Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What is your adjuvant therapy for node positive, low grade endometrioid endometrial adenocarcinoma?
Chemotherapy (typically carboplatin/paclitaxel x 6 cycles), restage, and if no progression, whole-pelvic RT. Consider brachytherapy boost if cervical stromal or vaginal involvement and/or presence of other risk factors for vaginal cuff recurrence (e.g. LVSI, deep myometrial invasion, grade 3 [not in...
How would you manage a bulky, locally advanced endometrial cancer with extensive parametrial involvement in a patient inoperable due to medical comorbidities?
PET CT staging. If suitable for definitive treatment, EBRT (concurrent chemo if able to get it) plus HDR brachytherapy.
Do you follow GOG, ASTRO, or PORTEC recommendations for adjuvant therapy in stage I endometrial cancer patients?
I believe the current ASTRO guidelines encompass the older GOG and PORTEC guidelines for the most part and we follow these guidelines though we review all for the sake of completeness.For the first patient, barring other risk factors, I would offer adjuvant vaginal cuff brachytherapy; for the second...
Is there a role for chemotherapy and/or vaginal cuff boost to EBRT in FIGO IB1 cervical adenocarcinoma, status post total hysterectomy?
Recently presented SHAPE trial shows non-inferiority of simple hysterectomy to radical for IB1 disease or lower disease. So for the above patient, that may not change anything but certainly would need nodal assessment which could be from surgery or RT after PETCT.
Do you ever alter dose/fractionation for early stage endometrial cancer patients receiving vaginal brachytherapy alone?
There are several commonly used regimens for vaginal brachytherapy alone. In GOG 249, the following regimens were allowed:HDR 6-7 Gy x 3 fractions, weekly, prescribed at a depth of 0.5 cm from the surface of the vagina.HDR 10-10.5 Gy, x 3 fractions, weekly, prescribed at the vaginal surface.HDR 6 Gy...
In light of the ongoing GOG 263 trial, do you consider adding concurrent chemo with RT for early stage cervical cancer as adjuvant after Rad Hyst off trial?
Adjuvant treatment is indicated after radical hysterectomy if pathologic risk factors are discovered. The GOG 92 trial with node negative intermediate risk patients had recurrence free survival rates of 88% for adjuvant RT versus 79% for the no treatment group. Longer term follow up shows PFS and tr...
Would you consider a single insertion HDR scheme for T&O brachytherapy (BID fractionation over 3 days)?
One can use the Vienna scheme where they do 7 Gy x2 with each insertion (2 insertion). I have done 5.5 to 6 Gy x5 with some patients with logisticical challenges. An important thing is planning should be 3D image guided, each fraction should be planned to account for change in applicator positioning...
How would you approach unresectable pelvic side wall recurrence in cervical cancer with previous definitive chemoradiation?
I would start with palliative chemo and if good response, plan for SBRT for residual disease with the dose based on OAR.
Would you change your approach to adjuvant radiation for an incompletely staged, at least IB, grade 1 endometrial cancer, if a uterine perforation occurred at time of surgery?
Similarly to the above authors, I agree with offering this patient vaginal brachytherapy. Though she does not definitively meet GOG99 criteria, given the situation with deep myometrial invasion and perforation, this is a reasonable and low-risk treatment opportunity to decrease local recurrence. The...
In patients diagnosed with endometrial cancer who do not undergo SLNB or LND at the time of hysterectomy, what criteria is used to recommend completion surgery for LN assessment?
The value of nodal dissection was negative for survival in two trials and PORTEC 1 and 2 (no nodal staging), and GOG 99 (nodal staging) didn’t show any difference in nodal recurrence for most endometroid stage I cancer. Unless management would change, we usually limit redo surgical staging to advers...