Questions discussed in this category

Would you consider using repretinib as first line therapy given its novel mechanism of action versus other treatment options?

The patient is in their 40s with right arm rhabdomyosarcoma s/p amputation. Path shows embryonal rhabdomyosarcoma 6.5 cm, margins neg. 11 of 19 lymph ...

Would you prefer doxorubicin based chemotherapy or are alternative TKIs useful in this scenario?

If so, what dose/fractionation? Pathology: High grade spindle cell sarcoma 

Relevant pathology features: 7.5cm, grade 3 with a 5mm bronchial margin, negative nodes. 

Would you cover the chest wall alone or would it be chest wall plus regional nodes? Patient factors: no prior radiation therapy

Would non-gastric GISTs, high mitotic rate, large size, and young age of patient affect your decision? Especially knowing that TKIs suppress cell grow...

If there were negative margins, what other factors would you consider to add adjuvant RT? Size of the tumor or depth of invasion?

Angiosarcoma is invading the brachial plexus and thoracic vertebral bodies. Prior radiation therapy: Radiation to the left chest wall and regional no...

Patient initially achieved CR with VAC-IE with resolution of presumed lung mets and 100% necrosis in LLE primary tumor on BKA. Then was NED again afte...

What role, if any, does molecular testing play in diagnosis and management in the absence of available clinical trials?

Would your systemic therapy choice be more similar to treatment of ovarian carcinoma or soft tissue sarcoma?

Tumor factor: Large axillary soft tissue sarcoma with involvement of the brachial plexus Other factor: Surgery would like to pursue upfront surgery t...

Margins are negative (closest 4mm), grade 2, 3 of 23 lymph nodes positive with no extranodal extension. What is your preferred chemotherapy approach a...

The patient presented with spinal cord compression, had subtotal resection and instrumentation with metallic hardware. Main concern is that post op su...

No evidence of distant disease elsewhere. Surgical resection is not possible. Would you recommend metastasis direct therapy to the liver (i.e. SBRT or...

This was resected over 2 years ago with reconstruction of the IVC with a PTFE graft. No preop or postop RT given and the recurrence is in the area whe...

What dose would you use? For negative margins do you offer 50-50.4 Gy/25-28 fractions? What target volume margins do you typically recommend on t...

50+ yo F. Mastectomy, chemo, and RT in 2016 for primary breast angiosarcoma, not RT induced. Had longstanding cyst on wrist, biopsied, and positive fo...

Would you use gem/docetaxel, anthracycline-based regimens or targeted therapies?

Prior treatment: GTR in 2020, adjuvant radiation 63Gy Patient factors: Medically inoperable and not fit for chemotherapy The recurrence is within th...

Ewing sarcoma of the right lung, status post bi-lobectomy and adjuvant VDC/IE, with recurrence 6 years in the right lung only. He has reached a cumula...

Would you change your management based on location, such as a sensitive area like the groin?  What volumes do you recommend? Does age influence y...

With conflicting data from the EORTC RCT and the Sarcoma meta-analysis collaboration, what factors determine when you would offer adjuvant chemotherap...

Would you off more radiation if the prior pre-op radiation was within a few cm to the recurrence? If there a time interval you would wait before offer...

How would you modify therapy for a younger, fit patient versus an older, frail patient? Lesions in stomach, small intestine, colon resulting in bleed...

When do you offer preop RT (50Gy) before the re-excision? When do you offer post-op RT after the re-excision?

Individuals often cite ARST0332 to justify radiation omission in high grade R0 resections, but R0 was defined as > 5 mm margins.

If a staging RPLND is NOT performed, is there a role for prophylactically irradiating the lymph nodes, even in the setting of a negative PET/CT at dia...

What would be your radiation volumes/dose and choice of chemotherapy?

Would your treatment approach be similar for a patient with suboptimal performance status?

In particular, is there any data on the efficacy of Ipilimumab/Nivolumab?

Given that risk definitions are based on size, mitotic activity, location and not necessarily genetics/biology, would an otherwise low-risk GIST, who ...

What is the role for adjuvant versus neoadjuvant chemotherapy?

Patient with hepC and advanced cirrhosis with multiple liver mets, but may be able to tolerate oral TKI or PARP. Would you offer this or focus on hosp...

These tumors are often low grade, but have a propensity for local recurrence.

Performance status is excellent. Second surgical opinion has also confirmed need for amputation, as the recurrence is now breaching intra and extra ar...

Osteosarcoma conventional type of the distal right femur. cT1N0M0 G3 Stage IIA on MAP protocol completed NACT followed by surgery on radical resection...

Patient received Pazopanib upfront with Ifos/Dox. Pulmonary metastatectomy is not an option as there are multiple mets.

