Ask a Doctor Your Questions about Uterine Cancer Radiation Treatments

00:00:00:00 - 00:00:32:20
Unknown
Cor. Okay. So that should put you. There you are. So let me do I'm going to introduce you, I'm going to do a spiel about share and then I'll do a little spiel about you. Not, not a huge thing, but hello and welcome to the program and asking Doctor Dr. Puja Venkat about radiation treatments. I'm Corby, uterine uterine cancer patient support coordinator at Share.

00:00:32:22 - 00:01:10:19
Unknown
And I want to tell you a little bit more about share. Share is a national nonprofit that supports, educates and empowers anyone who has been diagnosed with women's cancers and provides outreach to the general public about signs and symptoms because no one should have to face breast, ovarian, uterine, cervical, metastatic, breast and ovarian, uterine, cervical cancers alone. For more information about upcoming webinars, support groups and our helplines, please visit our website at Share Cancer Support dot org.

00:01:10:21 - 00:01:40:17
Unknown
I'll be here and everybody needs to mute themselves, which you did. Thank you so much. Once Dr. Van Capp finishes presenting, we'll begin the question and answer discussion. So feel free to ask any questions through the section at the bottom of the screen. Okay, So that would be in the chat, I guess. And then, and remember that Dr. Bankhead is unable to give specific medical medical advice.

00:01:40:19 - 00:02:14:01
Unknown
So please keep your questions general in nature and I will ask all questions directly to Dr. Venkat. This presentation is being recorded and will be available on Cher. I don't know how long, but and then after after about an hour, we'll be we'll have our newly diagnosed and in-patient support program. So Dr. Venkat is is my doctor. She's my radiologist and shoots at UCLA and she's also a professor.

00:02:14:03 - 00:02:40:10
Unknown
So she teaches other doctors our future doctors. And so go ahead, Pooja. Go ahead. Introduce yourself as I had on you. Thank you. It is my pleasure to be here. I feel very honored to have so many women here listening to me at this time of the night. For many of you, I am a radiation oncologist at UCLA.

00:02:40:10 - 00:03:05:20
Unknown
I specialize in GYN malignancies and particularly brachytherapy. I thought a lot about how to formulate this talk, and I, based on my interactions with met with my patients. I realized my patients know a lot. So I'm not going to sit here and lecture you with the basics. I'm going to jump right in and talk to like I talk to my colleagues and the residents I train.

00:03:05:22 - 00:03:28:07
Unknown
So this is an adaptation of one of the talks I give to our resident physicians on endometrial cancer. And I kind of like to think about medicine through my patients and through cases. That's how I learned, that's how I remember. So that's how we're going to frame this talk. I do have all your questions here. Many of them are not answered in this talk, but I promise to get to all of them.

00:03:28:07 - 00:03:49:24
Unknown
Okay. So let's just jump right in. And I also I'm happy to take any questions as we go along or if you chat them to the group, I will see those and I will keep my chair opens up. Pay attention to that. So we're going to jump right into case number one. We're going to start with a 70 year old woman who presents with postmenopausal bleeding.

00:03:49:24 - 00:04:22:23
Unknown
This is, of course, how many women with endometrial cancer present to the doctors. So when we see this, what do we do next? What's our workup? First, we start with a history and physical, and we have to make sure we assess the amount of bleeding, if there's any pain, dizziness. When I report the status, that means that your blood pressure drops when you stand up from a sitting or lying down position, which is a sign of not enough blood support, blood in the body due to bleeding.

00:04:23:04 - 00:04:48:12
Unknown
We also, of course, do a guy on exam. This is critical and unfortunately is often missed by our primary care and emergency medicine physicians. So I encourage all women to demand a giant exam when they have DVI on symptoms. So what am I looking at When I do an exam? I look at the whole external genitalia that includes the vulva, the skin in the groin, the entire area.

00:04:48:12 - 00:05:09:15
Unknown
I look at the bathroom walls, I look at the cervix, the cervical OSS, which is the opening from the cervix into the uterus. And then of course, we assess the uterus as well. In this case, there is no lesion visualized or palpate, and so I couldn't feel or see anything abnormal. So what do I do next? This is typically not the radiation oncologist.

