Gastrointestinal Cancers
Questions discussed in this category
Patient is 4 months s/p CRT with resolution of avid lymph nodes and no evidence of disease on anoscopy. PET avidity is currently <10 SUV from 30 SU...
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...
Of note, there is ~150 cc small bowel left and no further surgery was offered.
The patient declined palliative measures only and is motivated to receive treatment
If so, what is the evidence for this?
Given that the recurrence is peri-gastric, with what dose would you consider treating it and to what constraint would you limit the stomach? Of note, ...
PUMP-2 trial combined FUDR via HAIP with gemcitabine and cisplatin, no immunotherapy was on the protocol.
What fractionation would you use?
Is there a role for ctDNA?
Patient had previous 54 Gy in 25 fx to anal cancer with treatment of pelvic lymphatics, now with presacral local recurrence. He had a resection of rec...
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...
How would your planning be influenced by a possible, single inguinal lymph node metastasis?
Additionally, would you consider prophylactic stent placement and/or gastrostomy in anticipation of a fistula?
Post-operative surgical course was complicated by anastomotic leak, septic shock, candidemia, wound infections, PE & DVT. Now recovering well.
Should the recent publication of Chen et al., PMID 27207358 dose escalation study for inoperable SCC esophageal cancer patients treated with CCRT, sho...
Should concurrent chemotherapy be given? How would you modify the regimen in elderly/frail patients?
Additionally, is there a difference in surgical outcomes with long course chemoradiation + consolidative chemo vs. induction chemo + long course chemo...
Do you find that starting with chemoradiation increases the risk of complete obstruction secondary to transient tumor inflammation, or do you favor st...
Specifically, after chemo and RT to 36.0 Gy/15 fx with stable to slight progression of disease at 6 months, what (if any) regimen of reirradiation wou...
Specifically, will the higher rate of local failure in the TNT (short-course RT) arm lead you to consider a TNT approach with long-course CRT?Dijkstra...
Would you treat as cholangiocarcinoma with a gemcitabine/platinum regimen or would you use a more HCC regimen like atezo/bev or durva/trem?
Is there data on neoadjuvant chemo-RT or chemo in this setting?
Was this monitored in TOPAZ-1?
Assume the patient is young and active.
Specifically, in the case of a complete response following chemotherapy, do you approach with resection or radiation? If you are treating with RT, wha...
More specifically, the patient had a single, positive, 3 cm inguinal LN (no ECE, negative margins) removed at the time of APR. If offering RT, would y...
The Mayo Clinic protocol recommends initial fields -1.5 Gy BID initially to 45 Gy followed by a Brachytherapy boost. If HDR /LDR is not available, wha...
I.e. would you offer additional radiotherapy and if so, what technique and dose would you use?
How do you construct the caudal extent of your volume - for example, pelvic floor via RTOG/international consensus vs 4 cm below gross disease via RAP...
Specifically, on re-staging imaging, would the tumor regression be strictly defined by reduction in cranio-caudal direction only, or would other measu...
Particularly in the setting of "higher risk" features such as grade 3 and a negative, but close margin, would you still consider offering surveillance...
This includes duodenum, stomach, small bowel, colon, kidney, liver, etc.
And if so, which one? Does nodal status affect your decision? Is there any evidence for ctDNA in this space?
Would chemoRT be preferred over surgery if there is LVI or PNI?
While ESOPEC excluded squamous cell carcinoma, the Japanese JCOG1109 NExT trial also showed superiority of fluoropyrimidine/platinum/taxane over chemo...
If triplet chemotherapy is likely too morbid, would you prefer neoadjuvant chemoradiation per CROSS in this setting?
Or do you start with systemic therapy and then reassess?
RTOG 0848 presented at ASCO 2024 in abstract form: Abrams et al., Journal of Clinical Oncology 2024
What pathologic factors if any would you use to m...
Especially if using an escalated dose such as 58 Gy in 29 fractions for a T3-T4 primary
Would you use nivolumab or a taxane? Is the data from the ATTRACTION-3 trial with an all-Asian patient population applicable to practice to the US pop...
Assume the patient is a good surgical candidate, and the perforation happened prior to initiating any treatment. Is the stent enough reason to avoid c...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
No disease elsewhere. Previous history of treated rectal cancer a few years ago.
Tumor is PD-L1 positive and HER2 positive
ESOPEC compared perioperative FLOT vs neoadjuvant chemoradiation per the CROSS trial, and showed superior OS with perioperative FLOT. What concerns do...
What are your absolute & relative contraindications for bevacizumab use?
Nivo 3 + Ipi 1 Q2W x3 then Nivo alone? Or Nivo 3 Q2W & Ipi 1 Q6W until POD or toxicity? Or other?
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 ...
Are there factors which would make you more likely to use atezo/bev vs durva/treme vs TKI?
Would you cover the entire prostate?
How would the duration of 5FU infusion impact response?
Is there really a need to boost up to 50.4 Gy in this setting?
When using hypofractionated RT (i.e., 67.5 Gy in 15 fractions), can chemotherapy be delivered concurrently?
Options for systemic therapy in NCC...
Does histology (radioresistant or radiosensitive) play into this decision?
Would portal hypertensive gastropathy or colopathy sway you away from using it?
Is there a preferred method and should any of the following be avoided: esophageal stent, nasogastric tube, PEG, J-tube, or TPN?
Given the recent update from the NAPOLI-3 trial presented at GI ASCO 2023, the two regimens appear to have similar OS.
Or, to manage tenesmus and discomfort after any type of pelvic radiation.
Would you ever consider this approach for an initially polymetastatic patient?
And if delayed, should chemotherapy be started?
