Gynecologic Cancers
Questions discussed in this category
This patient previously received hysterectomy with adjuvant vaginal cuff brachytherapy without pelvic RT. Colonoscopy demonstrated invasive disease, b...
Do you prophylactically start all patients on B12, B-complex, and/or omega-3? If so, what dose? What about ice mittens and booties?
Considering the treatment of platinum resistant ovarian cancer as done in the AURELIA trial (Pujade-Lauraine et al., PMID 24637997).
If a patient presents with metastatic disease (by virtue of extensive PA nodal burden, mediastinal/SCV involvement, no solid organs) but received urge...
Are there any criteria you use to preferentially recommend primary chemoradiation instead of primary surgery?
Have you found Trendelenburg positioning helpful for situations in which small bowel falls into a high dose target volume?
Would you delay salvage surgery for a stage I primary vaginal cancer with partial response but no new disease at 3 months after radiation (EBRT + brac...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
If a weekly schedule is chosen, what would be the appropriate weekly dose given that PORTEC-3 and GOG 258 used two cycles of cisplatin 50 mg/m2?
Is there any particular reason to include or not include this in the treatment volumes?
The patient has no risk factors and would have been stage IB if it were not for the small nodule
How does the presence of specific mutations affect your adjuvant treatment planning or patient counseling?
Is this a clinical/radiographic or strictly pathologic diagnosis?
Specifically, what is considered the superior/top border of LUS?
Would you still take the primary to 60-70Gy?
After a diversion, would any other factors impact your recommendation (residual disease/response to chemoradiation, performance status)? Although brac...
Most interested in patient cohorts who have not demonstrated a good response to chemotherapy as measured by imaging and/or clinical/serological findin...
Does stage of the cervical cancer influence your decision? Does the amount of SUV uptake influence your decision? When does one biopsy? How long can o...
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...
Given data from metastatic breast cancer trials that show benefit with continuing trastuzumab despite progression.
Assuming minimal toxicities except fatigue from long, recurrent infusions.
At our institution we often give 5.5 Gy x 4 fractions. There really does not appear to be a general consensus regarding timing. Interested in what oth...
Do you increase EBRT or brachy dose by a certain amount based on interval?
If so, what dose would you recommend? What other management options would you consider?
Treat as invasive disease with concurrent chemotherapy? Any non-radiation options for large in-situ disease? If RT, would you include at least inguina...
Do you stop therapy at 2 years or continue until progression of disease?
Path significant for LVSI and MELF pattern. Post-operative CT negative for metastatic disease.
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
Ideally, treatment should be completed in 56 days (preferably < 50 days). If there has been a significant delay to brachytherapy (>2-3 months) d...
Would you recommend whole pelvis as well as vaginal cuff brachytherapy?
Assuming patient is <45 years old with cervical, vulvar, vaginal, anal, or head/neck cancers, or with CIN/VIN/VaIN/AIN/ oropharyngeal precancerous ...
Would you perform oophorectomy of the other ovary and an appendectomy?
Do you recommend upfront diversion? Are there unique planning considerations such as the inability to use bladder filling? How do you boost? What are ...
VC brachy, pelvic RT, +/- chemo?
Does your management change if it is confined to the endometrium without myometrium invasion or if it is only ...
Presented with 8cm pelvic mass and had large omental cake + significant carcinomatosis on diagnostic lap. Biopsy ultimately resulted non-epithelial ov...
Do you include pembrolizumab with platinum-taxane + bevacizumab or reserve it as a second line option?
A certain cm above the superior-most involved node? A certain number of vertebral body above? To the diaphragm and include retrocrural nodes?
If the patient had high risk features (for example age 60+ and LVI) do you treat with vaginal brachytherapy or WPRT? If you treat with whole pelvis ra...
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...
How do you maintain a trusting relationship with your patients when this relapse occurs?
Assuming low risk of progression to AML and eligible for low-risk chemotherapies per hematologic/oncology.
In the absence of the ability to use IGBT, would you continue to treat the target?
Assuming the nodal assessment is minimally invasive and the patient is otherwise healthy without postoperative complications.
Is it possible that the dehiscent is radiation induced?
https://pubmed.ncbi.nlm.nih.gov/34874631/
If the tumor was excised but there is infiltration and encasement of the sciatic nerve, would you offer radiation? If numerous lines of chemotherapy h...
