Gastrointestinal Cancers&nbsp;&nbsp;&nbsp;

Would you change treatment approach for rectal cancer with an associated intussusception?

How do you sequence hypofractionated radiation and systemic therapy for patients with unresectable cholangiocarcinoma?

When using hypofractionated RT (i.e., 67.5 Gy in 15 fractions), can chemotherapy be delivered concurrently? Options for systemic therapy in NCC...

What is the best way to proceed in anal cancer surveillance if PET avidity of the primary is reduced, but still avid at time point <6 months s/p chemo-RT?

Patient is 4 months s/p CRT with resolution of avid lymph nodes and no evidence of disease on anoscopy. PET avidity is currently <10 SUV from 30 SU...

When treating inguinal lymph nodes in the setting of pelvic RT, what is your preferred setup in order to minimize dose to the penis?

Would you dose escalate neoadjuvant radiotherapy for T3 and/or N+ rectal cancer in patients who are unwilling or unable to get chemotherapy?

Have the final results of the OPERA trial changed the way you approach organ preservation in rectal cancer?

Are you more inclined to offer brachytherapy boost instead of EBRT boost?

What proton dose regimen would you use for locally recurrent esophageal cancer previously treated with chemoRT?

For a patient with an access to proton beam therapy, what dose regimen would you use in the context of a locally recurrent esophageal cancer, previous...

Would you consider chemo-RT for duodenal adenocarcinoma s/p resection with at least 1 cm positive margin in a patient with a history of Crohn's disease?

Of note, there is ~150 cc small bowel left and no further surgery was offered.

Do you use different dose constraints for large bowel vs. small bowel?

If so, what is the evidence for this?

Would you consider SBRT to a single nodal recurrence in a patient with previously treated metastatic GEJ adenocarcinoma s/p a complete response to systemic therapy followed by 37.5 Gy to the primary who was NED for 12 months up until this recurrence?

Given that the recurrence is peri-gastric, with what dose would you consider treating it and to what constraint would you limit the stomach? Of note, ...

How do you manage persistent rectal bleeding in the setting of rectal adenocarcinoma in a treatment-naive patient?

Would you consider post operative boost radiation for positive margin in a patient with rectal cancer who underwent short course RT (25 Gy in 5 fractions) prior to TME?

What fractionation would you use?

Would you offer pelvic re-irradiation in the setting of locally recurrent anal cancer in the presacral region?

Patient had previous 54 Gy in 25 fx to anal cancer with treatment of pelvic lymphatics, now with presacral local recurrence. He had a resection of rec...

How would you plan a post-op, distal rectal adenocarcinoma s/p neo-adjuvant chemotherapy and APR with minimal treatment response?

How would your planning be influenced by a possible, single inguinal lymph node metastasis?

In a patient with a mid-esophageal squamous cell carcinoma with tracheal invasion confirmed on bronchoscopy, would you treat with definitive chemo-radiation with curative intent?

Additionally, would you consider prophylactic stent placement and/or gastrostomy in anticipation of a fistula?

When treating recurrent rectal cancer with re-irradiation using accelerated hyperfractionation (39-45 Gy at 1.2 or 1.5 Gy BID), what normal tissue constraints would you recommend for the bladder and bowel?

Should inoperable squamous cell carcinoma of the esophagus be treated to doses > 60 Gy?

Should the recent publication of Chen et al., PMID 27207358 dose escalation study for inoperable SCC esophageal cancer patients treated with CCRT, sho...

What is the appropriate radiation dose/volume for perianal basal cell carcinoma?

Should concurrent chemotherapy be given? How would you modify the regimen in elderly/frail patients?

Is there data to support worse surgical outcomes in short course RT followed by surgery vs. long course chemoradiation followed by surgery in rectal cancer?

Additionally, is there a difference in surgical outcomes with long course chemoradiation + consolidative chemo vs. induction chemo + long course chemo...

For patients with large, partially or nearly obstructing rectal cancers, how do you sequence TNT in order to avoid complete obstruction and surgical diversion?

Do you find that starting with chemoradiation increases the risk of complete obstruction secondary to transient tumor inflammation, or do you favor st...

Would you consider proton therapy as part of TNT for rectal cancer?

What is your approach to TNT sequencing for locally advanced rectal primaries with low volume metastatic disease to liver?

How would you manage a borderline resectable pancreatic cancer s/p induction chemo + chemo-RT who was unable to go to surgery?

Specifically, after chemo and RT to 36.0 Gy/15 fx with stable to slight progression of disease at 6 months, what (if any) regimen of reirradiation wou...

For locally advanced rectal cancer, will the recent update of RAPIDO lead you to change your practice when approaching TNT?

Specifically, will the higher rate of local failure in the TNT (short-course RT) arm lead you to consider a TNT approach with long-course CRT?Dijkstra...

How would you treat an MMR-proficient T2 N0 low-rectal cancer (measuring 2 cm extending 4-6 cm from the anal verge) in a patient who wishes to preserve his sphincter?

Is there data on neoadjuvant chemo-RT or chemo in this setting?

When treating pancreatic body/tail lesions that result in significant dose spread to the spleen, what is your threshold to offer pneumococcal, hemophilus influenza, and meningococcal vaccines?

How would you approach treatment of a patient with adenocarcinoma of unknown primary only found in a left supraclavicular lymph node?

After R1 resection of a locally advanced, node-positive neuroendocrine tumor of the terminal ilium, would you offer adjuvant radiation therapy?

Assume the patient is young and active.

What is your approach to high-grade neuroendocrine tumor of the stomach?

Specifically, in the case of a complete response following chemotherapy, do you approach with resection or radiation? If you are treating with RT, wha...

Would you offer inguinal nodal RT to a patient with anal SCC (pT1N1a, + inguinal node) following APR in the setting of prior prostate + pelvic nodal radiation?

More specifically, the patient had a single, positive, 3 cm inguinal LN (no ECE, negative margins) removed at the time of APR. If offering RT, would y...

In patients with perihilar cholangiocarcinoma eligible for liver transplant, what is the protocol for neoadjuvant chemo-RT, particularly when brachytherapy is not available?

The Mayo Clinic protocol recommends initial fields -1.5 Gy BID initially to 45 Gy followed by a Brachytherapy boost. If HDR /LDR is not available, wha...

How would you manage a middle thoracic esophageal squamous cell carcinoma (tumor is 25-30 cm from carina) with a positive supra-clavicular lymph node?

When a patient with pancreatic cancer received neoadjuvant chemo + chemo-RT, how do you manage an in-field, post operative positive margin?

I.e. would you offer additional radiotherapy and if so, what technique and dose would you use?

When treating a high rectal cancer, does your coverage of the caudal mesorectum depend on the surgical plan?

How do you construct the caudal extent of your volume - for example, pelvic floor via RTOG/international consensus vs 4 cm below gross disease via RAP...

How was treatment response assessed on the PROSPECT trial?

Specifically, on re-staging imaging, would the tumor regression be strictly defined by reduction in cranio-caudal direction only, or would other measu...

When would you opt to manage anal squamous cell carcinoma, HPV+ with surveillance vs adjuvant treatment following a trans-anal excision?

Particularly in the setting of "higher risk" features such as grade 3 and a negative, but close margin, would you still consider offering surveillance...

What are your constraints when treating an abdominal site with SBRT?

This includes duodenum, stomach, small bowel, colon, kidney, liver, etc.

Would you offer chemoRT to a colon cancer case with a resected polyp with positive margins if the patient wishes to avoid surgery?

Would chemoRT be preferred over surgery if there is LVI or PNI?

In a patient with amyloidosis and abnormal liver function but child Pugh A, would you still proceed with SABR for a liver metastasis?

Would you use triplet chemotherapy FLOT in lieu of chemoRT for patients with localized esophageal squamous cell carcinoma?

While ESOPEC excluded squamous cell carcinoma, the Japanese JCOG1109 NExT trial also showed superiority of fluoropyrimidine/platinum/taxane over chemo...

Do you always biopsy suspicious liver lesions if you have a biopsy from the pancreatic mass showing PDAC?

Or do you start with systemic therapy and then reassess?

What is the role of adjuvant radiation in R0 node positive resected pancreatic adenocarcinoma in light of the recently presented RTOG 0848 abstract?

RTOG 0848 presented at ASCO 2024 in abstract form: Abrams et al., Journal of Clinical Oncology 2024 What pathologic factors if any would you use to m...

When treating a bulky squamous cell carcinoma of the anal canal, do you try to limit the dose to the external anal sphincter to any particular number to reduce the risk of chronic fecal incontinence?

Especially if using an escalated dose such as 58 Gy in 29 fractions for a T3-T4 primary

For a patient with T3N1M0 esophageal adenocarcinoma, who suffered esophageal perforation necessitating metallic stent placement, would you favor a neoadjuvant chemoradiation or perioperative chemotherapy approach?

Assume the patient is a good surgical candidate, and the perforation happened prior to initiating any treatment. Is the stent enough reason to avoid c...

Are there circumstances when you would consider re-irradiation of the esophagus in a patient who is not a surgical candidate or declines surgery?

What are your top takeaways from ASCO GI 2023?

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice? ...

8 Answers available

Do you consider ablative radiation therapy for oligometastatic colon cancer with 5 pulmonary lesions responding to chemotherapy?

No disease elsewhere. Previous history of treated rectal cancer a few years ago.

How would you approach treating a patient who refuses surgery, but has significant residual disease after chemoradiotherapy for squamous cell carcinoma of the esophagus?

Tumor is PD-L1 positive and HER2 positive

Given the results of ESOPEC from ASCO 2024, for which patients with resectable esophageal adenocarcinoma would you favor neoadjuvant chemoradiation?

ESOPEC compared perioperative FLOT vs neoadjuvant chemoradiation per the CROSS trial, and showed superior OS with perioperative FLOT. What concerns do...

Are you using vaginal dilators during treatment of rectal cancer to spare anterior vaginal wall, or are you reserving this for anal cancers?

What dose constraints do you recommend for the heart when treating an intrahepatic cholagiocarcionma with ablative (15 fx) techniques when the tumor is adjacent to the right atrium?

What target volumes do you use for rectosigmoid/very superior rectal cancers?

Does it ever differ from a standard rectal field? For example, do you always treat the entire rectum, mesorectum, and entire length of internal iliac ...

How would you adjust your CTV for a locally advanced rectal cancer case with invasion of the prostate?

Would you cover the entire prostate?

Would 45 Gy to the pelvis be sufficient for a locally advanced rectal cancer that has a complete metabolic response to TNT?

Is there really a need to boost up to 50.4 Gy in this setting?

Is there a role for radiation in palliating malignant small bowel obstruction?

Does histology (radioresistant or radiosensitive) play into this decision?

How do you optimize nutrition for patients experiencing dysphagia while undergoing chemoradiation therapy for esophageal cancer?

Is there a preferred method and should any of the following be avoided: esophageal stent, nasogastric tube, PEG, J-tube, or TPN?

What anal squamous cell carcinoma patients, if any, do you take to 59.4 Gy?

What are your preferred strategies to manage mild to moderate rectal ulceration causing tenesmus and discomfort after chemoradiation for rectal adenocarcinoma?

Or, to manage tenesmus and discomfort after any type of pelvic radiation.

Would you offer consolidative full dose chemo-RT for local residual pancreatic disease in a patient with stage IV pancreatic adenocarcinoma with excellent response after induction chemotherapy?

Would you ever consider this approach for an initially polymetastatic patient?

In what situations would you treat a rectal mass as cancer despite negative biopsies?

For example, if mass is ulcerated and cannot be excised with polypectomy? Would you ever consider radiation and chemotherapy?

In which patients with early stage rectal cancer treated according to the PROSPECT paradigm do you recommend adjuvant chemotherapy?

Current NCCN guidelines do not include adjuvant chemotherapy for patients treated in this fashion; however, in the PROSPECT trial itself, an additiona...

How do you counsel patients and partners of patients with HPV+ cancers regarding the HPV vaccine?

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

What are magic mouthwash alternatives that you would recommend?

There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?

9 Answers available

In patients with active IBD and rectal cancer, do you take any precautions before starting TNT?

Would you wait until bowel symptoms are controlled or ever pursue diversion before starting treatment?

For anal radiation dermatitis, does anyone have experience with 3M Cavilon protectant?

What is your approach to cT3N0M0 mid rectal adenocarcinoma with clear circumferential resection margins on MRI?

How would you manage a solitary unresectable liver metastasis?

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...

What dose fractionation would you utilize for a large solitary liver metastases about 7 cm, abutting colon?

The patient has a primary breast cancer with a single progressive metastasis in liver.

What dose/fractionation would you choose for resected tail of pancreas adeno with positive margin, node negative?

Plan to give adjuvant chemotherapy.

Would you include the entire bladder in the treatment field of a patient with a history of T1 bladder cancer s/p intravesical therapy who is now being planned for chemoradiation for a T3N1 rectal cancer?

Intravesical therapy was delivered two years prior, and last cystoscopy was negative. One-third of the bladder would otherwise be included in the plan...

Does an esophageal stent impact your radiation treatment plan for a patient with non-metastatic GE junction adenocarcinoma?

In general, how does an esophageal stent affect what you might consider in terms of radiation dose and volume?

For patients with locally advanced rectal cancer who desire organ preservation and can tolerate fluoropyrimidine but not oxaliplatin, what is the appropriate treatment approach?

When treating rectal cancer with neoadjuvant chemoRT, is it appropriate to employ IMRT planning, rather than 3D conformal, for all cases, or should IMRT be reserved for special circumstances?

Would you recommend additional post-operative chemoradiation for a T2N1 proximal rectal cancer having received adjuvant capecitabine/oxaliplatin?

What factors might play into this decision?

For a patient who has T4 squamous cell esophageal carcinoma on imaging, and who has biopsy-confirmed disease in an involved local lymph node, are EUS or EGD still indicated to complete workup?

When do you offer radioembolization (Y90) in the treatment of unresectable HCC?

Should Y90 be offered before or after TACE (based on the Northwestern phase 2 study) or sorafenib (based on the SARAH trial)?

How do you treat locally advanced, operable, Siewert 3 GE junction adenocarcinomas?

What is the highest dose to which you treat a locally advanced esophageal cancer with a stent in place?

Would you ever treat with definitive intent in a "curative" patient who has a stent placed, or only palliatively? Does the addition of chemotherapy or...

For an otherwise resectable esophageal cancer with involved celiac lymph nodes, would you ever consider an SIB beyond 50.4 Gy?