For example, if mass is ulcerated and cannot be excised with polypectomy? Would you ever consider radiation and chemotherapy?
Current NCCN guidelines do not include adjuvant chemotherapy for patients treated in this fashion; however, in the PROSPECT trial itself, an additiona...
If so, what regimen? At what point is it safe to start chemo in a freshly transplanted liver?
This would apply to gynecologic and GI cancers as well. And as long as the patient's partner is within the recommend age of <45 yo
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
And is there any role in utilizing FGFR2 inhibitors in first line setting?
The PROOF trial utilizing Infigratinib in first line was stopped after the...
Would you wait until bowel symptoms are controlled or ever pursue diversion before starting treatment?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice...
Would you offer adjuvant nivolumab?
Is there data to support this approach?
Do you continue atezo alone if responding or switch to an alternative therapy such as dual IO or TKI? What about if the patient were experiencing subt...
Would the grade of the lesion affect your decision?
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
The patient has a primary breast cancer with a single progressive metastasis in liver.
Plan to give adjuvant chemotherapy.
Intravesical therapy was delivered two years prior, and last cystoscopy was negative. One-third of the bladder would otherwise be included in the plan...
Patient refuses further mFOLFIRINOX but may be open to less aggressive regimens. Is there any role for PARP inhibitors?
In general, how does an esophageal stent affect what you might consider in terms of radiation dose and volume?
What factors might play into this decision?
Should Y90 be offered before or after TACE (based on the Northwestern phase 2 study) or sorafenib (based on the SARAH trial)?
Is there a role for circulating tumor DNA in this setting?
Would you ever treat with definitive intent in a "curative" patient who has a stent placed, or only palliatively? Does the addition of chemotherapy or...
And if so, would you offer it pre or post-metastasectomy? Would time to recurrence or ctDNA play a role?
Assuming duodenum constraints are met, could there be any benefit to boosting a positive celiac node to 61.6 Gy in 28 fractions?
Consider some stalk invasion, but no deep submucosal extent and negative margins by 9 mm.
For instance, do you factor availability of RNAseq, inclusion of normal blood controls, and QNS rates into your decision?
Especially as the study was done before the adoption of total neoadjuvant therapy
Would you treat with immunotherapy ?
Or offer resection followed by adjuvant therapy?
Surgery would be very extensive and would not be likely to clear the disease. Do you divert these patients if treated with CRT?
Would you only give three cycles with radiation, or are you adding two more cycles of FOLFOX afterwards?
Does DOTATATE scan results/burden of disease change your preference?
Would you offer single agent immunotherapy or chemo-immunotherapy with gem/cis durva/pembro?
Would you consider dose reduction versus adding C-GSF?
Consider a patient who prioritizes fertility preservation, for whom one of three suspicious nodes approaches the CRM, and is <1 mm from the mesorec...
Do your recommendations differ between appendiceal, colorectal, and gastric cancer? If radiation is offered, would you boost the unresectable/gross re...
Would you approach with curative intent with locoregional treatment or systemic treatment alone?
PD-L1 CPS of 1, no other actionable mutations except HER2.
For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...
Would you treat both at the same time? Does one need to be prioritized over the other?
Does Xeloda have any efficacy against Merkel cell cancer?
How...
With trials like PROSPECT and FOWARC showing no statistically significant improvement in locoregional control and survival outcomes when comparing rad...
Especially consider a situation where surgical excision alone is not appropriate.
What if the radiation was LDR or HDR brachytherapy?
Is liquid biopsy helpful? Would you treat if this shows somatic mutation?
The CROSS trial showed a survival benefit with 4140 cGy and concurrent carbo/taxol, but I was always trained to treat to 5040 cGy. Is anyone de-escala...
For example, consider a patient who has had previous hepatectomy and total liver volume is only slightly greater than 700 cc.
The ICI adjuvant data we have so far doesn't clearly separate MSI-H disease from all comers.
Yaeger et al., PMID 36546659
How are you approaching patients with rectal cancer who meet PROSPECT criteria but have other higher risk features, such as >4 lymph nodes with sus...
Would you offer as first line treatment mitomycin/5FU with radiation or single agent immunotherapy?
Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...
Aside from chemoradiation, are there situations in which you might consider this alternate schedule?
Do you electively treat nodes and how does your approach change with intra- or extra-hepatic primaries?
Or use baseline PET followed by serial MRI/CT for monitoring?
In general: when would you recommend adjuvant radiation and capecitabine for a colon cancer?
The NCCN guidelines categorically recommend adjuvant XRT for a cT1-2N0 rectal adenocarcinoma upstaged to a pT3N0, yet there are multipl...
Would it make a difference whether the patient was planned for chemoradiation followed by surgery or definitive nonoperative chemoradiation?
How did the SWOG 1505 clinical trial influence your clinical practice?
Do you have a preference in ordering MRI, endoscopy, CT scan (chest, abdomen, pelvis), EUS, or other testing before starting any treatment, for re-sta...
Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?
Is there any data to support the use of immune checkpoint inhibitors either preoperatively or even definitively, similar to rectal or gastric?
Since there is no overlap between chemo regimens for these cancers, how would you sequence treatment?
Do you factor in the time interval when deciding cumulative dose constraints?
What systemic therapy is most appropriate, how would you sequence, and what RT dose fractionation would you use?
Would the location of the tumor (i.e. ultralow), symptoms (bleeding), or patient resistance to surgery play into this decision?
What constraints would you use for a 15 fraction regimen or other ablative regimen?
Would this change if the cancer was p16+ squamous cell carcinoma?
The patient has sustained a positive response for >1 year after diagnosis.
D-TORCH compared topical diclofenac to placebo
Staging/pre-op MRI only showed mild non-specific thickening.