Consideration for localized therapy alone vs. localized therapy + systemic chemotherapy.
No parametrial involvement on MRI.
Front-line PARP inhibitor maintenance therapy discontinued without progression.
How do you decide if it may be safe to continue immunotherapy?
Would involvement of the PA nodes be an indication?
And if the tumor is MSI-H, does that alter your thoughts?
No mesenteric/small bowel/lesser sac involvement on imaging
Do you try to keep Hb> 10 or 12? Or somewhere in between?
Genes such as ATM, CHEK2, PALB2, RAD51C/D, BRIP1 seem to show some potential increased risk of ovarian cancer. Should these patients under prophylacti...
EBRT vs VB? She technically meets PORTEC2, but also meets GOG99 and GOG249 (for pelvic RT) and PORTEC4. NCCN recommends for IB grade 1 vaginal brachyt...
For a young patient that underwent fertility sparing surgery for immature teratoma of the ovary, would you treat until tumor markers normalize even if...
Is there any indication for ENI in early stage disease or in advanced stages, without pathologic confirmation or PET positivity or CT size criteria?
Initial treatment of the primary invasive Paget's disease of the vulva that was metastatic to inguinal lymph node included resection and chemoradiatio...
The patient was initially observed after radical hysterectomy due to young age, FIGO IA grade 2 disease.
The patient had isolated, biopsy-proven vagi...
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Patient is 38yo, has a history of narcotic abuse, and may have an undiagnosed personality disorder.
Is there any role for completion surgery and/or RT in addition to chemotherapy?
12cm mass on ovary s/p TH/USO and preservation of grossly normal cont...
If not, how often do you repeat pelvic imaging?
Is the QuadShot a possible option?
If yes, what would be your target volume for this exceedingly rare histology for this location?
In women receiving HDR intracavitary brachytherapy to treat the vaginal cuff, how do you overcome the challenge of excess lateral vaginal tissue ("dog...
Could EBRT lead to rupture of the cyst?
This patient has pulmonary nodules that are too small to characterize.
Does ER/PR status help guide your decision?
No sarcomatous overgrowth seen.
Is anticoagulation for PE an absolute or relative contraindication to IS brachy? Would you favor placement of IVC filter prior to procedure?
For instance, in patients that have not had neoadjuvant chemotherapy
History of CDH1 mutation and prophylactic gastrectomy in 2017 - no other primary site found beyond vagina at diagnosis.
Vaginal tumor completely resp...
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
How do you manage the initial event, including length of steroid taper and the role of pancreatic enzyme monitoring?
What is your experience of subse...
Previously received pelvic EBRT and intracavitary brachytherapy. IORT was administered to the node-positive side wall at the time of exenteration.
Initially treated with definitive chemoRT but recurred with distant mets. Completed 6 cycles carb/tax/bev with minimal toxicity. Excellent performance...
Excellent KPS and long disease free interval from initial diagnosis. Initial recurrence 3-4cm at level of renal vessels and down to 1.3cm after chemo.
PET- CT before surgery visualised a tumor localised to the uterus and a PET positive 3 cm enlarged node at L3 level.
Final path: endometroid FI...
Lung is biopsy proven met cervix, SBRT is planned.
Patient did not previously receive para-aortic radiation. Considering RT vs RT + chemo vs chemo alone
Are there any effective non-pharm or pharm interventions?
Recurrence was 2cm and PET confirmed local. Excision with positive margins. Current plan for salvage whole pelvic RT and vaginal cuff brachytherapy +/...
s/p optimal debulking.
If this was an early-stage cancer would it change your adjuvant therapy recommendations?
If confirmed neuroendocrine and PD-L1 pending, how would you treat?
In patient with PD SCCA 15mm transverse; 5/20mm invasion; LVSI focally present; margins negative; 0/15 Left pelvic and 0/14 right pe...
Recurrence picked up incidentally on CT. No germ line mutations, somatic tumor testing of node resulted negative.
PET confirmed isolated recurrence
Planning carboplatin/taxol/trastuzumab. Cervical stromal invasion on path. Looking for pelvic vs brachy and timing with chemotherapy.
If a patient has limited surgical options and a well defined lesion, would SBRT be reasonable?
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
What non-pharmacological interventions do you recommend? Do you routinely prescribe prophylactic laxatives to patients initiating opioids? How do you ...
What dose and technique do you use and how do you integrate the subsequent definitive treatment plan?
