Radiation Oncology

Gastrointestinal Cancers   

Questions discussed in this category



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 ...

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...

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

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...

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

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

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

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

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

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

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...

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...

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

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

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

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

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...

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...

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

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?

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

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...

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

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

I am considering every 6 week pembrolizumab dosing in patients >70 years old in whom I want to reduce clinic visits for, especially in the context ...

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

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...

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

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...

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

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 ...

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

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

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

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

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

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...

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

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

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

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 ...

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

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...

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...

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?) ...

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...

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...

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...

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

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)?

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

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...

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

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...

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

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

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

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

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

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

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

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...

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 ...

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

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

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...

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

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

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

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...

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...

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

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?

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

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

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...

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...

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

Should the recent publication of Chen et al. dose escalation study for inoperable SCC esophageal cancer patients treated with CCRT, showing an 8% 5-ye...

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

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

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

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...

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

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...

How often do patients become unable to tolerate the dilator during the treatment course secondary to discomfort related to acute toxicity?

Would the radiation dose and fields be the same as for squamous cell carcinoma? What chemotherapy would you recommend? 

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

On the heels of the discussions regarding skin toxicity prophylaxis and treatment, I am interested in your thoughts and current practice regarding pat...

What would be your preferred management, surgical resection or radiation? If radiation is contemplated, what dose would be appropriate and would HPV s...

What features would help you decide between TACE vs. TARE vs. external beam radiation therapy?

Based on the UK OnCoRe matched cohort analysis, would you offer a watch-and-wait approach off protocol or are you uncomfortable treatin...

Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?

If the oropharyngeal cancer is operable (ex T1N1), would would your preference be upfront surgery?   Would you use chemoradiation therapy to bo...

Would you recommend only chemotherapy or would you offer chemotherapy followed by restaging and possible definitive CRT and surgery?

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...

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...

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...

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...

If so, how do you quantify this when making a decision about who may or may not be a candidate for SBRT?

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...

If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...

5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?  

Do you recommend 5FU/mitomycin chemoradiotherapy or radiotherapy alone? What evidence is there for efficacy and toxicity differences between the two ...

Is there any evidence to show that treating with a bellyboard is preferred? 

If the patient received neoadjuvant FOLFOX for 4 cycles then 50.4 Gy with concurrent capecitabine, is that enough treatment to omit surgery?

Surgery showed 1/5 and 1/4 LNs involved in the groins. What areas would you cover and with what corresponding doses?

What if the patient was not a candidate for additional chemotherapy?  Would your answer change if the patient received the CROSS regimen with <...

Is the approach chemoradiotherapy (Mitomycin-5FU) as for squamous carcinoma with surgery only for salvage or do you always perform surgery after neo-a...

In a patient who received upfront surgery and chemotherapy who later recurred in the regional nodes, s/p lymphadenectomy, would you offer RT?  If...

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

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...

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 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 ...

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...

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

The RTOG contouring atlas doesn't give a consensus on this issue.

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

What would be the RT dose and what percentages would you quote for toxicities? Would you recommend consideration of surgery instead?

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...

Given lack of strong evidence supporting the benefits of adjvuant RT in resected pancreatic adenocarcinoma (with results of the ongoing RTOG 0848 unav...

If so, what constraints would you use for central biliary and other normal structures and what dose/fractionation would you use?

Would you treat the node alone, unilateral/bilateral inguinal nodal basins, or cover any possible primary locations such as the anal mucosa?

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...

Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?

Have you ever seen toxicity related to diaphragm dose with conventional fractionation?  

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

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

In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...

RTOG 0529 guidelines were 2.5cm margin from GTVA to CTVA (except bone or air), do you still follow this practice?

If a patient developed locoregional recurrence after initial chemoradiation, would resection of known disease followed by observation be preferred?

With the current data, I'm struggling to justify addition of radiation for potentially resectable disease.  If in favor of RT, do you recommend s...

Does treatment of the pancreas with radiotherapy during an episode of acute pancreatitis increase the risk of acute and late side effects? Should one ...

At other sites we consider locally advanced disease and high risk of recurrence a contraindication for organ preservation. Would surgery improve likel...

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...

