Ideally, treatment should be completed in 56 days (preferably < 50 days). If there has been a significant delay to brachytherapy (>2-3 months) d...
Female in her 60s who had presented originally with well-differentiated endometrioid adeno clinically and radiographically involving bilateral paramet...
How does your approach differ for patients under age 60, between 60-70, and over age 70?
Do you assume some recovery since the prior course of RT? If so, how much over what time period?
Still do Tandem and Ring or opt for interstitial?
Patient will have diverting colostomy. Concern is whether the tandem will be stable enough with lar...
How does histology and/or molecular testing change your approach? How does the length of the disease free interval change your approach?
Assume a mild but diffuse case of lichens sclerosis with involvement of the ipsilateral breast. If node negative disease, would you recommend she unde...
This patient previously received hysterectomy with adjuvant vaginal cuff brachytherapy without pelvic RT. Colonoscopy demonstrated invasive disease, b...
How is your approach different from or similar to those who undergo surgical menopause?
What are the expected outcomes if you were to irradiate the pelvis in someone on peritoneal dialysis?
If a patient presents with metastatic disease (by virtue of extensive PA nodal burden, mediastinal/SCV involvement, no solid organs) but received urge...
Would you offer radiation therapy? If so, what dose and fractionation would you use?
This endometrial cancer was a fortuitous finding following vaginal hysterectomy.
If considering systemic therapy, would you consider standard chemotherapy or use biomarker-directed therapy (e.g., imatinib if ckit+, larotrectinib/en...
Would you do SIB to gross nodes in the pelvis and/or inguinal region? Would you do SIB to the primary unresected tumor?
If you were to offer radiation, what dose and fractionation would you use?
When do you continue with treatment and when do you terminate the plan? What is your criteria?
SIBs of 55-57.5 Gy in 25 fractions are frequently mentioned with bowel volume constraints at this dose, but assuming there is no bowel nearby (e.g., b...
For a large pelvic mass that is causing abdomino-pelvic pain, can hysterectomy be considered?
Are there guidelines that dictate who in the department should be present for treatment delivery?
Do you specific renal impairment or hydronephrosis/hydroureter criteria?
Does your decision change if a smit sleeve is being placed?
In patients <50y/o, would you a favor a surgical approach in cervical malignancies that have pre-operative borderline Sedlis criteria indications f...
Is there any particular reason to include or not include this in the treatment volumes?
The patient has no risk factors and would have been stage IB if it were not for the small nodule
Would you consider additional EBRT or vaginal cuff HDR in a patient with previous tx with EBRT (45Gy) + HDR (30Gy) for a R1 resection with a radial ma...
What are the pros and cons of using uterine artery embolization with regard to how it may affect the efficacy of radiation (+/- chemotherapy)?
Adjuvant chemoradiation? Would you boost the positive parametrial margin? Would you also boost vaginal cuff with brachy?
How long after hysterectomy would you consider delivering adjuvant radiation therapy? Would this differ for external beam versus brachytherapy?
Are t...
Have you found Trendelenburg positioning helpful for situations in which small bowel falls into a high dose target volume?
Would you delay salvage surgery for a stage I primary vaginal cancer with partial response but no new disease at 3 months after radiation (EBRT + brac...
If a weekly schedule is chosen, what would be the appropriate weekly dose given that PORTEC-3 and GOG 258 used two cycles of cisplatin 50 mg/m2?
Is this a clinical/radiographic or strictly pathologic diagnosis?
Specifically, what is considered the superior/top border of LUS?
Would you still take the primary to 60-70Gy?
After a diversion, would any other factors impact your recommendation (residual disease/response to chemoradiation, performance status)? Although brac...
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...
Do you increase EBRT or brachy dose by a certain amount based on interval?
If so, what dose would you recommend? What other management options would you consider?
Treat as invasive disease with concurrent chemotherapy? Any non-radiation options for large in-situ disease? If RT, would you include at least inguina...
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
Would you recommend whole pelvis as well as vaginal cuff brachytherapy?
Do you recommend upfront diversion? Are there unique planning considerations such as the inability to use bladder filling? How do you boost? What are ...
VC brachy, pelvic RT, +/- chemo?
