Questions discussed in this category
https://ascopubs.org/doi/10.1200/JCO-25-00746
If so, would you modify your field? Would you consider preoperative chemotherapy alone?
For example, would you use a cutoff such as PTV of 25 cc, or 4 cm diameter, or simply use nearby normal tissue constraints to alter your fractionation...
Would you switch to concurrent chemoradiation or continue FLOT as per ESOPEC protocol?
A very elderly patient who is a poor surgical candidate with a partially obstructing colonic mass that is bleeding and causing anemia.
Gilbert et al., PMID 40334666
Does this vary depending on the site you are treating, i.e. abdomen vs pelvis?
Patient with extrahepatic cholangiocarcinoma s/p Whipple in 2021 with negative margins and no positive nodes followed by adjuvant chemo with subsequen...
Oral contrast adds time (2 hours before scan) for both the patient and the facility. Some institutions feel indicated for all outpatients, while other...
Is there data on neoadjuvant chemo-RT or chemo in this setting?
NCCN recommends floropyrimidine-based chemoradiation (sandwiched by 5-FU or capecitabine), but many medical oncologists are utilizing multi-agent chem...
Unable to meet small bowel constraints due to bowel falling in the field; posterior to the rectum and anterior to the sacrum. V15 is 300 cc and loweri...
How do high risk features like LVI, PNI, or peri-pancreatic fat invasion inform your recommendation?
Patient has no evidence of recurrence but has bilateral reduced sensation and weakness in her legs.
RTOG 0848 presented at ASCO 2024 in abstract form: Abrams et al., Journal of Clinical Oncology 2024
What pathologic factors if any would you use to m...
Additional risk factors include T4, EMVI, N2+, involved/threatened MRF.
If so, what dose/volume would you use? Would you cover any nodal regions electively?
Is there a subset of patients you would avoid neoadjuvant CRT and operate first?
Assume the patient is young and active.
More specifically, the patient had a single, positive, 3 cm inguinal LN (no ECE, negative margins) removed at the time of APR. If offering RT, would y...
For example, will you lower the prescribed dose to achieve a lower mean liver dose?
Will higher doses per fraction increase the risk of fibrosis and cause permanent impediment to biliary flow?
Would you continue with RT as planned?
Do you have any preferred dose fractionation schedules? What kind of margins do you use?
Additional clinical features include grade 3, diffuse type, pT4a, pN2.
Margin is less than 1 mm. Would the grade of the tumor affect your decision? Would any other factors go into your decision?
If radiation has a role in treatment, what is the recommended dose? Would SpaceOAR placement be helpful?
In the adjuvant setting, what boost dose to vascular areas can be safely applied, assuming one has all the tech to reliably breath hold the patient an...
Would the lack of treatment response concern you enough to offer adjuvant chemo-RT, despite PROSPECT only pursuing adjuvant chemo-RT in the FOLFOX wit...
Does it improve the patient's quality of life?
Some patients have declined surgery knowing they achieved cCR. Would you observe or recommend chemoRT?
The primary tumor was resected previously.
Assume that a patient has had >1 year since previous SBRT treatment, and that they are not a surgical candidate. The previous dose was 30 Gy in 5 f...
How would your planning be influenced by a possible, single inguinal lymph node metastasis?
D-TORCH compared topical diclofenac to placebo.
Goodman et al., PMID 34077237
When using hypofractionated RT (i.e., 67.5 Gy in 15 fractions), can chemotherapy be delivered concurrently?
Options for systemic therapy in NCC...
Patient is 4 months s/p CRT with resolution of avid lymph nodes and no evidence of disease on anoscopy. PET avidity is currently <10 SUV from 30 SU...
Are you more inclined to offer brachytherapy boost instead of EBRT boost?
For a patient with an access to proton beam therapy, what dose regimen would you use in the context of a locally recurrent esophageal cancer, previous...
Of note, there is ~150 cc small bowel left and no further surgery was offered.
If so, what is the evidence for this?
Given that the recurrence is peri-gastric, with what dose would you consider treating it and to what constraint would you limit the stomach? Of note, ...
What fractionation would you use?
Patient had previous 54 Gy in 25 fx to anal cancer with treatment of pelvic lymphatics, now with presacral local recurrence. He had a resection of rec...
Additionally, would you consider prophylactic stent placement and/or gastrostomy in anticipation of a fistula?
Should the recent publication of Chen et al., PMID 27207358 dose escalation study for inoperable SCC esophageal cancer patients treated with CCRT, sho...
Should concurrent chemotherapy be given? How would you modify the regimen in elderly/frail patients?
Additionally, is there a difference in surgical outcomes with long course chemoradiation + consolidative chemo vs. induction chemo + long course chemo...
Do you find that starting with chemoradiation increases the risk of complete obstruction secondary to transient tumor inflammation, or do you favor st...
Specifically, after chemo and RT to 36.0 Gy/15 fx with stable to slight progression of disease at 6 months, what (if any) regimen of reirradiation wou...
Specifically, will the higher rate of local failure in the TNT (short-course RT) arm lead you to consider a TNT approach with long-course CRT?Dijkstra...
Specifically, in the case of a complete response following chemotherapy, do you approach with resection or radiation? If you are treating with RT, wha...
The Mayo Clinic protocol recommends initial fields -1.5 Gy BID initially to 45 Gy followed by a Brachytherapy boost. If HDR /LDR is not available, wha...
I.e. would you offer additional radiotherapy and if so, what technique and dose would you use?
How do you construct the caudal extent of your volume - for example, pelvic floor via RTOG/international consensus vs 4 cm below gross disease via RAP...
Specifically, on re-staging imaging, would the tumor regression be strictly defined by reduction in cranio-caudal direction only, or would other measu...