How would you sequence therapy, and what dose and volumes would you use for radiation? Prostate cancer is localized, Gleason 4+3, PSA 65.
Exploratory analysis of the MAGIC trial suggested perioperative chemotherapy was detrimental in this subset of patients. Has availability of IO altere...
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...
What factors do you consider - perforation, size?
And is it different when using pembrolizumab or a combination of ipilimumab/nivolumab?
Do you add VEGFR/EGFR antibodies? Or switch to another regimen?
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...
Taking into account follow up from NEO, OPERA and other organ preservation trials?
4 months of Neoadjuvant GAP resulted in conversion from unresectable to resectable.
Do you use the same high risk factors as adenocarcinoma when deciding on adjuvant treatment for early stage disease?
Please specify how your institution is allocating resources now or will be soon.
Are you more inclined to offer brachytherapy boost instead of EBRT boost?
Would you boost involved lateral pelvic lymph nodes in this scenario?
> 30s, female with metastatic colon cancer. Presented with a headache. Metastatic hemorrhagic mets per MRI 10/2022. Had radiation. Kras mutated, Br...
What special considerations or precautions would you keep in mind when considering re-irradiation? The prior radiation was post prostatectomy RT. ...
How do you reconcile the differences between the two studies?
Given the published results of the PRODIGE 23 trial where FOLFORINOX was used neoadjuvantly with FOLFOX post-op
Dose-escalation RT trials have had mixed results in the past for advanced rectal cancer, while in the early rectal stage there is a tendency towards a...
How do you weigh definitive chemoRT vs minimally invasive surgical approach with neoadjuvant chemo followed by transanal excision, in light of results...
Would sidedness matter? Do you use ctDNA assays to evaluate for acquired RAS mutations to guide this decision?
Does the patient's young age affect your decision when applying data from the IDEA collaboration?
Do the overall survival results of PARADIGM presented at ASCO 2022 change the standard of care?
Would you advocate for a targeted gene approach or a fully comprehensive NGS panel?
Instead of FOLFOXIRI and bevacizumab as per TRIBE trial
Would your recommendation change in a patient having pain from disease and you wanted a quick response?
Would you recommend pembrolizumab prior to surgery? Or after? Is there a role for FOLFOX?
E.g. loss of PMS2 expression by IHC only but MSI stable by PCR.
If so, how long would you treat?
Would you use a different chemotherapy regimen than mitomycin/5FU?
Are you more likely to consider a trans-anal resection?
If records have been destroyed, how do you factor prior pelvic radiation for prostate cancer into your decision?
How does your counseling about side-effects change when offering short vs long course radiation?
And if so, would you offer FOLFOX or Immunotherapy?
Would you offer EGFR inhibitors as second line?
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
Surgery has recommended against up-front diversion in order to avoid treatment delays. The patient has at least one suspicious internal iliac lymph no...
Based on CheckMate 577?Is DFS endpoint sufficient to establish SOC or is OS benefit needed?
Is there a role for ctDNA in this case? Would the approach change if the patient is MSI-H?
What about a low lying rectal cancer with involved inguinal lymph nodes?
Would you continue FOLFOX or switch to another agent?
KRAS WT, MSS, no targetable mutations
What if actively on immunosuppression or with active lupus? For this case, presume the patient is not a candidate for resection or IR guided therapies...
Specifically, would you consider either neoadjuvant or adjuvant immunotherapy in this setting, or only after recurrence?
Not a candidate for re-excision given proximity to the anal sphincter. Consider +PNI, -LVI.
Do we wait and watch vs start treatment based on ctDNA results?
Given that pembrolizumab/trastuzumab with chemotherapy is new SOC for metastatic disease, how would you approach those with recent fluoropyrimidine + ...
The Stanford report (Osmundson, IJROBP 2015) on central hepatobiliary tract toxicity recommended dose constraints to the cHBT that would limit dose to...
How do you reconcile RAPIDO and OPRA trial results? OPRA was a Watch and Wait trial but the rectum preservation rate was much higher in that study tha...
If the patient had PSC and baseline atrophy preventing brachytherapy boost (received SBRT boost instead), would this change your threshold for stentin...
Consider negative margins and a patient refusing further surgery.
Do you assume some recovery since the prior course of RT? If so, how much over what time period?
How would your decision differ if the patient was not on immunotherapy or other systemic therapy? Would your thinking differ depending on the timing o...
Patients with deficient mismatch repair (dMMR) and microsatellite instability high (MSI-H) harbor high tumor mutational burden which tends to have fav...
If the patient is amenable to adjuvant chemotherapy alone, but is worried about chronic diarrhea/urgency after radiation, how would you counsel them?
Patients with gastric cancer can acquire new targetable mutations on progression. This could aid in additional treatment options in this group which t...
What other molecular tests do you routinely order on such tumors?
NCCN discusses targeted therapies (Everolimus) but also Temodar / Xeloda combination.
If so, what dose-fractionation regimen do you utilize? What are your target volumes?
Do you rebiopsy or use a liquid assay?
NCCN recommends floropyrimidine-based chemoradiation (sandwiched by 5-FU or capecitabine), but many medical oncologists are utilizing multi-agent chem...
A021501 trial: mFOLFIRINOX vs mFOLFIRINOX with hypofractionated radiation (Katz et al., PMID 35834226)
Are there factors that would lead you to select either ramucirumab +/- paclitaxel vs T-Dxd vs chemo?
What volume do you treat? Initial disease extended from paratracheal to celiac LN. Residual disease now is only in celiac LN.
If so, what assay would you use in this population?
Do we have data on TMB/PDL1 status of long-term survivors?
I.E., can a patient with a questionable 5 mm node (MRI T2N1) which is negative on pathology after short course radiation be staged T2N0 and receive no...