Does your management change if it is confined to the endometrium without myometrium invasion or if it is only ...
A certain cm above the superior-most involved node? A certain number of vertebral body above? To the diaphragm and include retrocrural nodes?
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...
In the absence of the ability to use IGBT, would you continue to treat the target?
Is it possible that the dehiscent is radiation induced?
If the tumor was excised but there is infiltration and encasement of the sciatic nerve, would you offer radiation? If numerous lines of chemotherapy h...
Would involvement of the PA nodes be an indication?
Do you try to keep Hb> 10 or 12? Or somewhere in between?
EBRT vs VB? She technically meets PORTEC2, but also meets GOG99 and GOG249 (for pelvic RT) and PORTEC4. NCCN recommends for IB grade 1 vaginal brachyt...
Is there any indication for ENI in early stage disease or in advanced stages, without pathologic confirmation or PET positivity or CT size criteria?
The patient was initially observed after radical hysterectomy due to young age, FIGO IA grade 2 disease.
The patient had isolated, biopsy-proven vagi...
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Patient is 38yo, has a history of narcotic abuse, and may have an undiagnosed personality disorder.
Is the QuadShot a possible option?
If yes, what would be your target volume for this exceedingly rare histology for this location?
In women receiving HDR intracavitary brachytherapy to treat the vaginal cuff, how do you overcome the challenge of excess lateral vaginal tissue ("dog...
Could EBRT lead to rupture of the cyst?
This patient has pulmonary nodules that are too small to characterize.
No sarcomatous overgrowth seen.
Is anticoagulation for PE an absolute or relative contraindication to IS brachy? Would you favor placement of IVC filter prior to procedure?
History of CDH1 mutation and prophylactic gastrectomy in 2017 - no other primary site found beyond vagina at diagnosis.
Vaginal tumor completely resp...
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
Previously received pelvic EBRT and intracavitary brachytherapy. IORT was administered to the node-positive side wall at the time of exenteration.
Excellent KPS and long disease free interval from initial diagnosis. Initial recurrence 3-4cm at level of renal vessels and down to 1.3cm after chemo.
Patient did not previously receive para-aortic radiation. Considering RT vs RT + chemo vs chemo alone
Are there any effective non-pharm or pharm interventions?
Recurrence was 2cm and PET confirmed local. Excision with positive margins. Current plan for salvage whole pelvic RT and vaginal cuff brachytherapy +/...
In patient with PD SCCA 15mm transverse; 5/20mm invasion; LVSI focally present; margins negative; 0/15 Left pelvic and 0/14 right pe...
Recurrence picked up incidentally on CT. No germ line mutations, somatic tumor testing of node resulted negative.
PET confirmed isolated recurrence
Planning carboplatin/taxol/trastuzumab. Cervical stromal invasion on path. Looking for pelvic vs brachy and timing with chemotherapy.
If a patient has limited surgical options and a well defined lesion, would SBRT be reasonable?
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
What non-pharmacological interventions do you recommend? Do you routinely prescribe prophylactic laxatives to patients initiating opioids? How do you ...
What dose and technique do you use and how do you integrate the subsequent definitive treatment plan?
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 ...
The recently released STARS phase 3 RCT found improved DFS, decreased distant recurrence, with reduced toxicities for chemotherapy (cisplatin + taxol)...
For a patient with a very locally advanced cervical cancer, what is your upper/superior limit of considering para-aortic lymph nodes to be "pelvic" or...
To avoid disfiguring surgery, would you consider treating a 2 cm well lateralized tumor without surgery? If so, would you recommend concurrent chemoth...
How long is too long to wait for recovery? Is there a role for pre-procedure platelet transfusion and/or alternatives to epidural anesthesia?
Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?
Would you offer VBT alone in a completely resected vaginal cuff recurrence that is grade, recurrent stage IA endometrial cancer, is all staging imagin...
How many cycles do you prefer before and after? How long do you tend to wait before starting radiation after initial chemo and after radiation to resu...
How would you factor in a patient with profound thrombocytopenia?
Paraaortic nodes positive to left renal vein
Tumor felt to be technically unresectable due to extensive cervical/parametrial involvement.
ER/PR and HER2 testing are pending.
For instance, if you have anal canal involvement, do you cover the entire mesorectum? Any other adjacent organ invasion that would lead to modif...