Particularly in the setting of "higher risk" features such as grade 3 and a negative, but close margin, would you still consider offering surveillance...
This includes duodenum, stomach, small bowel, colon, kidney, liver, etc.
Would chemoRT be preferred over surgery if there is LVI or PNI?
While ESOPEC excluded squamous cell carcinoma, the Japanese JCOG1109 NExT trial also showed superiority of fluoropyrimidine/platinum/taxane over chemo...
Or do you start with systemic therapy and then reassess?
Especially if using an escalated dose such as 58 Gy in 29 fractions for a T3-T4 primary
Assume the patient is a good surgical candidate, and the perforation happened prior to initiating any treatment. Is the stent enough reason to avoid c...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
No disease elsewhere. Previous history of treated rectal cancer a few years ago.
Tumor is PD-L1 positive and HER2 positive
ESOPEC compared perioperative FLOT vs neoadjuvant chemoradiation per the CROSS trial, and showed superior OS with perioperative FLOT. What concerns do...
Does it ever differ from a standard rectal field? For example, do you always treat the entire rectum, mesorectum, and entire length of internal iliac ...
Would you cover the entire prostate?
Is there really a need to boost up to 50.4 Gy in this setting?
Does histology (radioresistant or radiosensitive) play into this decision?
Is there a preferred method and should any of the following be avoided: esophageal stent, nasogastric tube, PEG, J-tube, or TPN?
Or, to manage tenesmus and discomfort after any type of pelvic radiation.
Would you ever consider this approach for an initially polymetastatic patient?
For example, if mass is ulcerated and cannot be excised with polypectomy? Would you ever consider radiation and chemotherapy?
Current NCCN guidelines do not include adjuvant chemotherapy for patients treated in this fashion; however, in the PROSPECT trial itself, an additiona...
This would apply to gynecologic and GI cancers as well. And as long as the patient's partner is within the recommend age of <45 yo
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
Would you wait until bowel symptoms are controlled or ever pursue diversion before starting treatment?
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
The patient has a primary breast cancer with a single progressive metastasis in liver.
Plan to give adjuvant chemotherapy.
Intravesical therapy was delivered two years prior, and last cystoscopy was negative. One-third of the bladder would otherwise be included in the plan...
In general, how does an esophageal stent affect what you might consider in terms of radiation dose and volume?
What factors might play into this decision?
Should Y90 be offered before or after TACE (based on the Northwestern phase 2 study) or sorafenib (based on the SARAH trial)?
Would you ever treat with definitive intent in a "curative" patient who has a stent placed, or only palliatively? Does the addition of chemotherapy or...
Assuming duodenum constraints are met, could there be any benefit to boosting a positive celiac node to 61.6 Gy in 28 fractions?
Consider some stalk invasion, but no deep submucosal extent and negative margins by 9 mm.
Especially as the study was done before the adoption of total neoadjuvant therapy
Surgery would be very extensive and would not be likely to clear the disease. Do you divert these patients if treated with CRT?
Consider a patient who prioritizes fertility preservation, for whom one of three suspicious nodes approaches the CRM, and is <1 mm from the mesorec...
Do your recommendations differ between appendiceal, colorectal, and gastric cancer? If radiation is offered, would you boost the unresectable/gross re...
For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...
Would you treat both at the same time? Does one need to be prioritized over the other?
Does Xeloda have any efficacy against Merkel cell cancer?
How...
With trials like PROSPECT and FOWARC showing no statistically significant improvement in locoregional control and survival outcomes when comparing rad...
Especially consider a situation where surgical excision alone is not appropriate.
What if the radiation was LDR or HDR brachytherapy?
The CROSS trial showed a survival benefit with 4140 cGy and concurrent carbo/taxol, but I was always trained to treat to 5040 cGy. Is anyone de-escala...
For example, consider a patient who has had previous hepatectomy and total liver volume is only slightly greater than 700 cc.
How are you approaching patients with rectal cancer who meet PROSPECT criteria but have other higher risk features, such as >4 lymph nodes with sus...
Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...
Do you electively treat nodes and how does your approach change with intra- or extra-hepatic primaries?
In general: when would you recommend adjuvant radiation and capecitabine for a colon cancer?
The NCCN guidelines categorically recommend adjuvant XRT for a cT1-2N0 rectal adenocarcinoma upstaged to a pT3N0, yet there are multipl...
Would it make a difference whether the patient was planned for chemoradiation followed by surgery or definitive nonoperative chemoradiation?
Do you have a preference in ordering MRI, endoscopy, CT scan (chest, abdomen, pelvis), EUS, or other testing before starting any treatment, for re-sta...
Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?
Since there is no overlap between chemo regimens for these cancers, how would you sequence treatment?
Do you factor in the time interval when deciding cumulative dose constraints?
What systemic therapy is most appropriate, how would you sequence, and what RT dose fractionation would you use?
Would the location of the tumor (i.e. ultralow), symptoms (bleeding), or patient resistance to surgery play into this decision?
What constraints would you use for a 15 fraction regimen or other ablative regimen?
Would this change if the cancer was p16+ squamous cell carcinoma?
The patient has sustained a positive response for >1 year after diagnosis.
Staging/pre-op MRI only showed mild non-specific thickening.
How would you sequence therapy, and what dose and volumes would you use for radiation? Prostate cancer is localized, Gleason 4+3, PSA 65.
Is concurrent chemoradiation reasonable or excessive in a patient with life expectancy <5 yrs? Should the standard be 5 Gy x 5, and will this provi...
I can't convince the surgeons to refer their patients for adjuvant RT because the prospective data is messy and doesn’t seem to indicate a benef...
Taking into account follow up from NEO, OPERA and other organ preservation trials?
