now the issue which may remain is EBRT to Brachy ratio in the scenerio of EBRT doses ranging from 40-50Gy. the difference of 10 Gy delivered by brachytherapy can make lot of difference in local cervical growth control and also treatment time (5 days to none). this becomes especially important if you have pelvic LN >/=3cm and if you are not using SIB IMRT for addressing the nodes.

Couldn't agree more with Santam as above. Generically speaking, molecular agents are definitely a significant advantage compared to the "primitive chemotherapy" for we have known more about the molecular mechanisms this way. Nevertheless, targeting a single pathway is fraught with it's own set of issues.

I wouldn't be surprised if "combination molecular therapy" is actively promoted in future.

And then again, these agents have no impact on overall survival…..but thats another controversy.

I couldn't agree more with Rohit; even if you miss a patient, that's a "loss of an event".

I personally believe that secondary cancers is an overblown risk but at the same time it is hard to ignore the "low dose cloud". In what way does it fundamentally affect the patient?

Is it not that the cancer patients are predisposed towards secondary carcinoma risks over a period of time? But how much? How can this really be quantified?

With regards to the older "WART" studies, I would give them a huge benefit of doubt as far as the results are concerned. If you ask a surgeon to operate with a blunt scalpel, it is impossible to judge his "operating standards" because of sub-optimal tools. This does not mean that surgeon is incompetent.

Similarly for Radiation; outmoded machinery with lack of knowledge about long term effects on OAR's (which are still in process of being documented), does NOT mean that Radiation is "ineffective". The very essence of radio-pharmaceuticals is it's "targeted approach". So there. But then, that's opening up a minefield again.

Medicine, indeed, is an imperfect science, still.

Also we as a group need to think of generating new evidence rather than just adding to the experience later on.

And i absolutely agree with their conclusion.
Careful selection would be treat those with positive nodes or PET positive disease, and
omit it for those who have no para-aortic nodes.
Hence no role of treating para-aortic LN routinely as prophylactic intent ..as its too toxic.

Interesting fact about the 1st ref:
Damn, RTOG 92-10, how did they deliver 54-58 Gy to para-aortic region in the late 90s (hyperfractionated) with no IMRT ? ? any idea what BED small bowels and spinal cord would get.
No wonder they had 17% Gr IV toxicity. (unacceptable, and we cant tell pts here… you decide here….dont wanna have that conversation with andrew again) …

I wonder in these modern era, even with para-aortic nodes + ve, what experience do our members have of treating para-aortic LN…. what dose would you go upto ? with concomitant chemoRT of course….
Please specify what you ve done or seen in clinical practice, and not what you think or believe…… lets be practical.

UK practice ..no one has dared to go beyond 50.4 Gy @1.8 Gy / # ——> Routine practice (outside clinical trial)
Canadians ?
Australians ?

With regards to WART, the reference nikhilesh provided, was for pts who recd adjuvant chemo, and they further received consolidation WART.
WART has been used in few selected centres since 1980 but only as research tool / trial setting. I personally do not think, GOG, RTOG or these ICON groups would ever conduct an ovarian cancer trial looking into radiotherapy.
If i m not mistaken they have conducted early trials and gave up this concept.
These groups are the world leaders who have changed practice internationally.
Ph 2 trials dont mean std practice. and a ph 3 trial would involve at least 1000 pts minimum. Hence i would nt get excited about WART for at least another decade or 2, and if a trial does have positive trial, internationally ppl would wanna seek another confirmatory trial. You know what i m saying here……
With the explosion of newer agents, like EGFR , TKIs, MTOR inhib, kras, PI3K inhibitors, PARP inhibotrs, and god knows what else….. do you guys really believe RT has any chance to survive or even emerge…….. look at the next 10-20 yrs ahead of you.
RESERVE the sharp Radiotherapy cutting edge for something else….

Nikhilesh the article on 2nd malignancy says of 3266 (2862-3670) excess second solid cancers that could be related to radiotherapy, that is 8% (7-9) of the total in all radiotherapy patients (≥1 year survivors) and five excess cancers per 1000 patients treated with radiotherapy by 15 years after diagnosis.

I ve got no clue what these mean. Moresoever, what about the liquid cancers (lymphomas and leukemias).
Does Radiotherapy increase risk of those ? , if so were they taken into account.
Its a database at the end of the day… it gives you whatever you feed in the database.
You miss one patients foillowup, you potentially miss the chances of recording an event.
Database spans from 1973 to 2002, over last 37 yrs , we have more effective agents, and have potential more long term survivors…. was chemoradiotherapy or any of the std things we do, known then…. NO
Look at the patient population they chose…they left out Hodgkins i presume for a reason…
but anyways …nice publication for the cv for the authors…

Its difficult, what you routinely quote to your patients, the risk of 2nd malignancy ? ?
It proportionately increase over time.
risk at 20 yrs ?
risk at 30 yrs ?
risk at 50 yrs ?
Obviously this is relevant only for young patients,

http://www.ncbi.nlm.nih.gov/pubmed/11704321
http://www.ncbi.nlm.nih.gov/pubmed/19010522 (study closed)
http://www.ncbi.nlm.nih.gov/pubmed/19398095

(Off topic: )One more thing. I personally feel that Whole Abdomen Radiation is rather underused in the IMRT era and we should improve our thought process beyond the 'moving strip technique".

Borderline Serous Ovarian tumours are a heterogenous group of tumours, if they are restricted to ovary, the prognosis is excellent, while those with invasive peritoneal implants have poor prognosis. (Longacre et al, 2005).

The mainstay of treatment here is Surgery… Maximal cytoreduction is the predominant prognostic factor for the overall survival. Rest all is experimental and unproven.

There is no good evidence for any role of RT, and in view of her age = 26, one would usually like to avoid it for fear of second malignancy, as this lady would have a reasonable 5 yr survival between 55-75% (WHO , 2003).

Some clinicians wait for the third relapse and then treat with chemotherapy, while some select their patients at 2nd relapse, looking for poor prognostic factors, like ( suboptimal resection, invasive peritoneal implants) or factors like patient anxiety and preference.

Borderline tumours should be confirmed by at least 2 different pathologists.

Most commonly offered chemotherapy = Single agent carboplatin (AUC =6) x 6 #.
(Level 3 evidence for this approach).

Nikhilesh, the above approach mentioned was for recurrent Borderline tumours,
Now if i get it right, this lady has had a transformation from Borderline to Malignant (low grade).
She needs to be staged, she is at least stage IIIb if all disease confined to pelvis, and possibly IIIc if disease outside pelvis.

Std Mgt would be to offer Adjuvant chemo with either Single agent Carboplatin Vs Carboplatin + Paclitaxel.
(Level 1 evidence)
Again no role of RT, apart from clinical trials ..

Rohit Malde

Chemo Vs RT? Role of Chemo in low grade serous adenoca ? If RT, how do we do that, ? Whole Abdomen (patient has uterus in situ and wants her own baby, has tried IVF with 3 futile attempts in 2009-2010).

What is the treatment of choice here ?