Assuming duodenum constraints are met, could there be any benefit to boosting a positive celiac node to 61.6 Gy in 28 fractions?

For a pedunculated rectal polyp found to be adenocarcinoma after endoscopic removal, with PNI as the only adverse feature, would you recommend additional treatment such as surgery or chemoradiation?

Consider some stalk invasion, but no deep submucosal extent and negative margins by 9 mm.

How will the PROSPECT trial presented at ASCO 2023 change your current management of early rectal cancer?

Especially as the study was done before the adoption of total neoadjuvant therapy

For insurance, how do you justify medical necessity for IMRT to the pancreas in the preoperative, unresectable, and post-operative settings?

What is the best treatment regimen for a fungating SCCa of the scrotum arising from untreated genital warts invading the groin and base of the penis with bilateral inguinal nodes?

Surgery would be very extensive and would not be likely to clear the disease. Do you divert these patients if treated with CRT?

Would you offer neoadjuvant radiation therapy with concurrent chemotherapy for a T4 rectal carcinoma with an associated rectovesical fistula?

Would you offer treatment according to the PROSPECT trial for rectal cancer in which an involved lymph node approaches the circumferential resection margin (CRM)?

Consider a patient who prioritizes fertility preservation, for whom one of three suspicious nodes approaches the CRM, and is <1 mm from the mesorec...

For patients with peritoneal carcinomatosis and minimal response to neoadjuvant chemotherapy, is there a benefit to palliative cytoreductive surgery followed by whole abdominal radiotherapy?

Do your recommendations differ between appendiceal, colorectal, and gastric cancer? If radiation is offered, would you boost the unresectable/gross re...

For a patient with a lung tumor that is radiographically consistent with early-stage NSCLC but pathology with characteristics overlapping with upper GI origin, what additional diagnostic procedures would you consider before treating?

For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...

How would you treat an elderly patient (ECOG 0-1) with locally advanced rectal cancer and synchronous Merkel cell cancer of the extremity requiring adjuvant RT?

Would you treat both at the same time? Does one need to be prioritized over the other? Does Xeloda have any efficacy against Merkel cell cancer? How...

Should we be shrinking rectal cancer fields?

With trials like PROSPECT and FOWARC showing no statistically significant improvement in locoregional control and survival outcomes when comparing rad...

Is there a scenario in which you would consider neoadjuvant radiation for rectal cancer after previous definitive radiation for prostate cancer?

Especially consider a situation where surgical excision alone is not appropriate. What if the radiation was LDR or HDR brachytherapy?

What dose of radiation do you use for neoadjuvant chemoradiation in esophageal cancer?

The CROSS trial showed a survival benefit with 4140 cGy and concurrent carbo/taxol, but I was always trained to treat to 5040 cGy. Is anyone de-escala...

How would you approach adjuvant therapy for a patient with duodenal adenocarcinoma with ypT3 pN2 disease on Whipple resection after neoadjuvant FOLFOX x6?

How do you approach SBRT and constraining healthy liver for a small liver?

For example, consider a patient who has had previous hepatectomy and total liver volume is only slightly greater than 700 cc.

How would you manage a patient with synchronous locally advanced rectal adenocarcinoma (T3N2) and a large T2N0 adenocarcinoma of mid and distal esophagus?

For what patients are you adopting the PROSPECT approach into your rectal cancer practice?

How are you approaching patients with rectal cancer who meet PROSPECT criteria but have other higher risk features, such as >4 lymph nodes with sus...

How do you employ focal therapies in localized hepatocellular carcinoma?

Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...

What are your top takeaways in GI Cancers from ASCO 2023?

What volumes and prescription doses do you use when treating patients with unresectable cholangiocarcinoma?

Do you electively treat nodes and how does your approach change with intra- or extra-hepatic primaries?

Would you recommend adjuvant capecitabine and radiation in addition to adjuvant FOLFOX for a patient with resected pT3N2 rectosigmoid adenocarcinoma with other high-risk pathologic features?

In general: when would you recommend adjuvant radiation and capecitabine for a colon cancer?

In what setting do you omit adjuvant radiation therapy in a T3N0 rectal cancer?

The NCCN guidelines categorically recommend adjuvant XRT for a cT1-2N0 rectal adenocarcinoma upstaged to a pT3N0, yet there are multipl...

For esophageal adenocarcinoma with extensive associated Barrett's, would you extend your CTV coverage beyond the usual expansions to cover the areas of known Barrett's?

Would it make a difference whether the patient was planned for chemoradiation followed by surgery or definitive nonoperative chemoradiation?

For patients undergoing TNT for rectal cancer with planned operative management, what is the optimal sequencing and timing of workup imaging and procedures?

Do you have a preference in ordering MRI, endoscopy, CT scan (chest, abdomen, pelvis), EUS, or other testing before starting any treatment, for re-sta...

How would you approach a patient with clinical T3N1 anorectal malignant melanoma referred by a surgeon for neoadjuvant therapy?

Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?

How would you sequence treatment of a synchronous IC1 high-grade serous ovarian cancer and cT3N1 rectal cancer?

Since there is no overlap between chemo regimens for these cancers, how would you sequence treatment?

0 Answers available

What cumulative dose constraints would you use for the normal liver when repeating SBRT for liver metastases with a longer time interval (i.e. 2-3 years)?

Do you factor in the time interval when deciding cumulative dose constraints?

How would you treat a synchronous low rectal adenocarcinoma and anal squamous cell carcinoma with involved pelvic and inguinal nodes?

What systemic therapy is most appropriate, how would you sequence, and what RT dose fractionation would you use?

Would you offer adjuvant chemotherapy after SBRT for biopsy proven sub centimeter metastatic pulmonary nodule from rectal cancer?

Would you alter radiation recommendations for a patient with locally advanced rectal cancer and a history of abdominopelvic lymphoma radiation 40 years ago?

Would the location of the tumor (i.e. ultralow), symptoms (bleeding), or patient resistance to surgery play into this decision?

For ablative treatment of intrahepatic cholangiocarcinoma, what dose constraints do you recommend for the IVC when the tumor is adjacent to it?

What constraints would you use for a 15 fraction regimen or other ablative regimen?

In a patient with rectal adenocarcinoma and involved gluteal lymph nodes, what would your elective lymph node volume include?

Would this change if the cancer was p16+ squamous cell carcinoma?

How would you approach consolidative rectal irradiation for a patient with liver-confined metastatic rectal adenocarcinoma, who has sustained a near-CR after CAPEOX, capecitabine, and ongoing bevacizumab?

The patient has sustained a positive response for >1 year after diagnosis.

How would you alter your treatment volumes in a patient with distal esophageal cancer who has had prior gastric bypass surgery?

Would you offer adjuvant chemotherapy or radiation to a resected MSS T3N0 high-rectal lesion with low anterior resection without pre-op therapy?

Staging/pre-op MRI only showed mild non-specific thickening.

How would you treat synchronous high-risk prostate and rectal adenocarcinomas in an elderly man where the rectal cancer was resected secondary to obstruction (T3N0)?

How would you sequence therapy, and what dose and volumes would you use for radiation? Prostate cancer is localized, Gleason 4+3, PSA 65.

Would you offer post-operative radiation for a T2N0 rectal cancer with less than 12 lymph nodes found in the specimen after LAR?

What is the preferred palliative regimen for elderly patients with rectal cancer who elect to forego surgery?

Is concurrent chemoradiation reasonable or excessive in a patient with life expectancy <5 yrs? Should the standard be 5 Gy x 5, and will this provi...

In patients with perianal squamous cell carcinoma extending to the vulva, would you cover the entire vulva or would generous margins on the gross disease suffice?

How do you justify adjuvant radiotherapy in pancreatic cancer?

I can't convince the surgeons to refer their patients for adjuvant RT because the prospective data is messy and doesn’t seem to indicate a benef...

What is the recommended follow-up/surveillance schedule following organ preservation treatment approach for cT1-2N0 rectal cancer?

Taking into account follow up from NEO, OPERA and other organ preservation trials?

What dose constraint(s) would you use for a patient with a pelvic kidney transplant getting pelvic RT?

Are there select patients with rectal cancer where radiation field size reduction might be feasible?

For inoperable cholangiocarcinoma, do you recommend up-front chemotherapy prior to offering SBRT or combination chemoradiation?

Would you offer RT for a low-grade esophageal GIST if the patient was not a surgical candidate?

What are best practices for oncologists during the national platinum shortage?

Please specify how your institution is allocating resources now or will be soon.

13 Answers available

Do you ever utilize short-course radiation when lateral pelvic (extra-mesorectal) lymph nodes are involved?

Would you boost involved lateral pelvic lymph nodes in this scenario?

How would you approach a T3N1M0 mid rectal cancer that is MMR deficient?

Is there a role for radiation therapy in the management of unresectable solid papillary cystic tumor of the pancreas?

How would you manage a patient who received pelvic radiation 15 years ago and now has a 5 cm colon adenocarcinoma and squamous cell carcinoma of the anorectum?

What special considerations or precautions would you keep in mind when considering re-irradiation? The prior radiation was post prostatectomy RT. ...

Do you try to incorporate mFOLFIRINOX in total neoadjuvant therapy for rectal cancer?

Given the published results of the PRODIGE 23 trial where FOLFORINOX was used neoadjuvantly with FOLFOX post-op

Is there a correlation between rectal cancer stage and dose response to radiotherapy?

Dose-escalation RT trials have had mixed results in the past for advanced rectal cancer, while in the early rectal stage there is a tendency towards a...

For patients with cT1-T3 cN0 cM0 mid/low rectal cancer seeking organ preservation, what treatment approach do you recommend?

How do you weigh definitive chemoRT vs minimally invasive surgical approach with neoadjuvant chemo followed by transanal excision, in light of results...

Would you ever offer adjuvant immunotherapy after definitive chemoradiation for esophageal cancer?

Would you be willing to give definitive chemo-radiation and chemotherapy to a MSI-stable T2N0 low lying rectal cancer in a young healthy patient who wants to avoid surgery?

Are you more likely to consider a trans-anal resection?

What dose/fractionation would you offer a non-operable patient with a low-lying T2N0 rectal cancer in the setting of prior pelvic radiation >10 years ago?

If records have been destroyed, how do you factor prior pelvic radiation for prostate cancer into your decision?

Have you seen an increase in rectal spasms with short course vs long course radiation for rectal cancer?

How does your counseling about side-effects change when offering short vs long course radiation?

What is your treatment approach for patients with ampullary carcinoma who are poor surgical candidates but otherwise eligible for curative-intent therapy?

If blood counts are being checked during concurrent chemoradiation, is there a number at which point you would recommend a radiation treatment break?

For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...

How would you approach neoadjuvant radiation therapy for an adenocarcinoma of the anus involving the perirectal skin in a patient with a history of total proctocolectomy with an ileoanal J-pouch anastomosis?

Surgery has recommended against up-front diversion in order to avoid treatment delays. The patient has at least one suspicious internal iliac lymph no...

Would you use short course radiation for patients with rectal cancer and ulcerative colitis or Crohn's disease?

What about a low lying rectal cancer with involved inguinal lymph nodes?

Would you consider SBRT for a patient with a solitary HCC lesion, with SLE/lupus previously on immunosuppression?

What if actively on immunosuppression or with active lupus? For this case, presume the patient is not a candidate for resection or IR guided therapies...

What is your recommended management for a pT1N0 perianal moderately differentiated SCC s/p wide local excision with close 1 mm deep margin?

Not a candidate for re-excision given proximity to the anal sphincter. Consider +PNI, -LVI.

Is it feasible to treat central liver tumors +/- portal vein thrombus with SBRT while minding central hepatobiliary tract constraints?

The Stanford report (Osmundson, IJROBP 2015) on central hepatobiliary tract toxicity recommended dose constraints to the cHBT that would limit dose to...

Have the results of the OPRA trial influenced your decision to recommend long course chemoradiation vs short course radiation therapy for patients receiving TNT who intend to undergo surgery?

How do you reconcile RAPIDO and OPRA trial results? OPRA was a Watch and Wait trial but the rectum preservation rate was much higher in that study tha...

In the Nebraska/Mayo transplant protocol for perihilar cholangiocarcinoma, do you ever offer prophylactic biliary drainage/stenting to prevent obstruction post-chemoradiation?

If the patient had PSC and baseline atrophy preventing brachytherapy boost (received SBRT boost instead), would this change your threshold for stentin...

Would you offer adjuvant radiation for a patient who is incidentally found to have a pT2b NX adenocarcinoma of the gallbladder after a simple cholecystectomy?

Consider negative margins and a patient refusing further surgery.

How do you approach small bowel constraints in the setting of reirradiation?

Do you assume some recovery since the prior course of RT? If so, how much over what time period?

What is your approach to rectal cancer staging in patients who cannot undergo an MRI?

Would you consider SBRT or more conventionally fractionated radiation for an in-field mediastinal recurrence of esophageal adenocarcinoma s/p preoperative CRT, esophagectomy, and now progressing on immunotherapy?

How would your decision differ if the patient was not on immunotherapy or other systemic therapy? Would your thinking differ depending on the timing o...

Would you ever omit adjuvant radiation for a patient with rectal cancer originally staged cT1N0, but found to be pT1N1 after surgery?

If the patient is amenable to adjuvant chemotherapy alone, but is worried about chronic diarrhea/urgency after radiation, how would you counsel them?

In rectal cancer patients receiving total neoadjuvant therapy, do you prefer chemotherapy followed by long-course chemoradiation, or short-course RT followed by chemotherapy?

How would you treat a synchronous anal canal squamous cell carcinoma and localized high risk prostate adenocarcinoma?

Do you recommend definitive chemoradiation for unresectable gastric adenocarcinoma in a medically unfit patient?

If so, what dose-fractionation regimen do you utilize? What are your target volumes?

What is the role of adjuvant radiation for gastric cancer found to be locally advanced after up-front surgery in the setting of

NCCN recommends floropyrimidine-based chemoradiation (sandwiched by 5-FU or capecitabine), but many medical oncologists are utilizing multi-agent chem...

In light of the recently published Alliance A021501 trial, what is your approach to incorporating SBRT for the treatment of borderline resectable pancreatic cancer?

A021501 trial: mFOLFIRINOX vs mFOLFIRINOX with hypofractionated radiation (Katz et al., PMID 35834226)

Would you offer consolidative RT for NEC of the esophagus with good response to systemic therapy?

What volume do you treat? Initial disease extended from paratracheal to celiac LN. Residual disease now is only in celiac LN.