Please specify how your institution is allocating resources now or will be soon.
Would you boost involved lateral pelvic lymph nodes in this scenario?
What special considerations or precautions would you keep in mind when considering re-irradiation? The prior radiation was post prostatectomy RT. ...
Given the published results of the PRODIGE 23 trial where FOLFORINOX was used neoadjuvantly with FOLFOX post-op
Dose-escalation RT trials have had mixed results in the past for advanced rectal cancer, while in the early rectal stage there is a tendency towards a...
How do you weigh definitive chemoRT vs minimally invasive surgical approach with neoadjuvant chemo followed by transanal excision, in light of results...
Are you more likely to consider a trans-anal resection?
If records have been destroyed, how do you factor prior pelvic radiation for prostate cancer into your decision?
How does your counseling about side-effects change when offering short vs long course radiation?
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
Surgery has recommended against up-front diversion in order to avoid treatment delays. The patient has at least one suspicious internal iliac lymph no...
What about a low lying rectal cancer with involved inguinal lymph nodes?
What if actively on immunosuppression or with active lupus? For this case, presume the patient is not a candidate for resection or IR guided therapies...
Not a candidate for re-excision given proximity to the anal sphincter. Consider +PNI, -LVI.
The Stanford report (Osmundson, IJROBP 2015) on central hepatobiliary tract toxicity recommended dose constraints to the cHBT that would limit dose to...
How do you reconcile RAPIDO and OPRA trial results? OPRA was a Watch and Wait trial but the rectum preservation rate was much higher in that study tha...
If the patient had PSC and baseline atrophy preventing brachytherapy boost (received SBRT boost instead), would this change your threshold for stentin...
Consider negative margins and a patient refusing further surgery.
Do you assume some recovery since the prior course of RT? If so, how much over what time period?
How would your decision differ if the patient was not on immunotherapy or other systemic therapy? Would your thinking differ depending on the timing o...
If the patient is amenable to adjuvant chemotherapy alone, but is worried about chronic diarrhea/urgency after radiation, how would you counsel them?
If so, what dose-fractionation regimen do you utilize? What are your target volumes?
A021501 trial: mFOLFIRINOX vs mFOLFIRINOX with hypofractionated radiation (Katz et al., PMID 35834226)
What volume do you treat? Initial disease extended from paratracheal to celiac LN. Residual disease now is only in celiac LN.
I.E., can a patient with a questionable 5 mm node (MRI T2N1) which is negative on pathology after short course radiation be staged T2N0 and receive no...
For nodes just inferior to the celiac/SMA axis and no other distant metastatic disease? Stage is formally M1, but just barely. The patient is otherwis...
What contraindications or concerns do you have in this scenario beyond assessing the Child Pugh Score?
If borderline resectable, can the TOPAZ regimen be considered for downstaging effects?
C diff infection ruled out and CT abdomen pelvis shows diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field.
Would the presence of perianal extension and a positive inguinal lymph node affect your recommendation and how?
There is involvement of posterior vagina, left puborectalis, and peritoneal reflection. No nodes are involved.
If the patient is outpatient and coming into clinic each day, at what point would you initiate a C. diff workup?
Any adjustments in terms of elective nodal coverage?
What factors influence whether you treat an elective nodal volume vs gross nodal volume (plus a small margin) in the setting of oligometastatic or oli...
For example, portion is seen above and below the mesorectal fascia. Do you feel comfortable treating as colon cancer with surgery upfront?
Are there clinical scenarios in which you have found chemotherapy first has been beneficial?
(i.e., advanced T stage, extra-mesorectal LN, anat...
Which radiation doses would you use if there is a >4.5 cm LN?
Assume for this discussion: ECOG 0-1, life expectancy > 10How would nodal status influence your recommendation? Reference: Hawkins et al., PMI...
If radiation is indicated, what dose would you use?
Have you noted significant diarrhea until the ileostomy is reversed?
Would you offer standard ChemoRT or favour APR given the risks associated with RT?
Is there a risk of increased sphincter tone issues in these patients?
What would your approach be in a patient with a mid-esophageal squamous cell carcinoma treated with chemoradiation therapy followed by surgery, with P...
Are there any medications that you can prescribe? Diet changes? Does this typically resolve on its own after time?
Hypothetically not an ideal surgical candidate due to weight loss. Both cancers are non-metastatic and resectable if disregarding other cancer and com...
For T2N0 anal squamous cell carcinoma, RTOG 0529 used 50.4/42Gy in 28 fractions. However, for nodal disease >3cm, 54Gy in 30 fractions is used (and...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
What are the best references to help distinguish small and large bowel during contouring, if still unclear despite giving PO contrast?
Pleural fluid cytology is negative for malignancy but shows mesothelial cells. Would you use a PleurX or target with radiotherapy? From my understandi...
Is there a specific brand or formulation you prefer?
The literature supporting the use of probiotics does not standardize the type or dose of probiot...
What dose/fractionation would you give to the liver lesion and node? Would you treat just the celiac node or all there regional lymphatics?
ASTRO 2015 guidelines did not recommend coverage of stations 5/6/7 except for what is within 1 cm of the esophagus to limit lung dose. However, ARS 20...
What dose/fractionation do you use and what elective nodal areas do you cover? What studies do you order to aide in treatment planning (PET/CT? MRI?) ...
Do you change your dose constraints for lung tissue in patients with poor pulmonary function test results?
Does esophageal cancer continue to respond up to 6 months on PET, like anal SCC or p16+ oropharyngeal cancers?
Garcia-Aguilar J et al, JCO 2022
Final pathology showed pT3N0, 0/27 nodes, negative margins +perforation, +PNI, pMMR.