This patient had resection of the primary, requiring multiple resections to obtain an R0 resection, followed by adjuvant radiation to the primary. The...

Since desmoid tumors are associated with high estrogen states, is there an optimal contraception approach? Is there an optimal time for pregnancy? How...

What is your preferred risk stratification model?  There does not appear to be a consensus among experts as to what cutoff in recurrence risk ju...

How do you interpret the results from the recently published EORTC-62092: STRASS study that showed no benefit to preop RT+surgery vs surgery alone and...

In this patient dermatofibrosarcoma protuberans of the thoracic spine, which originally caused a cord compression and has since been debulked, gross r...

Post-auricular cutaneous angiosarcoma, pT1 (19 mm) with negative margins. Unclear if there is any indication for systemic therapy, given early stage a...

For example, gastric GIST, < 5 mitoses/hpf and size > 5 cm but < 10 cm is intermediate by NIH criteria but low by NCCN/CAP criteria.  Th...

If post-op with clear margins would you prefer adjuvant RT or close observation with surgery for optimal reduction of local recurrence? This particula...

No primary thoracic mass identified. Knowing these often following an aggressive clinical course, would you consider concurrent chemo/RT, incorporate ...

Would you consider adjuvant chemotherapy, radiation therapy, hormone therapy, or surveillance?

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...

In patients with symptomatic disease that observation would not be appropriate, what is your preferred treatment?

Which Radiation modality, if any, would be preferred? Typical chemotherapy does not work for SFT. In which circumstance would you use VEGF ( Temozolo...

Would you consider "neoadjuvant" hormonal therapy to shrink tumors and potentially make more amenable to complete cytoreduction at a later date? Woul...

Recent results from the STRASS trial suggest limited benefit from preoperative radiation therapy for retroperitoneal sarcomas.  https://pubmed.n...

Data suggest patients with D842V-mutated or KIT/PDGFRA WT GIST do not respond to imatinib, but NCCN guidelines does not take into consideration mutati...

More specifically there is no testicular invasion - would you cover the entire scrotal sac? What lymph node stations if any would you cover?

The interval since prior resection is between 3-5 years. Additionally, there is some evidence of nodal involvement but no evidence of metastatic disea...

Re-excision would result in amputation. And the patient had attempted pre-operative RT but quit at 16Gy due to toxicity/social reasons. Would you trea...

Would you use general sarcoma expansions or would smaller expansions like the ones in head and neck would be reasonable?

Specifically, when treating a tumor located in the head and neck region, would you consider treating closer to 64-66 Gy? Or would you be consistent wi...

When deciding to treat what would be your dose/volumes? And would a re-staging scan play a role in your treatment planning?

If a patient with a high grade sarcoma has gross residual/recurrent disease after resection and cannot undergo further surgery - would you boost this ...

Should treatment be based on current histology (rhabdomyosarcoma) or origin (germ cell)?

What if it was status post partial resection? And had bilateral level 2 lymph nodes?

Would you consider using recently approved agent for symptomatic / unresectable PN, Selumetinib prior to Systemic Chemotherapy in this setting?

For example, would you consider switching to an outpatient regimen in lieu of AIM for metastatic soft tissue sarcoma?

Would you consider regorafenib based on the REGOBONE trial? Or would you consider other agents knowing that we do not have positive survival data with...

What dose schedule would you use to treat plantar fibromatosis? How soon after resection would you begin treatment? And how happy were you with the re...

Tumor 13 cm on back with retiform and kaposiform features; all margins negative except one abuts inked margin; atypical cells with 4 mitosis/HPF. Add...

The case in question is a radiation-induced spindle cell sarcoma at the thoracic spine previously treated for a plasmacytoma to a dose of 60 Gy in 30 ...

For both the primary and re-resection surgeries, resection was achieved via both scrotal and inguinal incisions. And margins were reported as negative...

Sometimes wound healing can delay adjuvant radiotherapy by several months. For aggressive histology, such as high grade sarcomas or skin cancers with&...

How do you choose between single-agent or combination chemotherapy versus newer treatment strategies such as palbociclib?

Adverse features include increased nuclear size, nuclear atypia, and mitotic activity up to 10/50 HPF.

For example, if a biopsy reads: lesion comprised of spindle cells arranged in a fascicular pattern, elongated, hyperchromatic nuclei, focally positive...

Would your recommendations change in the neoadjuvant versus adjuvant or metastatic setting?

i.e. doxorubicin, ifosfamide + RT. Do you worry about decreased locoregional control or increased toxicities with the use of G-CSF in combination with...

Recurrence is in the radiation field right at the border of graft and scalp, and started to surface at about 20-24 Gy. It is visibly enlarging over se...