Tumor traverses the myometrium to focally involve the serosa; 1/6 sentinels with ITC and the rest negative.
Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?
Do you use specific tools or take into account certain factors when considering treatment options for older adults?
Pt is 73yo, Grade 1, 81% invasion, MELF like features, foci of LVSI, and 47 ITCs identified.
HER2 status is pending
Pt is 69yo, tumor 1.4cm, negative LVSI, ER/PR +
Does not technically meet high intermediate risk criteria.
NCCN vulvar guidelines only recommends inguinal LND but GOG 37 recommended PLND when groin nodes were positive. NCCN penile guidelines also recommende...
Margins widely negative - 1cm, and full bilateral inguinofemoral lymphadenectomy performed.
ex. in a patient with pulmonary micronodules, inguinal, pelvic, PA nodes
In an elderly woman who is not felt to be a good candidate for radical surgery is split course radiation alone an option for definitive intent radiati...
If bilateral inguinal LND showed no involved nodes and primary is unresectable (FIGO IVA), can one treat only the primary w/o elective radiation to th...
The 2020 NRG endometrial and cervix contouring guideline update said the anterior margin is a straight line between the aorta and IVC. Should there be...
Disease involves the lungs diffusely and bilaterally.
If only palliative treatment is recommended, what should be the target volume (primary only? pr...
Margins negative. Discussion included adjuvant RT versus observation and/or repeat resection with recurrence.
In the unfortunate setting where you cannot get an underinsured patient whose policy does not cover radiotherapy started on treatment without guarante...
Do you re-test patients who test positive for COVID-19 during or prior to starting cancer treatment?
There are mixed recommendations about re-testing vs simply waiting for a quarantine period prior to resuming therapy.
What indications do you use to consider adjuvant radiation therapy for vaginal cancer s/p resection?
Would you offer adj RT for a vaginal primary patient with paravaginal involvement s/p rad hyst w/ upper vaginectomy, BSO and inguinal node dissection?...
Would you consider adjuvant chemotherapy, radiation therapy, hormone therapy, or surveillance?
Do you use brachytherapy or external beam? What prescription / dose / regimen do you typically use? What if there is small bowel hanging into the fiel...
Vulvar cancer is well differentiated. Closest margin is 6mm. LVI is identified
T1b N2c
Vaginal cancer treated 20 yrs ago described as 5 cm in length...
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...
For example, RTOG1203 says to include "1-2 cm of tissue anterior to the S1, S2 and S3 sacral segments" but have also heard of stopped at S2 to limit r...
Particularly with IMRT when delineating volumes.
Would you consider SBRT or brachytherapy?
After optimizing symptoms and reversible factors, and attempting cognitive-behavioral interventions and exercise, do you recommend pharmacologic agent...
Would you offer EBRT alone or EBRT with vaginal cuff brachytherapy after surgery and chemotherapy for stage III (T3N0) carcinosarcoma of the uterus?
...
What dose would you consider for patients with bulkly pelvic disease and in what situations would you, if ever, dose escalate for local disease with b...
Small bowel is usually the dose limiting OAR while planning cervical HDR brachytherapy. Having the bladder empty during treatment planning and deliver...
Ie for patients who are inoperable due to comorbidities?
Would you consider this a new primary or recurrent disease?
For a patient with good response to immunotherapy (unable to receive chemotherapy due to kidney function, comorbidities) where previously avid LN have...
Does time since adjuvant cuff brachytherapy influence your radiotherapy approach, (for example 18 months vs 5 years)? Do you adjust your bladder/bowel...
E.g. a patient with progression of their primary cancer but still is testing COVID19+ over a month after infection?
http://abstracts.asco.org/199/AbstView_199_180760.html
http://abstracts.asco.org/199/AbstView_199_187537.html
Does cisplatin need to be administered on the start date of radiation
I care deeply about clinical trials but have always struggled on how to approach this topic. I would really appreciate tips from those of you who have...
If an external boost of a gyn primary is necessitated because of the target size or extensive involvement of a critical structure how would ...
How would tumor grade, presence of LVSI, and receipt of chemotherapy factor into your decision?
This has been a common practice in the community. Is there a benefit for certain patients?