Are bony landmarks used to guide patient placement?
When contouring pelvic lymph nodes in rectal and anal carcinoma, do you exclude bowel from your CTV?
The RTOG consensus guidelines suggest to not exclude small bowel when it falls into the space occupied by the rectal mesentery. Meanwhile, prostate an...
Would you treat differently if it was hypofractionation? How would your treatment management change if the prior radiation was within 2 years of the r...
Would you follow the same guideline recommendations for adenocarcinoma if the adenoma component is invading miscle wall?
Are you doing more TNT to prolong time to surgery? If so, do are you starting with CRT or chemotherapy?
Given multidisciplinary discussion has occurred and SBRT has been agreed upon as local therapy, how do you approach the presence of moderate/significa...
Do you do fluoroscopy first, match motion of diaphragm or fiducials? CBCT? Repeat Fluoro/CBCT? Do you use breath hold or gaiting or compression? Do yo...
What factors and evidence would you use in your decision?
Is there a benefit to EBRT/SBRT or would you choose observation until there is pathologic evidence of invasive pancreatic cancer?
If multi-agent systemic therapy, i.e. FOLFIRINOX, is also planned, is there a preferred sequence of therapies?
Do you treat the inguinal lymph nodes prophylactically when using RAPIDO-style total neoadjuvant therapy (25 Gy in 5 fractions followed by CAPOX or FO...
What about for a patient with complete radiographic response who declines surgical management?
If the margins contain in situ disease, would you recommend further wide local excision?
Would chronic immunosuppressive disease affect your treatmen...
Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate? Is there a decent equatio...
Pathology also notable for LVI +, PNI+, but with negative margins.
How do you delineate your boost volume and to what dose?
What dose would you use to boost suspicious remaining nodes and how are your doses impacted ...
Would you treat per OPRA, or try for a higher dose?
Or would you always aim to treat with combined chemotherapy and fractionated radiation?
Would your answer change in the postop setting for a tumor right above peritoneal reflection with positive pelvic nodes?
Do you use conventional fractionated RT, hypofractionated RT, or SBRT?
How do you counsel patients on the benefit of adjuvant therapy who thought surgical resection was curative?
What dose/fractionation scheme is appropriate? Can SBRT be utilized? Can chemorRT with Xeloda be curative in this setting?
CheckMate 577 only included patients with R0 resection.For R1 resections, guidelines suggest observation vs re-resection only.
Do you ever contour the normal pancreas, use any dose constraints, and/or counsel patients on any possible late effects such as pancreatic insufficien...
Is there increased toxicity in patients with duodenal stents receiving RT?
Is there a benefit of SBRT over Y90 or vice versa?
RTOG 1010 has Lungs-PTV constraint of V10 < or = 40% (per protocol) to 50% (variation acceptable), but V10 is not often used in other thoracic mali...
If RT/chemo is preferred, what is an acceptable final boost dose?
Surgical path confirmed CK7(-), CDX2(+), CK20(+), consistent with prior colonic adenocarcinoma.
Do you treat with radiation therapy and what dose do you use? What dose do you accept to the duodenum?
For example, not placing superior border at L5/S1.
Would you offer chemoradiation or radiation therapy to the primary? Would you consider consolidation of oligometastatic sites? What dose w...
Is it still necessary to treat to 50 Gy or can a lower dose safely be used as there is no gross disease (e.g., 42 Gy in 28 fractions to nodes and the ...
Do the multiple beam angles cover the skin adequately enough? Is full dose to the skin necessary? Do you take into account the amount of auto-bolus re...
Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.
Does extension to the anus affect your determination of T classification? Would you consider this a T2 tumor if it does not extend to the external sph...
These structures are mobile and their location changes depending on bowel filling, gas, patient set-up, etc. Is there an advantage to contouring small...
If so, at what interval? NCCN recommends annual CT/MRI.
Would you consider SBRT as post-chemo consolidation for a patient with a single unresectable focus of metastatic adenocarcinoma at the celiac axis?&nb...
A nuimber of options for treatment but not a lot of great data for this rare disease.
What fields/lymph node regions would you treat? What doses would you use both for the postop primary and the nodal regions?
In the case of multiple skip lesions in the thoracic esophagus and GE junction, the PTV may encompass nearly the entire esophagus, including the supra...
For example, would you give SBRT for HCC with concurrent liver abscesses or short course radiation therapy for a perforated rectal adenocarcinoma with...
What do you recommend if the patient would need an APR because of anal sphincter involvement and/or would like to attempt non-operative management?
Post-treatment PET/CT and MRI Pelvis at 3 months showed near resolution of iliac and inguinal lymphadenopathy but new avid retroperitoneal lymph nodes...
Or do you consider SBRT for any size lesion as long as the dose constraints for normal liver are met?
Colloid is a rare histologic subtype and considered to have more favorable outcomes compared with usual ductal adenocarcinoma, but no dedicated prospe...
Do you recommend chemoradiation with 5-FU and MMC or other agent? Does your elective nodal coverage change compared to typical squamous cell carcinoma...
If so, what clinicopathologic features would indicate consideration of radiation therapy?
RAPIDO and Myerson paper don’t mention any and it looks like T4 patients were treated, presumably covering external iliacs which would likely ha...
Would you use platinum/etoposide concurrent with radiation or would you opt for platinum only during radiation?
Would you use BID fractionation...
If no preop chemo was added, would you consider adj CRT? ARTIST2 interim results presented in 2019 does not seem to support chemoradiation, although i...
If so, for how long?
Would you recommend radiation, systemic therapy alone, or chemoRT? What about if this recurrence occurred during or shortly after completion of adjuva...
Does your answer change for long course chemoradiation vs short course radiation therapy?