No actionable genetic alterations were identified for this patient. Would you consider FOLFOX + durva, or even single-agent durva?
Would you use immunotherapy based on the TOPAZ trial?
For nodes just inferior to the celiac/SMA axis and no other distant metastatic disease? Stage is formally M1, but just barely. The patient is otherwis...
TOPAZ-1 trial allowed for up to 8 cycles of gem/cis. Were there differences in chemotherapy duration/# cycles between treatment groups? Does use of du...
No preop therapy; dMMR in poorly cohesive and mucinous carcinoma component, pMMR in tubular adenocarcinoma component
What contraindications or concerns do you have in this scenario beyond assessing the Child Pugh Score?
Would you give additional treatment after surgery?
If borderline resectable, can the TOPAZ regimen be considered for downstaging effects?
C diff infection ruled out and CT abdomen pelvis shows diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field.
Would the presence of perianal extension and a positive inguinal lymph node affect your recommendation and how?
Is there a difference in efficacy if dose is given later point during the course of therapy?
How would you balance the OS benefit from TOPAZ-1 with the risks of immunotherapy in this or other high-risk populations?
There is involvement of posterior vagina, left puborectalis, and peritoneal reflection. No nodes are involved.
How do you sequence systemic treatment options for in patients with Child's Pugh B (or greater) in context of IMbrave150 and HIMALAYA?
When do you in...
Is data sufficient to adopt this as the new standard of care?
Can you comment on the reported regional and race-based variations in outcomes? ...
If the patient is outpatient and coming into clinic each day, at what point would you initiate a C. diff workup?
Any adjustments in terms of elective nodal coverage?
Do you proceed with chemotherapy alone, neoadjuvant chemoRT, or definitive chemoRT? How do you communicate treatment intent to the patient?
What factors influence whether you treat an elective nodal volume vs gross nodal volume (plus a small margin) in the setting of oligometastatic or oli...
Would a negative dotatate PET change management for a patient for whom you were planning to start SSAs?
How reliable is somatic testing to detect an underlying germline predisposition?
For example, portion is seen above and below the mesorectal fascia. Do you feel comfortable treating as colon cancer with surgery upfront?
Would you extrapolate from the DESTINY-CRC01 study, even though RAS/RAF mutations were excluded?
Are there clinical scenarios in which you have found chemotherapy first has been beneficial?
(i.e., advanced T stage, extra-mesorectal LN, anat...
If so, what dose/volume would you use? Would you cover any nodal regions electively?
Which radiation doses would you use if there is a >4.5 cm LN?
For this example, Ki-67 of 80, MSS, low TMB
Patient with initially stage IIIC right sided colon cancer s/p resection found to have metastatic disease prior to starting adjuvant therapy. MSI-H an...
Assume for this discussion: ECOG 0-1, life expectancy > 10How would nodal status influence your recommendation? Reference: Hawkins et al., PMI...
If radiation is indicated, what dose would you use?
Have you noted significant diarrhea until the ileostomy is reversed?
Would you offer standard ChemoRT or favour APR given the risks associated with RT?
Multiple positive nodes
Do you offer more chemotherapy during this time interval?
Do somatotatin analogues work in this scenario?
Do you drop or adjust the temozolomide at any point, or rather continue to progression as long as temozolomide is well tolerated?
Is there a risk of increased sphincter tone issues in these patients?
What would your approach be in a patient with a mid-esophageal squamous cell carcinoma treated with chemoradiation therapy followed by surgery, with P...
Are there any medications that you can prescribe? Diet changes? Does this typically resolve on its own after time?
Would you consider switching to a different regimen?
Hypothetically not an ideal surgical candidate due to weight loss. Both cancers are non-metastatic and resectable if disregarding other cancer and com...
For T2N0 anal squamous cell carcinoma, RTOG 0529 used 50.4/42Gy in 28 fractions. However, for nodal disease >3cm, 54Gy in 30 fractions is used (and...
Would you consider the BEACON regimen (i.e., encorafenib/binimetinib + cetuximab) in this setting?
Which patients would you recommend active surveillance alone, a less morbid procedure such as enucleation, or a Whipple surgery? How does age influenc...
Total neoadjuvant therapy (TNT) included FOLFOX x 4 months and concurrent chemo-RT
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
If so, how many cycles would you give? Both the MAGIC and FLOT trials showed difficulty with administering adjuvant chemotherapy.
What are the best references to help distinguish small and large bowel during contouring, if still unclear despite giving PO contrast?
If you do not use prophylaxis, what skin care strategy do you employ?
Would you give trastuzumab every 2 or 3 weeks, pembrolizumab every 3 or 6 weeks?
Pleural fluid cytology is negative for malignancy but shows mesothelial cells. Would you use a PleurX or target with radiotherapy? From my understandi...
Is there a specific brand or formulation you prefer?
The literature supporting the use of probiotics does not standardize the type or dose of probiot...
Would you debulk with neoadjuvant therapy to achieve resectability?
Would you consider gem+Abraxane to avoid FOLFIRINOX toxicity in a small, node-negative tumor?
What dose/fractionation would you give to the liver lesion and node? Would you treat just the celiac node or all there regional lymphatics?
ASTRO 2015 guidelines did not recommend coverage of stations 5/6/7 except for what is within 1 cm of the esophagus to limit lung dose. However, ARS 20...
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 change your dose constraints for lung tissue in patients with poor pulmonary function test results?
Does esophageal cancer continue to respond up to 6 months on PET, like anal SCC or p16+ oropharyngeal cancers?
Garcia-Aguilar J et al, JCO 2022
Residual GEJ mass and progression in local lymph nodes after carbo+taxol chemoRT without distant metastases.