When would you recommend SRS vs WBRT?
Does the GOG 249 abstract guide you one way or the other?
How do you counsel a pre-menopausal female with endometrioid cancer desiring definitive RT with egg harvesting and IVF for fertility preservation inst...
Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...
Sentinel Lymph Nodes negative
What dose/fractionation would you recommend?
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...
When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...
How do you prevent early menopause in women? Please comment on freezing of eggs, oophopexy, supine vs prone position, vaginal dialator.
MRI with intravaginal gel shows no gross residual disease.
Insurance authorization for protons is pending, but if the patient cannot have protons would you treat with standard fractionation to ~70Gy or conside...
NCCN recommends brachytherapy plus or minus pelvic RT for surgically staged Grade 1, Stage II patients, but these originally staged IIB patients were ...
What fields would you cover and how much dose would you boost to the primary?
Would you consider EBRT or brachytherapy boost to the nodes? what dose would you recommend?
What field and dose would you recommend? Would you consider whole abdominal?
For the management of stage II endometrial cancer, NCCN says pelvic RT and/or vaginal brachytherapy. Do you ever add vaginal cuff boost to pelv...
If so, would you treat the whole pelvis, cuff brachytherapy, or both?
The patient had an initial partial vulvectomy and nodal dissection 6 years prior to recurrence, with no adjuvant RT offered initially due to lack of c...
Patient being treated for cervical cancer noted to have a < 1 cm posterior vaginal fornix defect with a small focus epiploclia herniating into the ...
Would you recommend any planning techniques or dosimetric constraints in this scenario?
MRI and cervical biopsy are negative for cervical involvement
Would there be a substanital increase in the risk of toxicity using such a scheme?
We frequently have patients who have to travel long distance...
In December 2018, Horn et al reported the results of a phase 3 clinical trial in the NEJM (N Engl J Med 2018; 379:2220-2229). This trial included prev...
The initial treatment did not include any adjuvant chemotherapy or radiation therapy.
For a patient with vaginal adhesions/stenosis, do you recommend any other therapy besides a dilator?
Would estrogen cream be helpful in this scenario?
If so, are there any lymph node cut-offs you would have in terms of lymph node number or pathological ECE before you would add contralateral RT? What ...
https://www.nejm.org/doi/full/10.1056/NEJMoa1813181
are there any positive or negative synergies from combined megestrol/RT treatment?
Should these patients be managed similar to p16 positive anal squamous cell carcinoma, and allowed six months or more for complete regression before c...
What chemotherapy and sequencing with radiation therapy would you recommend? IS surgery a component of the treatment?
What is your typical treatment depth prescribed to? What length of vaginal mucosa do you typically treat?
Do you have an SUV cutoff for physiologic activity of the ovary?
Surgeon is not planning vulvectomy, since biopsies showed 2 mm depth of invasion.
Also tumor board felt dose to the primary site should be only about...
In a patient, with multiple small volume lesions (5-25mm), would you offer pelvic RT?
At what point would you introduce the discussion of weight management, whether for risk reduction or overall health?
Do you cover common iliac nodes (L3/L4) or keep field edge at L4/L5 to reduce bone marrow toxicity?
The NCCN recommends either systemic therapy + brachytherapy or pelvic RT + brachy or brachy alone or observation. How do you decide among these option...
The disease involving the endocervix was felt to be separate and appeared like a drop metastases
Specifically, is hyperbaric oxygen therapy (HBO) an effective treatment for refractory radiation cystitis?
If so, what indications would you use other than Peters criteria?
What would be factors that would indicate the need to include the pelvic nodes?
Do you use a trimmed 10 mm expansion on HR-CTV? Do you also include the entire initial extent of disease? How much does your IR-CTV coverage affect yo...
What dose would you use?
Current NCCN guidelines suggest that vaginal brachytherapy is optional, and there may be concern for over-treatment locally given competing risk of di...
A literature search indicates that most port site recurrences are managed fairly aggressively with chemoRT or RT doses 45-66 Gy. This is understandabl...
Or do you wait for platinum resistance?
Sequentially or do you integrate the cuff brachy with the EBRT and if so what schedule, BIW, weekly, etc?