Would your counseling change if she reported a history of unplanned pregnancy? Is there any wording or waiver you might be able to use warning her of ...
The recently released STARS phase 3 RCT found improved DFS, decreased distant recurrence, with reduced toxicities for chemotherapy (cisplatin + taxol)...
Do you extrapolate from first line maintenance studies for duration of therapy?
30cm tumor, intraoperative rupture, all abdomino-pelvic surfaces and structures appeared free of disease.
Primary, R0 debulking in 2019, stage IA. Low volume recurrence, now again optimally cytoreduced.
Initial diagnosis was 15+ years ago
Despite the LACC trial, this year's SGO had many posters and discussions around MIS for early cervical cancer.
If you offer MIS, what are the key ele...
58 yo, grade 1 endometrioid endometrial cancer. TLH, BSO, sentinel nodes. Stage IA, focal LVSI, 20% myometrial invasion, negative sentinel nodes, posi...
For a patient with a very locally advanced cervical cancer, what is your upper/superior limit of considering para-aortic lymph nodes to be "pelvic" or...
To avoid disfiguring surgery, would you consider treating a 2 cm well lateralized tumor without surgery? If so, would you recommend concurrent chemoth...
Does your practice vary based on risk status (low vs high risk) or specific mutation status (BRCA+ vs HRD+) given PAOLA subset analyses?
How long is too long to wait for recovery? Is there a role for pre-procedure platelet transfusion and/or alternatives to epidural anesthesia?
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 ...
What specific platforms for determining somatic BRCA and HRD status do you use for a patient who does not carry a germline BRCA mutation?
Would you offer VBT alone in a completely resected vaginal cuff recurrence that is grade, recurrent stage IA endometrial cancer, is all staging imagin...
SIBs of 55-57.5 Gy in 25 fractions are frequently mentioned with bowel volume constraints at this dose, but assuming there is no bowel nearby (e.g., b...
Margins negative, no LVSI, PET/CT negative.
If yes, what type of testing platform would you use?
Are there clinical factors which help stratify? Does your practice vary based on mutation status (BRCA+ vs HRD+?)
How do the 5 year results of SOLO-1 at ESMO 2020 impact your recommendations?
How many cycles do you prefer before and after? How long do you tend to wait before starting radiation after initial chemo and after radiation to resu...
In what circumstances would you offer adjuvant radiation after resection of vulvar mucosal melanoma?
If so, what would your target volumes and doses be? How would you sequence with immunotherapy (eg nivolumab)?
Is MDS/AML risk increased with longer duration of therapy?
How would you factor in a patient with profound thrombocytopenia?
Paraaortic nodes positive to left renal vein
Primary R0 debulking in 2018 followed by Carbo/Tax for 6 cycles, and single agent Bevacizumab followed by Letrozole, now again with NGR
6.6cm tumor, 15% MI
How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?
Tumor felt to be technically unresectable due to extensive cervical/parametrial involvement.
ER/PR and HER2 testing are pending.
For instance, if you have anal canal involvement, do you cover the entire mesorectum? Any other adjacent organ invasion that would lead to modif...
Tumor traverses the myometrium to focally involve the serosa; 1/6 sentinels with ITC and the rest negative.
No hormonal or somatic tumor testing has been obtained.
Would PET-positive pelvic or paraaortic lymph nodes change this recommendation?
Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?
Do you use specific tools or take into account certain factors when considering treatment options for older adults?
Path significant for micropapillary features and micro-invasion
Patient has tolerated combination therapy well to date.
Pt is 73yo, Grade 1, 81% invasion, MELF like features, foci of LVSI, and 47 ITCs identified.
HER2 status is pending
Pt is 69yo, tumor 1.4cm, negative LVSI, ER/PR +
Currently 7 weeks pregnant, diagnosis based on CKC
Given recent approval of niraparib (Zejula) for the maintenance treatment of adult patients with advanced epithelial ovarian, fallopian tube, or prima...
Patient is 34yo and G0 referred from surgical oncology. Laparoscopic specimens of myoma and what appeared to be adhesions were significant for maligna...
If patient meets high intermediate risk criteria, would you consider chemotherapy in addition to radiation?
Does not technically meet high intermediate risk criteria.
Is there a role for continuing beyond 24 months?
NCCN vulvar guidelines only recommends inguinal LND but GOG 37 recommended PLND when groin nodes were positive. NCCN penile guidelines also recommende...