00:05:09:15 - 00:05:31:12
Unknown
This would be more the gland doctor. What would they do next in this setting? They would do a pelvic ultrasound to assess the thickness of the endometrial stripe. That's the area right in the middle of the uterus. It fits over a 3 to 5 millimeters. That is a sign that maybe there's something abnormal going on. And what would be our next step?

00:05:31:12 - 00:06:05:01
Unknown
That would be an end of me through a biopsy. It's a very, very effective test to assess for cancer in the uterus, 95% sensitivity. So doesn't get much better than that. But for those 5% of patients when that biopsy is negative, is that the end of it? Do we just say, well, you don't have cancer? No, You cannot just assume that you must proceed with A, D and C, which is more invasive surgical procedure to really get up inside the uterus and get more tissue out to make sure there's no cancer there.

00:06:05:03 - 00:06:32:17
Unknown
What histology do we expect? By histology, I mean, what do the cancer cells look like under the microscope? Where do these cancer cells come from? For 75 to 80% of women, endometrial cancer is look like endometrial adenocarcinoma cells are the most common type of uterine cancers, very common to the whole gene tract. In fact, the ovaries, fallopian tubes and the uterus are often endometrial adenocarcinomas.

00:06:32:19 - 00:06:58:08
Unknown
And fortunately we do have 10 to 15% uterine papillary serious carcinomas for clear cell carcinomas. These are more aggressive and harder to treat, and they do account for the majority of deaths from endometrial cancer. Our techniques and treatments have gotten better, but these are still a challenge for us. And even less common are sarcomas. About 3 to 7% of our cancers are sarcomas.

00:06:58:08 - 00:07:27:18
Unknown
We have carcinoma from us and of neutral stromal sarcomas. And on my sarcomas, I'm not going to talk too much about uterine sarcomas today because that is a whole separate topic. Moving on. So for this woman, remember, she was a 70 year old who presented with postmenopausal bleeding. We proceeded with an endometrial biopsy and we found a grade two and a metroid adenocarcinoma.

00:07:27:18 - 00:07:49:12
Unknown
So that, as I mentioned before, is the most common type of endometrial cancer, but which is a great to me. The options are grade one, two and three. Grade one is the most benign, the least aggressive type of cancer. And that's really a pathologist is looking at the cells under the microscope and looking for features of aggression. And grade one is not aggressive.

00:07:49:12 - 00:08:11:03
Unknown
Grade two is intermediate and grade three. Cancer cells are looking very, very aggressive. One way I like to think about that is when cancer cells start, they tend to be less aggressive and they look like the cell that they arose from. So they look like uterine cells with glandular definition, because uterine uterine cells have a lot of glands.

00:08:11:05 - 00:08:31:17
Unknown
Over time, those cells become more aggressive and they become more differentiated. They don't look like those glandular cells that they started with that started as they don't really look like a matrix adenocarcinoma. So that's what this lady has. What else do we want to know? We want to know many things. I'm going to start with some lab tests.

00:08:31:17 - 00:08:52:24
Unknown
I'm going to do a CBC, a stamp. now I'm just saying words. You might not know when to check your your blood counts, your white cells, red cells and platelets. I'm going to check your metabolic panels, check your kidney and liver function. The K 125 is a cancer marker that we often check. It's not a great cancer marker.

00:08:53:00 - 00:09:12:01
Unknown
It sometimes is effective for some women. Other times it's not. It's not as specific as we would want it to be, but it's something we tend to look at. And then of course, now in this case, but if someone is younger, we would want to do a pregnancy test before proceeding with imaging. And what imaging do I want?

00:09:12:01 - 00:09:32:01
Unknown
I want to assess the whole body for cancers. So typically what we would do would be a chest, abdomen. Pelvis is very common. You can do an MRI, pelvis if you want to get a better sense of the soft tissue anatomy in the pelvis before proceeding with treatment, you could do a chest X-ray for the chest instead of a CT scan.

00:09:32:01 - 00:09:53:23
Unknown
But I personally don't think those are particularly effective. And I think that's more of an old school technology. I think you should probably just get a city chest and really look at those lines just to make sure nothing has spread to that area. If there are symptoms that are affecting the bladder or bowel, you do need to assess whether the uterine tumor has invaded those organs.

00:09:54:00 - 00:10:15:20
Unknown
The old school way that is still recommended by some is to actually do a cystoscopy where you look in into the bladder or a pocket of sigmoidoscopy, where you look into the rectum and sigmoid colon, you actually look with your eyes or camera. One alternative to that is to just do an MRI office. And those tests are amazing.

