Genitourinary Cancers
Questions discussed in this category
Do you treat the pelvis or omit? Do you have more tighter constraints for rectum or bowel?
Given publication by Spratt, et al JCO 2021, how do you sequence ADT?
PMID: 33275486
JCO, 2021, Spratt D et. al, Prostate Radiotherapy With Adj...
Do you manage post radiotherapy onset of tensmus differently?
HDR CT planned prostate brachytherapy stipulates bladder V75% Rx<1cc. What bladder constraint is used for LDR prostate brachytherapy?
Are there any anatomical changes that would make the placement impractical or hurtful for the patient?
The STAMPEDE trial recently published in Lancet used 55 Gy in 20 fractions but did not include dose constraints.
Concern about tolerability of treatment in adding radiation to the penis given primary mode of failure will be distant.
We have encountered multiple patients whose pre-ADT Testosterone was >1500 (Normal range 264-916) and sent them to Endocrinology to evaluate for so...
Given consensus contours for prostate bed, volumes can approach the sigmoid and include a significant amount of bladder, how do you meet these objecti...
For patients who have progressed on first line checkpoint inhibitor (e.g. Nivo/Ipi) and second line TKI (e.g. Cabozantinib)
Should the prostate be rebiopsied, or would you proceed with radiation therapy given the relatively high failure rate of cryotherapy as initial treatm...
Given prognosis is poor per Oing, et al, Annals of Oncology, 2016, would you recommend radiation?
What systemic therapy options are available for ESRD patients?
If the location of the biochemically evident cancer cannot be determined, would you re-irradiate the prostate despite absence of histologic proof of l...
Would you add abiraterone or enzalutamide?
What neoadjuvant or adjuvant therapy would you give?
Assume they are undergoing systemic therapy (ADT, etc). At what time do you initiate SBRT?
It seems that patients have an easier time maintaining a full bladder at the beginning of treatment compared to end of treatment.
If a patient who has undergone radical prostatectomy many years previously presents with biochemical failure and is found to have a nodule in the pros...
Would you consider using them in patients with CHEK2 mutations?
NRG GU-006 included the following as part of its eligibility criteria: “Persistent elevation of PSA after prostatectomy measured within 90 days ...
Would nodal areas would you treat? What dose would you recommend?
Assume treatment was 5 years ago and patient no longer has diverting ostomy. Would surgery or radiation be preferred given both have increased risks? ...
Would you consider 55 Gy in 20 fx to the primary followed by SBRT to oligo sites? Would you consider concurrent immunotherapy? Or would you just proce...
How would treat the node? What dose?
For those of us just transitioning over to hypofractionation, what are reasonable, but conservative, constraints that you use?
A recent NCBD analysis (Rusthoven et al, JCO 2016) suggests that the addition of prostate RT significantly improves survival compared to ADT alon...
Assume patient has no history of IBD, UC, etc.
What dose, fractionation and treatment fields would you use?
The protocol for the James trial (NEJM 2012) states: "non-target tissue may be excluded at the discretion of treating physician." For gyn applications...
Ex: TKI alone, TKI + checkpoint inhibitor, checkpoint inhibitor alone, TKI + mTOR inhibitor. Please specify drug regimen, if applicable.
Would it change your decision if they had progressed on a first-line trial with cisplatin followed by pembrolizumab plus enfortumab vedotin maintenanc...
Assume treating to 64-66 Gy.
Do you simulate bladder cancer patients with full and/or empty bladder?
Do you ever add your own delayed IV contr...
Is there any available therapy?
Do you perform a DRE at consultation and/or in follow up? Do you feel that performing a DRE changes your management?
What clinical scenario(s) do you find results to be the most beneficial?
Is there a role for neoadjuvant cisplatin-based chemotherapy?
Do patients with sarcomatoid histology respond to checkpoint inhibitors?
Are they necessary? Any group of patients that you use them on (concurrent ADT, anemia, or use of whole pelvis, etc)?
Patient had had multiple surgeries and non healing wounds. If so, what dose/fractionation did you use? Did your patient have durable control of ...
Assuming no actionable mutations?
If so, how would you design and deliver the treatment?
Would you offer SBRT? What criteria do you use to consider SBRT? What dose limits do you place on the glenohumeral joint?
There are so many available options—standard fractionated RT, moderate hypofractionation, SBRT, protons, combined EBRT and brachy—how do y...
Does PSMA have enough data to use to guide therapy, even if the result is obtained as part of a clinical trial? Would you change your hormonal recomme...
No actionable mutation on NGS testing. What approved therapy do you prefer? Are there specific investigational agents currently in clinical trial...
Does the TURP defect in the prostate affect efficacy or toxicity or SBRT?
STAMPEDE arm H uses the CHAARTED definition for bone metastases in the axial skeleton. There is no mention of patients with non-regional nodes. Would ...
Any role of neoadjuvant chemotherapy?
What would you consider if the recurrence occurs multiple times in the prostate? Salvage surgery if a candidate? HIFU or cryo? ADT?
What makes you favor ADT vs local therapy? Any preferred local therapy options? Any other special considerations?
Prospective single arm studies with short term follow-up were recently presented in abstract form (Kishan et al, IJROBP, Oct 2017; Mallick et al, IJRO...
If no testicular mass on exam or ultrasound - is there a role for orchiectomy? What chemotherapy regimen would you use and how many cycles?
Patients can have this for many reasons including being completely anuric, incontinence, nephrostomy tubes, etc.
How would you treat an elderly, frail patient with a bulky penile SCC with bilateral inguinal nodes?
If you would offer radiation, what dose do you recommend? How do you simulate and treat the patient? The patient is not a surgical or chemo candidate.
Assume PSA less than 0.5. Would axumin positive nodes change your mind? What dose do you use? Do you require biopsy first to prove pathologic nod...
Does the specimen (blood vs tissue) used to detect mutation affect your consideration?
For example, is there any data to suggest a benefit to starting with immunotherapy prior to TKI or the alternative?
Are there particular populations in whom you would add an AR targeted agent after docetaxel?