If so, would you adjust 5-FU dosing?
Would your thinking change if the patient continues to be NED after an unplanned chemo break, e.g. for insurance issues?
Final pathology showed pT3N0, 0/27 nodes, negative margins +perforation, +PNI, pMMR.
Is it necessary to test CPS given the FDA approvals are not contingent on CPS %?
If you do test, do you check 28-8 (nivolumab), 22C3 (pembroliz...
Are bony landmarks used to guide patient placement?
When contouring pelvic lymph nodes in rectal and anal carcinoma, do you exclude bowel from your CTV?
The RTOG consensus guidelines suggest to not exclude small bowel when it falls into the space occupied by the rectal mesentery. Meanwhile, prostate an...
Would you treat differently if it was hypofractionation? How would your treatment management change if the prior radiation was within 2 years of the r...
Would you use reduced dose chemoimmunotherapy, single agent chemotherapy, or single agent immunotherapy if the patient is unlikely to tolerate full do...
Do you view CPS < 1% or 1-4% separately? Do you view the incremental benefit of adding immunotherapy still advantageous given relatively poor outco...
Do you go by FDA approval alone, or incorporate other data into your treatment decisions? How do you view updated recent presentation of CM-649 ...
Are there meaningful differences in the CHECKMATE 649 and KEYNOTE 590 studies to guide this decision?
Would you follow the same guideline recommendations for adenocarcinoma if the adenoma component is invading miscle wall?
Previously untreated
Are you doing more TNT to prolong time to surgery? If so, do are you starting with CRT or chemotherapy?
What combination of fluoropyrimidine, PD-1 inhibitor, or trastuzumab do you use?
If radiation has a role in treatment, what is the recommended dose? Would SpaceOAR placement be helpful?
Are there contraindications to drugs like oxaliplatin or abraxane?
Does chronicity or severity of the patient's underlying symptoms play a role in yo...
KEYNOTE 811 showed improved response rate with the addition of pembrolizumab, but very few patients in this study had low PDL1.
Given multidisciplinary discussion has occurred and SBRT has been agreed upon as local therapy, how do you approach the presence of moderate/significa...
Do you do fluoroscopy first, match motion of diaphragm or fiducials? CBCT? Repeat Fluoro/CBCT? Do you use breath hold or gaiting or compression? Do yo...
Would you always offer an FGFR inhibitor as second line therapy in these patients instead of a second line chemotherapy regimen?
What factors and evidence would you use in your decision?
The patient already received PLADO+sorafenib, Y90, and Atezolizumab/Bevacizumab complicated by recurrent episodes of bleeding from esophageal varices....
If an older patient is only fit enough for single agent fluoropyrimidine therapy, would you prefer to give this neoadjuvantly or adjuvantly?
Would you ever consider adjuvant chemotherapy rather than adjuvant immunotherapy after the publication of the CM-577 results? If so, in which pop...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
Is there a benefit to EBRT/SBRT or would you choose observation until there is pathologic evidence of invasive pancreatic cancer?
If multi-agent systemic therapy, i.e. FOLFIRINOX, is also planned, is there a preferred sequence of therapies?
Would you recommend 6 months of FOLFOX or just surveillance?
Pathology details: 75% high grade large cell neuroendocrine tumor of the cecum (20-30 mitoses per 10 hpf, Ki67 75%) and 25% adenocarcinoma. Patient ha...
Do you treat the inguinal lymph nodes prophylactically when using RAPIDO-style total neoadjuvant therapy (25 Gy in 5 fractions followed by CAPOX or FO...
G1 neuropathy and G3 neutropenia were observed with cycle 12 FOLFOX + bev.
Would you reintroduce oxali at a lower dose or switch to irinotecan+EGFRi ...
What about for a patient with complete radiographic response who declines surgical management?
If the margins contain in situ disease, would you recommend further wide local excision?
Would chronic immunosuppressive disease affect your treatmen...
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...
Pathology also notable for LVI +, PNI+, but with negative margins.
How do you delineate your boost volume and to what dose?
What dose would you use to boost suspicious remaining nodes and how are your doses impacted ...
If you had a patient with otherwise average risk stage 2 colon cancer but had signet ring or mucinous components to their pathology, would this sway y...
Of note - the tumor tissue biopsy NGS did not show KRAS or BRAF mutations. Microsatellite stable. Patient received first line FOLFOXIRI + Avastin .
Would you treat per OPRA, or try for a higher dose?
For patients who have already undergone trimodality treatment, what time frame do you consider for adjuvant IO?
Or would you always aim to treat with combined chemotherapy and fractionated radiation?
Would your answer change in the postop setting for a tumor right above peritoneal reflection with positive pelvic nodes?
This involves the primary site responding but progression with new bone marrow involvement with resulting cytopenias.
Do you use conventional fractionated RT, hypofractionated RT, or SBRT?
How do you counsel patients on the benefit of adjuvant therapy who thought surgical resection was curative?
Do you worry about fluoropyrimidine resistance with concurrent chemoRT? Is there any role for neoadjuvant immunotherapy?
What dose/fractionation scheme is appropriate? Can SBRT be utilized? Can chemorRT with Xeloda be curative in this setting?
What factors would influence your approach?
Are there other treatment variations by clinical subsets (eg tumor location, histology, stage II vs III, other biomarkers) seen in CM577 or other data...
CheckMate 577 only included patients with R0 resection.For R1 resections, guidelines suggest observation vs re-resection only.
Do you ever contour the normal pancreas, use any dose constraints, and/or counsel patients on any possible late effects such as pancreatic insufficien...
Is there increased toxicity in patients with duodenal stents receiving RT?
Is there a benefit of SBRT over Y90 or vice versa?