For example, there is a retrospective series out of MD Anderson (Kim, Acta Oncologica 2008) wherein 37 patients with gastric cancer were treated with ...

Will higher doses per fraction increase the risk of fibrosis and cause permanent impediment to biliary flow?

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...

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...

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...

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

How would your radiation treatment approach change in terms of dose and target definition? Would the time interval between diagnosis affect the optio...

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?

Do you use any age limit to determine whether pancreatic SBRT is appropriate?  

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 ...

In a case with negative margins, would you consider chemotherapy alone or sequence with chemoradiation?

Does the presense of ulcerative colitis, now in remission, affect your dose and fields?

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...

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 ...

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? 

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)?

In a patient with an R0 resection, would you routinely recommend postop chemoradiation, since these patients were included in the MacDo...

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? 

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...

Would you boost to >54Gy? 60Gy? Is there relevant literature/evidence for supporting a higher dose?

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...

I.e. Would you treat most of the normal esophagus to include a mediastinal lymph node? 

While the Nigro/Wayne state regimen consisting of Mito C &  5FU is well stablished for squamous cell carcinoma of the anus/perianal tissue, a...

What regional lymph nodes do you include perigastric, portahepatic, periesophageal, celiac, splenic, pancreaticoduodenal, sup. mesenteric, paraesophag...

How should we counsel young women who are receiving treatment for GI/GYN malignancies?

I have a healthy 70+ year old man recently diagnosed with cT3N1M0 rectal adenoCA and GS 3+4=7 prostate cancer in 1/6 cores with a PSA of 25. Is ...

I recently had a patient with unresectable disease ask for a PET before starting RT but I’m not sure there is a benefit. 

We use PET for esophageal, but not gastric cancer. GE junction seems like a grey area. 

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...


Papers discussed in this category


N. Engl. J. Med., 2012-05-31

Lancet Oncol., 2015-09-01

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Radiat Oncol, 2014-12-23

Lancet (London, England), 2009-03-07

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Ann. Surg. Oncol., 2017 May 30

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Cancer, 2015-04-01

JAMA, 2012 Jul 11

JAMA, 2008-03-05

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JAMA, 2007 Jan 17

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Practical radiation oncology, 2016

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N. Engl. J. Med., 2004-10-21

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J. Natl. Cancer Inst., 2016-12-01

Lancet, 2017-07-29

Pract Radiat Oncol, 2012 Oct-Dec

Curr Oncol, 2012-04-01

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American journal of clinical oncology, 2018-07

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Ann. Oncol., 2016-05-01

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Ann. Surg., 2015-09-01

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N. Engl. J. Med., 2001-08-30

J. Clin. Oncol., 2005-09-01

Lancet Oncol., 2017-03-01

International journal of radiation oncology, biology, physics, 2003-03-01

Int J Radiat Oncol Biol Phys, 2006 Dec 1

Practical radiation oncology, 2018

Int. J. Radiat. Oncol. Biol. Phys., 2012 Aug 14

Practical radiation oncology, 2017

Radiother Oncol, 2012 Feb 22

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Br J Surg,

Proc. R. Soc. Med.,

Lancet Oncol., 2011 May 17

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-03-20

J. Clin. Oncol.,

Practical radiation oncology, 2015

Radiother Oncol, 2014 Jun

J Clin Oncol, 2013 May 1

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-02-10

Journal of the National Cancer Institute, 2017-09-01

International journal of radiation oncology, biology, physics, 2005-12-01

N Engl J Med, 2007 Aug 16

The New England journal of medicine, 1999-08-12

Radiother Oncol, 2011 Oct 10

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Ann. Oncol.,

Br J Surg, 2016 Nov 01

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International journal of radiation oncology, biology, physics, 2014-11-01

Radiother Oncol, 2016 Aug

J. Thorac. Cardiovasc. Surg., 2014 Feb 10

International journal of radiation oncology, biology, physics, 2008-07-15

Clinical and translational radiation oncology, 2017-06

Radiat Oncol,

Gastroenterology, 2016-12

International journal of radiation oncology, biology, physics, 2018-03-15

Lancet,

Cancer,

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2005-02-20

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2012-08

J. Clin. Oncol., 2009 May 18

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2019-04

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