00:10:15:20 - 00:10:43:04
Unknown
Now you can really see most of what you need to see, what those and tends to be a little easier. I am just going to take one break. They're messaging me to do a procedure and I'm just going to ask if someone else can do it. One second. So sorry. I almost got everything done before but couldn't quite do it so in this case, all the studies are negative.

00:10:43:06 - 00:11:15:15
Unknown
The blood tests were normal, the imaging looked fine. So what is the patient stage? That's really where we start as radiation oncologist. What's the pathology? What's the state? This is actually a trick question because we have not stage the patient because for endometrial cancer there is only one way to stage the patient, and that is through surgery. So surgery is not only to treat uterine cancer, it's also to stage uterine cancer.

00:11:15:17 - 00:11:50:22
Unknown
One more message. So what's the next step? So the next step is actually surgical management Management and what surgery do I recommend? It's pretty standard surgery of a total abdominal hysterectomy and bilateral something out to me with pelvic and periodic lymph node dissection. Bilaterally, These are just listed here, some other regional nodes that we assess and take out and a little bit more what we do during the surgery.

00:11:51:02 - 00:12:13:13
Unknown
But the main point here is we take out the uterus, we take out the bilateral fallopian tubes and the bilateral ovary. So you also take just a little bit of the top of the vagina. And of course, you definitely need to take that cervix as well. And you also have to assess the lymph nodes on both sides of the pelvis, just not the not just the pelvic lymph nodes.

00:12:13:13 - 00:12:34:03
Unknown
We actually want to assess a little higher into that periodic region right above the pelvic inlet. So that's all really important. And that is going to give us our surgical pathology and help us stage the tumor and also decide what, if anything, to do with. So what do I look for on surgical pathology? You look at a lot of different things.

00:12:34:05 - 00:12:58:05
Unknown
We're looking at the histology. By that I mean, what type of cancer is this? Is it an adenocarcinoma, a clear cell? Is it a serious the grade, like I mentioned, grade one, two or three, very important for uterine cancers are looking at the depth of the male nutrient invasion. What does that mean? The cancers start at the middle of the uterus and then they grow out to the uterine wall or the male nutria.

00:12:58:07 - 00:13:27:24
Unknown
That percentage of invasion helps us stage tumors. And also if that tumor spreads outside all the way to the lining of the wall or the rosette that's going to upstage the tumor after it even gets outside of that dress, that, of course, is going to upstage it even more so that percent of male mutual invasion, it's important. Elvia Sci is a means lymph node vascular space invasion, which is a challenging thing to understand.

00:13:28:01 - 00:13:51:18
Unknown
I want to try to explain it in a way that makes sense to me. One Cancers first of all, they don't have full vascular space invasion. That is a feature they develop over time and it means it learns how to invade into the lymph. So vascular, the lymph node space or the vascular space, the black blood vessels, the arteries and veins.

00:13:51:22 - 00:14:12:24
Unknown
So it learns how to invade into those spaces. That doesn't mean it has it means it has the ability to. So that is a risk factor and that does make us just think a little bit more about where this cancer might spread to our campus. I also need to know if the cervix is involved as that upstages the tumor that comes down into the cervix.

00:14:13:01 - 00:14:36:12
Unknown
Of course we need our margins to be negative. Looking for disease in the lymph nodes size of the tumor is actually not that relevant. It's not part of the staging, but stuff like something I'm thinking about, if it's a very large tumor, which means anything over four centimeters, it just something that's in the back of my mind when I'm assessing a patient's risk location of the tumor matters.

00:14:36:12 - 00:14:59:15
Unknown
Does this tumors start at the top of the uterus or the fundus, which a start at all in the lower uterine segment, which is right above the cervix and vagina? That might help me to think about how the tumor might spread. I look at cytology as a surgeon has taken some cells from from the peritoneum or that's the space around the uterus.

00:14:59:17 - 00:15:43:02
Unknown
And then, of course, nowadays we're looking at molecular markers, we're looking at the DNA of cancer. So one thing we look at, particularly for endometrial cancer, is microsatellite instability or mismatch repair deficiency. So this is a finding we see in some DNA of endometrial cancer where there's an inability to repair a certain DNA defect, and that can lead to a worse prognosis, supports outcomes, but can also help tailor some of our more targeted treatments, like immunotherapy and molecular inhibitors.