Tolerated first line, however now with rising Beta-HCG, new mass in uterus, and pulmonary metastases.
Margins widely negative - 1cm, and full bilateral inguinofemoral lymphadenectomy performed.
ex. in a patient with pulmonary micronodules, inguinal, pelvic, PA nodes
In an elderly woman who is not felt to be a good candidate for radical surgery is split course radiation alone an option for definitive intent radiati...
If bilateral inguinal LND showed no involved nodes and primary is unresectable (FIGO IVA), can one treat only the primary w/o elective radiation to th...
The 2020 NRG endometrial and cervix contouring guideline update said the anterior margin is a straight line between the aorta and IVC. Should there be...
Patient is currently 7 weeks GA with 1.5cm visible lesion. MFM recommends 13wk CKC vs LEEP with cerclage at that time.
Would you change your approach based on platinum sensitivity or other factors?
Patient is s/p USO only, would you take her back to remove the contralateral ovary?
Disease involves the lungs diffusely and bilaterally.
If only palliative treatment is recommended, what should be the target volume (primary only? pr...
Patient is currently cycle 5/6 of carboplatin/taxol and tolerating well, has received no bevacizumab.
Margins negative. Discussion included adjuvant RT versus observation and/or repeat resection with recurrence.
In the unfortunate setting where you cannot get an underinsured patient whose policy does not cover radiotherapy started on treatment without guarante...
Do you re-test patients who test positive for COVID-19 during or prior to starting cancer treatment?
There are mixed recommendations about re-testing vs simply waiting for a quarantine period prior to resuming therapy.
Pathology with infiltrative subtype
EP vs C/T? Would you perform additional imaging, ie. PET Dotatate to evaluate for metastatic disease?
What indications do you use to consider adjuvant radiation therapy for vaginal cancer s/p resection?
Would you offer adj RT for a vaginal primary patient with paravaginal involvement s/p rad hyst w/ upper vaginectomy, BSO and inguinal node dissection?...
Would you consider adjuvant chemotherapy, radiation therapy, hormone therapy, or surveillance?
Do you use brachytherapy or external beam? What prescription / dose / regimen do you typically use? What if there is small bowel hanging into the fiel...
Do you give cuff and chemo or pelvic CRT or chemo alone?
The patient has a history of pelvic radiation and progressed through first line carboplatin/taxol. She has had a partial response to pembro/lenvatinib...
Vulvar cancer is well differentiated. Closest margin is 6mm. LVI is identified
T1b N2c
Vaginal cancer treated 20 yrs ago described as 5 cm in length...
Patient has been treated with carbo/taxol, hormonal therapies, and trametinib to date.
Final pathology showed grade 3 spindle cell sarcoma of thee vagina involving the anterior lateral cervix 5.6cm x 4.5 x 3.4cm, <0.1cm left lateral m...
Based on recent PAOLA-1
WHO score 8, for initial beta hCG, tumor size, and failure to respond to inpatient high dose MTX therapy (given as patient originally desired fertilit...
How (if at all) does this change your counseling and willingness to add bevacizumab to a regimen?
Would you consider "neoadjuvant" hormonal therapy to shrink tumors and potentially make more amenable to complete cytoreduction at a later date?
Woul...
For example, RTOG1203 says to include "1-2 cm of tissue anterior to the S1, S2 and S3 sacral segments" but have also heard of stopped at S2 to limit r...
Particularly with IMRT when delineating volumes.
Incidental diagnosis after hysterectomy
Does your management change if the patient is a BRCA1/2 mutation carrier?
Lesion measures 2cm and PET is otherwise negative.
CPS score is pending
Would you consider SBRT or brachytherapy?
After optimizing symptoms and reversible factors, and attempting cognitive-behavioral interventions and exercise, do you recommend pharmacologic agent...
This case involves an impressive ‘high volume’ vaginal recurrence and patient was not originally planned for adjuvant therapy. Concerned t...
Would you offer EBRT alone or EBRT with vaginal cuff brachytherapy after surgery and chemotherapy for stage III (T3N0) carcinosarcoma of the uterus?
...
What factors affect this decision?
Patient with remote history of hysterectomy for benign disease
What dose would you consider for patients with bulkly pelvic disease and in what situations would you, if ever, dose escalate for local disease with b...
Does residual grade 1-2 neuropathy from Taxol/ carbo 10 years ago affect your recommendation?
