Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you deliver pelvic radiation as cost-efficiently as possible for a patient with endometrial cancer?
I think that a 4 field plan to 45 Gy in 25 fractions without cuff brachytherapy would reduce cost without deviating from the standard of care. We would expect that to come with modestly more acute and chronic toxicity than IMRT. I think we need more evidence before a 5 fraction regimen could be reco...
When would you consider sequential chemotherapy and radiation rather than concurrent for early stage cervical cancer with high risk pathologic features?
How much of the results of the STARS (Huang et al., PMID 33443541) (showing improved DFS with SCRT compared to CCRT) driven by only a 62% completion rate of CCRT (compared to 73.4% in SCRT, p< 0.001) as per the specified protocol is unknown.While the authors state within their results section that t...
Do you add chemotherapy to salvage EBRT/brachytherapy for a pt with small vaginal cuff recurrence of cervical CA s/p hysterectomy?
Yes, we do treat with concurrent chemo radiation (not much data).
How would you treat a patient with pT1bN0 G1 endometrioid carcinoma with significant MMI (~80%) and +LVSI?
Brachy alone, unless substantial LVSI then would favor EBRT.
When, if ever, would you offer adjuvant radiation to a patient with stage IVB endometrial cancer following neoadjuvant chemotherapy and cytoreductive surgery?
Stage IVB can have a large spectrum based on the extent and volume of metastatic disease. The NCDB dataset has lots of selection bias in who gets EBRT and also no data on DFS or recurrence pattern. I have usually avoided adjuvant RT unless pelvis is only confined to stage IVB disease.
Is it ever acceptable to treat low pelvis (vs. whole pelvis) for an early vaginal recurrence of endometrial cancer?
Retrospective data suggest pelvic RT helps but the volume of pelvic RT is variable as much of the data is in the 2D era. I usually treat common, external, and internal iliac in recurrent disease but would be reasonable to exclude common illiac node if morbidity is a concern.Vargo et al., PMID 252419...
How do you manage a patient with cervical cancer who has FDG uptake in bilateral ischial tuberosities with lytic areas on CT correlate, and also has a history suspicious for untreated polymyalgia rheumatica with chronic symptoms in the same anatomic locations?
I would be very interested in the opinion of a rheumatologist regarding the etiology of the lytic disease in the ischial tuberosities. A decision should be made on whether to biopsy one of these lesions. My suspicion is that it is unrelated to cervical cancer, but that possibility needs to be consid...
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...