Radiation Oncology

Gynecologic Cancers   

Questions discussed in this category



Would there be a substanital increase in the risk of toxicity using such a scheme?  We frequently have patients who have to travel long distance...

In December 2018, Horn et al reported the results of a phase 3 clinical trial in the NEJM (N Engl J Med 2018; 379:2220-2229). This trial included prev...

MRI and cervical biopsy are negative for cervical involvement 

How long after hysterectomy would you consider delivering adjuvant radiation therapy? Would this differ for external beam versus brachytherapy? Are t...

If so, are there any lymph node cut-offs you would have in terms of lymph node number or pathological ECE before you would add contralateral RT? What ...

Could you discuss how you decide between IMRT or SBRT boost for a patient who is not able to receive intracavitary or interstitial HDR or LDR brachyth...

are there any positive or negative synergies from combined megestrol/RT treatment?

Should these patients be managed similar to p16 positive anal squamous cell carcinoma, and allowed six months or more for complete regression before c...

What chemotherapy and sequencing with radiation therapy would you recommend? IS surgery a component of the treatment?

Surgeon is not planning vulvectomy, since biopsies showed 2 mm depth of invasion. Also tumor board felt dose to the primary site should be only about...

At what point would you introduce the discussion of weight management, whether for risk reduction or overall health?

The NCCN recommends either systemic therapy + brachytherapy or pelvic RT + brachy or brachy alone or observation. How do you decide among these option...

Specifically, is hyperbaric oxygen therapy (HBO) an effective treatment for refractory radiation cystitis?

Do you use a trimmed 10 mm expansion on HR-CTV? Do you also include the entire initial extent of disease? How much does your IR-CTV coverage affect yo...

Female in her 60s who had presented originally with well-differentiated endometrioid adeno clinically and radiographically involving bilateral paramet...

For a woman with complete resection of serous intraepithelial carcinoma of the endometrium, would you recommend adjuvant radiation or chemotherapy? Wh...

Current NCCN guidelines suggest that vaginal brachytherapy is optional, and there may be concern for over-treatment locally given competing risk of di...

A literature search indicates that most port site recurrences are managed fairly aggressively with chemoRT or RT doses 45-66 Gy. This is understandabl...

Sequentially or do you integrate the cuff brachy with the EBRT and if so what schedule, BIW, weekly, etc?

Hydrogen peroxide douches? Antibiotics? (If so, what are you covering?) When do you initiate hyperbaric oxygen? Do you find pentoxyfyline helpful? How...

When you prescribe your dose at 0.5 cm depth of the vagina? For instance, if you measure a vaginal length to be 8 cm, would you prescribe to treat 4 c...

Would organ invasion (bladder/rectum), size, feasibility of T&O, or size of nodes push you toward neoadjuvant chemotherapy?

While EBRT + brachy may be preferred, what treatment would you offer if surgery has been performed? What dose and volume of EBRT, brachytherapy, or bo...

How do you weigh this concern with the need to prophylactically treat non-involved, high risk para-aortic lymphatics?

How high would you extend your field? Would you treat differently if the patient had lower PET avid pelvic lymph nodes?

Do you use size criteria (i.e. bulky nodes over 3 cm), specific adverse histology (adenocarcinoma), or location (near small bowel), etc. 

More recent Italian (Sozzi et al) and French data (Canlorbe et al) show associations of greater tumor size > 25-35mm with higher rates of local &am...

She has extensive colposcopic lesions at upper/mid vagina, but no palpable/visible lesions on standard pelvic exam. Pelvic MRI with 20cc US gel in vag...

PORTEC-3 assigned women with high risk stage I or stage II-III endometrial carcinoma to adjuvant external beam radiation vs adjuvant chemoradiation wi...

Has your institution changed practice patters based on the findings of the LACC Trial (Pedro et al., SGO in 3/2018) showing worse outcomes with roboti...

Would you deliver definitive RT in place of inguinal lymph node dissection in light of new data (PMID: 29336837) In the case of high risk but radiogr...

NCCN guidelines mention EBRT/vaginal brachytherapy as options in addition to chemotherapy in the adjuvant setting for high grade histologies, stages 1...

