Radiation Oncology

Genitourinary Cancers   

Questions discussed in this category

Patient had multiple positive margins and is on ADT.  What would your treatment volumes be and to what dose?

Do you recommend before and/or after procedures? Do you have the same recommendations for any or all the below: hydrogel space, fiducial placement, LD...

Given the publication by Malone, et al (JCO, 2019), how do you sequence ADT relative to the start of RT? https://ascopubs.org/doi/full/10.1200/JCO.19....

Do you routinely include pelvic lymph nodes, prostatic urethra, and prostate?

Patient had neoadjuvant ADT. Are there any preferred isotopes, seed activities, etc for small prostate brachytherapy?

Any difference if patient is undergoing HDR vs LDR? For example, prescription doses are 45Gy for EBRT and 10.5Gy x 2 for HDR boost. 

A recent study http://www.ncbi.nlm.nih.gov/pubmed/27480153 showed an improvement in bichemical failure with higher doses. How much impact do...

Given CHAARTED and STAMPEDE, what would you recommend? Would lymph node vs osseous mets change your recommendation given the trial did allow patients ...

Do you treat in this scenario if mild/moderate infiltration? What are your thoughts on the article Fischer-Valuck, et al, PRO, 2017 (PMID: 280895...

Would you recommend radiation to the prostatic fossa and/or the oligometastatic site? How would you dose these areas? Would you recommend ADT?

For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...

The patient's urologist will not offer testosterone supplementation unless he undergoes definitive therapy of his early stage prostate cancer. Are the...

Is a positive imaging enough to confirm the diagnosis? If not, what situations are appropriate for a biopsy?

Based on the RADICALS-RT trial presented at ESMO, can RT be omitted in post op prostate patients in favor of salvage RT? If not which group of patient...

If there was still was PSMA PET/CT activity in the prostate after a year of ADT would you offer RT to the prostate +/-nodes? 

Does time interval from initial radiation therapy matter. Assume this is in the case of castrate resistant prostate cancer in which all other avenues ...

Will your recommendation change if there is suspicious/confirmed locally recurrent nodule in the prostate bed?

68 y.o. Male underwent inguinal orchiectomy and spermatic cord resection of a 5 cm malignant fibrous histiocytoma of the spermatic cord. Margins of re...

Would you require the rituxan to be held prior to radiation?  Would this matter if it was in the post-prostatectomy setting?

Should cystectomy remain standard of care? (Recently debated in JAMA Oncology: http://jamanetwork.com/journals/jamaoncology/article-abstract/2520055...

If a patient had biopsy proven gleason 6 disease 3-5 years ago and has had a slowly rising PSA to between 15-20 over the past year or 2, would you req...

Per the ALSYMPCA study, they excluded patients with > 3cm lymphadenopathy. Patient is currently on Xtandi and Lupron and refuses taxotere.

Would you give chemotherapy concurrently with radiation? Would you change your radiation dose?

Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...

Would you offer definitive management with radiation and ADT? Or systemic therapy alone such as with ADT+abiraterone?

Do you prescribe antiandrogen beyond the typical 2-3 weeks after starting LHRH agonist therapy to prevent testosterone flare? If so, for how long do y...

For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...

Is there any role for definitive prostate radiation extrapolating from the Stampede and recent RTOG 0521?

Would you consider scrotum contaminated and consider including it in fields?

Would you administer extended field radiation therapy?  Would you omit radiation therapy?

The STAMPEDE trial recently published in Lancet used 55 Gy in 20 fractions but did not include dose constraints.

Does the update of RTOG 96-01, presented at ASTRO 2015, change your practice for these patients? Or should ADT be limited to a particular subgroup?

How does it vary by technique (standard fractionation, hypofractionation, or SBRT)? Does your PTV change if you are treating pelvic lymph nodes?

For example, if the patient has low PSA, Gleason 6 disease but has high volume (>50% positive cores) would that discourage you from recommending ac...

SBRT vs more comprehensive nodal RT with SIB to involved node? Would you include the prostate bed in your treatment volume? ADT duration? What other f...

Do you prefer LDR prostate brachytherapy first or as a "boost" following external beam radiation therapy?

Is there a benefit to one fractionation schedule v. the other?

Is there a strong rationale for treating the whole prostate (not prostatic urethra) electively to 41-50 Gy?