In the adjuvant setting, what boost dose to vascular areas can be safely applied, assuming one has all the tech to reliably breath hold the patient an...
Do you add on additional cycles of 5-FU/capecitabine to go beyond 3 months of treatment? Or would you stop at 3 months of therapy, dropping the oxalip...
Would the etiology of HCC affect your decision, e.g. non-viral hepatitis since less benefit was shown for this group in IMbrave150?
RTOG 1010 has Lungs-PTV constraint of V10 < or = 40% (per protocol) to 50% (variation acceptable), but V10 is not often used in other thoracic mali...
If RT/chemo is preferred, what is an acceptable final boost dose?
Surgical path confirmed CK7(-), CDX2(+), CK20(+), consistent with prior colonic adenocarcinoma.
Ki-67 > 95%, PET-CT negative for any additional disease.
Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?
For example, not placing superior border at L5/S1.
Would you offer chemoradiation or radiation therapy to the primary? Would you consider consolidation of oligometastatic sites? What dose w...
Is it still necessary to treat to 50 Gy or can a lower dose safely be used as there is no gross disease (e.g., 42 Gy in 28 fractions to nodes and the ...
Do the multiple beam angles cover the skin adequately enough? Is full dose to the skin necessary? Do you take into account the amount of auto-bolus re...
Would your decision be influenced by whether a pathologic complete response was attained?
The patient was started on a beta blocker, as this is standard in the area.
Would you consider using infigratinib after progression on pemigatinib?
Would you offer liver transplant in the setting of metastatic disease?
Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.
What therapy would you offer if the patient had a baseline grade 2 neuropathy?
What determines duration of therapy in patients who achieve stable disease or no evidence of disease on imaging?
Is there any role for radiation in t...
https://pubmed.ncbi.nlm.nih.gov/34077237/
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...
If so, at what interval? NCCN recommends annual CT/MRI.
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?
Would you extrapolate treatment from the paradigm of anal SCC?
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...
Does your decision for 3 vs 6 months of treatment change for low risk stage III colon cancer?
Patients can develop sensory and motor symptoms such as paresthesias, jaw/facial pain and stiffness, cramping and twitching, ptosis and vision changes...
Biopsy of other sites is more consistent with carcinoid tumor.
Would you use platinum/etoposide concurrent with radiation or would you opt for platinum only during radiation?
Would you use BID fractionation...
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...
eg LVI/PNI, poorly differentiated? If so, what regimen and for how long?
Has the recent approval of atezolizumab/bevacizumab impacted your decision making?
If so, for how long?
Would you recommend radiation, systemic therapy alone, or chemoRT? What about if this recurrence occurred during or shortly after completion of adjuva...
Does your answer change for long course chemoradiation vs short course radiation therapy?
Is there a subset of patients you would avoid neoadjuvant CRT and operate first?
What would you offer in the setting of bulky liver metastases?
The invasive component had depth of invasion 1.7 mm, horizontal extent 3.5 mm.
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?
Bulky hepatic metastasis
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?
Would you offer low dose or standard dose aspirin instead?
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...
Assuming all other factors are favorable (pT1-2, TME, negative margins).
Is there a threshold of when you would use chemo/radiation?
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 you do test, do you have a preferred testing method?
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...
In GEJ or gastric cancers, do you routinely image after surgery, prior to resuming systemic therapy?
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...
Would you cover elective lymph nodes?
How do you assess the risk of complications from including bevacizumab vs the known benefits of including it with chemotherapy?
Would you try atezolizumab/bevacizumab or switch to a TKI?
ASTRO 2015 esophagus guidelines recommended the abdominal para-aortic nodes to be included in the CTV whereas ARS 2020 guidelines did not. Instead, AR...
i.e. CA 19-9 >100
When would you consider gemcitabine/abraxane as an alternative treatment?
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?
What strategies do you use to meet those constraints?
Would your recommendation change based on the patient's age, performance status, comorbidities, or chemotherapy details?
Would your management change if the prostate and lymph nodes were treated with radiation two years ago?
Would chemotherapy alone suffice? Repeat biopsy and EUS were negative for residual disease.
Would you be confortable to give full dose CRT?
If so what is the crietria?
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...
Specifically, would you consider incorporating immunotherapy in this setting?
What is the risk of perforation / fistulization?
What method provides the best reproducibility? Abdominal compression? Inhale breath hold? Exhale breath hold?
No high risk features such as: lymphovascular invasion, perforation, or involved margins
The concern being that if patient does not go to surgery, you have delivered lower BED with 36/15.
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...
For example in a patient with a history of PE?
i.e. EGD surveillance for varices?
What parameters do you use to decide to treat beyond progression? Is there any efficacy data from this specific study subgroup in IMbrave150?
ex. VEGFR2 expression, inflammatory signature, PDL1, etc.
Does nodal positivity at time of surgery affect your decision?
Do you continue atezolizumab alone? Would you avoid anticoagulation?
Patient with ECOG 0-1
Would you consider adjuvant chemotherapy?
In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?
Do you screen even asymptomatic 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...
Would you use FOLFIRINOX as in Prodige 23 or FOLFOX as in RAPIDO?
In a patient who has undergone resection and adjuvant chemotherapy who then recurs locally, how would you recommend treating? Would you treat ju...
exam is + for ascites
Especially if the patient had advanced N3 disease and is reluctant to pursue surgery?
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?
What dose, fractionation and what elective coverage do you recommend?
When would you consider use of ctDNA to help with this decision?
Or would you consider IO agent be given only after progression on platinum + fluoropyrimidine?
If you would elect for adjuvant therapy, which study helps guide your choice of regimen?
Does the amount of time from 1st treatment change your management or thinking in this situation?