In stage 4 hilar cholangiocarcinoma, after stenting the biliary tree is there value in radiating the hilar area in addition to systemic therapy so as to maintain patency of the biliary system for a longer period of time or do you depend on the systemic therapy and the stenting alone?

For a rectal cancer with questionable T3 or questionable N+ by MRI, can short course radiation be given followed by surgery and the pathology still be interpreted to guide adjuvant chemotherapy?

I.E., can a patient with a questionable 5 mm node (MRI T2N1) which is negative on pathology after short course radiation be staged T2N0 and receive no...

How do you approach borderline non-regional mediastinum lymph nodes when treating locally advanced esophageal cancer?

How do you manage early stage anal or anal margin cancer that is locally excised with negative but close margins when going back for wider margins would require an APR?

How have the results of RTOG 1112 influenced your opinion of Y90 and other IR ablative strategies vs SBRT for HCC not amenable to surgery?

Would you offer local therapy to a patient with GEJ adenocarcinoma with FDG-avid para-aortic node oligometastasis?

For nodes just inferior to the celiac/SMA axis and no other distant metastatic disease? Stage is formally M1, but just barely. The patient is otherwis...

How long do you wait after fiducial marker placement to simulate patients undergoing liver SBRT?

Do you use liver SBRT to areas previously treated with Y90 and subsequently failed?

What contraindications or concerns do you have in this scenario beyond assessing the Child Pugh Score?

How do you follow up a patient with esophageal adenocarcinoma who is not a surgical candidate after finishing chemoradiation?

What is your approach to patients with unresectable, node-negative perihilar cholangiocarcinoma who have undergone biliary stenting and have no evidence of distant disease?

If borderline resectable, can the TOPAZ regimen be considered for downstaging effects?

What would your approach be for a patient with early stage gastric cancer who declines a gastrectomy?

How do you manage grade 3 enterocolitis from 5FU mitomycin and pelvic radiotherapy?

C diff infection ruled out and CT abdomen pelvis shows diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field.

How would you treat an elderly patient with squamous cell carcinoma of the anus who is not a chemotherapy candidate?

Would the presence of perianal extension and a positive inguinal lymph node affect your recommendation and how?

Would you consider upfront immunotherapy in a patient with MSI strongly positive locally advanced adenocarcinoma of the anus versus standard of care?

For Siewert 3 locally advanced GEJ adenocarcinoma, when do you offer preop chemoradiation (CROSS regimen) vs periop chemotherapy (MAGIC or FLOT)?

How would you manage a non-surgical poorly differentiated neuroendocrine tumor of unknown primary with a bulky nodal conglomerate causing pain?

How would you approach a locally advanced anorectal melanoma with local progression after 4 cycles of nivolumab and ipilimumab who is not a surgical candidate?

There is involvement of posterior vagina, left puborectalis, and peritoneal reflection. No nodes are involved.

In a patient with isolated inguinal nodal recurrence one year after a margin negative anal excision for Grade 1, T1 SCCA of the anus, would you include the anal canal/rectum as part of salvage chemoradiation therapy?

When would you consider a workup for C. diff in a patient with diarrhea under-going concurrent chemoradiotherapy for rectal cancer?

If the patient is outpatient and coming into clinic each day, at what point would you initiate a C. diff workup?

Would you treat rectal squamous cell carcinoma the same as rectal adenocarcinoma, stage for stage?

Any adjustments in terms of elective nodal coverage?

How do you manage osteonecrosis and pelvic insufficiency fractures after pelvic radiotherapy?

If tumor is stradling the peritoneal reflection how do you decide whether to treat with neoadjuvant chemo/RT vs just surgery?

How do you approach RT coverage of an abdominopelvic lymph node in the oligometastatic or oligorecurrent setting?

What factors influence whether you treat an elective nodal volume vs gross nodal volume (plus a small margin) in the setting of oligometastatic or oli...

How do you manage colorectal tumors that have components in the colon and rectum on MRI?

For example, portion is seen above and below the mesorectal fascia. Do you feel comfortable treating as colon cancer with surgery upfront?

In which clinical scenarios would you prefer to sequence chemotherapy prior to radiation therapy in total neoadjuvant therapy for locally advanced rectal cancer?

Are there clinical scenarios in which you have found chemotherapy first has been beneficial? (i.e., advanced T stage, extra-mesorectal LN, anat...

For patients receiving TNT for locally advanced rectal cancer who have received chemotherapy prior to chemoradiotherapy, do you treat the pre or post-chemotherapy volume for the boost, especially in patients who have had a near complete response?

Do you recommend adjuvant radiation in patients with intrahepatic cholangiocarcinoma (IHCC) resected with a positive margin (R1 resection)?

If so, what dose/volume would you use? Would you cover any nodal regions electively?

Do you recommend inguinal hernia repair before or after chemoRT for inguinal node positive anal cancer?

How would you treat a patient who is HIV+ with a p16+ SCC obturator node presumed to be T0N1 anal cancer?

Which radiation doses would you use if there is a >4.5 cm LN?

Is extramural venous invasion (EMVI) alone an indication to treat rectal cancer patients with total neoadjuvant therapy as opposed to neoadjuvant chemoradiation therapy or short course radiation therapy alone?

Would you recommend the addition of radiation to neoadjuvant chemotherapy in unresectable cT4b sigmoid adenocarcinoma (at or above the peritoneal reflection) adherent to the bladder?

Assume for this discussion: ECOG 0-1, life expectancy > 10How would nodal status influence your recommendation? Reference: Hawkins et al., PMI...

How do you manage dyschezia and tenesmus following TNT with short course RT?

How would you approach a patient with high-grade gastric lymphoma who achieved a CR following chemotherapy?

If radiation is indicated, what dose would you use?

Do you counsel patients with an ileostomy about significant diarrhea when treating the pelvis with radiotherapy?

Have you noted significant diarrhea until the ileostomy is reversed?

How would you manage a T2N0 anal squamous cell carcinoma in a patient with a history of FAP s/p remote proctocolectomy with J pouch creation?

Would you offer standard ChemoRT or favour APR given the risks associated with RT?

Is 500 cGy x 5 an appropriate palliative regimen for a patient with a low-lying metastatic rectal cancer with ongoing pain and bleeding despite chemotherapy?

Can short course radiation therapy (5 Gy x 5 fractions) be given for low lying rectal tumors, near the sphincter but not involving it?

Is there a risk of increased sphincter tone issues in these patients?

Would you offer a palliative or more aggressive course of radiation therapy for a symptomatic isolated supraclavicular recurrence of a squamous cell carcinoma of the esophagus?

What would your approach be in a patient with a mid-esophageal squamous cell carcinoma treated with chemoradiation therapy followed by surgery, with P...

How do you manage/treat acute radiation-induced enteritis?

Are there any medications that you can prescribe? Diet changes? Does this typically resolve on its own after time?

How do you approach the treatment of synchronous primary pancreatic and base of tongue cancers?

Hypothetically not an ideal surgical candidate due to weight loss. Both cancers are non-metastatic and resectable if disregarding other cancer and com...

What dose do you use for T2 anal squamous cell carcinomas measuring greater than 3cm?

For T2N0 anal squamous cell carcinoma, RTOG 0529 used 50.4/42Gy in 28 fractions. However, for nodal disease >3cm, 54Gy in 30 fractions is used (and...

How long to you wait after laparoscopic oophoropexy to deliver pelvic radiation?

What are your top takeaways in GI Cancers from ASCO 2022?

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?

How do you approach management of non-resectable periampullary adenocarcinoma in an elderly patient with otherwise good PS?

What is the most efficient way to contour small and large bowel?

What are the best references to help distinguish small and large bowel during contouring, if still unclear despite giving PO contrast?

How would you treat a recurrent chylothorax in a patient with metastatic cholangiocarcinoma?

Pleural fluid cytology is negative for malignancy but shows mesothelial cells. Would you use a PleurX or target with radiotherapy? From my understandi...

Do you recommend probiotics to patients receiving pelvic radiotherapy?

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 offer radiation to HCC with a single positive celiac node?

What dose/fractionation would you give to the liver lesion and node? Would you treat just the celiac node or all there regional lymphatics?

Do you include subcarinal, AP window, and mediastinal paraaortic nodes in your CTV for esophageal cancer?

ASTRO 2015 guidelines did not recommend coverage of stations 5/6/7 except for what is within 1 cm of the esophagus to limit lung dose. However, ARS 20...

Would you use SBRT to a localized low grade neuroendocrine carcinoma in the head of pancreas in a patient with high surgical risk?

How do you treat duodenal adenocarcinoma when using primary chemoradiation therapy?

What dose/fractionation do you use and what elective nodal areas do you cover? What studies do you order to aide in treatment planning (PET/CT? MRI?) ...

For a refractory GI bleed, would you ever consider re-irradiation of an unresectable gastric or GEJ tumor in a patient previously treated with definitive chemo-RT?

In a patient who has poor pulmonary function test results, do you treat esophageal cancer with concurrent chemoradiation therapy?

Do you change your dose constraints for lung tissue in patients with poor pulmonary function test results?

For esophageal cancer treated with primary chemoradiotherapy, with residual disease on 3 months PET, would you repeat a PET at 6 months?

Does esophageal cancer continue to respond up to 6 months on PET, like anal SCC or p16+ oropharyngeal cancers?

In light of the recently published OPRA trial, could one consider organ preservation as a standard treatment option for appropriately selected patients treated with total neoadjuvant therapy for locally advanced rectal cancer?

Garcia-Aguilar J et al, JCO 2022

How would you manage recurrent anal SCC after chemoradiation, with positive margins after resection?

Is post-operative radiation therapy indicated for a sigmoid colon cancer above the peritoneal reflection status post resection with operative/pathology findings of positive lymph nodes below the peritoneal reflection?

What adjuvant therapy would you offer for rectosigmoid junction adenocarcinoma after initial LAR?

Final pathology showed pT3N0, 0/27 nodes, negative margins +perforation, +PNI, pMMR.

How do you position patients in a prone belly board for reproducibility and optimal small bowel sparing for rectal cancer treatment?

Are bony landmarks used to guide patient placement?

When contouring pelvic lymph nodes in rectal and anal carcinoma, do you exclude bowel from your CTV?

The RTOG consensus guidelines suggest to not exclude small bowel when it falls into the space occupied by the rectal mesentery. Meanwhile, prostate an...

How would you treat an early stage rectal adenocarcinoma in a patient that had previously received EBRT prostate radiation?

Would you treat differently if it was hypofractionation? How would your treatment management change if the prior radiation was within 2 years of the r...

Do you offer adjuvant therapy for rectal intramucosal carcinoma within a large rectal adenoma?

Would you follow the same guideline recommendations for adenocarcinoma if the adenoma component is invading miscle wall?

How would you sequence treatment for HPV (+) concurrent advanced oropharynx and anal SCC?

What is your treatment paradigm for rectal cancer in the setting of COVID-19?

Are you doing more TNT to prolong time to surgery? If so, do are you starting with CRT or chemotherapy?

Are pancreatic fiducials necessary when delivering dose escalated radiation therapy for inoperable pancreatic cancer and using cone beam CT for IGRT?

With the RAPIDO trial demonstrating efficacy of short course XRT as part of TNT for locally advanced rectal cancer, is there a role for short course XRT to be integrated into watch and wait programs?

What is the optimal treatment for a locally advanced rectal cancer on the anterior wall abutting the prostate in a medically inoperable patient with a remote history of LDR brachytherapy for low risk prostate cancer?

If radiation has a role in treatment, what is the recommended dose? Would SpaceOAR placement be helpful?

How does the presence of ascites affect your treatment planning for SBRT for HCC?

Given multidisciplinary discussion has occurred and SBRT has been agreed upon as local therapy, how do you approach the presence of moderate/significa...

What is your IGRT motion management approach for liver SBRT?

Do you do fluoroscopy first, match motion of diaphragm or fiducials? CBCT? Repeat Fluoro/CBCT? Do you use breath hold or gaiting or compression? Do yo...

Do you recommend esophagectomy vs adjuvant chemoradiation vs surveillance for an otherwise healthy patient with a pT1b cN0 cM0 lower thoracic esophagus SCC status post endoscopic submucosal dissection?

What factors and evidence would you use in your decision?

How do you account for treatment breaks longer than one week for patients with anal cancer receiving definitive chemoradiation?

Would you consider definitive radiotherapy for IPMN in a patient who is not a surgical candidate?

Is there a benefit to EBRT/SBRT or would you choose observation until there is pathologic evidence of invasive pancreatic cancer?

Given the updated results of the PREOPANC study, how can gemcitabine-based neoadjuvant chemoradiation be best incorporated into the treatment of resectable or borderline resectable pancreatic cancer?

If multi-agent systemic therapy, i.e. FOLFIRINOX, is also planned, is there a preferred sequence of therapies?

What radiation approach do you prefer when using total neoadjuvant therapy for rectal cancer with extensive anal sphincter or pelvic floor involvement?

Do you treat the inguinal lymph nodes prophylactically when using RAPIDO-style total neoadjuvant therapy (25 Gy in 5 fractions followed by CAPOX or FO...

Would the diagnosis of skin-only morphea (localized scleroderma) alter treatment recommendations for localized anal cancer?

Can the results of Checkmate 577 be applied to patients who do not undergo surgery following chemoradiation because of a clinical complete response?

What about for a patient with complete radiographic response who declines surgical management?

Would you use de-escalated radiation or chemoradiation therapy for an incidental finding of invasive squamous cell carcinoma but with clear margins in a hemorrhoidecotomy specimen?

If the margins contain in situ disease, would you recommend further wide local excision? Would chronic immunosuppressive disease affect your treatmen...

When would you add an extra radiation dose to compensate for treatment breaks?

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...

Would you recommend post-operative chemoRT for a young female patient with cT2N0 rectal adenocarcinoma who had pT2N1 disease, with 1/21 lymph nodes positive?

Pathology also notable for LVI +, PNI+, but with negative margins.

What doses and volumes do you use in treatment of rectal cancer post-operatively?

How do you delineate your boost volume and to what dose? What dose would you use to boost suspicious remaining nodes and how are your doses impacted ...

What dose and volume would be recommended for a medically inoperable patient with a T4 rectal adenocarcinoma?

Would you treat per OPRA, or try for a higher dose?

Would you use radiotherapy (including SBRT) in a patient with locally advanced pancreatic cancer who has multiple cystic structures in the pancreatic head on imaging, possibly due to pancreatic leak, but is asymptomatic?