Is there an age limit you use to consider MAP? Would you consider using AIM instead?

How do you choose between local therapy (surgical debulking or ablation) v. 2nd line systemic therapy? Would you consider immunotherapy?

68 y.o. Male underwent inguinal orchiectomy and spermatic cord resection of a 5 cm malignant fibrous histiocytoma of the spermatic cord. Margins of re...

Would certain patient/disease characteristics make you choose RT therapy over chemotherapy or other locally ablative therapies? What dose/fraction wou...

Given metastatic disease and not a trial candidate, how would you approach this scenario? How does an underlying diagnosis of NF1 affect your decision...

When, if ever, do you utilize adjuvant RT or chemotherapy?

Did the publication earlier this year by Gundle et al. JCO 2018 ( alter your concept of close mar...

What margins (if any) do you consider appropriate to not require adj RT? And would you ever consider neoadj RT?

NCCN suggests to consider continuation of imatinib from some single/multi institution non-randomized trials for ~2 years, but does not suggest what fa...

Specifically the groin region? Or are there techniques or a change in the management style of radiation at these sites you would employ to minimize to...

If so, how do you choose your region of treatment? Dose? And elective nodal volume?

How would you treat metastatic, unresectable, solitary fibrous tumor in a patient with mild hemophilia A? Each anti-VEGF medication comes with a warni...

If margins are clear, would this tumor necessitate adjuvant radiotherapy? Synovial sarcomas often occur in a young patient subset, would this cause yo...

If so, what patients do you select for the boost? And what data do you give to adequately satisfy the insurance review and win approval?

How does grade or performance status affect your treatment decisions?

Does anatomic location (eg retroperitoneal or thoracic) affect your treatment decision?

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...

After and extensive en bloc resection, is there further surgery that would be recommended? Is radiation alone sufficient? 

Would you treat these sites to definitive or post-operative doses? If not, is there a dose constraint you use at these sites? Do you use tighter margi...

I have seen favorable clinical trial reports on dasatinib for metastatic disease, but no data on possible adjuvant use.  NCCN guidelines suggest ...

What other pathologic features may you use to guide therapy decisions (eg mitoses/grade or NGS)?  If you decide on adjuvant therapy, what regimen...

What things would you take into consideration for the simulation set-up? Specific instructions for treatment planning? If the PTV is confined to only ...

Is there any data to suggest delayed initiation of adjuvant treatment would be beneficial? Or would close surveillance be reasonable? Patient is asymp...

Is breast conserving surgery followed by radiation therapy an option? 

CIC-DUX4 fusion sarcoma is a rare entity, the aggressiveness of which is comparable to Ewing's sarcoma. A major dilemma is whether to treat these pati...

Do you follow pediatric protocols or treat this more like a high grade soft tissue sarcoma? Specifically for paratesticular pleomorphic RMS, do you ad...

What are some guidelines or principles that you use to recommend adjuvant radiation after complete resections of sarcoma? 

For example, in the setting of a lack of pre-operative imaging, what CTV margin(s) would you utilize for the initial and boost phases of treatment?

How does grade, margin status, and previous radiation dose factor into the recommendation? 

What time delay would make the benefit of adjuvant therapy likely no longer significant?

Do you offer neoadjuvant RT with resection and node dissection vs. definitive radiation?  How extensive does the nodal disease have to be for you...

Tumor involves stomach, liver, and lymph nodes. Pathology is suspicious for sarcomatoid carcinoma, possibly sarcomatoid cholangiocarcinoma.

Is there any role for consolidative RT/CRT to the lung and mediastinum after initial chemo? What dose and fractionation would be most appropriate for ...

If so, how to you address the scar? Do you use bolus? Do you place a 2mm retraction from skin for the target contour?

With the high rates of recurrence postoperatively with angiosarcomas of the scalp, adjuvant radiation is often recommended.  What margins would y...

Most guidelines discuss target delineation and contouring recommendations for extremity sarcomas, which generally suggest larger longitudinal than rad...

For example, a patient with liposarcoma of the lower extremity status post preoperative radiation to 50 Gy who then underwent resection and had focall...

Would the dose change based if there was tumor adherent to bowel versus abdominal wall or muscle?

Would the histological grade or histology affect the dose? Would you consider dose escalating to the center of the tumor if this would not affect orga...

I am treating a resected high grade liposarcoma with positive surgical margins to 66Gy. I would prefer to use IMRT to spare the humerus, but ...

When the disease (in this case, lymphoma) involves almost all of the entire muscle compartment of the distal lower extremity, what is a safe dose? I'm...

And does your dose changes with positive margins? I can't seem to find a good answer in the literature.

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