Small bowel is usually the dose limiting OAR while planning cervical HDR brachytherapy. Having the bladder empty during treatment planning and deliver...
Literature regarding treatment of diarrhea due to Trametinib is limited and does not address safety of Lomotil.
Ie for patients who are inoperable due to comorbidities?
Would you consider this a new primary or recurrent disease?
For a patient with good response to immunotherapy (unable to receive chemotherapy due to kidney function, comorbidities) where previously avid LN have...
Would you consider additional EBRT or vaginal cuff HDR in a patient with previous tx with EBRT (45Gy) + HDR (30Gy) for a R1 resection with a radial ma...
Does time since adjuvant cuff brachytherapy influence your radiotherapy approach, (for example 18 months vs 5 years)? Do you adjust your bladder/bowel...
HER2 positive
Since no data exists or is pending, and the two disease processes are similar, should we consider PARP inhibition in this setting? This is assumi...
E.g. a patient with progression of their primary cancer but still is testing COVID19+ over a month after infection?
https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.6000
http://abstracts.asco.org/199/AbstView_199_180760.html
http://abstracts.asco.org/199/AbstView_199_187537.html
Does cisplatin need to be administered on the start date of radiation
What if the sentinel nodes demonstrate macrometastatic disease?
Do you treat the whole bladder in the intial whole pelvic field to 45-50 Gy?
I care deeply about clinical trials but have always struggled on how to approach this topic. I would really appreciate tips from those of you who have...
If an external boost of a gyn primary is necessitated because of the target size or extensive involvement of a critical structure how would ...
How would tumor grade, presence of LVSI, and receipt of chemotherapy factor into your decision?
This has been a common practice in the community. Is there a benefit for certain patients?
Can it be prevented? How do you evaluate patients? What non-pharmacologic or pharmacologic interventions do you use for treatment?
Does the GOG 249 abstract guide you one way or the other?
How do you counsel a pre-menopausal female with endometrioid cancer desiring definitive RT with egg harvesting and IVF for fertility preservation inst...
Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...
Sentinel Lymph Nodes negative
What dose/fractionation would you recommend?
How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...
When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...
No adjuvant treatment was given upfront
How do you prevent early menopause in women? Please comment on freezing of eggs, oophopexy, supine vs prone position, vaginal dialator.
Margins are negative.
Specifically, if they are to be treated similar to GI cancers that receive FOLFOX/EPIC
MRI with intravaginal gel shows no gross residual disease.
Insurance authorization for protons is pending, but if the patient cannot have protons would you treat with standard fractionation to ~70Gy or conside...
NCCN recommends brachytherapy plus or minus pelvic RT for surgically staged Grade 1, Stage II patients, but these originally staged IIB patients were ...
What fields would you cover and how much dose would you boost to the primary?
Since there is no overall survival benefit, does the local control benefit outweigh the increased risk for distant metastasis? How do you select patie...
Would you consider EBRT or brachytherapy boost to the nodes? what dose would you recommend?
What field and dose would you recommend? Would you consider whole abdominal?
For the management of stage II endometrial cancer, NCCN says pelvic RT and/or vaginal brachytherapy. Do you ever add vaginal cuff boost to pelv...
If so, would you treat the whole pelvis, cuff brachytherapy, or both?
The patient had an initial partial vulvectomy and nodal dissection 6 years prior to recurrence, with no adjuvant RT offered initially due to lack of c...
Patient being treated for cervical cancer noted to have a < 1 cm posterior vaginal fornix defect with a small focus epiploclia herniating into the ...
SOLO1 trial studied stage 3/4 patients.
Would you recommend any planning techniques or dosimetric constraints in this scenario?
When, if ever, do you utilize adjuvant RT or chemotherapy?
The limited data on MDA (minimum deviation adenocarcinoma) suggests it has a worse prognosis, but it is hard to disentangle this from stage, as it is ...
MRI and cervical biopsy are negative for cervical involvement
Would there be a substanital increase in the risk of toxicity using such a scheme?
We frequently have patients who have to travel long distance...
RP node with treatment related changes and surgical specimen from TAH/BSO no other foci of malignancy found.
In December 2018, Horn et al reported the results of a phase 3 clinical trial in the NEJM (N Engl J Med 2018; 379:2220-2229). This trial included prev...
The initial treatment did not include any adjuvant chemotherapy or radiation therapy.