If technically feasible, would you consider SBRT for locally recurrent ampullary carcinoma in an inoperable radiation naive patient?

Or would you always aim to treat with combined chemotherapy and fractionated radiation?

Do you use the re-radiation schedule 39Gy in 26 fx BID for a rectal patient who initially received 25 Gy in 5 fractions and then has pelvic recurrence?

Would you give preop chemoradiation to a rectal cancer just above the peritoneal reflection with pelvic nodes seen on imaging?

Would your answer change in the postop setting for a tumor right above peritoneal reflection with positive pelvic nodes?

What radiation strategy do you use in clinically node positive pancreas cancer responding to neoadjuvant chemotherapy?

Do you use conventional fractionated RT, hypofractionated RT, or SBRT?

How long do you wait before performing liver-directed therapy on a colon cancer patient with liver-only disease and prior radiation-induced liver injury ?

0 Answers available

For rectal adenocarcinoma initially staged as T2N0 and treated with upfront surgical resection, but pathologically upstaged to pT3N0 without high risk features, how do you approach adjuvant therapy?

How do you counsel patients on the benefit of adjuvant therapy who thought surgical resection was curative?

Do you use adjuvant radiation therapy for low grade biliary neuroendocrine cancer with positive margin?

How would you treat an isolated pancreatic adenocarcinoma recurrence in the post-op bed with progression through chemotherapy and no prior radiation therapy?

What dose/fractionation scheme is appropriate? Can SBRT be utilized? Can chemorRT with Xeloda be curative in this setting?

How would you approach definitive RT for mid-esophageal cancer in a patient who declines or cannot get chemotherapy?

Can CM577 regimen of adjuvant nivolumab s/p neoadjuvant chemoRT with residual disease following surgery be extrapolated to patients with R1 resection unable to undergo re-resection?

CheckMate 577 only included patients with R0 resection.For R1 resections, guidelines suggest observation vs re-resection only.

Do you treat the normal pancreas as an organ at risk when delivering abdominal radiation therapy?

Do you ever contour the normal pancreas, use any dose constraints, and/or counsel patients on any possible late effects such as pancreatic insufficien...

What are the risks of treating locally advanced pancreatic cancer with chemoradiation with duodenal stent in place due to malignant obstruction?

Is there increased toxicity in patients with duodenal stents receiving RT?

For liver metastases, what criteria do you use to decide between SBRT vs Y90?

Is there a benefit of SBRT over Y90 or vice versa?

How does your approach to contouring change when treating pancreatic body/tail lesions vs head tumors in the postop setting?

Do you escalate the dose in adjuvant pancreatic cancer radiation therapy similar to how many are treating locally advanced disease with dose escalation?

In the adjuvant setting, what boost dose to vascular areas can be safely applied, assuming one has all the tech to reliably breath hold the patient an...

Do you look at or constrain V10 lung dose for your IMRT esophagus patients?

RTOG 1010 has Lungs-PTV constraint of V10 < or = 40% (per protocol) to 50% (variation acceptable), but V10 is not often used in other thoracic mali...

Following transanal excision with positive margins for for T1 or T2 rectal cancer, is it more appropriate to proceed with APR or attempt sphincter preservation with RT/Chemo?

If RT/chemo is preferred, what is an acceptable final boost dose?

How would you treat a biopsy-proven isolated uterine cervix metastasis of adenocarcinoma from a known colon cancer primary, previously stage IIIb at diagnosis two years prior?

Surgical path confirmed CK7(-), CDX2(+), CK20(+), consistent with prior colonic adenocarcinoma.

How do you treat stage I head of pancreas adenocarcinoma in an older patient who is not a candidate for chemotherapy or surgery?

Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?

In what situations can short course RT (5 Gy x 5fx) be used instead of chemoRT for rectal cancer?

When treating early stage rectal cancer (T1-2N0) with neoadjuvant long course CRT with the goal of downstaging for sphincter preserving surgery, do you reduce your radiation volumes to spare toxicity?

For example, not placing superior border at L5/S1.

Do you offer chemoradiation for de novo oligometastatic esophageal cancer after chemotherapy with no progression?

Would you offer chemoradiation or radiation therapy to the primary? Would you consider consolidation of oligometastatic sites? What dose w...

Do you consider adjuvant chemoradiation for resected pancreatic cancer with anterior surface “margin” positivity?

What dose should you treat the anal canal after excision of a T1 anal cancer with positive margins?

Is it still necessary to treat to 50 Gy or can a lower dose safely be used as there is no gross disease (e.g., 42 Gy in 28 fractions to nodes and the ...

When treating anal cancer with VMAT or IMRT, do you use bolus?

Do the multiple beam angles cover the skin adequately enough? Is full dose to the skin necessary? Do you take into account the amount of auto-bolus re...

How do you approach liver SBRT in patients with hepatocellular carcinoma who aren't candidates for surgery or other interventional procedures when the overall liver volume is small making it difficult to achieve liver constraints?

For locally advanced rectal cancer, would you consider utilizing the RAPIDO trial approach of short course radiation followed by neoadjuvant chemotherapy prior to surgery?

Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.

How would you manage early-stage low rectal cancer in a patient unable or unwilling to undergo surgery?

Would you consider short course radiation therapy for rectal cancer following APR?

Do you base liver SBRT dose fractionation on size, volume, or proximity of normal tissue?

For example, would you use a cutoff such as PTV of 25cc, or 4cm diameter, or simply use nearby normal tissue constraints to alter your fractionation f...

For low rectal adenocarcinoma that extends to the anus through the internal sphincter muscle, would you recommend neoadjuvant therapy in a patient who will undergo APR?

Does extension to the anus affect your determination of T classification? Would you consider this a T2 tumor if it does not extend to the external sph...

Is there a strong rationale for contouring small and large bowel structures for GI cases of IMRT/VMAT/3D-CRT separately?

These structures are mobile and their location changes depending on bowel filling, gas, patient set-up, etc. Is there an advantage to contouring small...

In a patient with an N+ anal cancer on pre-treatment PET, should a PET scan be repeated in follow-up?

If so, at what interval? NCCN recommends annual CT/MRI.

How would you treat single celiac focus of adenocarcinoma of unknown primary?

Would you consider SBRT as post-chemo consolidation for a patient with a single unresectable focus of metastatic adenocarcinoma at the celiac axis?&nb...

What clinical parameters determine when you treat a large HCC lesion with ablative radiation vs Y-90?

When is radiation indicated in the treatment of perianal paget's disease?

A nuimber of options for treatment but not a lot of great data for this rare disease.

How would you mange a completely excised true anal margin squamous cell carcinoma, with anal canal uninvolved, with positive inguinal nodes that were not managed surgically?

What fields/lymph node regions would you treat? What doses would you use both for the postop primary and the nodal regions?

How do you decide on the timing of neoadjuvant chemoRT or short course radiation for a patient with mid-upper rectal cancer with resectable liver only metastases?

How do you manage unresectable esophageal cancer involving both the thoracic esophagus and GE junction?

In the case of multiple skip lesions in the thoracic esophagus and GE junction, the PTV may encompass nearly the entire esophagus, including the supra...

Would you recommend stent placement upfront in a patient with cervical esophageal cancer and a TE fistula?

Is radiation therapy contraindicated in the setting of an active abdominopelvic infection?

For example, would you give SBRT for HCC with concurrent liver abscesses or short course radiation therapy for a perforated rectal adenocarcinoma with...

When giving total neoadjuvant therapy for rectal cancer, do you sequence radiation and chemotherapy differently depending on the tumor distance from the anal verge?

What do you recommend if the patient would need an APR because of anal sphincter involvement and/or would like to attempt non-operative management?

How would you manage a patient with new FDG avid retroperitoneal lymph nodes after completing definitive chemoradiation for stage III anal canal cancer?

Post-treatment PET/CT and MRI Pelvis at 3 months showed near resolution of iliac and inguinal lymphadenopathy but new avid retroperitoneal lymph nodes...

Would you consider perioperative chemotherapy in an anastomotic recurrence of gastric cancer after partial gastrectomy who did not receive prior chemotherapy or radiation?

Do you have a size cutoff for liver SBRT?

Or do you consider SBRT for any size lesion as long as the dose constraints for normal liver are met?

Do you offer adjuvant treatment for resected colloid pancreatic carcinoma?

Colloid is a rare histologic subtype and considered to have more favorable outcomes compared with usual ductal adenocarcinoma, but no dedicated prospe...

How would you treat an unresectable verrucous carcinoma invading the anal sphincter?

Do you recommend chemoradiation with 5-FU and MMC or other agent? Does your elective nodal coverage change compared to typical squamous cell carcinoma...

Do you consider post-operative radiation therapy for pancreatic neuroendocrine carcinoma?

If so, what clinicopathologic features would indicate consideration of radiation therapy?

Are there any bladder constraints for preoperative short course rectal RT?

RAPIDO and Myerson paper don’t mention any and it looks like T4 patients were treated, presumably covering external iliacs which would likely ha...

How would your elective nodal coverage change in a patient with anal cancer metastatic to a high external iliac node?

When treating a high grade neuroendocrine tumor of the rectum with involved pelvic lymph nodes, do you use the same approach (dose, fractionation, concurrent chemotherapies) as you would for a small cell lung cancer?

Would you use platinum/etoposide concurrent with radiation or would you opt for platinum only during radiation? Would you use BID fractionation...

Would you ever recommend post-op CRT for gastric adenocarcinoma treated with upfront surgery and D2 resection with R0?

If no preop chemo was added, would you consider adj CRT? ARTIST2 interim results presented in 2019 does not seem to support chemoradiation, although i...

What is your approach following R1 resection in a patient who has received total neoadjuvant therapy for rectal cancer?

Do you routinely prescribe vaginal estrogen therapy post chemo/XRT for female patients finishing anal cancer treatment?

If so, for how long?

What treatment would you offer a patient who underwent surgery for an extrahepatic cholangiocarcinoma and subsequently developed an isolated malignant biliary stricture?

Would you recommend radiation, systemic therapy alone, or chemoRT? What about if this recurrence occurred during or shortly after completion of adjuva...

What is the optimal time to wait prior to surgery following radiation therapy for rectal cancer to maximize the pathologic complete response rate?

Does your answer change for long course chemoradiation vs short course radiation therapy?

What dose regimen would you use to treat a patient with locally advanced esophageal SCC of the mid-esophagus who refuses chemo and surgery, agreeing only to radiation alone?

Which patients with rectal cancer who have not received neoadjuvant treatment do you offer adjuvant radiation to?

Is there a subset of patients you would avoid neoadjuvant CRT and operate first?

How do you manage a T1N0 well differentiated anal margin squamous cell carcinoma with low-grade dysplasia at the surgical margin who has already undergone re-excision and is not eligible for further excision without an APR?

The invasive component had depth of invasion 1.7 mm, horizontal extent 3.5 mm.

Would you consider 177Lu-Dotatate (Lutathera) in patients with midgut neuroendocrine carcinoma after treatment with a somatostatin analog but with Ki67 >20%?

This patient had a Ki67 of 27%. However, the inclusion criteria for the NETTER-1 Trial was Ki67<20%. Would Lutathera be an option if labs are withi...

How would you manage a patient with a growing central liver metastasis previously treated with SBRT who is ineligible for chemotherapy?

Is there a role for re-irradiation? What cumulative dose constraints do you use for re-irradiation to the central hepatobiliary tract?

How would you manage a patient with locally advanced rectal cancer with an ileal conduit?

Does your recommendation for radiation therapy and/or radiation planning change?

How would you approach isolated inguinal lymph node squamous cell carcinoma of occult primary?

If workup is negative for a primary lesion, would you consider prophylaxis of potential primary sites (anus/vulva?), and would you treat bilateral ing...

How do you treat locally advanced GE junction adenocarcinoma extending to the esophagus and cardia when the Siewert Type is indistinguishable between 2 and 3?

Considering a T2+ and/or N+ GE junction adeno, do you use neoadjuvant chemoradiation therapy or perioperative chemotherapy? Does your treatment...

Is tumor deposit (N1c) alone an indication for adjuvant chemoRT for rectal cancer that did not receive neoadjuvant therapy?

Assuming all other factors are favorable (pT1-2, TME, negative margins).

How would you manage an incidentally identified 1.0 mm anal squamous cell carcinoma (5.5 mm margin) in a background of severe dysplasia/CIS involving the peripheral excision margins found on a hemorrhoidectomy specimen?

Is there a threshold of when you would use chemo/radiation?

Should special precautions be taken patients with Ehlers-Danlos syndrome receiving radiation therapy?

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

For esophageal cancers with large gaps between the primary and PET positive lymph nodes, do you treat the gaps with continuous volumes or only involved areas?

For example, in an upper or mid-esophageal cancer with a PET positive lesser gastric curvature node. Is it reasonable to treat PET positive areas only...

Do you allow your CTV expansion to go into lung for IMRT esophagus cases or do you crop CTV expansion out of lung?

The CTV examples in the contouring guideline by Wu et al (https://www.ncbi.nlm.nih.gov/pubmed/26104943) don't appear to crop the CTV out of lung. Woul...

7 Answers available

Would you offer adjuvant pelvic RTto a patient with distal sigmoid colon adenocarcinoma, following LAR with pT4a pN1 with + radial margins and no room for further resection?

If there was no further resection and the initial LAR showed a pT4a (visceral peritoneum), pN1 pelvic nodal disease with positive radial margins, woul...

Do you offer consolidative RT to the pancreas for patients who initially present with metastatic disease and have radiographic CR after chemotherapy?

Would you offer liver SBRT without fiducial placement?

If you are treating a patient with liver SBRT, would you not treat a patient who cannot have fiducials? If you are treating without fiducials, are you...

Would you recommend adjuvant radiation therapy to a T4N0 colon cancer with invasion into other organs or the abdominal wall status post R1 resection?

Would you cover elective lymph nodes?

Do you contour the abdominal para-aortic nodes in your elective CTVnodes for T3N1 adenocarcinoma of the GEJ getting preop chemoRT?

ASTRO 2015 esophagus guidelines recommended the abdominal para-aortic nodes to be included in the CTV whereas ARS 2020 guidelines did not. Instead, AR...

For palliation of gastric bleeding due to malignancy, is a G-tube a contraindication for RT?

Would you reduce dose, e.g. from 30 Gy in 10 fractions to 20 Gy in 5 fractions, or hyperfractionate, e.g. 1.5 Gy bid to 20-30 Gy?