The invasive component had depth of invasion 1.7 mm, horizontal extent 3.5 mm.
This patient had a Ki67 of 27%. However, the inclusion criteria for the NETTER-1 Trial was Ki67<20%. Would Lutathera be an option if labs are withi...
Is there a role for re-irradiation? What cumulative dose constraints do you use for re-irradiation to the central hepatobiliary tract?
Does your recommendation for radiation therapy and/or radiation planning change?
If workup is negative for a primary lesion, would you consider prophylaxis of potential primary sites (anus/vulva?), and would you treat bilateral ing...
Considering a T2+ and/or N+ GE junction adeno, do you use neoadjuvant chemoradiation therapy or perioperative chemotherapy?
Does your treatment...
Assuming all other factors are favorable (pT1-2, TME, negative margins).
Is there a threshold of when you would use chemo/radiation?
Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?
For example, in an upper or mid-esophageal cancer with a PET positive lesser gastric curvature node. Is it reasonable to treat PET positive areas only...
The CTV examples in the contouring guideline by Wu et al (https://www.ncbi.nlm.nih.gov/pubmed/26104943) don't appear to crop the CTV out of lung. Woul...
If there was no further resection and the initial LAR showed a pT4a (visceral peritoneum), pN1 pelvic nodal disease with positive radial margins, woul...
If you are treating a patient with liver SBRT, would you not treat a patient who cannot have fiducials? If you are treating without fiducials, are you...
Would you cover elective lymph nodes?
ASTRO 2015 esophagus guidelines recommended the abdominal para-aortic nodes to be included in the CTV whereas ARS 2020 guidelines did not. Instead, AR...
Would you reduce dose, e.g. from 30 Gy in 10 fractions to 20 Gy in 5 fractions, or hyperfractionate, e.g. 1.5 Gy bid to 20-30 Gy?
What strategies do you use to meet those constraints?
Would your recommendation change based on the patient's age, performance status, comorbidities, or chemotherapy details?
Would your management change if the prostate and lymph nodes were treated with radiation two years ago?
Would you be confortable to give full dose CRT?
If so what is the crietria?
Aquaphor, barrier cream, sitz baths, domboro, silvadene, foam dressings?
ASTRO 2019 guidelines conditionally recommends elective nodal RT in unresectable pancreatic cancer. However, NCCN states that ELNI is controversial in...
What is the risk of perforation / fistulization?
What method provides the best reproducibility? Abdominal compression? Inhale breath hold? Exhale breath hold?
The concern being that if patient does not go to surgery, you have delivered lower BED with 36/15.
Liver SBRT maintaining 700 ccs of liver <15 Gy is a commonly used constrain; however, if the total liver volume is limited due to cirrhosis, prior ...
Does nodal positivity at time of surgery affect your decision?
Do you continue atezolizumab alone? Would you avoid anticoagulation?
In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?
In a patient with a large primary and a negative PET/CT for nodal disease, would you push for EUS for radiation planning? Or would this be an unnecess...
In a patient who has undergone resection and adjuvant chemotherapy who then recurs locally, how would you recommend treating? Would you treat ju...
If so, what dose-fractionation regimen do you utilize? What are your target volumes? Would you first recommend induction chemotherapy followed by rest...
What are you typical treatment volumes and doses for R0 vs R1 resections?
What dose, fractionation and what elective coverage do you recommend?
If you would elect for adjuvant therapy, which study helps guide your choice of regimen?
Does the amount of time from 1st treatment change your management or thinking in this situation?
Would preop RT still be the treatment option for these kind of patients? Assuming that the rectovaginal fistula was from tumor progression.
Is it possible or common for patients to have mucosal telangiectasias along the portions of the GI tract in the radiation fields? If present, would yo...
Would you go to a higher dose for the primary and/or nodal volumes?
If the medical oncologist does not feel comfortable giving cisplatin or mitomycin...
Do your constraints change when treating standard fields for T3 disease versus including external iliac lymph nodes for T4 disease when treating with ...
The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease.
Both ARTIST and Inte...
How would you adjust your small bowel dose constraints? What other considerations would be pertinent?
What-dose fractionation would you utilize? What small bowel constraints would you optimally set to achieve? How would your approach differ in a surgic...
Do you consider Macdonald type sandwich treatment 45Gy with xeloda?
Would you dose escalate gross node?
Would you treat stomach remnant and regional...
The recurrence is several adjacent nodes above the prior fields.
If biopsies consistently show high grade adenoma and there is a locally advanced rectal tumor with MRF involvement on imaging, what is the next step i...
For example, status post resection of a 4 cm high rectal carcinoma that was believed to be in the sigmoid colon but found interoperatively to be below...
Do you include external iliac nodes as for T4b (adjacent [anterior] organ invasion) or do you maintain the same coverage you use for T3 disease with a...
What dose would you use? How do you counsel on risk of damage to j-pouch?
If the patient is medically inoperable, is post-chemotherapy radiation therapy or SBRT advisable with no visible GTV?
How long is too long to resume SBRT, and would you increase doses? Is there a number of elapsed days that would cause you to abort completion of SBRT?
Would your recommendation change if the patient had prior radiation proctitis and cystitis (now resolved)? Previous treatment records limited, but pre...
The upfront plan is to use a definitive radiation dose of 66 Gy. My reading supports the use of 5FU + cisplatin but another doctor is recommending FOL...
Is diverticulosis in large bowel adjacent to a target a contraindication for SBRT? How would you manage?
Would you omit radiation therapy for some patients with Li-Fraumeni syndrome who would normally receive it?
MRI? Endoscopy? Physical exam?
Is there evidence for radiation therapy in this setting?
What is the added benefit of Chemo-RT vs RT alone?