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 the patient is responding to external beam and likely to be converted to resectable, what brachytherapy dose/fractionation do you prescribe and wha...

Assuming no distant metastases, should this scenario be managed with "sequential" chemoradiation to the para-aortic region with an external beam boost...

For HDR brachytherapy for cervical cancer do you use the dose optimization algorithm?  Is there a standard dwell time distribution that should be...

For example, assuming an excellent performance status, would you consider local radiation to the primary and metastasis in someone with a single ...

Patient had a single 3cm node s/p  excisional biopsy of the one node without nodal dissection. We have done anoscopy and a thorough GYN exam...

EBRT boost only? SBRT? If you recommend interstitial brachytherapy do you place needles freehand or with a template based approach?  

What would be the appropriate treatment for grade I endometrial cancer s/p TAH/BSO but with SLNB yielding negative nodes. The uterus contained a 2cm t...

For the management of stage II endometrial cancer, NCCN says pelvic RT and/or vaginal brachytherapy.   Do you ever add vaginal cuff boost to pelv...

Assuming the early stage endometrial cancer was treated with TAH+BSO initially and no further treatment, what would your recommendations be for HGIL? ...

 If so what dose/fractionation? This was reported here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918530/

For women treated with IMRT, there are multiple ways to define the upper border of the field 1) contouring the PAs up to where the renal vessels exit...

Type II endometrial cancers made up roughly 15% of GOG 249 the study population, but seemed to be balanced between both arms.  Single institutio...

After whole pelvis radiation therapy, what would be the highest dose you would allow in a single fraction, versus the total course EQD2 for small bowe...

Would you consider this in a patient with a single omental metastasis found and no other distant spread after surgery?

For example, a patient with cervical or anal SCC who has missed many treatments due to side effects, low blood counts, hospitalizations, or non-compli...

What factors influence your decision? Does high grade histology or pathological stage play a role? If the patient received chemotherapy due to +LN, pa...

Do you recommend upfront diversion? Are there unique planning considerations such as the inability to use bladder filling? How do you boost? What are ...

What are your specific protocols for monitoring and for dosing narcotics and sedatives?

What dose and technique do you use and how do you integrate the subsequent definitive treatment plan?

In what situations is it appropriate to offer observation (rather than VBT) to patients with stage II endometrial carcinoma who have had a radical hys...

If a patient has a gynecological cancer, how long should one wait after RT before a screening colonoscopy can be completed?

Does definitive or adjuvant setting effect your planned dose?  For example, for a woman with IB2 cervical cancer status post hysterectomy, who wa...

http://abstracts.asco.org/199/AbstView_199_180760.html http://abstracts.asco.org/199/AbstView_199_187537.html  

VC brachy, pelvic RT, +/- chemo?  Does your management change if it is confined to the endometrium without myometrium invasion or if it is only ...

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

Would you utilize IMRT to provide a boost to gross disease? If so, how would you define your treatment volumes and what dose would try to achieve? Als...

Would you add chemotherapy if there was gross residual disease, pN+ and/or ECE?

Can the classic indications for post-hysterectomy radiation (eg. "Sedlis" and "Peter's" criteria) be applied? Does the histology change radiation dose...

Is there evidence for SBRT for recurrent ovarian granulosa cell tumors? 

If offering radiation therapy, would you treat extended field whole pelvis or just cover the para-aortic LNs with an involved field volume? Would your...

How many cycles do you prefer before and after? How long do you tend to wait before starting radiation after initial chemo and after radiation to resu...

What are the pros and cons of completing a simple hysterectomy versus aborting surgery followed by chemoRT?

With stage I/II vaginal cancer and an excellent response to 4500cGy EBRT with <5mm residual thickness of tumor remaining, what is your dose/fractio...

When do you continue with treatment and when do you terminate the plan? What is your criteria? 

Close but negative radial margins? LVSI?  What fractionation/dose do you use for your vaginal cuff boost if used? 

Would your recommendations change based on stage? What factors would influence your decision to include presacral lymph nodes in a locally advanced en...

Does this differ if the primary is vaginal? Do you prescribe the same dose when using an intracavitary applicator for cervix cancer? 