There is a recent publication that nicely summarizes the molecular/genetic tests for prostate cancer (https://www.ncbi.nlm.nih.gov/pubmed/26123120). W...
Assuming patient received appropriate local therapy for brain metastases, which agent would you use?
Are there any chemotherapy regimens that can be used in elderly patients with poor PS who are not candidate for BEP?
HERO study - https://clinicaltrials.gov/ct2/show/NCT03085095
Is a detectable PSA on ADT a harbinger of biochemical recurrence? Is there a threshold value above which you are concerned (ie. 1.0 vs 0.5 Ng/mL...
If you recommend adjuvant radiation, how would you treat this? Because of the cystectomy, there is no typical prostatic fossa.
Based on the recent guidelines, should prostate SBRT dose be no higher than 3625 cGy in 5 fractions?
The recently published executive summary from ASTRO/ASCO/AUA hypofractionated radiation therapy for localized prostate cancer states "Five-fracti...
i.e. Cisplatin + Etoposide
Some considerations:
-Cabozantinib (Based on CABOSUN trial, NCCN does not list this as a Category 1 recommendation)-Nivolumab + Ipilimumab (CheckMate...
Is there any specific precautions or concerns to consider with TKI initiation if the patient has vasogenic edema?
RTOG 0815 protocol says 1 cm from base of SV in any direction. Some contour the SV visible in the slices within 1 cm sup/inf from base of SV.
P...
Would you do systemic treatment or observe?
(assuming that the patient is int-poor risk, has measurable disease outside of the CNS, warrants treatment with appropriate PS)
In a patient who has undergone prior cryoablation for prostate cancer and develops a biopsy proven local recurrence, what dose and fractionation would...
Given that ADT + abiraterone and ADT + docetaxel have not been directly compared.
Given CHAARTED and STAMPEDE, what would you recommend? Would lymph node vs osseous mets change your recommendation given the trial did allow patients ...
How reliable is MRI only diagnosis of prostatitis? Assume no prior PSA and Group grade 2 or 3. Would you treat prostatitis? How do you deal with ADT e...
Is there data to support proceeding directly to cystectomy?
What is the time window in which you would consider adding AR targeted therapy?
Is there a time frame in which you would NOT consider introducing sin...
Given the length of the scan and higher likelihood of patients being unable to hold their bladder, do you deviate from CT simulation and treatment ins...
What dose and fracionation? Would you use SBRT?
Does CBCT suffice for prostate SBRT?
If so, what regimen would you use? Would a carboplatin-based regimen be acceptable or only cisplatin?
Do you prefer surgery vs radiation?
For surgical patients, do you offer neoadjuvant chemotherapy? If so what regimen?
Is there an optimal strategy to minimize unnecesary steroid use?For example, pre-treatment dexamethasone or 3 day dexamethasone? Prednisone only conti...
If so, for how long would you treat?
What are the differences between Decipher, Oncotype, Prolaris?
Is there data and FDA approval for this indication?
What about for nodal failure after radiation?
Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?
Assume this is a PET Axumin avid node and is only site of disease. Previously this high risk prostate cancer patient had 45 Gy to the whole pelvis and...
How does your approach differ for patients with stage IIA versus IIB disease? Age?
Would you consider reirradiation, including SBRT?
How high would you try to boost those involved nodes if they are in a favorable location with respect to his rectum and small bowel?
NCCN guidelines recommend pelvic RT for N+, but what is the hard evidence for this?
Based on recent data published suggesting an OS advantage to the addition of ADT vs. brachytherapy boost to EBRT (Jackson et al, 2020), it is unclear ...
In the HERO trial, relugolix, a highly selective oral GnRH antagonist, demonstrated faster and sustained castration, faster testosterone recovery, and...
https://meetinglibrary.asco.org/record/186872/abstract
How do you weigh the negative results from IMvigor 010 of adjuvant atezolizumab vs the results...
Are there certain situations where a hydrogel spacer is most useful based on treatment modality (SBRT, protons, brachy, etc) or other factors?
Do you ever recommend TURP, short course of ADT or other treatments prior to RT to downsize?
An ASCO 2020 poster from the German Testicular Cancer Study Group found that 37% of CSIS seminoma and nonseminoma were miscatagorized resulting in ina...
If offering neoadjuvant chemotherapy, which regimen would you use?
If this upstages the patient, do you modify treatment recommendations?
What dose constraint would you use for the neobladder? Small bowel constraint of 54Gy? Or would you recommend observation or ADT alone or low dose RT ...
Does it change your treatment fields or dose?
Should treatment be based on current histology (rhabdomyosarcoma) or origin (germ cell)?
Any comments/recommendations regarding the UK approach using 52.5Gy in 20 fractions (Chin et al., IJROBP, 2020)?
Is there a contraindication to radiation therapy for prostate cancer in patients who are carriers of ATM mutation? Would you offer surgery upfront? Hy...
Would you recommend conventional fractionation or moderate hypofractionation over SBRT or brachytherapy?
Patient has MSKCC high risk disease. Immunosuppression is with mycophenolate mofetil and tacrolimus.
Would you consider this even though this falls out of scope of STAMPEDE trial? Under what circumstances would you consider such an approach versus not...
GI work up negative. NGS cancer type and isochromosome 12p ordered and pending. Pathology at RPLND was negative for cancer.
There are conflicting reports of increased incidence of bleomycin-induced lung toxicity with G-CSF.
Assume oligometastatic site will receive treatment.
Do you recommend targeted fusion biopsy?
Do you have a maximum bowel dose constraint?
Brain metastases have undergone resection, SBRT and WBRT
Is there data that hilar location is a contraindication? Any increased risk of ureteral stricture or other unforeseen issues? What dose/fractionation ...
This applies to both de novo cases and patients who have previously received injectable agents.
Are there any prospective studies?
If so, what dose and volume would you treat?
Would you treat the inguinal nodes and how?
Are there any complications to using LHRH agonists in patients using estrogen?