Hydrogen peroxide douches? Antibiotics? (If so, what are you covering?) When do you initiate hyperbaric oxygen? Do you find pentoxyfyline helpful? How...
When you prescribe your dose at 0.5 cm depth of the vagina? For instance, if you measure a vaginal length to be 8 cm, would you prescribe to treat 4 c...
Would organ invasion (bladder/rectum), size, feasibility of T&O, or size of nodes push you toward neoadjuvant chemotherapy?
While EBRT + brachy may be preferred, what treatment would you offer if surgery has been performed? What dose and volume of EBRT, brachytherapy, or bo...
How do you weigh this concern with the need to prophylactically treat non-involved, high risk para-aortic lymphatics?
How high would you extend your field? Would you treat differently if the patient had lower PET avid pelvic lymph nodes?
Do you use size criteria (i.e. bulky nodes over 3 cm), specific adverse histology (adenocarcinoma), or location (near small bowel), etc.
More recent Italian (Sozzi et al) and French data (Canlorbe et al) show associations of greater tumor size > 25-35mm with higher rates of local &am...
She has extensive colposcopic lesions at upper/mid vagina, but no palpable/visible lesions on standard pelvic exam. Pelvic MRI with 20cc US gel in vag...
PORTEC-3 assigned women with high risk stage I or stage II-III endometrial carcinoma to adjuvant external beam radiation vs adjuvant chemoradiation wi...
Has your institution changed practice patters based on the findings of the LACC Trial (Pedro et al., SGO in 3/2018) showing worse outcomes with roboti...
Would you deliver definitive RT in place of inguinal lymph node dissection in light of new data (PMID: 29336837)
In the case of high risk but radiogr...
NCCN guidelines mention EBRT/vaginal brachytherapy as options in addition to chemotherapy in the adjuvant setting for high grade histologies, stages 1...
If the patient is responding to external beam and likely to be converted to resectable, what brachytherapy dose/fractionation do you prescribe and wha...
Assuming no distant metastases, should this scenario be managed with "sequential" chemoradiation to the para-aortic region with an external beam boost...
For HDR brachytherapy for cervical cancer do you use the dose optimization algorithm? Is there a standard dwell time distribution that should be...
For example, assuming an excellent performance status, would you consider local radiation to the primary and metastasis in someone with a single ...
Patient had a single 3cm node s/p excisional biopsy of the one node without nodal dissection. We have done anoscopy and a thorough GYN exam...
EBRT boost only? SBRT? If you recommend interstitial brachytherapy do you place needles freehand or with a template based approach?
What have your liked or disliked about these newer applicators?
if so, would you favor brachytherapy alone? What dose?
What would be the appropriate treatment for grade I endometrial cancer s/p TAH/BSO but with SLNB yielding negative nodes. The uterus contained a 2cm t...
Assuming the early stage endometrial cancer was treated with TAH+BSO initially and no further treatment, what would your recommendations be for HGIL? ...
If so what dose/fractionation? This was reported here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918530/
For women treated with IMRT, there are multiple ways to define the upper border of the field
1) contouring the PAs up to where the renal vessels exit...
Type II endometrial cancers made up roughly 15% of GOG 249 the study population, but seemed to be balanced between both arms.
Single institutio...
After whole pelvis radiation therapy, what would be the highest dose you would allow in a single fraction, versus the total course EQD2 for small bowe...
Would you consider this in a patient with a single omental metastasis found and no other distant spread after surgery?
For example, a patient with cervical or anal SCC who has missed many treatments due to side effects, low blood counts, hospitalizations, or non-compli...
What factors influence your decision? Does high grade histology or pathological stage play a role? If the patient received chemotherapy due to +LN, pa...
Do you add an IMRT boost with possibly vaginal brachytherapy?
What are your specific protocols for monitoring and for dosing narcotics and sedatives?
In what situations is it appropriate to offer observation (rather than VBT) to patients with stage II endometrial carcinoma who have had a radical hys...
If a patient has a gynecological cancer, how long should one wait after RT before a screening colonoscopy can be completed?
Does definitive or adjuvant setting effect your planned dose? For example, for a woman with IB2 cervical cancer status post hysterectomy, who wa...
When should pelvic/inguinal lymph nodes be included?