00:15:43:04 - 00:16:03:24
Unknown
So that can sound like a bad thing when you're first diagnosed, but can also lead to newer and more targeted treatments down the road if we need. So just something to think about going back to our case. So for this patient, remember, she was a 70 year old woman. She has an endometrial adenocarcinoma. It was a grade two.

00:16:04:01 - 00:16:33:07
Unknown
So that intermediate grade she had 30% male mutual invasion, no alveoli and no lymph nodes were involved. So now I can actually stage this tumor and I'm going to stage her as stage one A And why is that? That's really based on the Mayo Mutual invasion being less than 50% and no obvious sign, no lymph nodes involved. And of course, there's there's other things I have listed here, but that's what we're staging her at.

00:16:33:09 - 00:16:59:22
Unknown
This is a table for the staging. We don't need to go into details here, but I just wanted to put this here because it is very complicated. It's not just a simple. This is what you have. We look at a number of different factors when we stage patients. This is actually no longer relevant because we have a completely new staging system that incorporates some of those molecular markers I mentioned, and that's brand new.

00:16:59:22 - 00:17:16:01
Unknown
Just published a month ago. It's going to change things. We just haven't gone to the point where it's changed treatment yet, so I didn't want to bring it in today and it's very complicated. So this is what we still use for treatment decisions right now and a lot goes into it and we don't need to go into specifics today.

00:17:16:01 - 00:17:38:11
Unknown
So for this patient, what do I recommend for a stage one, grade two? No VSI, no cervical involvement, and what do I recommend? And big question is why do I recommend it for this patient? I personally would recommend of brachytherapy, which I will show you some pictures of in a second. We look at risk factors. So this is a stage one.

00:17:38:13 - 00:18:03:14
Unknown
It's an early stage. It's the earliest stage that gets there is. But what am I looking at for risk? Factors of recurrence Age greater than 60 is actually just something to consider for women. Older women tend to have a worse, worse chance of cure. So increased risk of recurrence. So we're more aware of these risk factors in our older patients.

00:18:03:16 - 00:18:26:19
Unknown
That's invasion greater than 50% as one risk factor, although it's not greater than 50, less than 50. It's really a spectrum. So 49% is really no different than 51%. So I don't just look at yes or no here. It's really a spectrum. Same thing with age. Actually, 60 is way different than 90. We really got to look at the spectrum here.

00:18:26:21 - 00:18:48:11
Unknown
Obviously is more yes or no you have it, except it's not really because the pathologist will tell you you have focal obviously are extensive, obviously, or a moderate version. So also a gradient grade two or three, it seems like that's it's a great two or it's not a grade two. That's actually a spectrum, too. It's not like there's there's strict guidelines.

00:18:48:11 - 00:19:02:22
Unknown
So you have to have a good pathologist, someone you can talk to and trust and understand what they mean by a grade two or a grade three, or sometimes they're like, it's a grade 2 to 3. And you're like, That's not helpful. You need to call it one way or another, but it is a spectrum. So I do understand.

00:19:02:24 - 00:19:24:15
Unknown
So for this patient, she is over 60. Her depth of invasion is less than 50%. She did not have LV aside, but she had a grade two. And when we think about what we recommend, we want to consider vaginal brachytherapy. A patient has one risk factor. Strongly suggest if two risk factors and like I said, those risk factors are continuous variables.

00:19:24:15 - 00:19:46:19
Unknown
So seven year old is quite a bit older than 60 with a grade two tumor. Even without any other risk factors, I would still recommend partial brachytherapy for this patient. So there are studies that support this. Of course, I'm just making this up by square. So what studies? What is the risk of recurrence and what what is the treatment actually look like?

00:19:46:19 - 00:20:06:03
Unknown
So that's what we'll look at. Now, there's four trials. These are randomized trials that we think about for early stage endometrial cancer. We don't need to go too much into details here, but we have got do 99 and for type one were the two original trials that we looked at and what we were trying to look at in these early stage patients, can we omit radiation?

00:20:06:03 - 00:20:38:13
Unknown
That was the question. So what we learned was that when you had some of these risk factors, there were too many recurrences. So when we looked at judging 99, the local recurrence risk, if we committed radiation, was 9% versus 1.5% with radiation. So that's a big difference and a big benefit with radiation tech one. The other similar trial actually had 15% local regional recurrence versus a 4% because it matters what you're looking at.