Do you recommend TACE, RFA, radioembolization, systemic therapy or SBRT? What if the size is >5 cm?
Should these patients be managed with high dose chemoradiation similar to the Danish study (Lancet in July 2015)? To what dose would you take the prim...
The CRITICS trial showed there was no OS or PFS benefit with adj chemo vs CRT. Is there potentially still a role for CRT to reduce heme toxicity and p...
Would you offer definitive or neo-adjuvant chemo-RT in the setting of a single lung or bone metastasis?
What is the duodenal stump dose constraint?
In which clinical situations is there a good rationale for the use of proton therapy for GI cancers?
Should we give concurrent capecitabine?
For a patient not on dialysis? Outside of single agent 5FU, all other standard chemotherapeutic options would be contraindicated for nephrotoxicity.&n...
Higher radiation dose was shown to be associated with longer survival in Tao et al., JCO 2016. What dose constraints do you use when using these ...
Would you consider the addition of chemotherapy to proton beam therapy?
Would you be concerned with more and higher grade hepatobiliary toxicity with concurrent use of checkpoint inhibitors (i.e. Keytruda)?
When using short course RT, the NCCN guidelines currently recommend short course RT followed by chemotherapy, followed by surgery. Many surgeons are h...
What is your preferred combination and order of therapy for a T4 rectal tumor invading the uterus leading to both rectal and vaginal bleeding?
...
What dose and volumes of radiation would you use?
For those that tend to contour rather than set fields based on bony anatomy, how do you draw your CTVs?
Is there such thing a definitive radiotherapy in this setting, or would this be a purely palliative approach? If you would treat, what would your targ...
Would your recommendations change if you were treating a GI primary (e.g. rectal or anal cancer) vs non-GI primary?
Do factors such as large tumor size and/or node positivity affect the decision?
If so, what dose fractionation do you prefer?
How do you prevent early menopause in women? Please comment on freezing of eggs, oophopexy, supine vs prone position, vaginal dialator.
When indicated as in the setting of positive margins and/or positive lymph nodes, do you use V45 <195cc (QUANTEC), or V45 <15% (RTOG 0848), and ...
What factors do you use in deciding whether or not to electively cover the celiac axis?
*What dose and fractionation do you recommend for metastases >4cm in favorable positions (ie. not abutting mucosal tissue)?
Total neoadjuvant therapy consisted of with FOLFOX and chemoradiation therapy with Xeloda and 50.4 Gy.
Would you deliver a boost to the area and if s...
Is neoadjuvant chemoradiation or perioperative chemotherapy preferred?
If you were to treat, what do you include in your treatment?
The German trial included patients with tumors up to 16cm from the anal verge, while the Swedish trial update found no local control benefit for tumor...
NCCN allows a range from 5.4-9 Gy for adjuvant boost and German trial used 55.8 Gy.
What factors might sway you to give a higher / lower dose? Is mor...
If so, what dose do you boost these nodes to?
Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...
Would your recommendation change with the following aggressive features: 8 cm, pericolic extension, positive radial margin, perineural invasion presen...
Would you be concerned about toxicity given that he has ulcerative colitis?
Would you alter your SBRT dose? How long would you hold the VEGF inhibitor before and after? Does the primary matter (e.g. NSCLC vs. colorectal)?
The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.
Would you treat with definitive doses?
If the patient will be having a total colectomy, would up-front surgery be a better consideration?
Would your answer depend on the response of the primary site?
Is there a role for additional treatment?
Would you offer local therapy to the liver?
Do you include the whole seminal vesicles and prostate, or just the whole seminal vesicles? Do you add external iliac lymph node coverage in this scen...
Further surgery is not possible.
The patient refuses surgery.
Do you worry about migration or scatter dose from the metal?
If so, what dose and fractionation?
Given this rare histology, would you treat this patient as a skin cancer or as an anal adenocarcinoma with inguinal nodal coverage?
Is this practice still relevant to the modern IMRT approach where skin toxicity is much lower?
Would you consider "neoadjuvant" RT to 45-50.4 Gy followed by a resimulation and a boost to a "definitive" dose of 54+ Gy depending upon disease respo...
Assuming good liver function currently, without evidence for recurrent cirrhosis?
Would your decision be affected if it was a primary HCC vs Liver me...
Or should total neoadjuvant therapy be reserved for bulkier disease (T4N2)?
I understand the perioperative trials are not based on tumor regression in cancer cells.
Do you recommend definitive therapy? Would your approach change if there are more than 1 site of bone metastases, such as 2-3?
Let's re-open the debate!
Is there any data to support delayed treatment?
For instance, in borderline cases for neoadjuvant therapy (e.g. T2N1 disease), should both be obtained to increase accuracy?
What dose would you recommend? Any role for systemtic therapy?
Do you have any specific bowel constraints when treating patients with palliative radiation 3000/10?
Do you look at max dose or are there specific volumetric constraints you use for the small or large bowel?
Do you boost the positive nodes beyond your standard pelvic dose?
Our hospital has an aggressive and talented interventional radiology group. We have wanted to start a stereotactic liver radiotherapy program but are ...
What dose do you take the primary to?
If so, how would you approach your radiotherapeutic plan and what dose-fractionation would you utilize?
This will influence the decision to operate or not, so you want to give it enough time to see a response, but given that it's a disease predisposed to...
Would you consider a re-biopsy after chemoRT to confirm viable tumor and if so, how long would you wait after chemoRT before biopsy? If you did ...
If so, what would your target encompass?
Colonoscopy reveals inflammation in the colon and rectum due to Crohn's and patient also has perianal fistula due to Crohn's.
Do you use concurrent Xeloda?