Would you utilize IMRT to provide a boost to gross disease? If so, how would you define your treatment volumes and what dose would try to achieve? Als...
Would you still consider this high risk? If so, would you recommend pelvic radiation AND chemotherapy?
Would you add chemotherapy if there was gross residual disease, pN+ and/or ECE?
Can the classic indications for post-hysterectomy radiation (eg. "Sedlis" and "Peter's" criteria) be applied? Does the histology change radiation dose...
Is there evidence for SBRT for recurrent ovarian granulosa cell tumors?
If offering radiation therapy, would you treat extended field whole pelvis or just cover the para-aortic LNs with an involved field volume? Would your...
What are the pros and cons of completing a simple hysterectomy versus aborting surgery followed by chemoRT?
With stage I/II vaginal cancer and an excellent response to 4500cGy EBRT with <5mm residual thickness of tumor remaining, what is your dose/fractio...
Would your recommendations change based on stage? What factors would influence your decision to include presacral lymph nodes in a locally advanced en...
Does this differ if the primary is vaginal? Do you prescribe the same dose when using an intracavitary applicator for cervix cancer?
For palliation of vulvar cancer, what fractionation due you typically use. Can some of the toxicity be avoided with a shorter course of treatmen...
Prior to starting vaginal cuff brachytherapy, do you wait for a specificed period of time prior to vaginal cuff brachy after hysterectomy? Do y...
With the results of the EMBRACE protocol, how do you approach MRI planning? Do you plan with applicators in situ, or use preimplant (post EBRT) ...
Does this management depend on treatment site?
For definitive vulvar ca, is 5940 cGy the minimum acceptable dose for gross disease? 5760cGy? Or should the dose be escalated beyond 60Gy?
Can the drug continue during radiation therapy or should it be discontinued at a specified time prior to initiation of radiation?
And if so, in which situations do you offer differing doses?
For example, would you consider adjuvant chemotherapy alone to be sufficient in a patient with an isolated pelvic recurrence and positive margin after...
For example, how do you decide between applicators such as tandem and ovoid versus tandem split ring insertion for cervical brachytherapy patients?&nb...
For instance, RTOG 0418 did not allow clear cell or papillary serous histologies, but subsequent trials that allow IMRT have (GOG 0249, 0258, RTOG 120...
Interstitial needles can result in hot spots in the bladder, but how well tolerated is that? On the other hand, intracavitary applicators usually don'...
For example, in an otherwise intermediate risk localized endometrial cancer (Grade 2, FIGO IB)?
What clinicopathologic features do you typically consider?
In the setting of a negative lymph node sampling, would you treat a full pelvis or mini-pelvis to compensate for lack of the appropriate surgery? Is a...
In patients who don't meet traditional criteria for adjuvant chemoradiation from Peters (GOG 109) and < 2 high risk factors from Rotman (GOG 92) fo...
If the post-operative simulation films reveal a significant lymphocele secondary to pelvic lymph node sampling, is it imperative that the entire lymph...
The gyn oncs at my institution sometimes will not perform lymphadenectomy if biopsy indicates low risk disease. Would LVSI as sole adverse risk factor...
Do you use SIB or sequential approach? Do size of lymph nodes influence your dose or decision?
What exactly do you contour and what is your dose constraint to that volume?
Does using something like a vienna applicator allow you to avoid dose escalation with more external beam? How do you recommend doing a classic pa...
Some classic references recommend the coverage of the entirety of the sacrum but the volume delineation guidelines for both seem to only cover the mos...
The patient failed previous excisions and medical therapy and is no longer a surgical candidate.
Does hydroureter and leg edema alter your opinion?
Brachytherapy, EBRT or both and what is the best dose?
How should we counsel young women who are receiving treatment for GI/GYN malignancies?
Do you plan every fraction, every other fraction, or use one plan for the whole treatment?
The most recent ABS guidelines don't discuss a dose constraint for the small bowel.
What schedule is best for preventing fibrosis and for patient compliance?
Does your strategy change if bladder invasion is present?
Do you treat PAs if pelvic nodes are positive? If common iliacs are involved? Only if there are positive PA nodes?
Do the urethral constraints used in prostate brachytherapy apply to women undergoing gyn brachy?
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