How long after hysterectomy would you consider delivering adjuvant radiation therapy? Would this differ for external beam versus brachytherapy?
Are t...
Would you be more or less likely to use a cisplatin-containing regimen if a patient had previously responded to chemoradiation with concurrent cisplat...
For a patient with vaginal adhesions/stenosis, do you recommend any other therapy besides a dilator?
Would estrogen cream be helpful in this scenario?
If so, are there any lymph node cut-offs you would have in terms of lymph node number or pathological ECE before you would add contralateral RT? What ...
Could you discuss how you decide between IMRT or SBRT boost for a patient who is not able to receive intracavitary or interstitial HDR or LDR brachyth...
https://www.nejm.org/doi/full/10.1056/NEJMoa1813181
are there any positive or negative synergies from combined megestrol/RT treatment?
Should these patients be managed similar to p16 positive anal squamous cell carcinoma, and allowed six months or more for complete regression before c...
What chemotherapy and sequencing with radiation therapy would you recommend? IS surgery a component of the treatment?
Is pembrolizumab considered standard of care in the 2nd line treatment of recurrent cervical cancer?
Does the phase II KN-158 provide sufficient evidence to change management?
Should this be done at the time of recurrence or after failure of 1st line therapy for recurrence?
With the recent publication of GOG252 - does this change your management for patients with ovarian cancer who undergo primary surgery who have an opti...
What is your typical treatment depth prescribed to? What length of vaginal mucosa do you typically treat?
Do you have an SUV cutoff for physiologic activity of the ovary?
How does fertility preservation factor into your decision making?
Surgeon is not planning vulvectomy, since biopsies showed 2 mm depth of invasion.
Also tumor board felt dose to the primary site should be only about...
In a patient, with multiple small volume lesions (5-25mm), would you offer pelvic RT?
At what point would you introduce the discussion of weight management, whether for risk reduction or overall health?
Do you cover common iliac nodes (L3/L4) or keep field edge at L4/L5 to reduce bone marrow toxicity?
The NCCN recommends either systemic therapy + brachytherapy or pelvic RT + brachy or brachy alone or observation. How do you decide among these option...
The disease involving the endocervix was felt to be separate and appeared like a drop metastases
Specifically, is hyperbaric oxygen therapy (HBO) an effective treatment for refractory radiation cystitis?
Given the recent press release regarding the update on the phase 3 soft tissue sarcoma study of LARTRUVO (olaratumab) showing no benefit to the combin...
If so, what indications would you use other than Peters criteria?
What would be factors that would indicate the need to include the pelvic nodes?
Do you use a trimmed 10 mm expansion on HR-CTV? Do you also include the entire initial extent of disease? How much does your IR-CTV coverage affect yo...
Should this be the new standard of care based on the results from the recently published SOLO-1 trial?
Two new phase 2 studies this year with apatinib/oral etoposide (AEROC) and sorafenib/topotecan (TRIAS) were released, and NCCN also lists many single ...
What dose would you use?
Female in her 60s who had presented originally with well-differentiated endometrioid adeno clinically and radiographically involving bilateral paramet...
For a woman with complete resection of serous intraepithelial carcinoma of the endometrium, would you recommend adjuvant radiation or chemotherapy? Wh...
Current NCCN guidelines suggest that vaginal brachytherapy is optional, and there may be concern for over-treatment locally given competing risk of di...
A literature search indicates that most port site recurrences are managed fairly aggressively with chemoRT or RT doses 45-66 Gy. This is understandabl...
Or do you wait for platinum resistance?
Sequentially or do you integrate the cuff brachy with the EBRT and if so what schedule, BIW, weekly, etc?
Hydrogen peroxide douches? Antibiotics? (If so, what are you covering?) When do you initiate hyperbaric oxygen? Do you find pentoxyfyline helpful? How...
When you prescribe your dose at 0.5 cm depth of the vagina? For instance, if you measure a vaginal length to be 8 cm, would you prescribe to treat 4 c...
Would organ invasion (bladder/rectum), size, feasibility of T&O, or size of nodes push you toward neoadjuvant chemotherapy?
While EBRT + brachy may be preferred, what treatment would you offer if surgery has been performed? What dose and volume of EBRT, brachytherapy, or bo...
How do you weigh this concern with the need to prophylactically treat non-involved, high risk para-aortic lymphatics?