Assume MRI noted this on exam and patient is minimally symptomatic.
How does recommendation change if this a favorable intermediate, unfavorable intermediate or high risk patient? Is additional imaging or biopsy recomm...
Would you use SBRT, hypofractionated or standard fractionated boost?
Assume we are using 37.5Gy in 15 fractions
Would you forego neoadjuvant chemotherapy?
Are you using growth factor support differently?
Any changes to immunotherapy?
Other considerations?
Is this also a marker of TKI sensitivity?
Residual disease with bulky retroperitoneal masses also present on scans
U of Alabama paper states no max dose constraints used but they try to keep V60 < 10% or 10 cc (these constraints appear to be difficult to achieve...
Would you consider SBRT and if so what dose/fractionation would you use if the lesion was in the head of the mandibula?
If not would you give a fract...
Assuming patient is not a surgical candidate and wishes to pursue definitive radiotherapy, what duration of ADT would you give?
What concerns do you have about a colonoscopy?
Is a positive imaging enough to confirm the diagnosis? If not, what situations are appropriate for a biopsy?
How do the results of RTOG 0534 presented at ASTRO affect your decision making?
There was an abstract in European J of Cancer (Srinivasan R, 2014:50: S6, P8) showing a good response rate with Bevacizumab and Erlotinib. Would you u...
How would a much higher risk cancer affect decision making? How would you treat him?
If a patient has had a diagnostic MRI, can you obtain another planning MRI after fiducial marker and SpaceOAR placement?
Concurrent? Neoadjuvant and concurrent? If neoadjuvant, how long before?
Abstract 5014 at ASCO annual meeting 2019 showed superiority of PSMA-PET imaging over fluciclovine-PET imaging. Are you utilizing these speciali...
Would you be more mindful of bladder dose or hotspots? Are urinary outcomes different if the surgical procedures are done before or after radiation?&n...
Patient had multiple positive margins and is on ADT. What would your treatment volumes be and to what dose?
Are there any special considerations with the PNET?
Do you recommend before and/or after procedures? Do you have the same recommendations for any or all the below: hydrogel space, fiducial placement, LD...
Given the publication by Malone, et al (JCO, 2019), how do you sequence ADT relative to the start of RT? https://ascopubs.org/doi/full/10.1200/JCO.19....
Do you routinely include pelvic lymph nodes, prostatic urethra, and prostate?
In the SPARTAN trial, median PSA at study entry was ~ 7. Does the MFS benefit extend to patients with low PSA(< 2 or < 1)?
Patient had neoadjuvant ADT. Are there any preferred isotopes, seed activities, etc for small prostate brachytherapy?
Does the extent of the surgery matter?
Any difference if patient is undergoing HDR vs LDR? For example, prescription doses are 45Gy for EBRT and 10.5Gy x 2 for HDR boost.
Indefinitely seems to be a typical recommendation, but rarely done.
What dose do you recommend for salvage radiotherapy after biochemical recurrence in prostate cancer?
A recent study http://www.ncbi.nlm.nih.gov/pubmed/27480153 showed an improvement in bichemical failure with higher doses. How much impact do...
Which radiation modality for definitive prostate cancer has the lowest risk of erectile dysfunction?
How do you counsel the patient regarding his risk of ED?
Do you treat in this scenario if mild/moderate infiltration? What are your thoughts on the article Fischer-Valuck, et al, PRO, 2017 (PMID: 280895...
Would you recommend radiation to the prostatic fossa and/or the oligometastatic site? How would you dose these areas? Would you recommend ADT?
For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...
NCCN include active surveillance as an option in specific circumstances based on Rini et al. (Lancet Oncology 2016) however this set is not well defin...
Any role to switch to MVAC?
Would you treat with chemoimmunotherapy based on IMvigor130 data presented at ESMO Congress 2019?
Would it matter if their PET axumin was negative?
e.g. lymph node metastasis, presence of tumor involving the peritoneal surfaces and/or the abdominal wall. If so, which regimen would you offer?
The patient's urologist will not offer testosterone supplementation unless he undergoes definitive therapy of his early stage prostate cancer. Are the...
Are there clinical factors that go into your decision making?
Wouldn't lymph node dissection improve sensitivity of staging and inform adjuvant treatment decisions?
Based on the RADICALS-RT trial presented at ESMO, can RT be omitted in post op prostate patients in favor of salvage RT? If not which group of patient...
Would you treat until progression or for a defined "adjuvant" course after nephrectomy?
Assuming a negative workup otherwise.
i.e. gross disease on scans that is too diffuse to be removed completely and/or decreasing but not normal markers
Do you pursue close surveillance, s...
If there was still was PSMA PET/CT activity in the prostate after a year of ADT would you offer RT to the prostate +/-nodes?
Does time interval from initial radiation therapy matter. Assume this is in the case of castrate resistant prostate cancer in which all other avenues ...
Will your recommendation change if there is suspicious/confirmed locally recurrent nodule in the prostate bed?
In this case, Gleason 5+5 in all cores, clinical T4.
If so, would you give it concurrently with radiation and ADT or adjuvantly? Would you consider it in post-prostatectomy patients?
Do you recommend additional x-ray, CT scans, MRI or biopsy?
Specifically, would you consider utilizing sodium thiosulfate in adults based on the pediatric data from Brock et al. NEJM 2018?
68 y.o. Male underwent inguinal orchiectomy and spermatic cord resection of a 5 cm malignant fibrous histiocytoma of the spermatic cord. Margins of re...
How do you assess risk of tumor lysis syndrome, and is hydration sufficient or should hypouricemic agents be used as well?
Given the national shortage of etoposide starting in February 2018?
What would be a safe dose for ifosfamide and how would you time with HD? Alternatively, would you recommend a different regimen? What about using neoa...
Is prostate bed radiation therapy safe in this setting? Would you modify your planned prescription dose?
What dose and fractionation would you consider?
Is it possible to spare and minimize kidney dose?
How long would you continue androgen deprivation after radiation?
Would you require the rituxan to be held prior to radiation? Would this matter if it was in the post-prostatectomy setting?