For those of us just transitioning over to hypofractionation, what are reasonable, but conservative, constraints that you use?

Would you consider EBRT alone, brachytherapy alone, or EBRT with a brachy boost? Would you counsel these patients differently regarding short/long ter...

If the patient had pelvic adenopathy, would you include that in your treatment volumes?  What dose and fractionation would be considered appropri...

The original study used 50% of positive cores, but the MSKCC nomogram can give a high risk of EPE with just 4-5 positive cores out of 12

Given that it is cleared from the body by renal filtration, are you concerned about clearance issues?

For example, in standard high-risk we generally cover proximal 2cm to elective dose, before doing cone down boost to prostate and proximal 1cm. If a ...

In particular would it affect the decisions for brachytherapy or androgen deprivation? How do you monitor for treatment response since they may not m...

Are there problems with volume changes from the spacer dissolving while the patient is on treatment? What is your department's protocol for these type...

Assuming no advanced imaging is available, what lymph node morphologic criteria (ie. lack of fatty hilum, size, number of nodes, etc.) do you use to u...

If a patient's PSA goes from undetectable to minimally detectable (ie 0.03-.05) would you wait to offer salvage radiation?  Would your recommenda...

For example, are PET Axumin or PSMA studies being ordered in the upfront setting? 

Which risk estimator is felt to be the most accurate and what threshold? What's the best contouring guidelines for ENI for prostate?

A recent NCBD analysis (Rusthoven et al, JCO 2016) suggests that the addition of prostate RT significantly improves survival compared to ADT alon...

The recently published executive summary from ASTRO/ASCO/AUA hypofractionated radiation therapy for localized prostate cancer states "Five-fracti...

If the patient is in remission for metastatic melanoma but continue to take an anit-PD1 therapy, it giving ADT, EBRT + brachytherapy safe for a high r...

For example, do you change your prescription dose, treatment schedule, or OAR constraints? Have you noticed increased toxicity in older patients, e.g....

For example, for the first 25 fractions, you would treat the rest of the pelvis in 1.8 Gy/fx to 45 Gy, and then using a SIB treat the prostate/proxima...

What factors would you consider? What if this meant treatment of the full kidney? If treatment is recommended, would you utilize an SBRT approach...

Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...

Node-positive patients were not eligible for ASCENDE-RT, and the current NCCN guidelines do not list brachy boost as an option for regional ...

What is the upper limit of size you would consider offering a patient a five fraction regimen?

If so, what dose? What if there is positive a PA lymph node but no signs of distal mets? 

If so, would you offer pelvic lymph node irradiation in these patients if they have pathologically node positive disease?

Do you change your treatment volumes, particularly when treating the seminal vesicles, to avoid the ureters?

Is there a dose response relationship, as suggested in the phase I MSKCC dose escalation study presented at ASTRO 2017?

Do you use a specific threshold number of sites to make your decision? Apart from assessing for cytopenias, do you consider any other patient factors?

Would you treat this patient any differently than any other very high risk prostate cancer patient?  Are there any additional dose constraints fo...

Do you maximize rectal emptiness at the time of sim (ex with enema if needed) or do you simulate with a full rectum since this is most reproducible?&n...

Specifically, would the addition of a brachytherapy boost impact his ability to receive future intravesical therapy?

If the patient is refusing hormone therapy is there a contraindication to prostate RT with concurrent 5FU-based chemotherapy?

Many patients are still able to orgasm but are disturbed by the loss of seminal fluid.

There is a recent publication that nicely summarizes the molecular/genetic tests for prostate cancer (https://www.ncbi.nlm.nih.gov/pubmed/26123120). W...

Is MRI fusion is adequate for urethral delineation and sparing?  Would you worry about prostate deformation by placement and removal of catheter ...

Specifically, does the Decipher score influence the incorporation and/or duration of ADT? Can it be used to better stratify intermediate risk patients...

Specifically, in patients who have an undetectable PSA post-op, with high risk features such as seminal vesicle invasion, positive margins, or extrapr...

Using the standard whole bladder dose fractionation used in BC2001, 55 Gy in 2.75 Gy fractions.

For instance: urologists who only refer for a rising PSA, even in a patient with high-risk features, those who use Decipher results to decide when to ...

Based on the updated results of the PCS IV trial is 18 months of ADT the new standard of care for men with high-risk prostate cancer treated with...