What are your volumes for a patient undergoing total neoadjuvant chemotherapy for rectal cancer who has initially bulky disease and is node positive and has a complete response on restaging MRI after neoadjuvant chemotherapy and before chemoradiation?

What are your dose constraints for SBRT pancreas (absolute and relative) when treating with 5 fractions?

What strategies do you use to meet those constraints?

In a patient with newly diagnosed anal squamous cell carcinoma, who has an extensive history of active autoimmune disease including Crohn's, Lupus, and arthropathies on multiple therapies, would you forgo radiation therapy and proceed to APR upfront?

Would you electively treat any lymph node regions for small cell carcinoma of the pancreas?

Would your recommendation change based on the patient's age, performance status, comorbidities, or chemotherapy details?

How would you manage a male with a prior history of localized prostate cancer s/p radiation to prostate only (two years ago), who now presents with a T1N0 squamous cell carcinoma of the anus?

Would your management change if the prostate and lymph nodes were treated with radiation two years ago?

How would you manage a patient with T3N0 rectal cancer status post transanal excision, who is not a surgical candidate, and who received pelvic radiation for prostate cancer 20 years ago?

Would you be confortable to give full dose CRT?

Do you offer SBRT Liver for patients with low platelets?

If so what is the crietria?

How do you manage grade 3 dermatitis during chemoradiation therapy for anal cancer?

Aquaphor, barrier cream, sitz baths, domboro, silvadene, foam dressings?

7 Answers available

Do you recommend elective nodal irradiation when treating unresectable pancreatic adenocarcinoma?

ASTRO 2019 guidelines conditionally recommends elective nodal RT in unresectable pancreatic cancer. However, NCCN states that ELNI is controversial in...

Is it safe to treat a recurrent esophageal SCC with definitive chemoradiation after a prior endoscopic mucosal resection?

What is the risk of perforation / fistulization?

How do you do immobilization for liver SBRT?

What method provides the best reproducibility? Abdominal compression? Inhale breath hold? Exhale breath hold?

For borderline resectable pancreas treated with induction chemo therapy and minimal radiographic response, if unable to do SBRT, do you prefer 36/15 or 50.4/28 (given that is where we have more data)?

The concern being that if patient does not go to surgery, you have delivered lower BED with 36/15.

How do you approach SBRT liver constraints when the total liver volume is <700 cc?

Liver SBRT maintaining 700 ccs of liver <15 Gy is a commonly used constrain; however, if the total liver volume is limited due to cirrhosis, prior ...

What kidney constraints would you use for a patient with horseshoe kidney?

How do you decide timing of adjuvant radiation with respect to chemotherapy for a patient with resected pancreatic adenocarcinoma with microscopic positive margins?

Does nodal positivity at time of surgery affect your decision?

How do you manage patients on atezolizumab/bevacizumab with advanced HCC who develop arterial thrombosis?

Do you continue atezolizumab alone? Would you avoid anticoagulation?

How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?

In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?

Would you give RT to an ulcerated resected T2 BCC of the perianal margin, with close margins, and no anal canal involvement?

Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?

Do you utilize EUS to determine the nodal radiation fields in esophageal adenocarcinoma?

In a patient with a large primary and a negative PET/CT for nodal disease, would you push for EUS for radiation planning? Or would this be an unnecess...

How would you recommend treating locally recurrent pancreatic cancer?

In a patient who has undergone resection and adjuvant chemotherapy who then recurs locally, how would you recommend treating? Would you treat ju...

What radiation dose would you use when giving definitive chemoradiation for inoperable rectal cancer with extensive invasion into gluteal musculature?

Are there any contraindications to or concerns with radiating a rectal cancer patient receiving bevacizumab?

Do you offer definitive chemoradiation for a primary duodenal adenocarcinoma?

If so, what dose-fractionation regimen do you utilize? What are your target volumes? Would you first recommend induction chemotherapy followed by rest...

How do you approach adjuvant radiation for perihilar cholangiocarinoma?

What are you typical treatment volumes and doses for R0 vs R1 resections?

What is your approach to adjuvant radiation for anorectal mucosal melanoma s/p wide local excision?

What dose, fractionation and what elective coverage do you recommend?

Is there a role for radiation therapy after neoadjuvant systemic therapy and irreversible electroporation in patients with locally advanced pancreas cancer?

Are there scenarios that new visits/consults with patients can be done virtually amidst the COVID-19 outbreak?

How do you manage a patient with gastric/GE junction carcinoma who has positive lymph nodes at resection after neoadjuvant chemotherapy?

If you would elect for adjuvant therapy, which study helps guide your choice of regimen?

In a patient treated with chemoradiation therapy for anal cancer 10+ years ago who presents again with localized anal squamous cell carcinoma, would you consider repeat chemoradiation for organ preservation instead of APR since so much time has passed since the first treatment?

Does the amount of time from 1st treatment change your management or thinking in this situation?

What would be the recommended management for patients with rectal adenocarcinoma with rectovaginal fistula at presentation?

Would preop RT still be the treatment option for these kind of patients? Assuming that the rectovaginal fistula was from tumor progression.

How would you manage gastrointestinal bleeding after radiation therapy for pancreas cancer?

Is it possible or common for patients to have mucosal telangiectasias along the portions of the GI tract in the radiation fields? If present, would yo...

How would you manage RT for a locally advanced squamous cell carcinoma of the anal canal in a >90-year old if chemotherapy is not recommended?

Would you go to a higher dose for the primary and/or nodal volumes? If the medical oncologist does not feel comfortable giving cisplatin or mitomycin...

What small bowel dose constraints do you use when treating with short course radiation for rectal cancer?

Do your constraints change when treating standard fields for T3 disease versus including external iliac lymph nodes for T4 disease when treating with ...

When do you offer adjuvant radiation in addition to chemotherapy for patients with high risk localized gastric adenocarcinoma who did not receive pre-operative therapy?

The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease. Both ARTIST and Inte...

When treating anal squamous cell carcinoma, how does your radiotherapy regimen change when there is a bleeding anal fissure?

How would you approach definitive chemoradiation for node positive anal cancer with a history of ulcerative colitis status-post total proctocolectomy?

How would you adjust your small bowel dose constraints? What other considerations would be pertinent?

How would you approach neoadjuvant chemoradiation in a patient with a history of Crohn’s disease diagnosed with regional lymph node-positive esophageal adenocarcinoma of the GE junction?

What-dose fractionation would you utilize? What small bowel constraints would you optimally set to achieve? How would your approach differ in a surgic...

How would you manage a patient with profound dyspareunia after pelvic radiation for anal cancer?

9 Answers available

In a patient treated with peri-operative chemotherapy via the MAGIC regimen for gastric cancer who has a locoregional relapse in unresectable celiac node, how would you approach radiation treatment?

Do you consider Macdonald type sandwich treatment 45Gy with xeloda? Would you dose escalate gross node? Would you treat stomach remnant and regional...

In patients with inflammatory bowel disease with low rectal cancer with planned proctocolectomy, would you consider creation of a pouch?

How would you treat a oligometastatic para-aortic recurrence 1 year after definitive chemo-radiation for anal cancer?

The recurrence is several adjacent nodes above the prior fields.

What is the optimal work-up for patient with repeatedly negative biopsies of a mid-rectal lesion with signs of malignant etiology?

If biopsies consistently show high grade adenoma and there is a locally advanced rectal tumor with MRF involvement on imaging, what is the next step i...

In a patient with a pT3N0 rectal adenocarcinoma, would you consider omitting nodal RT and treating only the rectal bed with adjuvant chemoradiation therapy when a large number of nodes have been removed and all found to be negative?

For example, status post resection of a 4 cm high rectal carcinoma that was believed to be in the sigmoid colon but found interoperatively to be below...

In rectal cancer in patients receiving total neoadjuvant therapy of FOLFOX followed by 5FU-radiation, is there a role for additional adjuvant chemotherapy based on significant residual disease at time of surgery?

What elective lymph node areas do you cover for T4a rectal adenocarcinoma?

Do you include external iliac nodes as for T4b (adjacent [anterior] organ invasion) or do you maintain the same coverage you use for T3 disease with a...

Would you offer postop chemoRT to a patient with pT3N2bM0 rectal cancer and ulcerative colitis s/p prococolectomy with j-pouch creation?

What dose would you use? How do you counsel on risk of damage to j-pouch?

How would you manage initially unresectable node-negative pancreatic adenocarcinoma that after upfront chemotherapy achieves a complete radiographic response on interval MRI and CT?

If the patient is medically inoperable, is post-chemotherapy radiation therapy or SBRT advisable with no visible GTV?

How would you manage a treatment interruption during SBRT to the liver?

How long is too long to resume SBRT, and would you increase doses? Is there a number of elapsed days that would cause you to abort completion of SBRT?

What dose-fractionation would you utilize to palliate a symptomatic distal rectal cancer in an inoperable elderly gentleman with previous prostate bed radiation therapy 30 years prior?

Would your recommendation change if the patient had prior radiation proctitis and cystitis (now resolved)? Previous treatment records limited, but pre...

Does liver-directed therapy (SBRT, Y-90, TACE, RFA, microwave ablation, etc) improve overall survival?

Does it improve patient quality-of-life?

What chemotherapy regimen do you recommend with radiation therapy for cervical esophageal squamous cell carcinoma?

The upfront plan is to use a definitive radiation dose of 66 Gy. My reading supports the use of 5FU + cisplatin but another doctor is recommending FOL...

Would the presence of diverticulosis change your dose constraint for large bowel?

Is diverticulosis in large bowel adjacent to a target a contraindication for SBRT? How would you manage?

Do you offer radiation therapy for locally advanced, node positive rectal adenocarcinoma in patients with Li-Fraumeni syndrome?

Would you omit radiation therapy for some patients with Li-Fraumeni syndrome who would normally receive it?

What surveillance do you recommend for a patient with locally advanced rectal adenocarcinoma who had a complete clinical response to total neoadjuvant therapy and declines to undergo surgery?

MRI? Endoscopy? Physical exam?

How do you manage patients with pancreatic adenocarcinoma who progress during neoadjuvant FOLFIRINOX, such that borderline resectable disease is now unresectable but still localized?

Is there evidence for radiation therapy in this setting?

For localized esophageal cancer in patients with preexisting neuropathy, what do you use concurrently with radiation therapy?

What is the added benefit of Chemo-RT vs RT alone?

Does p16 negative status of anal squamous cell carcinomas affect your treatment approach?

What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?

Do you recommend TACE, RFA, radioembolization, systemic therapy or SBRT? What if the size is >5 cm?

How do you manage patients with low-lying rectal adenocarcinoma who refuse surgery?

Should these patients be managed with high dose chemoradiation similar to the Danish study (Lancet in July 2015)? To what dose would you take the prim...

Should adjuvant CRT be considered in gastric cancer patients who received pre-op chemo based on the recent results of the CRITICS trial?

The CRITICS trial showed there was no OS or PFS benefit with adj chemo vs CRT. Is there potentially still a role for CRT to reduce heme toxicity and p...

What is your approach to a patient with GE junction or esophageal cancer with oligomestatic disease at presentation?

Would you offer definitive or neo-adjuvant chemo-RT in the setting of a single lung or bone metastasis?

What is a safe dose to deliver to a gastric bed recurrence adjacent to the duodenal stump post total gastrectomy for gastric carcinoma?

What is the duodenal stump dose constraint?

In which clinical situations is there a good rationale for the use of proton therapy for GI cancers?

Should we give concurrent capecitabine?

What radiation sensitizer do you recommend for early stage poorly differentiated squamous cell carcinoma of the anus, in a patient with stage IV chronic kidney disease?

For a patient not on dialysis? Outside of single agent 5FU, all other standard chemotherapeutic options would be contraindicated for nephrotoxicity.&n...

What dose constraints do you use for 15-25 fraction hypofractionated RT for cholangiocarcinoma?

Higher radiation dose was shown to be associated with longer survival in Tao et al., JCO 2016. What dose constraints do you use when using these ...

Is there any advantage to proton beam therapy in a locally recurrent anal carcinoma, which has already been treated with concurrent chemo RT as well as APR for relapse?

Would you consider the addition of chemotherapy to proton beam therapy?

Is it acceptable to deliver ablative hypofractionated radiation therapy for unresectable intrahepatic cholangiocarcoma in conjunction with concurrent checkpoint inhibitor?

Would you be concerned with more and higher grade hepatobiliary toxicity with concurrent use of checkpoint inhibitors (i.e. Keytruda)?

How do you sequence short course radiation for locally advanced rectal cancer when using the total neoadjuvant approach?

When using short course RT, the NCCN guidelines currently recommend short course RT followed by chemotherapy, followed by surgery. Many surgeons are h...

How would you treat a T4 rectal cancer invading the uterus that is causing rectal and vaginal bleeding?

What is your preferred combination and order of therapy for a T4 rectal tumor invading the uterus leading to both rectal and vaginal bleeding? ...

Would you offer radiation therapy to a patient with sigmoid colon cancer that is medically inoperable?

What dose and volumes of radiation would you use?

Would you consider short course RT for rectal cancer in the post-op setting given COVID-19?

For T2-T3 N+ rectal patients with large (2+ cm) bilateral sidewall nodes outside the TME volume, should you extend elective nodal volumes anteriorly to include external iliacs?

When treating locally advanced/borderline resectable pancreatic cancer with SBRT, what are the typical duodenal dose constraints you utilize?

What form of surveillance do you recommend for esophageal adenocarcinoma s/p NACRT and resection at what frequency?

Do your post-operative rectal fields differ from pre-operative fields?

For those that tend to contour rather than set fields based on bony anatomy, how do you draw your CTVs?

For a patient with a solitary kidney, what dose constraints would you use for SBRT to a nearby site?

How would you treat an early-stage gastric adenocarcinoma in a patient who is medically inoperable and not fit enough for chemotherapy?

Is there such thing a definitive radiotherapy in this setting, or would this be a purely palliative approach? If you would treat, what would your targ...

Do you hold pelvic radiation for patient with clostridium difficile-associated diarrhea?

Would your recommendations change if you were treating a GI primary (e.g. rectal or anal cancer) vs non-GI primary?

What dose and fractionation would you recommend for anal melanoma that is localized but refusing surgery?

Do you recommend post-operative radiation therapy for gastric cancer after pre-operative chemotherapy when there is no pathologic response to chemotherapy?

Do factors such as large tumor size and/or node positivity affect the decision?