00:20:38:13 - 00:21:00:15
Unknown
So DOJ 99 had four year follow up and protect one had a follow up. So that's probably why those numbers were a little higher. These these two trials used external beam radiation as their radiation method. So we started asking ourselves, do we need to do external beam or can we do a batch of brachytherapy, have some pictures that will explain what that is.

00:21:00:21 - 00:21:23:19
Unknown
And that was part tech to really looked at external beam versus vaginal breaking. We learned that fragile braking was preferred in this group due to side effects. The side effects with or breaking were quite low, but you should be here. Yes, here. So grade one such as side effects were 12% with that breaking versus over a 50% with external beam.

00:21:23:19 - 00:21:50:11
Unknown
So big difference. Big benefit. Then the Aldrich trial also showed it's a little more complicated trial, but it basically showed that external beam definitely had some value, but not extreme value and definitely had more side effects. So for a lot of these patients, we really just do brachytherapy alone. Here I have the National Cancer Center guidelines. I think this I use this with the residents a lot.

00:21:50:11 - 00:22:14:10
Unknown
Just to put things in perspective, just a stage here, stage one A that's the tumors with less than 50% of mutual invasion and one be greater than 50%. And then by grade, what we'd recommend can see for the stage one, a grade one patients observations preferred for the stage one, Grade two patient. We prefer a fragile breaky if there are any risk factors.

00:22:14:10 - 00:22:39:07
Unknown
That's what we had with this case. And then we'll go through some of the other options as we go through. I wanted to put this slide in here to first of all, actually show you what our breakthrough therapy is. This is one of my patients plans. I basically I put this cylinder directly in the vagina and I deliver the radiation through that cylinder.

00:22:39:07 - 00:23:03:13
Unknown
So you're delivering the radiation right where it needs to be in orange. Here is the rectum. In yellow here is a bladder. And you can see the cylinder sits right in between in the vagina. So you can see this is a challenging area to treat. On this side, you can see even there's bowel right up against the cylinder and this is the sigmoid colon right up against.

00:23:03:13 - 00:23:27:06
Unknown
So I'm trying to put radiation between all these normal tissues that are literally touching my target. And the reason we laugh as well, brachytherapy is I can do this and I can do it safely. You can see kind of it in here. It's not the easiest thing in yellow. This yellow line right around my cylinder, which is this white thing, is 100% of the dose.

00:23:27:08 - 00:23:50:02
Unknown
It's actually a green line that yes, there's a green line in here 100% on the dose and then that dose drops down. This blue line is 50% of the dose and it drops down within within a centimeter. You're dropping down to 50% of the dose, which is what's actually touching the normal structure. So I am actually able to get good dose and take care of safely.

00:23:50:04 - 00:24:19:13
Unknown
And these are some of the possible treatment regimens. Grade G, Why? Here is it stands for Gray. It's the unit of radiation we're delivering. What I recommend is six great times, five treatments delivered at the surface of the cylinder. Another option is seven great times, three delivered at five millimeters. That is a recommended treatment option. It's a possibility.

00:24:19:13 - 00:24:41:19
Unknown
I do think there might be higher side effects with that higher dose per treatment, so I actually rarely do that. I like the six great times five. And then after external beam, there's some other recommendations, but you don't have to go into that. So that is what I have for first case. So for early stage endometrial cancer, definitely I want to consider rationale brachytherapy.

00:24:41:19 - 00:25:11:02
Unknown
If you have some risk factors for case two, we're going to progressively get a little more advanced in our diseases. So we still have a 70 year old woman with pathology showing mild neutral invasion of 55% in grade three disease. So what stage would this be? This is going to be A stage one B, because we're over that 50% neutral invasion and grade three disease.

00:25:11:02 - 00:25:38:08
Unknown
And then I see a very good question here about side effects of brachytherapy. So let me just jump to that, since we're talking about brachytherapy here. So brachytherapy has very few side effects for when you think about cancer treatment, it's one of the treatments that has the least side effects. I also just want to say brachytherapy. There's many different types of brachytherapy right now.

00:25:38:08 - 00:26:09:24
Unknown
I'm talking about vaginal cylinder brachytherapy in the setting of post hysterectomy, endometrial cancer, really mild side effects do this all the time, but really doing it right now, you just can't tell the cylinder and deliver the radiation. The treatment takes about 5 minutes. You don't feel the radiation. It's like getting an X-ray or city scan. Just have this weird cylinder in your vagina.