UpToDate indicates that VIP is an alternative to BEP for men who are not candidates for bleomycin, and that one criteria for not being such a candidat...
Patient has small cell carcinoma of the bladder with extensive hepatic metastases. Would you extrapolate the approach from IMpower133?
Retrospective data show very low response rate of immunotherapy in FGFR mutated patients.
Should cystectomy remain standard of care?
(Recently debated in JAMA Oncology:
http://jamanetwork.com/journals/jamaoncology/article-abstract/2520055...
In a patient with a prior response to ADT and progression on taxane and platinum chemotherapy, would you consider AR directed therapy?
If you would include it, what would you anticipate in regards to the impact on this fistula?
If a patient had biopsy proven gleason 6 disease 3-5 years ago and has had a slowly rising PSA to between 15-20 over the past year or 2, would you req...
Per the ALSYMPCA study, they excluded patients with > 3cm lymphadenopathy. Patient is currently on Xtandi and Lupron and refuses taxotere.
Would you give chemotherapy concurrently with radiation? Would you change your radiation dose?
Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...
Would you offer definitive management with radiation and ADT? Or systemic therapy alone such as with ADT+abiraterone?
Do you prescribe antiandrogen beyond the typical 2-3 weeks after starting LHRH agonist therapy to prevent testosterone flare? If so, for how long do y...
Do you utilize EQD2 rectal and bladder constraints?
Could these be subclinical metastases that responded to ADT? Do they require further workup?
Mixed opinions about efficacy of IO therapy in this subtype.
ENZAMET and TITAN trials published at ASCO 2019 show benefit to both 2nd generation AR antagonists when compared to placebo but wondering how this wil...
What factors do you consider to aid in this decision making? The TIGER trial is a prospective randomized trial comparing these approaches.
If so, how should one approach it?
For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...
Is there any role for definitive prostate radiation extrapolating from the Stampede and recent RTOG 0521?
Would you consider scrotum contaminated and consider including it in fields?
Is there any data as to whether TKI or immunotherapy is more effective in this population?
Would you administer extended field radiation therapy? Would you omit radiation therapy?
Assuming that surgery and brachytherapy are not options.
Does the update of RTOG 96-01, presented at ASTRO 2015, change your practice for these patients? Or should ADT be limited to a particular subgroup?
Are there any patient and/or pathologic features that would lend you to considering IL-2 over other approved I/O or TKI therapies?
How do the biopsy results guide your management? Would you still treat if the biopsy is negative?
How does it vary by technique (standard fractionation, hypofractionation, or SBRT)? Does your PTV change if you are treating pelvic lymph nodes?
For example, if the patient has low PSA, Gleason 6 disease but has high volume (>50% positive cores) would that discourage you from recommending ac...
SBRT vs more comprehensive nodal RT with SIB to involved node? Would you include the prostate bed in your treatment volume? ADT duration? What other f...
I have seen the question regarding treatment of non-clear cell RCC in general: https://www.themednet.org/question/3934. Is there any data or experienc...
Arterial events have clear instructions to permanently discontinue on the FDA label. Especially in HCC without many other treatment options, giv...
Do you prefer LDR prostate brachytherapy first or as a "boost" following external beam radiation therapy?
Is there a benefit to one fractionation schedule v. the other?
Is there a strong rationale for treating the whole prostate (not prostatic urethra) electively to 41-50 Gy?
If so, does it differ from the assessment you would perform in men receiving long term ADT?
Would you consider EBRT alone, brachytherapy alone, or EBRT with a brachy boost? Would you counsel these patients differently regarding short/long ter...
Does your approach change based on risk group?
If the patient had pelvic adenopathy, would you include that in your treatment volumes? What dose and fractionation would be considered appropri...
The original study used 50% of positive cores, but the MSKCC nomogram can give a high risk of EPE with just 4-5 positive cores out of 12
Given that it is cleared from the body by renal filtration, are you concerned about clearance issues?
For example, in standard high-risk we generally cover proximal 2cm to elective dose, before doing cone down boost to prostate and proximal 1cm.
If a ...
If so, what dose do you use?
In particular would it affect the decisions for brachytherapy or androgen deprivation?
How do you monitor for treatment response since they may not m...
Are there problems with volume changes from the spacer dissolving while the patient is on treatment? What is your department's protocol for these type...
In light of the data from ERA223 showing increased deaths and fractures with the combination of radium-223 and abiraterone compared to abiraterone alo...
Assuming no advanced imaging is available, what lymph node morphologic criteria (ie. lack of fatty hilum, size, number of nodes, etc.) do you use to u...
If a patient's PSA goes from undetectable to minimally detectable (ie 0.03-.05) would you wait to offer salvage radiation? Would your recommenda...
For example, are PET Axumin or PSMA studies being ordered in the upfront setting?
Do you follow a routine imaging schedule such as regular FDG-PET scans?
Assuming there was an initial period of response to the mCRPC treatment.
Which risk estimator is felt to be the most accurate and what threshold?
What's the best contouring guidelines for ENI for prostate?
Would you add atezolizumab to carboplatin + etoposide for small cell/neuroendocrine prostate cancer?
Treatment for small cell/neuroendocrine prostate is extrapolated from data on small cell lung cancer. It now appears that Carboplatin + Etoposide + At...
If the patient is in remission for metastatic melanoma but continue to take an anit-PD1 therapy, it giving ADT, EBRT + brachytherapy safe for a high r...
Are you directed by symptoms, PSA changes or do you have a standard schedule regardless of those factors?
For example, do you change your prescription dose, treatment schedule, or OAR constraints? Have you noticed increased toxicity in older patients, e.g....
Late relapse, previously treated with BEP 30 years ago.
For example, for the first 25 fractions, you would treat the rest of the pelvis in 1.8 Gy/fx to 45 Gy, and then using a SIB treat the prostate/proxima...
What factors would you consider? What if this meant treatment of the full kidney? If treatment is recommended, would you utilize an SBRT approach...