If colostomy is indicated prior to Nigro for locally advanced anal SCC, would you wait to simulate after this procedure or do you feel pelvic anatomy will not be distorted?

Do you offer liver SBRT for metastatic colorectal cancer after local recurrence following previous treatments such as radiofrequency ablation (RFA), radioembolization, and chemoembolization?

If so, what dose fractionation do you prefer?

Do you recommend chemoradiation following neoadjuvant FOLFIRINOX for resectable pancreatic cancer?

What techniques do you use to address fertility preservation in young female patients being treated with chemoradiation therapy for cancer in the pelvis?

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

What small bowel dose constraints do you utilize when treating resected pancreatic cancer?

When indicated as in the setting of positive margins and/or positive lymph nodes, do you use V45 <195cc (QUANTEC), or V45 <15% (RTOG 0848), and ...

Do you electively cover the celiac axis in a patient with node negative middle third to distal, and GEJ esophageal carcinoma?

What factors do you use in deciding whether or not to electively cover the celiac axis?

Is prior radioembolization with Yttrium-90 microspheres for a primary liver cancer a contra-indication to external beam radiation therapy with either stereotactic body radiation therapy (SBRT) or proton beam therapy?

How do you choose between SBRT and RFA for CRC metastases to the liver?

*What dose and fractionation do you recommend for metastases >4cm in favorable positions (ie. not abutting mucosal tissue)?

Is there a role for a post-operative boost in a patient with rectal cancer who has a positive margin after total neoadjuvant chemo and chemoradiation therapy?

Total neoadjuvant therapy consisted of with FOLFOX and chemoradiation therapy with Xeloda and 50.4 Gy. Would you deliver a boost to the area and if s...

What dose constraint do you use for the ostomy site when treating a patient with close/adjacent disease?

Would you offer adjuvant chemoRT for node positive high rectal cancer above the peritoneal reflection?

How would you treat a patient with adenocarcinoma of the GE junction in the setting of interstitial lung disease?

Is neoadjuvant chemoradiation or perioperative chemotherapy preferred?

Would you offer SBRT in a patient with history of CRC, subsequently found to have a solitary liver metastasis treated with chemotherapy followed metastasectomy with positive margins?

In what situations would you treat with adjuvant radiation for resected gallbladder cancer?

If you were to treat, what do you include in your treatment?

Is there a role for dose escalation beyond 50.4 Gy in neoadjuvant chemoradiation therapy for rectal cancer?

Do you treat rectosigmoid/upper rectal cancers with neoadjuvant chemoradiation?

The German trial included patients with tumors up to 16cm from the anal verge, while the Swedish trial update found no local control benefit for tumor...

What dose do you use for postoperative rectum boost?

NCCN allows a range from 5.4-9 Gy for adjuvant boost and German trial used 55.8 Gy. What factors might sway you to give a higher / lower dose? Is mor...

Would you recommend chemoradiation to the pelvis for a patient with squamous cell carcinoma of the anus metastatic to the liver who has had a complete response to chemotherapy in the pelvis and a liver resection?

In patients undergoing pre-operative chemoradiation for rectal adenocarcinoma with clinically positive pelvic sidewall nodes that may not be surgically accessible, do you boost these nodes above 50.4 Gy?

If so, what dose do you boost these nodes to?

How do you sequence antiviral therapy and cancer-directed therapy in a newly diagnosed patient with hepatocellular carcinoma and incidentally found hepatitis C?

Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...

Is it common to have atypical squamous cells on pap smear s/p chemoradiation for anal cancer in a female?

What radiation dose, fractionation and volume would you use in an elderly patient with localized extensive anorectal malignant melanoma status post laparoscopic APR?

Would your recommendation change with the following aggressive features: 8 cm, pericolic extension, positive radial margin, perineural invasion presen...

How would you manage an elderly patient with GE junction adenocarcinoma who is not interested in surgery and who has ulcerative colitis (not currently on medication or symptomatic)?

Would you be concerned about toxicity given that he has ulcerative colitis?

How would you approach potential SBRT to liver metastases in a patient on a VEGF inhibitor?

Would you alter your SBRT dose? How long would you hold the VEGF inhibitor before and after? Does the primary matter (e.g. NSCLC vs. colorectal)?

For a patient with terminal ileal Crohns disease who requires chemoRT for distal rectal cancer, can mercaptopurine (6MP) be continued during that phase of treatment?

Is there evidence to support routine use of adjuvant chemotherapy for resected rectal cancer treated with pre-operative chemoradiation?

The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.

Would you consider upfront chemoradiation therapy for a patient with metastatic anal squamous cell carcinoma if they have a large burden of disease at the anus?

Would you treat with definitive doses?

Should neoadjuvant chemoradiation ever be considered in the a patient with high risk rectal cancer in the setting of active ulcerative colitis?

If the patient will be having a total colectomy, would up-front surgery be a better consideration?

Is there a role for consolidative definitive radiation therapy for metastatic rectal adenocarcinoma with good response to systemic therapy (patient is not symptomatic)?

In a patient with distal esophageal cancer with a single non-regional neck lymph node, would you offer chemoradiation therapy or surgery to the primary site if the lymph node has a complete radiographic response after chemotherapy?

Would your answer depend on the response of the primary site?

How would you manage a patient who received neoadjuvant CRT per the CROSS trial for esophageal cancer, but refuses surgery after imaging shows a good radiographic response?

Is there a role for additional treatment?

How would you manage a patient with oligometastatic colon cancer status post resection of the primary whose single unresectable liver lesion has had a complete response to FOLFOX chemotherapy by PET?

Would you offer local therapy to the liver?

In patients with rectal cancer receiving neoadjuvant chemoradiation, how does possible seminal vesicle involvement on MRI affect the contours of your target?

Do you include the whole seminal vesicles and prostate, or just the whole seminal vesicles? Do you add external iliac lymph node coverage in this scen...

How would you approach a small mucinous adenocarcinoma of the anal verge (without anal canal involvement) with positive margins after resection?

Further surgery is not possible.

How would you manage a patient with Lynch syndrome who is s/p surgery and pelvic RT 20+ years ago for endometrial carcinoma with a new T3N0M0 squamous cell carcinoma of the anus?

The patient refuses surgery.

Do you use a metal biliary stent as a fiducial marker for cholangiocarcinoma?

Do you worry about migration or scatter dose from the metal?

Would you consider chemoradiation to the primary in a patient with resectable pancreatic cancer s/p neoadjuvant chemotherapy found to have single liver metastasis on re-staging?

If so, what dose and fractionation?

How would you approach a mucinous adenocarcinoma of the anal verge without anal canal involvement, status post excision with positive margins but without the possibility of additional surgery?

Given this rare histology, would you treat this patient as a skin cancer or as an anal adenocarcinoma with inguinal nodal coverage?

Should anal cancer patients undergoing definitive chemoradiation be put on a treatment break for neutropenic status?

Is this practice still relevant to the modern IMRT approach where skin toxicity is much lower?

Is there a role for pre-operative RT (+/-chemo) for a borderline resectable Klatskin tumor as an attempt to try to get them to surgery?

How do you treat unresectable pancreatic adenocarcinoma invading into the duodenum?

Would you consider "neoadjuvant" RT to 45-50.4 Gy followed by a resimulation and a boost to a "definitive" dose of 54+ Gy depending upon disease respo...

What constraints do you use for the gallbladder when giving liver SBRT to lesions close to the gallbladder?

How soon after ChemoRT for a head and neck cancer can you safely initiate esophageal dilation?

Would you offer liver SBRT to a patient with a history of a liver transplant?

Assuming good liver function currently, without evidence for recurrent cirrhosis? Would your decision be affected if it was a primary HCC vs Liver me...

If a patient has distal esophageal adenocarcinoma and a PET+ left supraclavicular lymph node, and nothing in between, would you cover the entire esophagus? Both supraclavicular fields?

What role, if any, is there for Y90 in metastatic gallbladder cancer to the liver?

Can total neoadjuvant therapy be considered an option equivalent to standard of care treatment for patients with T3N0 or T3N1 rectal adenocarcinoma?

Or should total neoadjuvant therapy be reserved for bulkier disease (T4N2)?

What adjuvant therapy do you give after surgery to patients with gastric CA who undergo 3 cycles of FLOT with no tumor effect on pathology and maintain good PS?

I understand the perioperative trials are not based on tumor regression in cancer cells.

How do you approach rectal cancer with a solitary bone metastasis that is biopsy proven?

Do you recommend definitive therapy? Would your approach change if there are more than 1 site of bone metastases, such as 2-3?

Do you recommend neoadjuvant radiation or chemoradiation for patients with T1-2 N0 adenocarcinoma of the anal canal prior to APR?

What dose do you use for definitive treatment of squamous cell carcinoma of the cervical esophagus?

Let's re-open the debate!

When treating node positive anal squamous cell carcinoma, dose your lymph node boost include only gross disease with margin or do you boost the entire nodal region?

Would you still offer adjuvant chemoradiation therapy to a patient with pT3 pN1a rectal cancer who did not receive any neoadjuvant treatment, and whose adjuvant treatment is delayed by 4 months due to post-operative complications?

Is there any data to support delayed treatment?

In what situations do you obtain both a pelvic MRI and EUS for rectal cancer staging and treatment planning?

For instance, in borderline cases for neoadjuvant therapy (e.g. T2N1 disease), should both be obtained to increase accuracy?

Is it appropriate to treat unresectable secretory insulinoma of tail of the pancreas with radiation therapy?

What dose would you recommend? Any role for systemtic therapy?

In a patient with gastric adenocarcinoma with +peritoneal cytology status post an R1 resection, would you consider post operative chemoradiation?

Would you consider prone SBRT (with solid image guidance techniques) if bowel is lying on a target, for instance bowel surrounding an oligometastatic lymph node or next to a kidney tumor?

Do you have any specific bowel constraints when treating patients with palliative radiation 3000/10?

Do you look at max dose or are there specific volumetric constraints you use for the small or large bowel?

In patients receiving neoadjuvant CRT for cN+ rectal cancer, do you expand your elective nodal volumes to include the external iliac chain or to extend more superiorly along the common iliac chain?

Do you boost the positive nodes beyond your standard pelvic dose?

What is the role of liver SBRT in the setting of an excellent interventional radiology program?

Our hospital has an aggressive and talented interventional radiology group. We have wanted to start a stereotactic liver radiotherapy program but are ...

When do you consider total neoadjuvant therapy (chemotherapy and chemoradiation) for rectal cancer?

For gastric cancer receiving FLOT perioperatively with negative margins but multiple positive nodes, do you offer postoperative chemoRT?

How do you manage an anal SCC status post a non-oncologic excision of a 2-3 cm primary and positive excisional biopsy of an inguinal node with pathology revealing LVSI, positive surgical margins, and more regional lymph nodes on PET?

What dose do you take the primary to?

How do you decide what elective lymph node stations to include in your treatment volume for cervical and upper and middle thoracic esophagus cancer?

In patients witih locally advanced pancreatic cancer, how long would you wait after 1st line induction chemotherapy with FOLFIRINOX before you image for assessment of response and deciding about 2nd-line therapy?

What is your general approach to treating bleeding gastric masses with palliative RT?

Do you have any preferred dose fractionation schedules? What kind of margins do you use?

Would you offer radiation therapy for pleural- or peritoneal-based pseudomyxoma peritonei?

If so, how would you approach your radiotherapeutic plan and what dose-fractionation would you utilize?

Would you offer adjuvant chemoRT to a patient with pancreatic adenocarcinoma who underwent neoadjuvant therapy with FOLFIRINOX and SBRT but had a positive (neck) margin on resection and is now s/p adjuvant chemotherapy?

Would you recommend SBRT for locally advanced pancreatic adenocarcinoma invading the stomach s/p multiple rounds of chemotherapy?

In light of the 2015 ASTRO plenary session presentation about involved-field radiation vs elective nodal radiation therapy, are you including elective nodal fields (celiac, mediastinal, supraclavicular) in the treatment of locally advanced esophageal cancer?

How long after pancreatic SBRT do you wait to re-image?

This will influence the decision to operate or not, so you want to give it enough time to see a response, but given that it's a disease predisposed to...

How would you approach a patient with locally recurrent esophageal carcinoma who is s/p previous chemoRT and refuses salvage surgery?

Would you offer additional radiation therapy in a medically inoperable patient with rectal adenocarcinoma who has a persistently palpable tumor after definitive chemoradiation therapy?

Would you consider a re-biopsy after chemoRT to confirm viable tumor and if so, how long would you wait after chemoRT before biopsy? If you did ...

When would you offer adjuvant RT after R0 resection for a distal esophageal adenocarcinoma?

If so, what would your target encompass?

What dose-fractionation would you utilize when treating an elderly patient with local-only pancreatic cancer who is not eligible for systemic therapy or surgery?

Would you recommend pre operative (chemo)radiotherapy for a patient with a T3 N0 low rectal cancer in a patient with active Crohn's disease?

Colonoscopy reveals inflammation in the colon and rectum due to Crohn's and patient also has perianal fistula due to Crohn's.

Do you treat elective nodes in unresectable pancreas when treating with 15fx?

Do you use concurrent Xeloda?

Is there any data comparing neoadjuvant pancreatic SBRT vs standard fractionation in terms of its ability to convert unresectable tumors to resectable tumors?

What percentage of unresectable T4N0 pancreatic body adenocarcinomas with celiac axis involvement and no response to 6c chemo, will convert to resecta...

Do you use any dose constraints for the spleen while delivering abdominal radiation therapy?

How do you time same-day chemotherapy and radiation for patients undergoing concurrent chemoRT?

For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...

Would you treat the supraclavicular nodes electively for a patient with esophageal adenocarcinoma originating in the mid-esophagus but extending above the carina?

What is the most appropriate radiation dose and volume for elderly and/or frail patients with advanced SCC of the anal canal not receiving chemotherapy to attain durable local control?

When a large malignant appearing GI mass is encountered on endoscopy but biopsies show dysplasia or carcinoma in situ, would you recommend additional biopsies or proceed with treatment for invasive cancer?

I am currently managing two patients (one esophageal and one anal) with this scenario and the referring physicians and patients are reluctant to under...

Do you consider adjuvant radiation for low grade T1bN0 gallbladder adenocarcinoma with negative margins after oncologic resection?

The data is scarce- do you recommend chemotherapy only or would you consider RT for local control?

How would you approach oligometastatic (solitary) recurrence with previously resected pancreatic adenocarcinoma and adjuvant chemotherapy with a prolonged disease-free interval?