Is there any information on how ADT affects the test operating characteristics?  

Does histology, i.e. urothelial carcinoma versus squamous cell carcinoma, impact this decision?

Are there any other medications, outside of anticoagulation, that would be considered absolute or relative contraindications?

Is a single-fraction HDR boost appropriate following conventionally fractionated EBRT to 45-50.4Gy?

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...

What is your preferred dose and fractionation? Do you utilize 4D simulation? Additionally, how conservative are your constraints for ipsilateral uninv...

What dose would you use?  Would your approach to elective nodal radiation be different in the preoperative setting?

If the two intermediate risk factors are on the lower end of intermediate risk (ex GS 3+4 and PSA 11) with a very small volume disease, can a more int...

Do you sim and treat with their bladder as is? Or do you have patients who do urinate fill their bladder somewhat? Fluid overload is often a considera...

Is it better to treat without hormone suppression?  Or would this be reason enough to push the patient toward prostatectomy?

Assuming you are treating whole bladder only with concurrent chemotherapy, when would you recommend hypofractionated radiation (20 fractions) vs stand...

Are there special tests you order for SBRT but not IMRT? How does the PSA change differ (if at all) compared to IMRT. Do you still use the Pheonix de...

In the case of patients many years out from RP who have a slowly rising PSA, do you offer salvage RT while the PSA is still very low or follow the PSA...

If a patient who has undergone radical prostatectomy many years previously presents with biochemical failure and is found to have a nodule in the pros...

If Dynamic Sentinel Lymph Node biopsy is not available, would you refer the patient for node dissection, radiate, or observe? What nodal regions would...

In a patient who has a rising PSA, palpable nodule, MRI findings etc., is it ethical to treat the patient with inadequate information and ri...

Prospective single arm studies with short term follow-up were recently presented in abstract form (Kishan et al, IJROBP, Oct 2017; Mallick et al, IJRO...

For example, previous RT for seminoma several decades ago. How about a more recently treated rectal cancer with pre-op chemoradiation?

How do you prioritize alignment of bony anatomy, prostate and nodes? Do you have varying PTV margins for different structures or as compared to prost...

ASCENDE-RT excluded these patients as well as those with a PSA > 40, but it seems these patients may stand to benefit as well.

Would you offer adjuvant radiation? (Dose? Target?) Would you add ADT? Would the number of lymph nodes involved influence your decision?

Does the 1 year of ADT used in the ASCENDE-RT trial present a new option of the standard of care in timing ADT when combined with brachtherapy boost?

The current treatment for bladder adenoCA is surgery. However in non-surgical candidates, RT is an option. Would you consider adding chemo ? Also woul...

Do you have a prostate volume/size threshold? Baseline urinary function? Any other anatomy or patient factors that may make patient not suitable for...

Our urologists routinely get these scans prior to definitive therapy and at times in the postprostatectomy setting.  The high sensitivity makes f...

Specifically, what criteria do you use to quantify "low-volume" prostate cancer?  What other criteria do you consider when defining low volume in...

In addition to scans, would you biopsy the prostate/SV? Would radiation therapy to the untreated pelvic nodes with hormonal therapy be a consideratio...

cT3 patients were a minority of patients in the data demonstrating superiority of tri-modality therapy. While cT3b patients have particularly poor out...

Can radium-223 be given to patients with progressive diffuse osseous metastases if they have a history of visceral metastatic disease that resolved wi...

In patients with new bone pain and without any evidence of bone metastases receiving GnRH agonists, how do you manage pain symptoms?

Are the results of the STAMPEDE trial presented at ASCO 2017 practice changing?

Is there a length of time that would be considered too long between TURBT and CRT? At what time point would you recommend another cystoscopy to evalua...

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...

With biopsy-proven, negative systemic restaging disease, what dose and fractionation is appropriate if treating with IMRT? Should ADT generally b...

Would you offer it for positive margins? NCCN says to consider adjuvant radiation for pT3-T4 or pN0-2. Is there sufficient evidence for adjuvant radia...

Would you consider this an indication to treat lymph nodes, if you would typically not do so?

How high would you try to boost those involved nodes if they are in a favorable location with respect to his rectum and small bowel? 

Is there an upper limit to offer definitive RT? Is it possible to have a PSA of 100-500 and still have only local disease?

