For a patient who has vaginal cuff recurrence <6 months after adjuvant pelvic radiotherapy to a dose of 45 Gy, how would you approach management?  

If amenable to a potentially curative brachytherapy approach, I would generally want to do this first and then give systemic treatment. The risk of local progression during systemic treatment is significant, and if this occurs, the patient has often lost the chance to be cured. However, if the decis...

I will start with systemic therapy and then add brachytherapy as local treatment with dose adjusted based on response and cumulative OAR dose.

I would consider interstitial brachytherapy alone. Especially if it's possible to get to definitive doses (perhaps EQD2 of 60ish) to GTV without exceeding the embrace "hard" constraints, including her EBRT dose. If dMMR, would start with IO and hope she has a great response. 

I agree with the above, especially if the patient is not symptomatic. Rapid recurrence may portend a very high risk of distant metastatic disease. I would consider rebiopsy of the tumor and complete molecular/sequencing analysis to see if there are any targets (that may be different from the origina...