Is there a role for SBRT with or without the addition of systemic therapy?

How do you manage a patient who presents with a tracheoesophageal fistula from a lung or esophageal primary that is non-metastatic?

As a for instance, a centrally located primary tumor with mediastinal adenopathy that results in a TE fistula? Currently we would recommend esophagea...

What image guidance do you use when treating rectal and anal cancers?

When using oral contrast for simulation, how much prior to simulation do you have patients drink the contrast?

Does this vary depending on the site you are treating, i.e. abdomen vs pelvis?

What neoadjuvant approach is best for an adenocarcinma of the GE junction (arising in Barret's) with a large hiatal hernia?

Would you recommend neoadjuvant chemotherapy to spare the stomach?

Should definitive concurrent chemoRT be offered to patients with anal canal SCCa with common iliac nodal involvement (by definition M1 disease) without evidence for other distant disease?

How would you treat a patient with locally and distant recurrent rectal cancer who has previously received chemoradiation but now presents with pain and bleeding from the site of local recurrence?

How do you approach treatment planning for preoperative radiation therapy in gastric cancer?

If considering that it is not gastroesophageal junction, what margin do you place on the clipped GTV to formulate CTV? Is there any role for SIB to PE...

When treating rectal cancer with conventional neoadjuvant chemoradiation (45 Gy to pelvis with boost to 50.4 Gy), what volume do you use for the boost?

There is no RTOG consensus on boost volume, except to say that it should include the entire mesorectum/presacral region at involved levels + 2 cm in c...

In patients with oligometastatic disease, would you offer SBRT to a metastatic lymph node abutting the trachea and/or esophagus?

If so, what dose and dose constraints would you consider? How would you counsel the patient about risk of trachesophageal fistula?

How do you create an ITV for liver SBRT (metastatic lesions) when you don't have a 4D-CT or fiducials?

Is it sufficient to use fluoroscopy to assess total motion, fuse MRI and PET to create an ITV, and use abdominal compression to limit motion?

In the case of a thoracic esophageal cancer that will require extensive volume coverage, >2/3 of the esophagus, do you prophalactically prescribe a feeding tube or observe?

Would you recommend adjuvant chemoradiation for a resected ampullary adenocarcinoma?

What features would make you more likely to recommend radiation therapy with chemotherapy?

What would you recommend for a patient with a new or locally recurrent anal cancer s/p chemoRT for anal cancer 15 years ago?

What treatment would you recommend for a 3 cm basal cell carcinoma of the perianal skin with anal canal involvement?

The patient has no evidence of lymph node involvement.

How would you treat oligoprogressive metastatic GIST to the liver with a single enlarging liver lesion while on imatinib and no other evidence of active disease, where surgery and RFA are not possible?

If you would recommend radiation therapy, what dose-fractionation would you utilize?

For postoperative gastric patients status post total gastrectomy, how do you approach anastamotic coverage?

Detailed instructions regarding lymph node coverage have been published, but how do you think about coverage of the anastamoses from the gastrectomy?

Do you regularly utilize antiemetic or GI prophylaxis when treating abdominal sites with SBRT?

What timing do you recommend? What drug and what dose do you use?

How would you approach a young patient with metastatic rectal cancer and a painful local recurrence who underwent chemoRT to 50.4 Gy two years ago and declined surgery?

How would you mange true anal margin squamous cell carcinoma (with no involvement of anal canal) if wide local excision cannot be done and chemoradiation therapy is being used instead?

Anal cancer guidelines mostly refer to anal canal tumors with less information about tumors of skin in perianal area (ie true anal margin). Would IMR...

How would you treat very locally aggressive rectal cancer extending into muscle and causing internal iliac tumor thrombus, in a patient who is not a surgical candidate?

What volumes and doses of radiation would you recommend? To what dose would you limit the rectum, especially in a patient with no salvage surgical opt...

How do you approach patients with squamous cell carcinoma of anal canal with ano-vaginal fistula?

Do you consider diversion colostomy, or abdominoperineal resection up front?

Do you ever treat patients with rectal or anal cancer with IMRT in the prone position?

What is the best treatment approach for locally advanced (T3+ and/or N+) rectal cancer status post low anterior resection in a patient who has a remote history of seed implant for low risk prostate cancer?

What are your thoughts on dose, avoidance structures, re-tx risk, etc?

In what situations do you recommend preoperative chemoradiation for gastric cancer?

Should patients who received pelvic radiation get colonoscopy screenings more often than what is recommended for the general population?

In view of higher risks of rectal cancer after pelvic radiation, is more frequent screening warranted?

Do you routinely use any type of motion management or breathing techniques when treating a lower esophageal cancer?

How do you manage gastroesophageal junction cancer after resection with a positive circumferential surgical margin when no neoadjuvant treatment has been given?

Would you recommend adjuvant chemoradiation for T1N0 gastric adenocarcinoma status post R0 resection but no D2 lymph node dissection?

Does the lack of D2 dissection automatically necessitate adjuvant chemoradiation therapy (ie <5 LN obtained)? Would the presence of high risk facto...

Would you use standard neoadjuvant chemoradiation for a patient with advanced rectal cancer and a history of previous pelvic RT for another cancer?

For a patient with cT3-4N0 rectal cancer, does the dose of the previous RT affect your decision making (for example, 45 Gy to the pelvis with boo...

When would you consider initial induction chemotherapy (e.g. FOLFOX) followed by neoadjuvant chemoradiation, over neoadjuvant chemoradiation alone, in patients with locally advanced rectal cancer?

How do you manage unresctable thoracic esophageal cancer invading the trachea?

What chemotherapy and radiation doses/fractionation would you use once the airway has been stabilized to provide reasonably safe and effective palliat...

What is your preferred palliative regimen for pancreatic cancer with pain related to celiac plexus involvement?

Do you consider palliative SBRT 25Gy in 5 fractions? I often find that these patients are in severe pain and my typical regimen is 30 Gy in 10 fractio...

When treating adenocarinoma of the pancreas to 75 Gy in 25 fractions, what dose constraints do you use for small bowel, large bowel, and stomach?

What are your fields? Do you treat nodes electively?

When treating an inoperable patient with squamous cell carcinoma of the thoracic esophagus, do you ever dose escalate beyond 50.4Gy?

What doses do you use?

When treating a patient with anal cancer with a vaginal dilator, do you routinely simulate the patient with and without the dilator in place?

How often do patients become unable to tolerate the dilator during the treatment course secondary to discomfort related to acute toxicity?

How would you treat a p16+ small cell neuroendocine tumor of the anal canal with or without metastatic inguinal lymph node metastasis?

What radiation doses would you use? Would the radiation dose and fields be the same as for squamous cell carcinoma? What chemotherapy would you recomm...

In a thin patient with anal cancer, do you use bolus over the inguinal nodal volume when treating with an IMRT technique?

What positioning and immobilization technqiues do you use for anal canal carcinoma radiotherapy in the era of IMRT?

On the heels of the discussions regarding skin toxicity prophylaxis and treatment, I am interested in your thoughts and current practice regarding pat...

What dose do you typically prescribe to the primary tumor for definitive treatment of squamous cell carcinoma of the anal canal (given concurrently with chemotherapy)?

Do you have different preferences based on T-stage?

What approach have you found works best in treating persistent acute radiation proctitis in patients undergoing pelvic EBRT?

How do you manage patients with history of multiple perianal condylomas who develop focal high grade squamous intraepithelial lesions in the anal margin?

What would be your preferred management, surgical resection or radiation? If radiation is contemplated, what dose would be appropriate and would HPV s...

What factors determine the choice of treatment in the management of intermediate (BCLC stage B) hepatocellular carcinoma?

What features would help you decide between TACE vs. TARE vs. external beam radiation therapy?

What are your preferred target doses for bulky T4 rectal adenocarcinomas with extensive GU and anal sphincter involvement as well as common illiac and inguinal adenopathy, as part of total neoadjuvant therapy when future APR is planned?

In particular, many guidelines suggest a max point dose of 50Gy for small bowel but in cases of extensive disease how do you reconcile loops of bowel ...

In locally advanced rectal cancer treated with total neoadjuvant therapy, do you adjust boost volumes to only include post-chemo gross disease/nodes plus a margin?

What types of sexual side effects do you discuss with men undergoing radiation therapy for rectal and/or anal cancer?

Is there a risk for anejaculation?

Can you skip elective inguinal treatment in PET negative squamous cell carcinoma of anal canal?

Which patients would you offer a watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer?

How would you approach treatment in recurrent, localized rectal mucinous adenocarcinoma?

Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?

How would you treat a synchronous anal and oropharyngeal squamous cell carcinoma?

If the oropharyngeal cancer is operable (ex T1N1), would would your preference be upfront surgery? Would you use chemoradiation therapy to bo...

How would you approach a low-lying rectal cancer wtih para-aortic lymphadenopathy?

Would you recommend only chemotherapy or would you offer chemotherapy followed by restaging and possible definitive CRT and surgery?

How do you manage a patient with a 3.5 cm squamous cell carcinoma of the perianus (with no involvement of the anal canal) with a positive inguinal node?

Are the treatment volumes the same as those for squamous cell carcinoma of the anal canal?

When treating younger men with anal cancer do you consider dose to the prostate?

Given risk of secondary malignancies do you make an effort to avoid/spare the prostate or give any specific dose constraints when treating young men w...

How would you manage a patient with a very large adenocarcinoma of the rectum (10 cm) that extends to the anal verge with positive peri-rectal and inguinal lymph nodes, but no distant organ involvement?

Is this patient considered to have metastatic disease? Should definitive surgery be considered?

How would you manage a patient who presented with synchronous squamous cell carcinoma of the anus (cT2N0) and adenocarcinoma of the rectum (cT3N0) at 7cm from the anal verge?

For rectal cancer with solitary liver metastasis, do you recommend neoadjuvant chemoradiation?

Are these patients better candidates for preop chemotherapy alone?

Would you consider PCI for a patient with neuroendocrine carcinoma of the esophagus?

What are your treatment volumes for patients with gastric cancer receiving adjuvant chemoRT for a positive margin following gastrectomy and D2 nodal dissection?

Will you treat only the anastamosis and remnant stomach without elective nodal RT, or will you include elective nodal RT in your treatment fields, ass...

Would you ever recommend radiation alone for a T1N0 anal cancer?

How do you treat localized esophageal carcinoma in patients who are unwilling or unable to undergo chemotherapy or surgery?

If a patient is unable or unwillling to undergo dual or tri-modality therapy with chemotherapy or surgery, would you use a palliative radiation treatm...

What dose fractionation would you recommend for large (>5 cm) perianal Bowen's disease (squamous cell CIS)?

Is extensive abutment of the duodenum without invasion a contraindication to SBRT for pancreatic tumors?

If so, how do you quantify this when making a decision about who may or may not be a candidate for SBRT?

What methods do you use to decrease genital skin reaction when delivering pelvic radiation to patients in the prone position?

How would you manage a patient with synchronous locally advanced H&N (p16+) and locally advanced rectal adenocarcinoma?

If treating the H&N first, would you anticipate some effect of chemo on the rectal cancer? Would you include 5FU in the H&N chemo for be...

Would you consider induction chemotherapy prior to starting chemoradiation therapy in squamous cell carcinoma of the esophagus?

If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...

What treatment do you recommend for patients with Siewert III gastroesophageal junction cancer with periesophageal or mediastinal lymph node involvement beyond what is considered regional for gastric cancer?

Would you recommend chemoradiation therapy or chemotherapy upfront?

How would you manage an inguinal-only recurrence of a previously treated low lying rectal cancer?

Any role for surgery? What radiation volumes would be used?

How do you manage urgency and frequency of bowel movements secondary to radiation proctitis?

Which chemotherapy regimen do you prefer for concurrent treatment with radiation therapy for anal squamous cell carcinoma?

5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?

How would you treat an excised T1N0M0 anal canal well-differentiated squamous cell carcinoma with positive microscopic margin?

Do you recommend 5FU/mitomycin chemoradiotherapy or radiotherapy alone? What evidence is there for efficacy and toxicity differences between the two ...

Do you prefer to treat patients prone (on a belly board) or supine when treating rectal cancers?

Is there any evidence to show that treating with a bellyboard is preferred?

How would you manage locally advanced anal cancer patients with PET positive para-aortic lymph nodes?

Does external iliac coverage, such as in a T4 primary, justify IMRT for rectal cancer?

Do you offer adjuvant radiation therapy for patients with hepatocellular carcinoma status post partial hepatectomy with positive parenchymal margins?

What dose and volumes would you use?

Would you consider observation instead of a Whipple in a borderline resectable pancreatic cancer patient treated with neoadj CRT who has a radiographic CR?

If the patient received neoadjuvant FOLFOX for 4 cycles then 50.4 Gy with concurrent capecitabine, is that enough treatment to omit surgery?

How would you manage a patient with distal rectal adenocarcinoma involving the anal canal and a single non-bulky inguinal nodal metastasis?

Is curative intent surgery off the table?

Would you give post-operative radiation therapy and/or chemotherapy after an APR for anal cancer if inguinal lymph nodes were involved but margins were negative?

Surgery showed 1/5 and 1/4 LNs involved in the groins. What areas would you cover and with what corresponding doses?

Would you boost a positive margin (R1 resection or R2 resection) in a GEJ esophageal carcinoma that completed neoadjuvant chemoradiation?

What if the patient was not a candidate for additional chemotherapy? Would your answer change if the patient received the CROSS regimen with <...

Has SBRT shown to improve OS or PFS in patients with localized pancreatic cancer who are not a eligible for surgery due to other comorbidities?

How do you treat anal adenocarcinoma?

Is the approach chemoradiotherapy (Mitomycin-5FU) as for squamous carcinoma with surgery only for salvage or do you always perform surgery after neo-a...

What SBRT dose and tissue constraints would you choose for a presacral rectal recurrence status post preoperative chemoradiation to 50.4 Gy followed by surgical resection in a patient who is not a candidate for surgical re-resection?

Would irreversible elctroporation (IRE) performed at the time of Whipple affect your plans or dose for radiation in the setting of adjuvant treatment for pancreatic adenocarcinoma?

What is the appropriate follow up after chemoradiotherapy for patients with anal SCC?

Is obtaining serial MRIs or other imaging appropriate?

Would you consider maintenance therapy for patients who achieve complete response after palliative chemoradiation for metastatic distal esophageal adenocarcinoma?

If so, what regimen would you consider?