What percentage of unresectable T4N0 pancreatic body adenocarcinomas with celiac axis involvement and no response to 6c chemo, will convert to resecta...
For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...
I am currently managing two patients (one esophageal and one anal) with this scenario and the referring physicians and patients are reluctant to under...
The data is scarce- do you recommend chemotherapy only or would you consider RT for local control?
Is there a role for SBRT with or without the addition of systemic therapy?
As a for instance, a centrally located primary tumor with mediastinal adenopathy that results in a TE fistula?
Currently we would recommend esophagea...
Would you recommend neoadjuvant chemotherapy to spare the stomach?
If considering that it is not gastroesophageal junction, what margin do you place on the clipped GTV to formulate CTV? Is there any role for SIB to PE...
There is no RTOG consensus on boost volume, except to say that it should include the entire mesorectum/presacral region at involved levels + 2 cm in c...
If so, what dose and dose constraints would you consider? How would you counsel the patient about risk of trachesophageal fistula?
Is it sufficient to use fluoroscopy to assess total motion, fuse MRI and PET to create an ITV, and use abdominal compression to limit motion?
What features would make you more likely to recommend radiation therapy with chemotherapy?
The patient has no evidence of lymph node involvement.
If you would recommend radiation therapy, what dose-fractionation would you utilize?
Detailed instructions regarding lymph node coverage have been published, but how do you think about coverage of the anastamoses from the gastrectomy?
What timing do you recommend? What drug and what dose do you use?
Anal cancer guidelines mostly refer to anal canal tumors with less information about tumors of skin in perianal area (ie true anal margin).
Would IMR...
What volumes and doses of radiation would you recommend? To what dose would you limit the rectum, especially in a patient with no salvage surgical opt...
Do you consider diversion colostomy, or abdominoperineal resection up front?
What are your thoughts on dose, avoidance structures, re-tx risk, etc?
In view of higher risks of rectal cancer after pelvic radiation, is more frequent screening warranted?
Does the lack of D2 dissection automatically necessitate adjuvant chemoradiation therapy (ie <5 LN obtained)? Would the presence of high risk facto...
For a patient with cT3-4N0 rectal cancer, does the dose of the previous RT affect your decision making (for example, 45 Gy to the pelvis with boo...
What chemotherapy and radiation doses/fractionation would you use once the airway has been stabilized to provide reasonably safe and effective palliat...
Do you consider palliative SBRT 25Gy in 5 fractions? I often find that these patients are in severe pain and my typical regimen is 30 Gy in 10 fractio...
What are your fields? Do you treat nodes electively?
What doses do you use?
How often do patients become unable to tolerate the dilator during the treatment course secondary to discomfort related to acute toxicity?
What radiation doses would you use? Would the radiation dose and fields be the same as for squamous cell carcinoma? What chemotherapy would you recomm...
On the heels of the discussions regarding skin toxicity prophylaxis and treatment, I am interested in your thoughts and current practice regarding pat...
Do you have different preferences based on T-stage?
What would be your preferred management, surgical resection or radiation? If radiation is contemplated, what dose would be appropriate and would HPV s...
What features would help you decide between TACE vs. TARE vs. external beam radiation therapy?
In particular, many guidelines suggest a max point dose of 50Gy for small bowel but in cases of extensive disease how do you reconcile loops of bowel ...
Is there a risk for anejaculation?
Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?
If the oropharyngeal cancer is operable (ex T1N1), would would your preference be upfront surgery?
Would you use chemoradiation therapy to bo...
Would you recommend only chemotherapy or would you offer chemotherapy followed by restaging and possible definitive CRT and surgery?
Are the treatment volumes the same as those for squamous cell carcinoma of the anal canal?
Given risk of secondary malignancies do you make an effort to avoid/spare the prostate or give any specific dose constraints when treating young men w...
Is this patient considered to have metastatic disease? Should definitive surgery be considered?
Are these patients better candidates for preop chemotherapy alone?
Will you treat only the anastamosis and remnant stomach without elective nodal RT, or will you include elective nodal RT in your treatment fields, ass...
If a patient is unable or unwillling to undergo dual or tri-modality therapy with chemotherapy or surgery, would you use a palliative radiation treatm...
If so, how do you quantify this when making a decision about who may or may not be a candidate for SBRT?
If treating the H&N first, would you anticipate some effect of chemo on the rectal cancer? Would you include 5FU in the H&N chemo for be...
If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...
Would you recommend chemoradiation therapy or chemotherapy upfront?
Any role for surgery? What radiation volumes would be used?
5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?
Do you recommend 5FU/mitomycin chemoradiotherapy or radiotherapy alone?
What evidence is there for efficacy and toxicity differences between the two ...
Is there any evidence to show that treating with a bellyboard is preferred?
What dose and volumes would you use?
If the patient received neoadjuvant FOLFOX for 4 cycles then 50.4 Gy with concurrent capecitabine, is that enough treatment to omit surgery?
Is curative intent surgery off the table?
Surgery showed 1/5 and 1/4 LNs involved in the groins. What areas would you cover and with what corresponding doses?
What if the patient was not a candidate for additional chemotherapy? Would your answer change if the patient received the CROSS regimen with <...
Is the approach chemoradiotherapy (Mitomycin-5FU) as for squamous carcinoma with surgery only for salvage or do you always perform surgery after neo-a...
Is obtaining serial MRIs or other imaging appropriate?
If so, what regimen would you consider?
In a patient who received upfront surgery and chemotherapy who later recurred in the regional nodes, s/p lymphadenectomy, would you offer RT? If...
Antacids? Anti-motlity agents? Dietary changes? Combination?
How do you deliver it safely? Even when there is adherence to other organs (T4) or positive margins, I'm hesitant to offer RT because the volumes are ...
