Gastrointestinal Cancers   

Questions discussed in this category



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...

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...

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

Ampullary carcinoma is not in the NCCN guidelines. Please address not only the role for therapy but the optimal regimen (i.e. Gem based, vs mFOLFIRINO...

This involves the primary site responding but progression with new bone marrow involvement with resulting cytopenias.

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

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

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

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...

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

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?

Which neo-adjuvant or peri-operative chemotherapy regimen would you choose? NCCN guidelines recommend FLOT or FOLFOX in the peri-operative setting vs....

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

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

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

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

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

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

Patients can develop sensory and motor symptoms such as paresthesias, jaw/facial pain and stiffness, cramping and twitching, ptosis and vision changes...

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...

Has the recent approval of atezolizumab/bevacizumab impacted your decision making? 

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

Is single agent immunotherapy an option if CPS>10 if these patients cannot tolerate combination chemo and immunotherapy? Is single agent paclitaxe...

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...

Does it differ in the curative vs palliative setting? Specifically thinking about adjuvant CAPOX in a patient with a BSA of 3. ~400 mg of oxaliplatin ...

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

Benefit of oxaliplatin in patients >70 years of age is not proven and only 5FU/capecitabine in a MSI-H tumor is of questionable efficacy. What woul...

Would you use a small cell regimen over a more traditional FOLFOX-esque approach?

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

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

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

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

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 ...

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...

If so, do you avoid pegfilgrastim given that <12 days will lapse between its administration and the next cycle?

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...

If so, how long do you wait after surgery prior to imaging to avoid post-operative findings?

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

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...

How do you assess the risk of complications from including bevacizumab vs the known benefits of including it with chemotherapy?

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

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?

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

Would chemotherapy alone suffice? Repeat biopsy and EUS were negative for residual disease.

In a patient who is not a surgical candidate, do you offer concurrent carbo/taxol rather than 5FU/oxaliplatin? 

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

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

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

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 ...

Does the advent of more effective therapies like peptide receptor radioligand therapy (PRRT) and capecitabine and temozolomide (CAPTEM) dampen enthusi...

Do you use the same high risk factors as adenocarcinoma when deciding on adjuvant treatment for early stage disease?

What parameters do you use to decide to treat beyond progression? Is there any efficacy data from this specific study subgroup in IMbrave150?

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?

If so, how many cycles would you give? Both the MAGIC and FLOT trials showed difficulty with administering adjuvant chemotherapy.

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

Or would you consider IO agent be given only after progression on platinum + fluoropyrimidine?

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 it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?

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?

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...

How would the sidedness of the tumor, BRAF, RAS,HER2 or MSI status affect your decision?

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?

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

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 ...

Patients oftentimes have cardiac co-morbidities with requirement for anti-coagulation making TKIs, including Bevacizumab, difficult to dose. Would the...

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?  ...

Would you use dual agent chemotherapy such as FOLFIRI, combination of chemo with biologic- IRI/Cetux or all 3 drugs simultaneously? How would sidednes...

Upfront surgery vs neoadjuvant therapy? And if neoadjuvant therapy, which regimen? Patient has a good PS.

Quite often we encounter cholestatic hyperbilirubinemia, wherein GI and IR do not believe ERCP with stents or PTC will alleviate jaundice. If the pati...

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...

Would you treat with typical small cell paradigms such as surgery followed by adjuvant platinum doublet +/- radiation vs definitive chemoradiation? Or...

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

Given that majority of benefit is derived from the capecitabine, would this be an acceptable option to decrease patient contact with the healthcare sy...

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. 

Would presence of features considered high risk in stage II sway your interpretation of the IDEA trial? 

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 ...

With extensive use of NGS testing, it is commonplace to identify mutations that have no validated therapeutic intervention, but strong biologic signal...

*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...

In your experience, what approach has been successful to bridge to surgery?

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?) ...

Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?

Up to six cycles of treatment were given in the ABC02 trial.  Do you offer other treatments if you don't continue gem/cis beyond 24 weeks?

Of note, CLASSIC (Noh; Lancet Onc 2014) nor ARTIST (Lee; JCO 2012) evaluated other histologic subtypes, is the approach to treatment any different tha...

In light of the results of the ESPAC-4 trial, is combination gemcitabine plus capecitabine being considered over single agent gemcitabine for adjuvant...

If so, for what platelet count threshold and do you have a preference as to which agent?

In practice, does starting with chemoradiation followed by chemotherapy result in a significant delay in initiating chemotherapy or a patient's abilit...

Would the presence of peritoneal carcinomatosis change your treatment strategy? If Ki-67 <50%, would you avoid platinum based cytotoxics?

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...

Given the variable and sometimes indolent disease course of these patients, as well as the absence of a clear overall survival benefit in the PROMID&n...

Would you approach with curative intent with locoregional treatment or systemic treatment alone?