Would you consider treatment based upon imaging alone or would you wait for tissue confirmation of metastatic disease?
Do we need to really worry about neutron contamination?
NCCN guidelines suggest systemic therapy only or concurrent chemoradiotherapy. What is your approach?
Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...
Node-positive patients were not eligible for ASCENDE-RT, and the current NCCN guidelines do not list brachy boost as an option for regional ...
What is the upper limit of size you would consider offering a patient a five fraction regimen?
If so, what dose? What if there is positive a PA lymph node but no signs of distal mets?
Prospective International Randomized Phase II Study of Low-Dose Abiteraterone with Food versus Standard Dose Abiraterone In Castration-Resistant Prost...
If so, would you offer pelvic lymph node irradiation in these patients if they have pathologically node positive disease?
Do you change your treatment volumes, particularly when treating the seminal vesicles, to avoid the ureters?
Is there a dose response relationship, as suggested in the phase I MSKCC dose escalation study presented at ASTRO 2017?
Do you use a specific threshold number of sites to make your decision? Apart from assessing for cytopenias, do you consider any other patient factors?
Would you be concerned about SBRT worsening rectal bleeding in this situation?
In a patient s/p orchiectomy and with pelvic lymphadenopathy, would you consider lymph node biopsy to confirm involvement by non-seminomatous germ cel...
Would you treat this patient any differently than any other very high risk prostate cancer patient? Are there any additional dose constraints fo...
Most of the studies have excluded non clear cell histologies. If you use a similar approach to clear cell, have you seen similar responses?
How do performance status and comorbidities affect your recommendation?
For which patients would you consider addition of apalutamide or enzalutamide? How do you decide between the 2 drugs?
The recent SPARTAN trial showed a remarkable improvement in metastasis free survival and many other secondary endpoints except the lack of significant...
Do you maximize rectal emptiness at the time of sim (ex with enema if needed) or do you simulate with a full rectum since this is most reproducible?&n...
NCCN recommends to change therapy or maintain current therapy in this setting without further clarification. What thresholds would cause a change in t...
Specifically, would the addition of a brachytherapy boost impact his ability to receive future intravesical therapy?
Is there any role for orchiectomy in this setting?
What are the special considerations in the non-metastatic setting vs metastatic setting?
If the patient is refusing hormone therapy is there a contraindication to prostate RT with concurrent 5FU-based chemotherapy?
Many patients are still able to orgasm but are disturbed by the loss of seminal fluid.
Testicular ultrasound, CT, and tumor markers are without abnormalities outside of the mass.
There are now five PD-1/PDL-1 inhibitors approved for metastatic bladder CA, one (Atezolizumab) as first-line therapy in cisplatin-ineligible patients...
Is MRI fusion is adequate for urethral delineation and sparing? Would you worry about prostate deformation by placement and removal of catheter ...
Specifically, does the Decipher score influence the incorporation and/or duration of ADT? Can it be used to better stratify intermediate risk patients...
Specifically, in patients who have an undetectable PSA post-op, with high risk features such as seminal vesicle invasion, positive margins, or extrapr...
What bowel dose constraints do you use when treating bladder cancer with moderate hypofractionation?
Using the standard whole bladder dose fractionation used in BC2001, 55 Gy in 2.75 Gy fractions.
For instance: urologists who only refer for a rising PSA, even in a patient with high-risk features, those who use Decipher results to decide when to ...
What systemic therapy do you use? Do you incorporate any multi-modality therapies?
Based on the updated results of the PCS IV trial is 18 months of ADT the new standard of care for men with high-risk prostate cancer treated with...
If yes, what factors push you to test for AR-V7 or would you test all patients in this clinical scenario?
Is the total time of ADT or the length of adjuvant ADT more important?
Is there any information on how ADT affects the test operating characteristics?
Would you initiate abiraterone or enzalutamide for the rising PSA or wait until the patient is symptomatic or has a new site of metastasis?
Does histology, i.e. urothelial carcinoma versus squamous cell carcinoma, impact this decision?
Are there any other medications, outside of anticoagulation, that would be considered absolute or relative contraindications?
Is a single-fraction HDR boost appropriate following conventionally fractionated EBRT to 45-50.4Gy?
Is there data to support this practice, which appears in the NCCN guidelines?
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...
Current NCCN guidelines seem to support a variety of approaches.
The patient is cisplatin ineligible due to renal dysfunction.
What is your preferred dose and fractionation? Do you utilize 4D simulation? Additionally, how conservative are your constraints for ipsilateral uninv...
Pt previously treated with radical prostatectomy and adjuvant radiotherapy.
If recommending therapy, what is the role of concurrent abiraterone + AD...
What dose would you use? Would your approach to elective nodal radiation be different in the preoperative setting?
Based on new FDA approval of nivolumab plus ipilimumab in the first-line setting for intermediate- and poor-risk disease, would you give the combinati...
Could observation and serial cystoscopy be a reasonable option or is surgery necessary? If recommending surgery, can a procedure less than a nephroure...
For example, in a patient with prior colectomy. Would you consider using a spacer?
If the two intermediate risk factors are on the lower end of intermediate risk (ex GS 3+4 and PSA 11) with a very small volume disease, can a more int...
If they return to nadir, when (if ever) are they considered to have failed?
Do you sim and treat with their bladder as is? Or do you have patients who do urinate fill their bladder somewhat? Fluid overload is often a considera...
Is pelvic radiation contraindicated?
In particular, for men who have no strong indication for ADT?
Do you favor surgery or radiation in this setting?
Is it better to treat without hormone suppression? Or would this be reason enough to push the patient toward prostatectomy?
Data reported by Motzer et al Lancet 2015 demonstrated a statistically superior PFS benefit of lenvatinib monotherapy over everolimus alone. In partic...
Assuming you are treating whole bladder only with concurrent chemotherapy, when would you recommend hypofractionated radiation (20 fractions) vs stand...
Are there special tests you order for SBRT but not IMRT?
How does the PSA change differ (if at all) compared to IMRT. Do you still use the Pheonix de...