00:26:09:24 - 00:26:31:18
Unknown
So it's definitely weird. It's definitely uncomfortable to place the cylinder. It really shouldn't be painful to put it in because it isn't made for vaginas. The radiation has no immediate effects. You feel exactly the same when you leave as when you came in. I deliver the five treatments over a week and a half every other day over that week, and a half.

00:26:31:20 - 00:26:56:08
Unknown
Patients can honestly have zero side effects, but there is the potential for some mild side effects fatigue, low stools, increased frequency or burning with urination. If those happen, they're very mild. I almost never have to do anything about it, like give any meds or any supportive care. What women mostly tell me is they feel like their vaginas inflate.

00:26:56:10 - 00:27:26:04
Unknown
It's not like they're calling me, telling me that. It's just, you know, they're seeing me two days later when I do the next insertion and procedure. And I'm like, How are you doing? And they tell me, I just feel like it's a little inflamed and it's not really a complaint by patients do very well with this. I think more the downside than physical side effects is the mental like this is a mentally challenge treatment for many women.

00:27:26:04 - 00:28:02:18
Unknown
It feels very just a lot of trauma with this. Most women have had bad vaginal exams in the past, some bad experience with some pelvic exam, or a procedure that was challenging, painful under medicated. There might be some trauma history that they're dealing with. So I think emotionally this can be a very challenging treatment to undergo. And it's you feel very exposed even with my team.

00:28:02:18 - 00:28:26:07
Unknown
And we try as hard as we can to make it as comfortable as possible. But I do have patients. No. As that being said, I think it's talk. Talk it out, Explain everything you're going to do at the same team, be supportive, be there. It's very reasonable to of long term side effects are much more important to me because these are early stage tumors.

00:28:26:11 - 00:28:49:07
Unknown
I'm planning to cure them and have women have their normal life expectancy. With this treatment. I don't want to impact their lives with side effects. So what are the chances of long term damage to the bowel, the sigmoid colon, the rectum here and the bladder here? All these structures are right next to that. So the treatment site. So what are those long term risks?

00:28:49:08 - 00:29:11:05
Unknown
Less than 1 to 2% of any long term side effects with this treatment to those organs. It's not zero, but it is low. Most of my patients and follow ups will just undergo a batch of Reiki. We have like social visits for follow up. There's really not a lot of side effect management long term, and I follow my patients for five years.

00:29:11:07 - 00:29:40:10
Unknown
What's the one side effect that will happen? We can prevent and that is spinal stenosis or scar tissue of the vaginal. And this is something I'm actually very passionate about preventing, and it's it is 100% preventable. So there's really no excuse for that's basically the vagina is always closed unless we put something in it. After getting cancer surgery, radiation body gets confused and wants to heal it.

00:29:40:12 - 00:30:10:08
Unknown
So it starts to form scar tissue at the top. Simply by putting something in the vagina, we can prevent that scar tissue from forming. But it's something we have to do repetitively. And, you know, sexual intercourse counts, but it doesn't happen consistently for most people. So we do something called fragile dilation, and I can talk more about that and give some maybe some information that I use.

00:30:10:10 - 00:30:39:21
Unknown
We could give out the interesting I have another question about case one here. We can talk about side effects of external beam a little bit later when I have an external beam case and then you can definitely skip the transvaginal ultrasound and post-menopausal. Is that true? Because it like I said, even if it doesn't show anything, you're going to end up doing the biopsy.

00:30:39:21 - 00:31:09:19
Unknown
So I leave that up to the guy and I apologize. You can still get more information from the ultrasound, though, so it's not really a bad thing to do. Regardless, I personally would one would want to get that ultrasound, but it's not necessary. Okay. Okay. I think that takes us to case one, unless there are any last minute questions on case one, and I can talk more about dilate or so at the end if we have time now.

00:31:09:19 - 00:31:33:16
Unknown
But for special type terminators. That takes me a long time though, so I'll jump into the case two where we'll talk about the external beam side effects. So like I said, this was A stage one B grade three disease. What is our recommendation and from what study? We could talk about the Alders trial, which included one B grade three disease.