What would be the next line of treatment, PRRT, capecitabine and temozolomide or other?

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...

If you do employ this strategy, are there a number of liver lesions (eg <4) or duration of response that guide your decision making?

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)?

A number of phase 2 trials support various combinations (e.g. gem/ox, cape/cis, cape/ox, 5-FU based) -- how do you decide either between these regimen...

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

How do you choose between local therapy (surgical debulking or ablation) v. 2nd line systemic therapy? Would you consider immunotherapy?

Would presence of TP53 mutation weigh in on the offer of radiation? Would there be any change expected on the chemo regimen?

Would you consider adding trastuzumab to cis/gem in the first line? If not, would you consider adding Her2 directed therapy to FOLFIRI or FOLFOX in th...

Do you continue with FOLFIRI for a period and then switch to olaparib (and if so, when do you make that switch) or do you switch directly after FOLFIR...

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...

Does the precise location of duodenal cancer even matter given that treatment would be 5FU/platinum based. Also with the knowledge of impact of sidedn...

On occasion, patients with locally advanced gastric cancer are poor candidates for FLOT-like chemotherapy. Should such patients be taken to surgery up...

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...

Has the utility of BRAF in CRC expanded beyond guiding prognosis? Is there a role in non-metastatic CRC?

Patient characteristics would unarguably be a deciding factor, but outside of these how would you approach the situation?

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

Exploratory analysis of the MAGIC trial suggested perioperative chemotherapy was detrimental in this subset of patients. Has availability of IO altere...

There is some data on TMZ and 5FU based regimens, but convincing evidence is lacking. How would you approach this situation?

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?

There is increased stroke risk after 65 years of age with bevacizumab. Does that stop you from using it?  

KEYNOTE-062 showed deep durable responses are possible with upfront pembro, specifically in the CPS >10 subset, with OS advantage when compare...

For those that do receive adjuvant therapy with stage II disease, we know magnitude of benefit to be lower.  If the decision is made to administe...

Do you offer perioperative chemo with metastectomy with an isolated liver metastasis? The RENAISSANCE/AIO-FLOT5 trial (PMID:30448343) is seeking to an...

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...

When 5FU is a backbone to so many regimens, when (if ever) do you consider re-challenging so as not to abandon an entire line of therapy?

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? 

This is specifically in regards to metastatic colon cancer with good disease control of disease on FOLFOX and preserved hepatic function.  

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

What would be the optimal sequence of surgery, radiation, and chemotherapy for this patient? This patient has an excellent performance status and...

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...

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...

I have seen favorable clinical trial reports on dasatinib for metastatic disease, but no data on possible adjuvant use.  NCCN guidelines suggest ...

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?

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...

Currently, nivolumab is approved as a second line systemic therapy for patients with metastatic HCC with Child-Pugh (CP) A-B7 based on results fr...

How do you approach a decision to retry a previously failed therapy if patient does not wish to pursue a clinical trial? Does sidedness (left or right...

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...

Do you offer chemotherapy upfront in all patients or only if borderline resectable/unresectable?  If you treat, what regimen do you use and how l...

What would you consider in the first and second line settings with intact MMR/MSI?

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 switch chemotherapy regimens (i.e if the patient received FOLFOX/Avastin, change to FOLFIRI/Avastin)? Would you treat wuth immunotherapy per...

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...

Does presence of intraperitoneal spread and solitary extraperitoneal visceral metastasis affect management?

Can you comment based on the results of PRODIGE 24 from ASCO 2018?   http://abstracts.asco.org/214/AbstView_214_218335.html

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...

Do you start with 1250 mg/m2 BID and then dose reduce based on toxicities? Many studies across varied types of malignancies have shown good tolerabili...

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 ...

Would you consider referring the patient for HIPEC at some point in their treatment, possibly after giving adjuvant chemotherapy, especially if patien...

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

What factors dictate choice of observation versus 6 months of adjuvant peri-operative chemoradiation plus chemotherapy especially if patient did not r...

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...

Taking into account the overlap between treatment regimens for esophageal and gastric cancers, in what clinical context might you feel comfortable tre...

NCCN lists CRT as category 1 but also lists chemotherapy alone as an option.  Is this decision based on discussion between surgeon and oncologist...

The abstract of the pooled meta-analysis is not definitive (JCO 35, 2017: suppl; abstr LBA1), and of the phase III trials (SCOT, TOSCA, Alliance/SWOG ...

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

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 ...

If a patient with stage II or III colon adenocarcinoma who presents to your clinic 12-16 weeks after surgical resection do you give adjuvant chemother...

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 ...

Does HER2 or PD1/PDL1 positivity change first line treatment (i.e. preferential enrollment on clinical trials) or do such patients still receiving sta...

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...

The GTX (gemcitabine, docetaxel, capecitabine) regimen is listed as a category 2B recommendation in the NCCN guidelines- when would this be ...