Would you recommend radiation and/or systemic therapy? If you would irradiate, what would your fields/volumes look like?
In the case of patients many years out from RP who have a slowly rising PSA, do you offer salvage RT while the PSA is still very low or follow the PSA...
Recent evidence has been mixed, with no DFS or OS benefit in 1 trial (ASSURE, Haas et al, Lancet 2016) and DFS benefit in another (S-TRAC, Ravaud et a...
Is there a treatment that you prefer for such patients?
Is microscopically positive renal vein margin an indication?
Should a bone scan and/or MRI of the pelvis be obtained as well?
If Dynamic Sentinel Lymph Node biopsy is not available, would you refer the patient for node dissection, radiate, or observe? What nodal regions would...
In a patient who has a rising PSA, palpable nodule, MRI findings etc., is it ethical to treat the patient with inadequate information and ri...
For example, previous RT for seminoma several decades ago.
How about a more recently treated rectal cancer with pre-op chemoradiation?
Given the apparently stronger results from KEYNOTE 052 (pembrolizumab) compared to IMvigor 211 (atezolizumab), would you consider pembrolizumab for pa...
How do you prioritize alignment of bony anatomy, prostate and nodes?
Do you have varying PTV margins for different structures or as compared to prost...
ASCENDE-RT excluded these patients as well as those with a PSA > 40, but it seems these patients may stand to benefit as well.
Would you offer adjuvant radiation? (Dose? Target?)
Would you add ADT?
Would the number of lymph nodes involved influence your decision?
Does the 1 year of ADT used in the ASCENDE-RT trial present a new option of the standard of care in timing ADT when combined with brachtherapy boost?
The current treatment for bladder adenoCA is surgery. However in non-surgical candidates, RT is an option. Would you consider adding chemo ? Also woul...
Do you have a prostate volume/size threshold?
Baseline urinary function?
Any other anatomy or patient factors that may make patient not suitable for...
Our urologists routinely get these scans prior to definitive therapy and at times in the postprostatectomy setting. The high sensitivity makes f...
Would you also add EBRT and/or ADT?
If salvage EBRT - what dose?
Specifically, what criteria do you use to quantify "low-volume" prostate cancer? What other criteria do you consider when defining low volume in...
In addition to scans, would you biopsy the prostate/SV?
Would radiation therapy to the untreated pelvic nodes with hormonal therapy be a consideratio...
If so, what chemotherapy regimen would you use? If not, what management options would you generally recommend?
Alternatively, would a biopsy of a metastatic bone lesion be preferred in a patient who has already progressed on chemo and hormonal therapy?
Given the FDA breakthrough therapy designation for olaparib in BRCA1/2 and ATM mutated mCRPC, when do you sequence mCRPC? Do you have a preferred...
Based on 2-3% MSH2 mutation and 1% MLH1 mutation rates in metastatic disease regardless of castration sensitivity, should we be looking for this earli...
cT3 patients were a minority of patients in the data demonstrating superiority of tri-modality therapy. While cT3b patients have particularly poor out...
Would you offer definitive radiation/chemoradiation if he is refusing cystectomy?
If current systemic treatment is otherwise controlling the disease and is well-tolerated, is there value to locally aggressive therapy in an attempt t...
How would you interpret this finding when MRI was not used in defining risk category for prostate cancer?
Should high risk prostate cancer patients be placed on more potent ADT in the upfront setting with definitive RT?
Can radium-223 be given to patients with progressive diffuse osseous metastases if they have a history of visceral metastatic disease that resolved wi...
In patients with new bone pain and without any evidence of bone metastases receiving GnRH agonists, how do you manage pain symptoms?
What dose constraints would you use in planning?
Pending head-to-head comparisons, do you believe there are any subgroups who might benefit more from one or the other?
Are the results of the STAMPEDE trial presented at ASCO 2017 practice changing?
Is there a length of time that would be considered too long between TURBT and CRT? At what time point would you recommend another cystoscopy to evalua...
Do you use the same constraints that you would for the rectum? Or perhaps employ a lower dose limit, such as not exceeding 65Gy to a small volume of t...
With biopsy-proven, negative systemic restaging disease, what dose and fractionation is appropriate if treating with IMRT? Should ADT generally b...
Given the non-specific nature of AFP and its elevation in various benign conditions, is there an AFP cutoff level or change over time for which you wo...
Would you offer it for positive margins? NCCN says to consider adjuvant radiation for pT3-T4 or pN0-2. Is there sufficient evidence for adjuvant radia...
Which patients do you consider to be chemotherapy-ineligible for the sake of this treatment decision? How strong does the contraindication need to be?
Would you consider this an indication to treat lymph nodes, if you would typically not do so?
What clinical considerations factor into your decision to choose leuprolide vs goserelin vs triptorelin vs degarelix, etc?
NCCN guidelines offer suggested schedules for interval imaging and laboratory studies, but also make it clear that the quality of evidence for these r...
Is there an upper limit to offer definitive RT? Is it possible to have a PSA of 100-500 and still have only local disease?
What determines which you select first? How do concerns about cross-resistance factor in after progression on one of these agents?
To what extent do you worry about overlapping myelosuppression? Is there any advantage to overlapping therapy?
Standard RTOG constraints include guidelines for rectal v60, v65, v70, v75, but is there a relative or absolute volume constraint for rectal v80 that ...
Is there a role for salvage LN dissection or salvage RT to the node? And is there a role for systemic therapy (ADT or chemotherapy) in addition? If yo...
Should the workup change with the PSA level (for example, >2 vs <2 ng/ml post-op PSA)? Is there a PSA level for which salvage radiotherapy...
Two retrospective studies from Stanford showed that patients who received ADT had an increased risk of dementia and Alzheimer's. Is this finding ...
Are patients with extracapsular extension at diagnosis good candidates for brachytherapy boost? If extracapsular disease that can't be effectively&nbs...
How do you minimize these risks? If using local anesthesia only in the outpatient setting, how is pain control at the area of injection?
