Treat

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Have a patient with FIGO IIB disease, declined concurrent chemotherapy.

I'm inclined to treat with extended field RT, on the basis of RTOG 7920, and especially since there's one PET avid external iliac node.

However, I'm also aware that this study did not show any benefit for DFS or distant disease free survival. Furthermore, there's also an EORTC study which shows no benefit.

If there wasn't any involved node, would anyone not treat?
 

Palex80

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In my opinion the problem with extended field RT is increased acute toxicity.
Since the patient already declined concurrent chemo, the question is what did she agree on?
Will she undergo brachytherapy or will she also skip that? And how big is the primary? Do you think, you are going to be able to control with RT alone (with or without brachy) or will the patient probably need salvage surgery? And would she agree to that?

And why did she not agree chemo and what chemo was the one she didn't agree on.
From my experience some patients are reluctant to get cisplatin because of the potential side effects, but many of them can simple get Carbo AUC2, which is quite manageable in terms of toxicity (but probably less efficient too).

I wouldn't do extended field RT.
 

medgator

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Agree with what Palex said with the caveat that if the pt absolutely could NOT get some weak cis/carbo weekly regimen (really would try to push for something), I'd consider EFRT using IMRT. The brachy question needs to be addressed as well with the pt.
 

seper

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I would not do EFRT unless there are suspicious pelvic nodes on PET. Remember, chemo is nowadays always low dose weekly cisplatin, which has no cytotoxic activity by itself anyway. Isolated PA failure is unlikely to be an issue for this patient.
 
OP
T

Treat

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Thanks for all the replies!

The patient has agreed to brachy, and chemo is out.

There's one PET avid external iliac node. I believe that in such a scenario, the patient has a significant risk of para aortic disease..? And hence my consideration for EFRT
 
OP
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Treat

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Agree with what Palex said with the caveat that if the pt absolutely could NOT get some weak cis/carbo weekly regimen (really would try to push for something), I'd consider EFRT using IMRT. The brachy question needs to be addressed as well with the pt.
Would the presence or absence of pelvic nodes affect your decision for EFRT?
 

medgator

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Would the presence or absence of pelvic nodes affect your decision for EFRT?
I'd be more apt to do it with + pelvic nodes. Would use imrt
 
OP
T

Treat

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Sep 21, 2015
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In my opinion the problem with extended field RT is increased acute toxicity.
Since the patient already declined concurrent chemo, the question is what did she agree on?
Will she undergo brachytherapy or will she also skip that? And how big is the primary? Do you think, you are going to be able to control with RT alone (with or without brachy) or will the patient probably need salvage surgery? And would she agree to that?

And why did she not agree chemo and what chemo was the one she didn't agree on.
From my experience some patients are reluctant to get cisplatin because of the potential side effects, but many of them can simple get Carbo AUC2, which is quite manageable in terms of toxicity (but probably less efficient too).

I wouldn't do extended field RT.
Thanks for your detailed reply.

The primary is about 4cm if memory serves.. Brachy is in, chemo is out. Haven't discussed salvage surgery, but I'm pretty sure she'll never go for it.

May I know why not EFRT? Is it purely the toxicity, or do you have doubts about efficacy? And even with a + pelvic node and no chemo?
 

Palex80

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With a 4 cm primary and with brachy, you may have a chance of controlling the primary. Despite that, I fear that this patient will rather have a pelvic recurrence than an isolated paraaortal lymph node failure.
I also have concerns that the additinal toxicity of EFRT may jeopardize the pelvic treatment, i.e. the patient may want treatment breaks, skip brachy, etc...