Since immune check point inhibitors have been approved for GEJ and gastric cancer, would a distal esophogeal adenocarcinoma be considered GEJ or does ...

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

Would you consider subtotal gastrectomy vs medical therapy?

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

Most oncologists are comfortable offering FOLFOX for 1st line metastatic adenocarcinoma. Would you be comfortable offering FOLFOX to met. squamous eso...

Is there a change in approach over the past few years? Would there be a role for the 12-gene recurrence score?

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...

NCCN puts "preferred" regimens but only category 1 is cisplatin and fluoropyrimidine. When would you use that regimen over FOLFOX?

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?

In a patient who developed oligometastatic disease before completing adjuvant XELOX, what treatment(s) and duration of treatment would you recommend?

I have a few patients with kras braf mutation negative metastatic colon cancer treated with upfront FOLFOX- bev followed by 5FU-bev who had regression...

When PDL1 expression is negative, but IHC for mismatch repair expression is consistent with mismatch repair deficiency (MLH2, MSH2, and MSH6 expressed...

NCCN discusses targeted therapies (Everolimus) but also Temodar / Xeloda combination.

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

Regorafenib has been approved for patients with advanced HCC post-sorafenib, but the benefits are slight and toxicity substantial.  Nivolumab has...

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...

Given recent FDA accelerated approval of pembrolizumab for MSI-H tumors regardless of site of origin, does it make sense to apply MSI testing, in...

If biopsy of the lesion is consistent with GI origin adenocarcinoma and there are no other sites of disease, would wedge resection followed by adjuvan...

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?  

Tumor involves stomach, liver, and lymph nodes. Pathology is suspicious for sarcomatoid carcinoma, possibly sarcomatoid cholangiocarcinoma.

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?

How would the new data presented at ASCO GI 2021 from from Alliance A021501 influence your answer?

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

Would you use 5-FU and radiation alone? Would your management be different for loco-regional (curative) vs metastatic situations?

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?

How do you weigh the recently presented/published data from the NETTER-1 and RADIANT-4 trials in your decision making?

Is salvage liver resection considered the next step in treatment for patients who may have resectable tumors after TACE?  If so, do specific tumo...

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 your practice, has tumor molecular profiling in pancreatic cancer led to the identification of any actionable targets for which a patient was put o...

Does the location of the pancreatic mass respective to the major vessels alter initial management (surgery, chemotherapy, radiation,  or some com...

Do you have a preference for Regorafenib or Lonsurf or do you refer to clinical trials immediately given the known low response rates to these drugs?&...

Would you consider HER-2 directed therapy (lapatinib-trastuzumab)? Does being KRAS-mutated affect your decision? 

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...

Do you treat with standard of care therapy for microsatellite stable (MSS) colorectal cancers or pursue further work-up? Does this differ between adju...

Since some prior subset analyses have suggested that oxaliplatin may not improve outcomes of older patients with colon cancer in the adjuvant settin...

Does the recent Hopkins trial of pembrolizumab change your management of these patients?

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? 

Should oxaliplatin/capecitabine alone be the standard of care?

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


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

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Cancer, 1983-05-15

Cancer, 2010-02-15

International journal of radiation oncology, biology, physics, 2013-05-01

International journal of radiation oncology, biology, physics, 2007-02-01

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Journal of cancer research and therapeutics, 2011

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JAMA, 2012 Jul 11

JAMA, 2008-03-05

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2011-08-01

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American journal of clinical oncology, 2011-02

International journal of radiation oncology, biology, physics, 2013-12-01

JAMA, 2007 Jan 17

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Curr Oncol, 2020 Dec 01

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Lancet Gastroenterol Hepatol, 2019 Jul 29

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N Engl J Med,

Pancreas, 2013-07

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JAMA oncology, 2018-01-01

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2002-03-01

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-01-20

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International journal of radiation oncology, biology, physics, 2013-07-01

Br. J. Cancer, 2005-04-11

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Diseases of the colon and rectum, 2018-07

International journal of radiation oncology, biology, physics, 2015-04-01

Practical radiation oncology, 2016

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The Lancet. Oncology, 2011-07

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N. Engl. J. Med., 2004-06-03

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-08-20

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

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Pancreas, 2010-08

Br. J. Cancer, 2016-08-09

The New England journal of medicine, 2005-05-05

Pract Radiat Oncol, 2012 Oct-Dec

Curr Oncol, 2012-04-01

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Practical radiation oncology, 2017

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Cancer medicine, 2016-12

American journal of clinical oncology, 2018-07

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Lancet Oncol., 2014-07-01

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J. Clin. Oncol., 2015-10-01

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The Lancet. Oncology, 2014-10

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N. Engl. J. Med.,

Br. J. Cancer,

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Radiat Oncol J, 2019 Jun 30

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