To what extent do you worry about overlapping myelosuppression? Is there any advantage to overlapping therapy?

Standard RTOG constraints include guidelines for rectal v60, v65, v70, v75, but is there a relative or absolute volume constraint for rectal v80 that ...

Is there a role for salvage LN dissection or salvage RT to the node? And is there a role for systemic therapy (ADT or chemotherapy) in addition? If yo...

Should the workup change with the PSA level (for example, >2 vs <2 ng/ml post-op PSA)?  Is there a PSA level for which salvage radiotherapy...

Two retrospective studies from Stanford showed that patients who received ADT had an increased risk of dementia and Alzheimer's. Is this finding ...

Are patients with extracapsular extension at diagnosis good candidates for brachytherapy boost? If extracapsular disease that can't be effectively&nbs...

How do you minimize these risks? If using local anesthesia only in the outpatient setting, how is pain control at the area of injection?

Do you use a PSA threshold, PSA doubling time, or only evidence of metastatic disease to trigger ADT? For those without rapid doubling time, do you ev...

Is there any benefit to delaying start of RT or perhaps changing to complete adrogen blockage if maximal PSA response is not achieved in 2 mo?   ...

If so, when? There seems to be an increasing trend among urologists to offer surgery to high-risk prostate cancer patients despite the low probability...

Are fiducials always necessary? Does your answer differ if you're treating with standard vs. moderate vs. extreme hypofractionation?

We are being referred more patients for salvage radiation after this procedure, not sure what the evidence is.

Specifically if sentinel node mapping and sampling has not been performed or refused?

Do you have a cut off in terms of prostate size, IPSS score,  post-residual void volume, or any other criteria?

Do you perform a DRE at consultation and/or in follow up?  Do you feel that performing a DRE changes your management?

Do you prefer to treat patients with factors such as large prostate volume, significant comorbidities, anticoagulation use, history of TURP, or high A...

If so, is there a role for IMRT?  I was taught to use the RTOG style ports with whole pelvis 4 field box and then boost field to entire bladder ...

In the recent 10 year update of the ARO (adjuvant pelvic RT versus observation) trial, their definition of PSA failure was 2 successive rise...

How would you manage the small bowel/prostatic interface? Have you tried SpaceOAR in this context? SpaceOAR + protons? What dose would you escalate to...

For a patient with a history of non-muscle invasive disease in the bladder, presenting with a prostatic urethra only recurrence, do you approach this ...

Is it true that urinary obstruction can improve with HDR brachy, as it can have an ablative effect on the prostate?

Radium-223 has an overall survival benefit and lower hematologic toxicity, but at a significantly increased cost.  Does the cost-effectiveness fa...

Would a minor adverse pathologic features such as capsular penetration (not SV or positive margins) influence the decision for radiation treatment? W...

There is limited data to guide us in this relatively uncommon situation (PMID 7853587, PMID 2836634). Would this presentation...

The mid treatment cystoscopy has been standard, but treating with or without mid-RT cystoscopy are both included in the NCCN guidelines. Can the treat...

Would a specific Gleason score, age, pathological feature, or PSA be an indication for covering the pelvic nodes? Would giving concurrent ADT affect y...

Given recent advancements in the understanding of biological differences in prostate cancer patients of African vs. other ancestry, does your manageme...

The forrest plot in the recent meta-analysis published in European Urology is rather impressive, even in the more recent high dose radiation series.&n...

Does PSADT play a factor in your decision-making? If so, how specifically?  I've tended to wait until the PSA is 10-15, re-image, and then begin...

Should it be routinely used for all patients? Or should it be used for specific risk groups such as unfavorable intermediate risk patients to rule out...

Are there certain situations where a hydrogel spacer is most useful based on treatment modality (SBRT, protons, brachy, etc) or other factors?

In situations where there is a significant risk of either local or nodal persistence/recurrence post prostatectomy with a rising PSA, or nodal involve...

Given the excellent results from the ASCENDE-RT trial, should we be combining EBRT and brachytherapy? What criteria do you use to determine when ...

If a patient has only IR disease factors but "findings suspicious of extraprostatic extension" on biopsy or MRI or both, would this upstage the patien...

There are a wide range of seemingly safe/effective regimens in the published literature, with an associated array of BED/EQDs and little more to guide...