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...
How would you adjust your small bowel dose constraints? What other considerations would be pertinent?
Patient had a solitary lung metastasis
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...
The recurrence is several adjacent nodes above the prior fields.
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...
For example, a FANC mutation
For example, status post resection of a 4 cm high rectal carcinoma that was believed to be in the sigmoid colon but found interoperatively to be below...
No known cardiac risk factors
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...
What dose would you use? How do you counsel on risk of damage to j-pouch?
Would it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?
If the patient is medically inoperable, is post-chemotherapy radiation therapy or SBRT advisable with no visible GTV?
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...
Does it improve patient quality-of-life?
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...
Liver and skeletal metastasis with no disease in the lung.
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?
MRI? Endoscopy? Physical exam?
Is there evidence for radiation therapy in this setting?
What are there most evidence-based options?
What is the added benefit of Chemo-RT vs RT alone?
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?
Preferred options in NCCN guidelines: 5FU+cisplatin, 5FU+oxaliplatin, paclitaxel+carboplatin?
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?
What is the duodenal stump dose constraint?
Would you consider using PARP Inhibitor in this situation?
Are you placing more weight on patient risk factors such as age >65 or co-morbidities?
Is FOLFOX or 5FU acceptable without XRT if D2 resection?
In which clinical situations is there a good rationale for the use of proton therapy for GI cancers?
Should we give concurrent capecitabine?
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 ...
Would you consider the addition of chemotherapy to proton beam therapy?
Patients oftentimes have cardiac co-morbidities with requirement for anti-coagulation making TKIs, including Bevacizumab, difficult to dose. Would the...
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?
...
What dose and volumes of radiation would you use?
If so, which patients are the best candidates?
Would you use dual agent chemotherapy such as FOLFIRI, combination of chemo with biologic- IRI/Cetux or all 3 drugs simultaneously? How would sidednes...
Would you continue to trend ctDNA to detect early recurrence?
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...
Does this also apply to somatic mutations?
Do you routinely test for this with a re-biopsy?
If so, are there particular patient/tumor characteristics that influence your decision?
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...
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?
If so, how much systemic therapy would you give before considering surgery?
Do factors such as large tumor size and/or node positivity affect the decision?
What factors other than the Khorana score influence your decision regarding prophylactic anticoagulation in these patients? If prescribing an agent, w...
If so, what dose fractionation do you prefer?
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?
Would you choose to use IO or BRAF directed therapy based on BEACON? Or would you continue to use cytotoxic chemotherapy?
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 factors do you use in deciding whether or not to electively cover the celiac axis?
With extensive use of NGS testing, it is commonplace to identify mutations that have no validated therapeutic intervention, but strong biologic signal...
Package insert indicates discontinuing bevacizumab in PE and there are no guidelines on re-challenging after acute clot is managed.
*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?
Is neoadjuvant chemoradiation or perioperative chemotherapy preferred?
ex. age, surgical risk, and/or performance status
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?
Do you have a similar approach in younger population?
CPS score of 40%. How and when do you incorporate immunotherapy into the treatment of metastatic gastric adenocarcinoma?
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...
If so, what agent(s) would you consider given the concurrent amplification and mutation?
If you were to treat, what do you include in your treatment?
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...
If so, what dose do you boost these nodes to?
Does the pathology outweigh usual staging and risk factors?
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 be concerned about toxicity given that he has ulcerative colitis?
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.
Would you treat with definitive doses?
Do you utilize it immediately following chemoRT or wait until disease progression?
If the patient will be having a total colectomy, would up-front surgery be a better consideration?
Would your answer depend on the response of the primary site?
How do you choose between local therapy (surgical debulking or ablation) v. 2nd line systemic therapy? Would you consider immunotherapy?
Is there a role for additional treatment?
Would you offer local therapy to the liver?
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...
Provided the patient can have the solitary met treated definitively with SBRT and is otherwise a good surgical candidate
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...
Further surgery is not possible.
The patient refuses surgery.
Do you worry about migration or scatter dose from the metal?
On occasion, patients with locally advanced gastric cancer are poor candidates for FLOT-like chemotherapy. Should such patients be taken to surgery up...
In a patient with a good performance status, would you consider this?
If so, what dose and fractionation?
Given this rare histology, would you treat this patient as a skin cancer or as an anal adenocarcinoma with inguinal nodal coverage?
Is this practice still relevant to the modern IMRT approach where skin toxicity is much lower?
PDL1 is > 50%. There was no perforation or lymph node involvement.
I have seen anywhere from 4-6 months utilized. Is there any data to guide your strategy?
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...
There is some data on TMZ and 5FU based regimens, but convincing evidence is lacking. How would you approach this situation?
Or should total neoadjuvant therapy be reserved for bulkier disease (T4N2)?
I understand the perioperative trials are not based on tumor regression in cancer cells.
Do you recommend definitive therapy? Would your approach change if there are more than 1 site of bone metastases, such as 2-3?
Let's re-open the debate!
Is there any data to support delayed treatment?
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?
What dose would you recommend? Any role for systemtic therapy?
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 have any specific bowel constraints when treating patients with palliative radiation 3000/10?
Do you look at max dose or are there specific volumetric constraints you use for the small or large bowel?
Do you boost the positive nodes beyond your standard pelvic dose?
Our hospital has an aggressive and talented interventional radiology group. We have wanted to start a stereotactic liver radiotherapy program but are ...
How do you interpret results when IHC is < 1% but CPS > 1?
What dose do you take the primary to?
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?
Arterial events have clear instructions to permanently discontinue on the FDA label. Especially in HCC without many other treatment options, giv...
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 ...
If so, what would your target encompass?
