Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
Given patients with substantial LVSI experience a pelvic recurrence rate of ~25%, how do you counsel patients with stage IA endometrioid endometrial cancer with LVSI regarding the relative risks/benefits of EBRT versus VBT alone?
Updated analysis of PORTEC-1 and 2 noted that 5-year pelvic lymph node recurrence was 26.3% when >4 vessels had LVSI involvement, compared to 6.7% with 1-3 foci and 3.3% with no LVSI1. Based on the data from PORTEC-2 which randomized patients to vaginal cuff brachytherapy or EBRT, on multivariable a...
Will you be changing your management of locally advanced cervical cancer based on the results of the recently published INTERLACE trial?
Absolutely NOT. INTERLACE results are in abstract form only, including early-stage disease I-II at 86%, and the details regarding radiation are minimal, stating it's prescribed to point A and recommend CT/MR planning (we do not know how many patients underwent image-guided brachytherapy). Also, ind...
Do you have concerns about the validity of the INTERLACE data, considering the long study recruitment period (10 years) and evolution of radiation techniques that have occurred during that time frame?
The long recruitment period and change in the practice of brachytherapy do create some uncertainty in interpretation. As mentioned, 60% had point A-based brachytherapy in INTERLACE. Any modern cervical cancer trial needs to have current technology especially IMRT (helps with nodal boost, conformity,...
Are there any situations in which you would offer brachytherapy alone instead of whole pelvis RT +/- brachytherapy for an endometrial cancer vaginal cuff recurrence?
Limited series in the past where only brachytherapy alone was done for salvage without EBRT reported high pelvic nodal relapse.One such series is Baek et al., PMID 27614661The only situation where I have done brachy alone is in patients who have had previous EBRT or have other contraindications to E...
When do you transfuse cervical cancer patients undergoing chemoradiation?
Although we try to keep hemoglobin 10 gm and above for patients on chemo Rt, it is not clear whether it makes any difference to outcome. Anemia is associated with inferior treatment outcome in cervix cancer, but hemoglobin levels prior to and during treatment are strongly correlated with tumor size,...
Do you offer vaginal cuff brachy alone, vaginal cuff brachy and chemo, or WPRT for surgically staged IB grade 3 endometrial cancer?
All patients who have stage IBG3 fall into the GOG249 eligibility criteria. However, it is important to recognize that patients within this group have broadly varying risks. First of all, serous cancers (which have a greater propensity to spread intraperitoneally and may demand variant-specific appr...
Do you take patients off anticoagulation for tandem and ovoid or tandem and ring procedures?
We don't take them off anti coagulant for intracaviatry alone unless using a hybrid applicator
How would the presence of micro-metastatic disease in multiple sentinel pelvic lymph nodes change your recommendation for adjuvant therapy in a patient with otherwise stage I endometrioid adenocarcinoma?
Currently, we treat like stage III disease with chemotherapy followed by adjuvant EBRT for decreasing LRR and control any residual nodal disease (could be 30% based on FIRES) left behind as had only SNLN done. The outcome appears to be better than macrometastases.If only ITC then no chemo for now bu...
How would you manage a cervical cancer patient who develops new oligomet to the spine during primary cis/RT?
The finding of metastatic disease to the spine during primary radiation therapy for cervical cancer suggests the presence of systemic, hematogenous disease at the start of treatment. PET-CT scan and/or bone scan are useful diagnostic tools to detect distant metastases and also to differentiate betwe...
How do you manage a patient with an endocervical cancer indeterminate for endometrial or cervical origin status post TAH/BSO and sentinel node biopsy?
P16 and CEA positivity (although focal) favor cervical cancer. Can also do high risk HPV and p53 as suggested. Either way, the patient looks like they had a simple hysterectomy done and would favor EBRT plus brachy (would consider adding weekly cisplatinum if the overall picture is cervical).