For example, a patient with cervical or anal SCC who has missed many treatments due to side effects, low blood counts, hospitalizations, or non-compli...
The RTOG contouring atlas doesn't give a consensus on this issue.
Would you send the patient for a stent or do palliative RT?
http://ascopubs.org/doi/full/10.1200/JCO.2015.64.2710
What would be the RT dose and what percentages would you quote for toxicities? Would you recommend consideration of surgery instead?
Fecal incontinence can be one indication. What are others?
Should radiation be offered as a bridge to transplant? Should this depend on whether SBRT is feasible (i.e. is fractionated IMRT an appropriate option...
Given lack of strong evidence supporting the benefits of adjvuant RT in resected pancreatic adenocarcinoma (with results of the ongoing RTOG 0848 unav...
If so, what constraints would you use for central biliary and other normal structures and what dose/fractionation would you use?
Would you treat the node alone, unilateral/bilateral inguinal nodal basins, or cover any possible primary locations such as the anal mucosa?
Is better systemic control needed to make radiation therapy beneficial?
Do you use the same constraints that you would for the rectum? Or perhaps employ a lower dose limit, such as not exceeding 65Gy to a small volume of t...
What about bulky nodal disease?
Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?
Have you ever seen toxicity related to diaphragm dose with conventional fractionation?
In what situation, if ever, do you include mediastinal nodes?
In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...
RTOG 0529 guidelines were 2.5cm margin from GTVA to CTVA (except bone or air), do you still follow this practice?
If a patient developed locoregional recurrence after initial chemoradiation, would resection of known disease followed by observation be preferred?
Is inguinal coverage always required?
How would the new data presented at ASCO GI 2021 from from Alliance A021501 influence your answer?
Specifically, are hilar nodes metastatic?
Does treatment of the pancreas with radiotherapy during an episode of acute pancreatitis increase the risk of acute and late side effects? Should one ...
At other sites we consider locally advanced disease and high risk of recurrence a contraindication for organ preservation. Would surgery improve likel...
Per NCCN, only well-differentiated T1 lesions (with 1cm surgical margins) should be excised (with no other treatment). Do you follow this at your inst...
For example, there is a retrospective series out of MD Anderson (Kim, Acta Oncologica 2008) wherein 37 patients with gastric cancer were treated with ...
Would your recommendation change if the histology was adenocarcinoma (excluding GE junction tumors)?
Reference: https://www.ncbi.nlm.nih.gov/pubmed/23578724
Is your approach similar in unresectable disease? Is there evidence to support one approach over the other?
Is MRI being considered the primary mode of imaging in multidisciplinary tumor boards, especially in light of the results of the MERCURY trial (JCO 20...
What if a large portion of small bowel is located within PTV45?
Would taking the drug at a specific time point prior to their radiation appointment time to maximize blood levels of the drug be clinically beneficial...
How would your radiation treatment approach change in terms of dose and target definition?
Would the time interval between diagnosis affect the optio...
Do you target the whole pelvis or a smaller "boost-like" field?
If so, what is your preferred regimen?
In a patient who is not a surgical candidate and has a negative PET/CT and EUS, would you include celiac lymph nodes in the radiation field?
Specifically - anus, pancreas, gastric?
Do you use any age limit to determine whether pancreatic SBRT is appropriate?
How do you manage a patient a with a PET positive inguinal lymph node who has a typical anal cancer? If a biopsy is done and it is negative, is it is ...
In a case with negative margins, would you consider chemotherapy alone or sequence with chemoradiation?
Does the presense of ulcerative colitis, now in remission, affect your dose and fields?
When planning SBRT cases for primary liver cancers, it is very difficult to see the tumor on the non-contrast 4D scan. How do you use information from...
In my training, we used an abdominal compression paddle, but in my current practice, my physicist says that we cannot treat through multiple parts of ...
Are there any precautions to prevent formation of a TE fistula?
Would your approach change if the histology were adenocarcinoma?
In a lesion <2.5 cm from anal verge arising in a tubulovillous adenoma, does the data from Taylor, et. al. Red Journal 2001 apply?
What are the targets (tumor bed, positive margin, nodes etc.)?
Would you avoid any RT in these patients, including palliation for a portal vein thrombus? Or would you consider a short course of RT (like 20Gy/5fx)?
In a patient with an R0 resection, would you routinely recommend postop chemoradiation, since these patients were included in the MacDo...
For cases with positive margins, do you boost to 54 Gy? If so, do you boost the entire tumor bed or only the area of the positive margin?
Should standard post operative radiation fields be used, treating up to the L5-S1 interspace? Or is it acceptable to treat a lower field, for ins...
Fore example for a T3N0 rectal cancer on EUS?
In the past, I haven't seen great results in palliating the presacral area. The pain is excruciating for many patients. Is there an effective option f...
I.e. Would you treat most of the normal esophagus to include a mediastinal lymph node?
While the Nigro/Wayne state regimen consisting of Mito C & 5FU is well stablished for squamous cell carcinoma of the anus/perianal tissue, a...
If so, what dose?
What regional lymph nodes do you include perigastric, portahepatic, periesophageal, celiac, splenic, pancreaticoduodenal, sup. mesenteric, paraesophag...
Are there any indications to choose one over the other?
How should we counsel young women who are receiving treatment for GI/GYN malignancies?
Is there a consensus on the MAGIC v. MacDonald debate?
I recently had a patient with unresectable disease ask for a PET before starting RT but I’m not sure there is a benefit.
We use PET for esophageal, but not gastric cancer. GE junction seems like a grey area.
Does the advent of FLOT in gastric cancers, change your approach to GE adeno's? Would anyone consider FLOT followed by chemoradition followed by surge...
What techniques work best?
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