What is the role of radiation in regionally recurrent gastric cancer?

In a patient who received upfront surgery and chemotherapy who later recurred in the regional nodes, s/p lymphadenectomy, would you offer RT? If...

What techniques do you use to minimize gas artifacts on cone beam CT when treating upper abdominal lesions?

Antacids? Anti-motlity agents? Dietary changes? Combination?

In what situations do you recommend adjuvant radiotherapy for colon cancer?

How do you deliver it safely? Even when there is adherence to other organs (T4) or positive margins, I'm hesitant to offer RT because the volumes are ...

Would you consider BID treatment for a patient with a pelvic SCC (e.g. cervix or anal) if a significant amount of treatment days have been missed?

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...

Do you treat inguinal lymph nodes for rectal cancers involving the anal canal?

The RTOG contouring atlas doesn't give a consensus on this issue.

How would you manage dysphagia and odynophagia in an otherwise healthy patient with newly diagnosed metastatic esophageal cancer with a large primary in the mid to distal esophagus?

Would you send the patient for a stent or do palliative RT?

When giving hypofractionated ablative doses of radiation for cholangiocarcinoma, do you give concurrent Xeloda or hold chemo during radiation?

http://ascopubs.org/doi/full/10.1200/JCO.2015.64.2710

Would you recommend repeat radiation therapy for a painful perineal recurrence in a patient who failed definitive CRT, and recurred again after salvage abdominoperineal resection (APR)?

What would be the RT dose and what percentages would you quote for toxicities? Would you recommend consideration of surgery instead?

When is it appropriate to recommend a diverting colostomy for treatment of anal cancer or low lying rectal cancer?

Fecal incontinence can be one indication. What are others?

What is the appropriate role for radiation therapy in patients with HCC or intrahepatic cholangiocarcinoma who are transplant candidates?

Should radiation be offered as a bridge to transplant? Should this depend on whether SBRT is feasible (i.e. is fractionated IMRT an appropriate option...

What is the appropriate dose and volume for adjuvant treatment of a sigmoid colon adenocarcinoma adherent to the L5 vertebral body with a positive radial margin?

Do you offer adjuvant radiotherapy for pancreatic adenocarcinoma following surgical resection?

Given lack of strong evidence supporting the benefits of adjvuant RT in resected pancreatic adenocarcinoma (with results of the ongoing RTOG 0848 unav...

Do you ever offer repeat radiation for hepatobiliary cancers in cases of local recurrence after definitive external beam or SBRT?

If so, what constraints would you use for central biliary and other normal structures and what dose/fractionation would you use?

Can pre-op chemoRT be used to potentially downstage an early stage rectal cancer (i.e. T2 N0) for a sphincter sparing operation?

In a male patient with a single inguinal node containing SCC, with no identifiable anal or penile lesions, what areas would you cover and to what dose?

Would you treat the node alone, unilateral/bilateral inguinal nodal basins, or cover any possible primary locations such as the anal mucosa?

For patients receiving concurrent chemoradiation for anal cancer, what is your ANC threshold for holding radiation or switching to a boost plan to limit myelotoxicity?

Have the results of LAP07 caused your institution to pursue more aggressive systemic therapy before radiotherapy in the treatment of pancreatic cancer?

Is better systemic control needed to make radiation therapy beneficial?

When treating prostate or other pelvic malignancies, what dose constraints do you use for the sigmoid colon?

Do you use the same constraints that you would for the rectum? Or perhaps employ a lower dose limit, such as not exceeding 65Gy to a small volume of t...

Would you recommend an inguinal node dissection as part of definitive treatment for adenocarcinoma of the anus with suspicious inguinal nodes?

What about bulky nodal disease?

How do you treat hiccups in cancer patients?

Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?

What dose constraint, if any, do you use for the diaphragm when treating liver or lung tumors with SBRT?

Have you ever seen toxicity related to diaphragm dose with conventional fractionation?

In patients with newly diagnosed cervical esophageal cancer with limited metastatic disease, do you treat the primary with chemoradiation?

What treatment volume is appropriate when treating postoperatively for esophageal carcinoma?

In what situation, if ever, do you include mediastinal nodes?

In light of the recently published LAP07 trial, what is the role of radiation in unresectable pancreatic cancer?

In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...

What GTV to CTV margin do you typically use for the primary lesion in anal cancer?

RTOG 0529 guidelines were 2.5cm margin from GTVA to CTVA (except bone or air), do you still follow this practice?

How would you treat locoregionally recurrent anal CA?

If a patient developed locoregional recurrence after initial chemoradiation, would resection of known disease followed by observation be preferred?

Are there situations in which elective nodal volumes may be reduced for T1/T2N0 anal SCC?

Is inguinal coverage always required?

Do you recommend neoadjuvant chemotherapy or induction chemo + chemoRT for borderline resectable pancreatic cancer?

How would the new data presented at ASCO GI 2021 from from Alliance A021501 influence your answer?

For esophageal and gastroesophageal junction cancers, which lymph nodes are metastatic versus regional?

Specifically, are hilar nodes metastatic?

Is acute pancreatitis a contraindication to radiotherapy for patients with pancreatic cancer?

Does treatment of the pancreas with radiotherapy during an episode of acute pancreatitis increase the risk of acute and late side effects? Should one ...

Given the significant risk of recurrence after chemoradiation for locally advanced anal carcinoma, should resection be considered (with or without neoadjuvant treatment) in select cases?

At other sites we consider locally advanced disease and high risk of recurrence a contraindication for organ preservation. Would surgery improve likel...

How do you treat anal margin tumors?

Per NCCN, only well-differentiated T1 lesions (with 1cm surgical margins) should be excised (with no other treatment). Do you follow this at your inst...

Is it safe and appropriate to palliatively treat abdominal or thoracic tumors with concurrent chemotherapy when using fractions of 250-300 cGy?

For example, there is a retrospective series out of MD Anderson (Kim, Acta Oncologica 2008) wherein 37 patients with gastric cancer were treated with ...

What is the optimal dose fractionation for treating liver metastases in the central liver causing obstruction of biliary flow?

Will higher doses per fraction increase the risk of fibrosis and cause permanent impediment to biliary flow?

Are there any special considerations when treating a patient with anal cancer who has poorly managed HIV/AIDS?

Is there an advantage in treating with a SIB (simultaneous integrated boost) over sequential boost for anal cancer?

In what situations, if any, do you offer postoperative radiation or chemoradiation for patients with squamous cell carcinoma of the esophagus?

Would your recommendation change if the histology was adenocarcinoma (excluding GE junction tumors)?

How do you interpret the results of the ACT II trial in terms of the choice between cisplatin and mitomycin in the treatment of anal cancers?

Reference: https://www.ncbi.nlm.nih.gov/pubmed/23578724

When treating borderline resectable pancreatic adenocarcinoma patients with neoadjuvant chemoradiation, do you treat the elective nodal regions or the primary alone?

Is your approach similar in unresectable disease? Is there evidence to support one approach over the other?

In a patient with a small cell of the esophagus in which trimodality therapy is planned what dose of preoperative radiation would you use and would you utilize BID fractionation?

How do you approach disease monitoring in patients with localized rectal cancer who have received treatment with chemoradiation?

Is MRI being considered the primary mode of imaging in multidisciplinary tumor boards, especially in light of the results of the MERCURY trial (JCO 20...

In a patient with a large condyloma adjacent to a squamous cell carcinoma of the anal canal being treated with chemoradiation how would you incorporate the condyloma in the target volume if it is PET negative and would it receive a different dose?

What maximum volume (in cc's) of small bowel would you allow to receive 45 Gy in a patient with node positive squamous cell carcinoma of the anal canal receiving concurrent chemoradiation with 5-FU/MMC being treated with IMRT?

What if a large portion of small bowel is located within PTV45?

Should capecitabine be administered at a specific time prior to RT in pre-op chemoradiation treatment for rectal cancer?

Would taking the drug at a specific time point prior to their radiation appointment time to maximize blood levels of the drug be clinically beneficial...

Would you advocate for sphincter preserving chemoradiation therapy for a patient with a diagnosis of anal canal carcinoma who has previously been treated with pelvic radiation such as EBRT or brachytherapy?

How would your radiation treatment approach change in terms of dose and target definition? Would the time interval between diagnosis affect the optio...

Is there any role for adjuvant radiation for a low grade, intraductal papillary mucinous neoplasm (IPMN) of the pancreas after resection with a positive pancreatic margin?

What is your typical target/field when treating a patient with 5 Gy x 5 fractions pre-operatively for rectal cancer?

Do you target the whole pelvis or a smaller "boost-like" field?

Is there a benefit to adjuvant chemotherapy for patients with a solitary liver metastasis from previously treated colorectal cancer?

If so, what is your preferred regimen?

What would you include in the radiation field for a patient with T2 N0 M0 adenocarcinoma of the distal 1/3 of the esophagus?

In a patient who is not a surgical candidate and has a negative PET/CT and EUS, would you include celiac lymph nodes in the radiation field?

Is it acceptable for a medical oncologist to use Xeloda in place of 5FU when treating GI sites other than rectal?

Specifically - anus, pancreas, gastric?

Is it appropriate to use SBRT on unresectable pancreatic tumors invading the duodenum?

Do you use any age limit to determine whether pancreatic SBRT is appropriate?

Should patients with anal canal SCC undergo an FNA biopsy of any palpable inguinal LN that is also FDG avid on PET/CT or should these nodes be assumed to be positive and treated to a higher dose?

How do you manage a patient a with a PET positive inguinal lymph node who has a typical anal cancer? If a biopsy is done and it is negative, is it is ...

What adjuvant therapy recommendations would you make for a patient with pT3N0M0 duodenal cancer?

In a case with negative margins, would you consider chemotherapy alone or sequence with chemoradiation?

Is chemoradiation the preferred treatment for T2 SCC of the anal canal in a patient with IBD?

Does the presense of ulcerative colitis, now in remission, affect your dose and fields?

How do you use a 4D CT to account for hepatocellular carcinoma tumor motion?

When planning SBRT cases for primary liver cancers, it is very difficult to see the tumor on the non-contrast 4D scan. How do you use information from...

Is there an "ideal" method for abdominal motion control when treating upper abdomen malignancies?

In my training, we used an abdominal compression paddle, but in my current practice, my physicist says that we cannot treat through multiple parts of ...

Are special precautions necessary for esophageal cancer with tracheal invasion prior to chemoradiation?

Are there any precautions to prevent formation of a TE fistula?

What is your preferred dose for definitive radiation of squamous cell cancer of the thoracic esophagus that will be combined with chemothererapy?

Would your approach change if the histology were adenocarcinoma?

Would you treat the inguinal nodes in a patient who had an adenocarcinoma excised from the anal canal?

In a lesion <2.5 cm from anal verge arising in a tubulovillous adenoma, does the data from Taylor, et. al. Red Journal 2001 apply?

What is the evidence that there is a benefit to giving doses higher than 3060 cGy-3600 cGy in the elective treatment of uninvolved lymph nodes in the treatment of SCC of anal canal with chemoradiation?

When is SBRT or hypofractionated radiation appropriate as adjuvant treatment for pancreatic cancer?

What are the targets (tumor bed, positive margin, nodes etc.)?

Is liver radiotherapy contraindicated in patients with Child-Pugh C liver function?

Would you avoid any RT in these patients, including palliation for a portal vein thrombus? Or would you consider a short course of RT (like 20Gy/5fx)?

For elderly patients with locally advanced rectal cancer who are not candidates for surgery or chemotherapy, what would be an appropriate palliative regimen?

Do you recommend adjuvant chemoradiation for T2N0 gastric adenocarcinoma?

In a patient with an R0 resection, would you routinely recommend postop chemoradiation, since these patients were included in the MacDo...

When treating pancreatic cancer with adjuvant chemoradiation, do you treat the initial field to 50 Gy, as per RTOG 0848, or to 45 Gy?

For cases with positive margins, do you boost to 54 Gy? If so, do you boost the entire tumor bed or only the area of the positive margin?

What dose and upper field border would you use following transanal excision for rectal cancer found to be T2 by final pathology but without LVSI or perineural invasion?

Should standard post operative radiation fields be used, treating up to the L5-S1 interspace? Or is it acceptable to treat a lower field, for ins...

What is the appropriate treatment for a low lying rectal cancer in the setting of prior definitive prostate IMRT?

Fore example for a T3N0 rectal cancer on EUS?

Is it possible to palliate presacral recurrences of rectal cancer in patients who previously received neoadjuvant chemoradiation to the rectum?

In the past, I haven't seen great results in palliating the presacral area. The pain is excruciating for many patients. Is there an effective option f...

For a GE junction tumor with a lymph node distant from the primary site, would the treatment volume be contiguous?

I.e. Would you treat most of the normal esophagus to include a mediastinal lymph node?

How do you manage squamous cell carcinoma in situ of the anus?

While the Nigro/Wayne state regimen consisting of Mito C & 5FU is well stablished for squamous cell carcinoma of the anus/perianal tissue, a...

For a patient who has undergone preoperative chemoradiation to 50Gy for locally advanced rectal cancer followed by LAR or APR, would you treat a positive margin with radiation therapy?

If so, what dose?

How do you contour distal esophageal cancer in the postop setting after Ivor-Lewis pT3N3 (perigastric and periesophageal LN)?

What regional lymph nodes do you include perigastric, portahepatic, periesophageal, celiac, splenic, pancreaticoduodenal, sup. mesenteric, paraesophag...

Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?

Are there any indications to choose one over the other?

What is the likelihood of a successful pregnancy following pelvic irradiation?

How should we counsel young women who are receiving treatment for GI/GYN malignancies?

Which regimen is better for gastric adenocarcinoma- neoadjuvant chemotherapy or adjuvant chemoradiation?

Is there a consensus on the MAGIC v. MacDonald debate?

Is there a role for PET/CT in pancreatic cancer staging or treatment planning?

I recently had a patient with unresectable disease ask for a PET before starting RT but I’m not sure there is a benefit.

Should I use PET/CT for GE junction treatment planning?

We use PET for esophageal, but not gastric cancer. GE junction seems like a grey area.

Do you stage and treat GE junction tumors like gastric or esophageal cancer?

Does the advent of FLOT in gastric cancers, change your approach to GE adeno's? Would anyone consider FLOT followed by chemoradition followed by surge...

Do you ever give postoperative chemoradiation in patients who underwent preoperative chemotherapy for gastric adencocarcinoma?

How do you control for organ motion when treating pancreatic cancer?

What techniques work best?