How high would you extend your field? Would you treat differently if the patient had lower PET avid pelvic lymph nodes?
Do you use size criteria (i.e. bulky nodes over 3 cm), specific adverse histology (adenocarcinoma), or location (near small bowel), etc.
Certainly ovarian cancer will respond to carboplatin and paclitaxel and it sounds like a reasonable chemotherapy to give to a stage IV NSCLC, however ...
More recent Italian (Sozzi et al) and French data (Canlorbe et al) show associations of greater tumor size > 25-35mm with higher rates of local &am...
She has extensive colposcopic lesions at upper/mid vagina, but no palpable/visible lesions on standard pelvic exam. Pelvic MRI with 20cc US gel in vag...
PORTEC-3 assigned women with high risk stage I or stage II-III endometrial carcinoma to adjuvant external beam radiation vs adjuvant chemoradiation wi...
Is it reasonable to use single agent carboplatin for elderly patients?
Has your institution changed practice patters based on the findings of the LACC Trial (Pedro et al., SGO in 3/2018) showing worse outcomes with roboti...
Would you deliver definitive RT in place of inguinal lymph node dissection in light of new data (PMID: 29336837)
In the case of high risk but radiogr...
NCCN guidelines mention EBRT/vaginal brachytherapy as options in addition to chemotherapy in the adjuvant setting for high grade histologies, stages 1...
If the patient is responding to external beam and likely to be converted to resectable, what brachytherapy dose/fractionation do you prescribe and wha...
Assuming no distant metastases, should this scenario be managed with "sequential" chemoradiation to the para-aortic region with an external beam boost...
For HDR brachytherapy for cervical cancer do you use the dose optimization algorithm? Is there a standard dwell time distribution that should be...
For example, assuming an excellent performance status, would you consider local radiation to the primary and metastasis in someone with a single ...
Patient had a single 3cm node s/p excisional biopsy of the one node without nodal dissection. We have done anoscopy and a thorough GYN exam...
EBRT boost only? SBRT? If you recommend interstitial brachytherapy do you place needles freehand or with a template based approach?
What have your liked or disliked about these newer applicators?
In a patient who underwent laparoscopy for endometriosis and was found to have a 1mm focus of neuroendocrine tumor, would you recommend further surger...
if so, would you favor brachytherapy alone? What dose?
What would be the appropriate treatment for grade I endometrial cancer s/p TAH/BSO but with SLNB yielding negative nodes. The uterus contained a 2cm t...
Assuming the early stage endometrial cancer was treated with TAH+BSO initially and no further treatment, what would your recommendations be for HGIL? ...
If so what dose/fractionation? This was reported here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918530/
For women treated with IMRT, there are multiple ways to define the upper border of the field
1) contouring the PAs up to where the renal vessels exit...
She has metastatic disease beyond the pelvis (lungs).
Type II endometrial cancers made up roughly 15% of GOG 249 the study population, but seemed to be balanced between both arms.
Single institutio...
After whole pelvis radiation therapy, what would be the highest dose you would allow in a single fraction, versus the total course EQD2 for small bowe...
Would you consider this in a patient with a single omental metastasis found and no other distant spread after surgery?
For example, a patient with cervical or anal SCC who has missed many treatments due to side effects, low blood counts, hospitalizations, or non-compli...
What factors influence your decision? Does high grade histology or pathological stage play a role? If the patient received chemotherapy due to +LN, pa...
Do you add an IMRT boost with possibly vaginal brachytherapy?
What are your specific protocols for monitoring and for dosing narcotics and sedatives?
If so, what dose/ volume is prescribed? How do you account for motion?
In what situations is it appropriate to offer observation (rather than VBT) to patients with stage II endometrial carcinoma who have had a radical hys...
If a patient has a gynecological cancer, how long should one wait after RT before a screening colonoscopy can be completed?
Would you approach this situation as synchronous primaries (eg. FIGO IA in both) or as a locally advanced endometrial cancer (FIGO IIIA)?
What adjuva...
Does definitive or adjuvant setting effect your planned dose? For example, for a woman with IB2 cervical cancer status post hysterectomy, who wa...
When should pelvic/inguinal lymph nodes be included?
Do you assume some recovery since the prior course of RT? If so, how much over what time period?
Would you utilize IMRT to provide a boost to gross disease? If so, how would you define your treatment volumes and what dose would try to achieve? Als...
