Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
For a medically inoperable clinically-staged FIGO IA endometrial cancer with serous, clear cell or other non-endometrioid, high-risk histology treated with EBRT alone, would you cover elective lymph nodes, or treat the uterus alone?
I would utilize a combination of EBRT and HDR-BT as well as adjuvant chemotherapy, if medically fit for such. If declining brachytherapy, recent reports on SBRT for GYN cancers as a boost modality can help guide planning to avoid excess toxicity risk.The ESGO/ESTRO guidelines have a section for medi...
How would you treat recurrent endometrial carcinoma with a presentation of inguinal and external iliac adenopathy?
I would treat with definitive intent with either surgery followed by (chemo) RT or definitive (chemo) RT targeting the pelvic at least up to the common iliac and bilateral inguinal region.
Would uterine perforation at the time of hysterectomy push you to recommend pelvic RT in a patient who would otherwise receive cuff brachytherapy?
It very likely would. I suppose that various factors could impact the decision, including the usual prognostic factors, patient's general condition and co-morbidities, etc. But, yes, a uterine perforation at the time of hysterectomy would represent another risk factor that would push me to be more a...
Would focal clear cell features change your management for a grade 2 endometrial adenocarcinoma?
We do know clear cell predicts for worse outcome but don’t know volume required for it to be independent factor. In clinical trial they require at least 10 percent of volume to be clear cell not based on outcome but more on consensus. In our practice, if they have focal clear cell I would at least o...
In what situations would you perform a sentinel lymph node biopsy for cervical cancer?
At my institution we currently consider doing sentinel lymph node dissections for all patients with FIGO stage IA2-IB2 (2018 staging system) who have normal appearing nodes on CT scan. Our protocol utilizes indocyanine green (ICG) tracer and the near infrared detection with ultrastaging. If one side...
What is your strategy for treatment of FIGO IIB cervical cancer in a patient who poorly tolerated the first insertion and refuses subsequent insertions?
Not other equivalent options. That being said, I would plan IMRT/IGRT boost with total dose to HRCTV (75-80 Gy) based on dose to rectum, bladder, and small bowel with tight PTV margin.
What is the longest interval to proceed with brachytherapy boost for cervical CA after EBRT?
I would proceed with brachytherapy even after a delay of 2-3 months as that is still better than no brachy and if local recurrence occurs, then the patient would need exenteration. Another option to consider, if imaging and scan show great response to EBRT, it is the possibility of a hysterectomy. I...
Is adjuvant treatment recommend for a 0.8cm serous endometrial CA confined to polyp s/p hysterectomy + surgical staging?
For surgically staged IA confined to polyp, the risk of recurrence reported in literature varies but on average, appears to be low and recent ESGO guidelines favor no treatment.
What is your technique to calculate the vaginal surface dose in gyn intracavitary brachytherapy?
The limited published data on image based brachytherapy has not found any dosimetric correlate of upper vaginal morbidity. The traditional point dose tolerence has underassessed tolerence of the upper vaginaThe recent multi-institutional EMBRACE study with different techniques and dose of cervical b...
What is your approach to a cervical SCC patient in which you're unable to properly place a T&O, due to obliterated cervical os, after completion of EBRT?
In our experience this is an extremely rare circumstance if the implant is done with ultrasound guidance--certainly <1% of cases. Depending on your level of experience and confidence, it may be worth referring the patient to a more experienced brachytherapist. That said, there are rare cases, partic...