Colonoscopy reveals inflammation in the colon and rectum due to Crohn's and patient also has perianal fistula due to Crohn's.
Do you use concurrent Xeloda?
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...
NCCN lists multiple preferred options.
The data is scarce- do you recommend chemotherapy only or would you consider RT for local control?
Is there a role for SBRT with or without the addition of systemic therapy?
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...
Does this vary depending on the site you are treating, i.e. abdomen vs pelvis?
Would you recommend neoadjuvant chemotherapy to spare the stomach?
The patient had minimal to no response to neoadjuvant therapy.
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?
The patient has no evidence of lymph node involvement.
Does the presence of BRAF mutation affect your decision?
If you would recommend radiation therapy, what dose-fractionation would you utilize?
Detailed instructions regarding lymph node coverage have been published, but how do you think about coverage of the anastamoses from the gastrectomy?
What timing do you recommend? What drug and what dose do you use?
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?
What are your thoughts on dose, avoidance structures, re-tx risk, etc?
In view of higher risks of rectal cancer after pelvic radiation, is more frequent screening warranted?
Do you test for COX-2 and PIK3CA mutations?
Would you offer chemotherapy alone per data from BILCAP or is there any role of radiation?
Does the lack of D2 dissection automatically necessitate adjuvant chemoradiation therapy (ie <5 LN obtained)? Would the presence of high risk facto...
Does the Child Pugh score factor in your treatment decision, i.e. Child Pugh score C?
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...
What are your fields? Do you treat nodes electively?
What doses do you use?
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...
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 have different preferences based on T-stage?
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?
In particular, many guidelines suggest a max point dose of 50Gy for small bowel but in cases of extensive disease how do you reconcile loops of bowel ...
How would being MSI-H/dMMR influence your choice of adjuvant treatment?
Is there a risk for anejaculation?
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?
does it matter whether it is given frontline vs later?
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?
Are the treatment volumes the same as those for squamous cell carcinoma of the anal canal?
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?
Is this patient considered to have metastatic disease? Should definitive surgery be considered?
Are these patients better candidates for preop chemotherapy alone?
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...
Would you use this combination in frontline vs later lines of therapy ?
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...
Has the new data with the Natera assay from Reinert T et al in JAMA Oncology May 2019 changed your practice?
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...
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...
Would you recommend chemoradiation therapy or chemotherapy upfront?
Any role for surgery? What radiation volumes would be used?
Would you consider an aggressive approach such as hepatic resection if the patient is young and has good PS?
What adjuvant options would you consider? chemotherapy? radiation?
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 chemotherapy either before or after the lung resection?
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?
Is re-challenge with 5-FU safe? Do you consider Capecitabine?
What factors dictate choice of observation versus 6 months of adjuvant peri-operative chemoradiation plus chemotherapy especially if patient did not r...
What dose and volumes would you use?
If the patient received neoadjuvant FOLFOX for 4 cycles then 50.4 Gy with concurrent capecitabine, is that enough treatment to omit surgery?
Is curative intent surgery off the table?
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...
Is obtaining serial MRIs or other imaging appropriate?
Specifically, rising levels noted while on somatostatin analogue.
If so, what regimen would you consider?
As in removing the 5-FU bolus from the start of therapy and not because of toxicity?
When will you prescribe 3 v. 6 months of FOLFOX or XELOX for the adjuvant treatment of colon cancer?
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...
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...
Antacids? Anti-motlity agents? Dietary changes? Combination?
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 send the patient for a stent or do palliative RT?
Would you consider subtotal gastrectomy vs medical therapy?
http://ascopubs.org/doi/full/10.1200/JCO.2015.64.2710
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?
Fecal incontinence can be one indication. What are others?
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?
For patients receiving adjuvant gemcitabine alone, would you now switch to adjuvant capecitabine alone?
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...
Would you treat the node alone, unilateral/bilateral inguinal nodal basins, or cover any possible primary locations such as the anal mucosa?
Stenting is not possible/not able to bring down the bilirubin level.
Is better systemic control needed to make radiation therapy beneficial?
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...
What about T3N0 disease? Would you use a recurrence score to help inform decisions?
What about bulky nodal disease?
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.
In what situation, if ever, do you include mediastinal nodes?
In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...
The pathology shows both adenocarcinoma and neuroendocrine features.
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?
Is inguinal coverage always required?
How would the new data presented at ASCO GI 2021 from from Alliance A021501 influence your answer?
Specifically, are hilar nodes metastatic?
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?
If so, how would HIV/Hepatitis status affect you decision?
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...
Would your recommendation change if the histology was adenocarcinoma (excluding GE junction tumors)?
Reference: https://www.ncbi.nlm.nih.gov/pubmed/23578724
Is your approach similar in unresectable disease? Is there evidence to support one approach over the other?
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?
What if a large portion of small bowel is located within PTV45?
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...
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...
Do you target the whole pelvis or a smaller "boost-like" field?
Does the recent Hopkins trial of pembrolizumab change your management of these patients?
If so, what is your preferred regimen?
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?
Specifically - anus, pancreas, gastric?
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 ...
Are there any precautions to prevent formation of a TE fistula?
Would your approach change if the histology were adenocarcinoma?
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?
What are the targets (tumor bed, positive margin, nodes etc.)?
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...
Fore example for a T3N0 rectal cancer on EUS?
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...
If so, what dose?
What regional lymph nodes do you include perigastric, portahepatic, periesophageal, celiac, splenic, pancreaticoduodenal, sup. mesenteric, paraesophag...
Are there any indications to choose one over the other?
How should we counsel young women who are receiving treatment for GI/GYN malignancies?
Is there a consensus on the MAGIC v. MacDonald debate?
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...
What techniques work best?
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