Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
What alternative boost methods (techniques / dose) do you recommend for a vaginal cuff boost after whole pelvis when imaging shows bowel adherent to the vaginal cuff?
I usually prescribe to surface in these scenario rather than thickness. 6Gy x2
Would you recommend radiotherapy for a para-aortic recurrence of endometrial cancer in a patient who previous completed surgery, chemotherapy, and WPRT?
Yes, as a set of these patients are cured. I would treat pa chain with SIB to node along with concurrent cisplatinum to definitive dose
How do you plan for excess nonconforming vaginal tissue with a HDR cylinder?
CT based plan. You do end up seeing paravaginal tissue not covered by single channel cylinder. We have not chased that in adjuvant setting with outcome data showing low recurrence rate. Similar thoughts about small air gaps Richman et al., PMID 33384254.
What is the best method for ensuring that vaginal cuff cylinder is in proper position at each fraction?
The best method depends on local context and what tech is available. For imaging, one can: re-CT each treatment, use fluoro (we have a C-arm), use the kV or MV imager on a Linac with an orthogonal pair or a CBCT. There are other methods also. Some practices don’t image verify (makes me nervous). For...
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...