For palliation of vulvar cancer, what fractionation due you typically use.  Can some of the toxicity be avoided with a shorter course of treatmen...

For instance, if you have anal canal involvement, do you cover the entire mesorectum?  Any other adjacent organ invasion that would lead to modif...

Prior to starting vaginal cuff brachytherapy, do you wait for a specificed period of time prior to vaginal cuff brachy after hysterectomy?   Do y...

With the results of the EMBRACE protocol, how do you approach MRI planning?  Do you plan with applicators in situ, or use preimplant (post EBRT) ...

For definitive vulvar ca, is 5940 cGy the minimum acceptable dose for gross disease? 5760cGy? Or should the dose be escalated beyond 60Gy?

Does time since adjuvant cuff brachytherapy influence your radiotherapy approach, (for example 18 months vs 5 years)? Do you adjust your bladder/bowel...

Can the drug continue during radiation therapy or should it be discontinued at a specified time prior to initiation of radiation?

For example, would you consider adjuvant chemotherapy alone to be sufficient in a patient with an isolated pelvic recurrence and positive margin after...

For example, how do you decide between applicators such as tandem and ovoid versus tandem split ring insertion for cervical brachytherapy patients?&nb...

For instance, RTOG 0418 did not allow clear cell or papillary serous histologies, but subsequent trials that allow IMRT have (GOG 0249, 0258, RTOG 120...

Interstitial needles can result in hot spots in the bladder, but how well tolerated is that? On the other hand, intracavitary applicators usually don'...

For example, in an otherwise intermediate risk localized endometrial cancer (Grade 2, FIGO IB)?

In the setting of a negative lymph node sampling, would you treat a full pelvis or mini-pelvis to compensate for lack of the appropriate surgery? Is a...

In patients who don't meet traditional criteria for adjuvant chemoradiation from Peters (GOG 109) and < 2 high risk factors from Rotman (GOG 92) fo...

If the post-operative simulation films reveal a significant lymphocele secondary to pelvic lymph node sampling, is it imperative that the entire lymph...

The gyn oncs at my institution sometimes will not perform lymphadenectomy if biopsy indicates low risk disease. Would LVSI as sole adverse risk factor...

NCCN recommends brachytherapy plus or minus pelvic RT for surgically staged Grade 1, Stage II patients, but these originally staged IIB patients were ...

Do you use SIB or sequential approach? Do size of lymph nodes influence your dose or decision?

Do you give cuff and chemo or pelvic CRT or chemo alone?

Is there any indication for ENI in early stage disease or in advanced stages, without pathologic confirmation or PET positivity or CT size criteria?

What exactly do you contour and what is your dose constraint to that volume?

Does using something like a vienna applicator allow you to avoid dose escalation with more external beam? How do you recommend doing a classic pa...

Some classic references recommend the coverage of the entirety of the sacrum but the volume delineation guidelines for both seem to only cover the mos...

Do you try to keep Hb> 10 or 12? Or somewhere in between? 

The patient failed previous excisions and medical therapy and is no longer a surgical candidate.

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

Do you plan every fraction, every other fraction, or use one plan for the whole treatment?

The most recent ABS guidelines don't discuss a dose constraint for the small bowel.

Do you treat PAs if pelvic nodes are positive? If common iliacs are involved? Only if there are positive PA nodes?

Do the urethral constraints used in prostate brachytherapy apply to women undergoing gyn brachy?