Do you use a PSA threshold, PSA doubling time, or only evidence of metastatic disease to trigger ADT? For those without rapid doubling time, do you ev...
And how should we compare checkpoint inhibitors? Given the FDA approval of atezolizumab and nivolumab as second-line agents for metastatic urothe...
If so, what criteria do you use to guide your decision?
The Intergroup 0162 trial did not demonstrate noninferiority, although OS difference only 5.1 vs. 5.8 yrs. Would pattern of spread affect your d...
Is there any benefit to delaying start of RT or perhaps changing to complete adrogen blockage if maximal PSA response is not achieved in 2 mo?
...
If so, when? There seems to be an increasing trend among urologists to offer surgery to high-risk prostate cancer patients despite the low probability...
Are fiducials always necessary?
Does your answer differ if you're treating with standard vs. moderate vs. extreme hypofractionation?
We are being referred more patients for salvage radiation after this procedure, not sure what the evidence is.
Is there a role for adjuvant nodal irradiation for early stage squamous cell carcinoma of the penis?
Specifically if sentinel node mapping and sampling has not been performed or refused?
Is there data demonstrating an advantage of one particular IGRT strategy over another?
When would you use surveillance versus repeat excision or adjuvant systemic or local therapy?
Do you have a cut off in terms of prostate size, IPSS score, post-residual void volume, or any other criteria?
Do you prefer to treat patients with factors such as large prostate volume, significant comorbidities, anticoagulation use, history of TURP, or high A...
If so, is there a role for IMRT?
I was taught to use the RTOG style ports with whole pelvis 4 field box and then boost field to entire bladder ...
The CABOSUN trial showed a benefit in PFS and ORR, with unchanged OS, over sunitinib.
In the recent 10 year update of the ARO (adjuvant pelvic RT versus observation) trial, their definition of PSA failure was 2 successive rise...
In the setting of recent craniotomy and a plan for SRS to the surgical cavity, which systemic therapy would you choose and when would you&nb...
How would you manage the small bowel/prostatic interface? Have you tried SpaceOAR in this context? SpaceOAR + protons? What dose would you escalate to...
For a patient with a history of non-muscle invasive disease in the bladder, presenting with a prostatic urethra only recurrence, do you approach this ...
How do you approach management of locally-advanced, unresectable, but non-metastatic bladder cancer?
When do you offer trimodality bladder-sparing approaches? Is there any role for starting standard neoadjuvant therapy in an attempt to convert to rese...
Or in patients with metastatic disease on ADT who have not had primary therapy? In what situations do you consider palliative prostatectomy?
After confirming castration levels of testosterone, is the next best step to add docetaxel (as in CHAARTED and STAMPEDE, although not explicitly for G...
When are you concerned for a false positive? FDA guidelines include a suggestion to try another assay in case heterophile antibodies are causing a fal...
Is it true that urinary obstruction can improve with HDR brachy, as it can have an ablative effect on the prostate?
Radium-223 has an overall survival benefit and lower hematologic toxicity, but at a significantly increased cost. Does the cost-effectiveness fa...
If so, at what point? McDermott et al. demonstrated some lasting responses after discontinuation of therapy (JCO 2015), but these responses are s...
Would a minor adverse pathologic features such as capsular penetration (not SV or positive margins) influence the decision for radiation treatment?
W...
How might a recent (within 6 months) myocardial infarction affect your recommendations?
Will this study change your practice?
For patients who developed oligometastases while off systemic treatment, do you start systemic therapy following local therapy or return to active sur...
What is the best treatment option when the PSA indicates occult metastatic disease? What is the benefit of salvage RT?
Are there circumstances when you would choose IL-2 over checkpoint inhibitor trials or TKIs for fit patients? How should IL-2 be sequenced with these ...
In which circumstances should high-dose chemotherapy with autologous stem cell transplant be considered, versus second-line chemotherapy regimens or c...
Based on the abstract from IMvigor 210 presented at ASCO this year, are you offering atezo to patients who otherwise may not tolerate platinum-based c...
Based on a recent single-arm phase II trial, is there a role for paclitaxel, ifosfamide, and cisplatin (TIP) as a first-line regimen instead of BEP?
There is limited data to guide us in this relatively uncommon situation (PMID 7853587, PMID 2836634). Would this presentation...
Do other factors (i.e. Gleason score, pretreatment PSA, or pT stage) affect your decision?
The mid treatment cystoscopy has been standard, but treating with or without mid-RT cystoscopy are both included in the NCCN guidelines. Can the treat...
Would a specific Gleason score, age, pathological feature, or PSA be an indication for covering the pelvic nodes? Would giving concurrent ADT affect y...
Given recent advancements in the understanding of biological differences in prostate cancer patients of African vs. other ancestry, does your manageme...
The forrest plot in the recent meta-analysis published in European Urology is rather impressive, even in the more recent high dose radiation series.&n...
How has CARMENA changed your practice?
For patients who remain fit and interested in treatment, but for whom a clinical trial is not an option, what systemic therapy do you reach for in thi...
Only the mCRPC population was included in the Fizazi et al. study, but the FDA approval is for prevention of skeletal related events from any solid tu...
Does PSADT play a factor in your decision-making? If so, how specifically?
I've tended to wait until the PSA is 10-15, re-image, and then begin...
Should it be routinely used for all patients? Or should it be used for specific risk groups such as unfavorable intermediate risk patients to rule out...
Are there specific subsets for whom these results should change management?
If so, how do you sequence this with other therapies? In addition, in the absence of an effect on radiographic PFS or serum PSA, how do you asse...
In situations where there is a significant risk of either local or nodal persistence/recurrence post prostatectomy with a rising PSA, or nodal involve...
In the IMvigor 210 trial, increased PD-L1 expression in patients’ tumors was associated with response to atezolizumab, but some patients whose t...
Given the excellent results from the ASCENDE-RT trial, should we be combining EBRT and brachytherapy? What criteria do you use to determine when ...
A recent systematic review suggested that disease progression owing to a testosterone "flare" may not be a real phenomenon: http://www.ncbi.nlm.nih.go...