Would you still consider this high risk? If so, would you recommend pelvic radiation AND chemotherapy?
Would you add chemotherapy if there was gross residual disease, pN+ and/or ECE?
Can the classic indications for post-hysterectomy radiation (eg. "Sedlis" and "Peter's" criteria) be applied? Does the histology change radiation dose...
Is there evidence for SBRT for recurrent ovarian granulosa cell tumors?
If offering radiation therapy, would you treat extended field whole pelvis or just cover the para-aortic LNs with an involved field volume? Would your...
What are the pros and cons of completing a simple hysterectomy versus aborting surgery followed by chemoRT?
With stage I/II vaginal cancer and an excellent response to 4500cGy EBRT with <5mm residual thickness of tumor remaining, what is your dose/fractio...
When do you continue with treatment and when do you terminate the plan? What is your criteria?
Close but negative radial margins? LVSI? What fractionation/dose do you use for your vaginal cuff boost if used?
Would your recommendations change based on stage? What factors would influence your decision to include presacral lymph nodes in a locally advanced en...
Does this differ if the primary is vaginal? Do you prescribe the same dose when using an intracavitary applicator for cervix cancer?
For palliation of vulvar cancer, what fractionation due you typically use. Can some of the toxicity be avoided with a shorter course of treatmen...
Prior to starting vaginal cuff brachytherapy, do you wait for a specificed period of time prior to vaginal cuff brachy after hysterectomy? Do y...
With the results of the EMBRACE protocol, how do you approach MRI planning? Do you plan with applicators in situ, or use preimplant (post EBRT) ...
Does this management depend on treatment site?
For definitive vulvar ca, is 5940 cGy the minimum acceptable dose for gross disease? 5760cGy? Or should the dose be escalated beyond 60Gy?
Can the drug continue during radiation therapy or should it be discontinued at a specified time prior to initiation of radiation?
And if so, in which situations do you offer differing doses?
For example, would you consider adjuvant chemotherapy alone to be sufficient in a patient with an isolated pelvic recurrence and positive margin after...
For example, how do you decide between applicators such as tandem and ovoid versus tandem split ring insertion for cervical brachytherapy patients?&nb...
For instance, RTOG 0418 did not allow clear cell or papillary serous histologies, but subsequent trials that allow IMRT have (GOG 0249, 0258, RTOG 120...
Interstitial needles can result in hot spots in the bladder, but how well tolerated is that? On the other hand, intracavitary applicators usually don'...
For example, in an otherwise intermediate risk localized endometrial cancer (Grade 2, FIGO IB)?
What clinicopathologic features do you typically consider?
In the setting of a negative lymph node sampling, would you treat a full pelvis or mini-pelvis to compensate for lack of the appropriate surgery? Is a...
In patients who don't meet traditional criteria for adjuvant chemoradiation from Peters (GOG 109) and < 2 high risk factors from Rotman (GOG 92) fo...
If the post-operative simulation films reveal a significant lymphocele secondary to pelvic lymph node sampling, is it imperative that the entire lymph...
The gyn oncs at my institution sometimes will not perform lymphadenectomy if biopsy indicates low risk disease. Would LVSI as sole adverse risk factor...
Do you use SIB or sequential approach? Do size of lymph nodes influence your dose or decision?
What exactly do you contour and what is your dose constraint to that volume?
Does using something like a vienna applicator allow you to avoid dose escalation with more external beam? How do you recommend doing a classic pa...
Some classic references recommend the coverage of the entirety of the sacrum but the volume delineation guidelines for both seem to only cover the mos...
My patient’s family has asked that I don’t tell her that she has metastatic cancer because it will devastate her. I am planning on palliat...
The patient failed previous excisions and medical therapy and is no longer a surgical candidate.
Does hydroureter and leg edema alter your opinion?
Brachytherapy, EBRT or both and what is the best dose?
How should we counsel young women who are receiving treatment for GI/GYN malignancies?
Do you plan every fraction, every other fraction, or use one plan for the whole treatment?
The most recent ABS guidelines don't discuss a dose constraint for the small bowel.
What schedule is best for preventing fibrosis and for patient compliance?
Does your strategy change if bladder invasion is present?
Do you treat PAs if pelvic nodes are positive? If common iliacs are involved? Only if there are positive PA nodes?
Do the urethral constraints used in prostate brachytherapy apply to women undergoing gyn brachy?
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