Papers discussed in this category


Gynecol. Oncol.,

Int. J. Radiat. Oncol. Biol. Phys., 2011-11-15

Lancet, 2010-03-06

Obstet Gynecol, 1980-10-01

Lancet, 2009-01-10

Int. J. Radiat. Oncol. Biol. Phys., 2005-08-01

Int. J. Radiat. Oncol. Biol. Phys., 1990-02-01

Brachytherapy, 2013 May-Jun

Int J Radiat Oncol Biol Phys, 2011 Feb 1

Int J Radiat Oncol Biol Phys, 2013 Jul 9

Gynecol Oncol, 2003 Dec

Int. J. Radiat. Oncol. Biol. Phys., 2014-05-01

Brachytherapy, 2015 Sep-Oct

Gynecol Oncol, 2014 Nov

Gynecol Oncol, 2009 Oct

J Clin Oncol, 2006 Jan 1

Gynecol. Oncol., 2013 Jul 09

Gynecol. Oncol., 2012 Oct 17

Eur. J. Cancer, 2010 Jul 07

J. Clin. Oncol., 2019 Apr 17

Am J Clin Oncol, 2013 Dec 7

Curr Urol Rep, 2018 Apr 13

Urology, 2016 Apr 25

Urology,

J. Urol.,

Urol. Int., 2012 Jul 10

Gynecol Oncol, 2014 Dec

Gynecol Oncol, 2013 Aug

J Clin Oncol, 2012 May 10

Ann. Oncol., 2011-02-01

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

Int. J. Radiat. Oncol. Biol. Phys., 1994-07-30

Obstet Gynecol, 2009-09-01

Radiother Oncol, 2015 24

Brachytherapy, 2012 Jan-Feb

Int J Gynecol Cancer, 2011 Jul

Lancet Oncol., 2017-03-01

Gynecol. Oncol., 2008-11-01

Eur. J. Cancer, 2016-09-01

Gynecol Oncol, 2004 Apr

Am J Obstet Gynecol, 2010 Oct

Obstet Gynecol, 1988-01-01

Int. J. Gynecol. Cancer, 2014-11-01

Gynecol Oncol, 2015 Jun

Int J Radiat Oncol Biol Phys, 2017 Mar 1

Gynecol Oncol, 2006 Oct

Gynecol Oncol, 2009 Mar

Br. J. Cancer, 2006-08-07

Gynecol. Oncol., 2009-07-01

Medicine (Baltimore), 2015-04-01

Cancer Nurs, 2017-04-21

Am J Clin Oncol, 2017 Feb 20

Gynecol Oncol, 2014 Dec

Int J Radiat Oncol Biol Phys, 2005 Dec 1

Brachytherapy, 2016 Nov - Dec

Radiother Oncol, 2016-09-01

Int J Radiat Oncol Biol Phys, 2012 Dec 27

Int J Radiat Oncol Biol Phys, 2013 Jul 9

Eur. J. Obstet. Gynecol. Reprod. Biol., 2015 Aug 22

Cancer Res Treat, 2014 Jan 15

Gynecol Oncol, 2017 Nov

Int J Radiat Oncol Biol Phys, 2005 May 1

Int. J. Radiat. Oncol. Biol. Phys.,

Radiother Oncol, 2016 Apr 29

Gynecol Oncol, 2014 May

Int J Radiat Oncol Biol Phys, 2014 Dec 1

Pract Radiat Oncol, 2015 Jul-Aug

Curr Oncol Rep,

Cochrane Database Syst Rev,

J Clin Oncol, 2012 Jun 10

Lancet Oncol, 2017 Jun

Lancet, 2017 Oct 28

N Engl J Med, 2016 Dec 1

N Engl J Med, 2012 Apr 12

Lancet Oncol.,

Radiother Oncol, 2014 Oct

Cochrane Database Syst Rev, 2010 Sep 08

Pract Radiat Oncol, 2017 Jan - Feb

Gynecol. Oncol.,

Int J Radiat Oncol Biol Phys, 2017 Apr 1

Int. J. Radiat. Oncol. Biol. Phys., 2018 Dec 31

Cochrane Database Syst Rev, 2012 May 16

Int. J. Gynecol. Cancer,

Gynecol Oncol, 2018 Oct

Int J Clin Exp Med, 2015 Sep 15

Pathol. Int.,

Oncotarget,

Semin Radiat Oncol, 2004-01-01

Pract Radiat Oncol, 2016 Nov 13

Semin Radiat Oncol,

Int. J. Radiat. Oncol. Biol. Phys.,

Int J Radiat Oncol Biol Phys, 2010 Dec 1

J Thorac Oncol, 2010 Jun

Int J Radiat Oncol Biol Phys, 2006 Aug 1

Gynecol Oncol, 2005 Nov

Gynecol Oncol, 2017 Aug

J Gynecol Oncol, 2015 Nov 23

N. Engl. J. Med.,

Int J Gynaecol Obstet,

Int J Womens Health, 2017 May 02