If a patient has only IR disease factors but "findings suspicious of extraprostatic extension" on biopsy or MRI or both, would this upstage the patien...
In this abstract the 5-year probability of survival without clinical/biochemical relapse was significantly improved with ADT.
Since the benefit of neoadjuvant chemotherapy is well-defined in muscle-invasive bladder cancer, is it reasonable to consider this in upper-tract tumo...
The role of adjuvant docetaxel with ADT following RT for high risk disease has been previously elucidated by RTOG 0521. Following prostatectomy,...
At the ASCO 2016 annual meeting, results of the PRINCE trial were reported. A strategy of intermittent docetaxel was found to be non-inferior to conti...
There are a wide range of seemingly safe/effective regimens in the published literature, with an associated array of BED/EQDs and little more to guide...
Does it differ for localized vs. node-positive?
The serum testosterone is minimally low at 250 and the patient has some fatigue.
In a patient with node positive disease, treated definitively with radiation, should continuous or intermittent ADT be administered? If a patien...
Typically radium-223 is reserved for men with symptomatic bone disease after failure of multiple other therapies. Is there a population of men w...
Recently, Epstein et al proposed using a Grade Group system of Groups 1 (GS < 6), 2 (GS 3+4=7), 3 (GS 4+3=7), 4 (GS 4+4=8), and 5 (GS 9-10). T...
In this trial, 6 months of concurrent LHRH agonist therapy improved 5-year progression-free survival from 62% to 80%, with similar benefit in low-risk...
Is any amount of teratoma or PNET an indication for surgery?
What can be done prior to RT to prevent this? (Flomax/hormones not helping)
Do you treat to full dose or a lower dose with a cone down to the prostate PTV? Is there any data to support a particular dose?
For a recurrence after nephrectomy, the NCCN recommends surgery or, in inoperable patients, systemic therapy. There is no mention of SBRT in...
In a man with castrate resistant disease invading into the bladder and rectum, I have been told that 30Gy/10 fractions to the prostate is inadequate, ...
Guidelines dont seem to account for this possibility. Could it just be normal prostate tissue growing back that is leading to PSA, why just assume it ...
What number of cores and what % cores involved do you look at to consider them low-intermediate risk for prostate SBRT?
Do you offer RT if the patient is well controlled on medications?
What are the late effect risks in a patient status post a total colectomy if treated with IMRT for prostate cancer?
In starting prostate SBRT at an instutution, what are issues with the treatment that one should pay special attention to?
In other words, is there a PSA value above which metastases are imminent?
Although the landmark randomized trials treated up to 64 Gy, there is data out of Italy suggesting that higher doses yield better biochemical control ...
On what other factors should be considered in making a treatment recommendation for salvage radiation therapy?
Do you favor a short palliative regimen, or a full course definitive treatment to 64.8Gy? How does your management change if the patient has a good pe...
What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...
With ultra-sensitive PSA, it's unclear to me whether a doubling from 0.01 to 0.02 or 0.02 to 0.04 is significant. Is there a certain value that you wo...
If a patient is deemed high risk enough to require hormones with RT in the salvage setting, how long would you maintain them on ADT? Would you extrapo...
Would you favor only offering salvage therapy if the PSA rises?
When counseling patients with organ-confined prostate cancer, what rates of impotence, incontinence, rectal toxicity, and urethral stricture shou...
Would a history of prior vasectomy in a stage IIA seminoma be an indication to include the inguinal nodes in the RT treatment field?
Is there any advantage to primary RT as opposed to just orchiectomy? Additionally, in order to confirm Tis, a biopsy is required, which is typica...
The optimal timing of post-prostatectomy RT in high-risk patients is debatable and currently the question of prospective randomized trials; however, g...
I've heard justification for treating the whole bladder to 60-64 Gy based on the UK MRC study (James et al. NEJM 2012 and Huddart et al. IJROBP 2013) ...
Fore example for a T3N0 rectal cancer on EUS?
In this case, the patient is currently on maintenance BCG.
Realistically, there will always be some (hopefully small) inconsistency with bladder filling, and thus some small bowel could easily receive &ge...
Assuming a patient who could tolerate either, which is preferred? Does this depend on the choice for concurrent chemotherapy (5FU+mitomycin vs ci...
The Chung validation study did not find that size > 4cm or rete testis invasion are risk factors for relapse and the current NCCN guideline discour...
Specifically, for high grade T1 bladder cancer, is there evidence that definitive radiation yields similar control rates compared to cystectomy?
If so, what selection criteria do you use for such patients?
Following a mini-pelvis field?
Do you use a particular cut-off? For example, someone in their 40's?
The patient has a positive bone scan (2 lesions), grade 4+5=9/10 prostate, and cancer cannot urinate without a catheter.
In the definitive setting, and would that change if cystecomy was planned if there was a complete response after CRT? (similar to TCC paradigm).
Eight years after brachytherapy for a low risk prostate cancer, a patient has unresectable high grade squamous cell carcinoma of the bladder. Should I...
More specifically, which cardiac risk factors do you look for? Diabetes? Previous MI? Dyslipidemia? Peripheral vascular disease? CHF?
In general how do you counsel patients with high risk prostate cancer when choosing radiation verse prostatectomy? What numbers do you quote for ...
This is a patient who would have been an appropriate candidate for radiation upfront, but was managed with androgen deprivation therapy instead. On th...
Sometimes the scans don’t line up well because of differences in rectal and bladder fullness- any tips to optimize the fusion?
I ask this because I am seeing more and more patients who have had surgery despite presenting with high risk disease.
I know many do not treat the pelvis at all, but for those who do, what criteria do you use? Risk? Gleason? PSA? T stage?
I have a healthy 70+ year old man recently diagnosed with cT3N1M0 rectal adenoCA and GS 3+4=7 prostate cancer in 1/6 cores with a PSA of 25.
Is ...
And should special precautions be taken (such as dose reduction, prophylactic symptom management, etc)?
Would you treat this as high risk?
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