 In a patient with node positive disease, treated definitively with radiation, should continuous or intermittent ADT be administered? If a patien...

Recently, Epstein et al proposed using a Grade Group system of Groups 1 (GS < 6), 2 (GS 3+4=7), 3 (GS 4+3=7), 4 (GS 4+4=8), and 5 (GS 9-10). T...

In this trial, 6 months of concurrent LHRH agonist therapy improved 5-year progression-free survival from 62% to 80%, with similar benefit in low-risk...

What can be done prior to RT to prevent this? (Flomax/hormones not helping)

Do you treat to full dose or a lower dose with a cone down to the prostate PTV? Is there any data to support a particular dose?

For a recurrence after nephrectomy, the NCCN recommends surgery or, in inoperable patients, systemic therapy. There is no mention of SBRT in...

In a man with castrate resistant disease invading into the bladder and rectum, I have been told that 30Gy/10 fractions to the prostate is inadequate, ...

Guidelines dont seem to account for this possibility. Could it just be normal prostate tissue growing back that is leading to PSA, why just assume it ...

What number of cores and what % cores involved do you look at to consider them low-intermediate risk for prostate SBRT?

In starting prostate SBRT at an instutution, what are issues with the treatment that one should pay special attention to?

Although the landmark randomized trials treated up to 64 Gy, there is data out of Italy suggesting that higher doses yield better biochemical control ...

On what other factors should be considered in making a treatment recommendation for salvage radiation therapy?

Do you favor a short palliative regimen, or a full course definitive treatment to 64.8Gy? How does your management change if the patient has a good pe...

What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...

With ultra-sensitive PSA, it's unclear to me whether a doubling from 0.01 to 0.02 or 0.02 to 0.04 is significant. Is there a certain value that you wo...

If a patient is deemed high risk enough to require hormones with RT in the salvage setting, how long would you maintain them on ADT? Would you extrapo...

When counseling patients with organ-confined prostate cancer, what rates of impotence, incontinence, rectal toxicity, and urethral stricture shou...

Would a history of prior vasectomy in a stage IIA seminoma be an indication to include the inguinal nodes in the RT treatment field?

Is there any advantage to primary RT as opposed to just orchiectomy? Additionally, in order to confirm Tis, a biopsy is required, which is typica...

The optimal timing of post-prostatectomy RT in high-risk patients is debatable and currently the question of prospective randomized trials; however, g...

I've heard justification for treating the whole bladder to 60-64 Gy based on the UK MRC study (James et al. NEJM 2012 and Huddart et al. IJROBP 2013) ...

Realistically, there will always be some (hopefully small) inconsistency with bladder filling, and thus some small bowel could easily receive &ge...

Assuming a patient who could tolerate either, which is preferred? Does this depend on the choice for concurrent chemotherapy (5FU+mitomycin vs ci...

The Chung validation study did not find that size > 4cm or rete testis invasion are risk factors for relapse and the current NCCN guideline discour...

Specifically, for high grade T1 bladder cancer, is there evidence that definitive radiation yields similar control rates compared to cystectomy?

Do you use a particular cut-off? For example, someone in their 40's?

The patient has a positive bone scan (2 lesions), grade 4+5=9/10 prostate, and cancer cannot urinate without a catheter.

In the definitive setting, and would that change if cystecomy was planned if there was a complete response after CRT?  (similar to TCC paradigm).

Eight years after brachytherapy for a low risk prostate cancer, a patient has unresectable high grade squamous cell carcinoma of the bladder. Should I...

More specifically, which cardiac risk factors do you look for? Diabetes? Previous MI? Dyslipidemia? Peripheral vascular disease? CHF?

In general how do you counsel patients with high risk prostate cancer when choosing radiation verse prostatectomy? What numbers do you quote for ...

This is a patient who would have been an appropriate candidate for radiation upfront, but was managed with androgen deprivation therapy instead. On th...

Sometimes the scans don’t line up well because of differences in rectal and bladder fullness- any tips to optimize the fusion?

I ask this because I am seeing more and more patients who have had surgery despite presenting with high risk disease.

I know many do not treat the pelvis at all, but for those who do, what criteria do you use? Risk? Gleason? PSA? T stage?

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.

And should special precautions be taken (such as dose reduction, prophylactic symptom management, etc)?

Papers discussed in this category

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