00:31:33:18 - 00:32:16:17
Unknown
We saw a local recurrence, three benefit local recurrence decreased from 25% to 5% with external beam radiation. So we definitely want to consider external beam radiation for these patients since it's one B grade three. This is kind of a group where you can do a number of different things. I would do 45 grade of external beam plus federal cylinder brachytherapy, although that is there's not strong data at the original cylinder brachytherapy, but we know what grade three patients, they're at a high risk of recurrence so it is recommended to consider it.

00:32:16:19 - 00:32:48:12
Unknown
However, my my in oncology colleagues have now started recommending chemotherapy for this population. So when they give chemotherapy, I might want to deescalate some of my radiation. So this one is less clear and there are a lot of different options. You could do chemo and vaginal cylinder, you could do chemo, an external beam, external beam alone, the external demand brachytherapy and all those options are actually probably pretty good with recurrence rates about 5%.

00:32:48:12 - 00:33:15:14
Unknown
So they all work. We just don't have a lot of randomized data pushing us one way or another with this group. These patients were included in a study called Protect three, which we will talk about later. But this subset of group patients didn't benefit from the addition of chemo to radiation. So there is this debate on these patients, and I think I'll probably leave it at that because it gets a little complicated.

00:33:15:16 - 00:33:41:19
Unknown
So review of some stage one recommendation. And so for stage one eight, grade one or grade two, you can consider observation or partial brachytherapy if there are risk factors for one, a grade three patients, I prefer vaginal brachytherapy for one, be grade one or grade two. Also fragile. It's the one B grade three patients that it's a little complicated.

00:33:41:19 - 00:34:14:10
Unknown
You could do external bleeding plus or minus five plus or minus systemic therapy. I think external beam is still standard of care, but I also discussed this with my guide, Joanne Oncology colleagues to come up out of the heart of was that a question? And then I always add basil brachytherapy to external beam. The cervix was involved by tumor because that cervix sits right at the top of the vagina and increases the risk for vaginal recurrence if that's involved.

00:34:14:12 - 00:34:37:23
Unknown
But I think that that was that the group that we have a little less randomized data for, but all the options are actually good. We just need to talk through with the options with your patient and your topics. So this one's a little more clear. We have a seven year old with endometrial adenocarcinoma, a grade three, again, 65% neutral involvement with cervical stromal invasion.

00:34:37:23 - 00:35:03:21
Unknown
So the cervix is involved by tumor limits notes. So that makes this a stage two. And what's a treatment for a stage two? You can do external beam and vaginal brachytherapy. Like I said, I would do 45 gram of external beam followed by fragile brachytherapy. You could also argue to add chemotherapy to these patients just like with stage one degrades risk.

00:35:03:23 - 00:35:29:05
Unknown
So far this is one I want to talk a little bit more about that external beam radiation. We'll talk about side effects as well. It's do I ever offer external beam radiation targeted to fragile calf instead of brachytherapy? That is a good question, but now is definitely the 100%. No external beam can never be as targeted as brachytherapy.

00:35:29:05 - 00:35:55:05
Unknown
Whatever Many of my radiation oncology college colleagues may tell you, they just simply don't do brachytherapy. Really, brachytherapy is the most targeted type of radiation that will ever exist. This is the old staging system, not the new staging system from a few months ago, because that's a little less very new and we're not using it for treatment yet.

00:35:55:07 - 00:36:28:16
Unknown
We need a little more data for the new staging system. So this is the 2008 staging system. Great. Thanks for the question so far. External beam Radiation. Post hysterectomy. You must always do something called IMRT or intensity modulated radiation therapy. This is as opposed to older technique called 3D conformal radiation or a four field box technique didn't actually include pictures of that.

00:36:28:16 - 00:36:51:01
Unknown
But here this is a picture of one of my patients that I did IMRT for post operatively. And what you see in purple here is what I want to treat. These are the lymph node regions and the pelvis can see they run right in front of your lumbar and sacral spine. And then this is the marginal cup here in purple.

00:36:51:03 - 00:37:16:16
Unknown
This is another way to look at it. All the three different things we use and then the other colors are the dose. So in red you see that prescription dose of 45% and then the dose slowly falls off to this is the 50% line. And what you see is I've looped our watch to the dose outside of all this bowel in the middle is somehow getting radiation.

00:37:16:16 - 00:37:45:15
Unknown
Yes. And that's because despite this being a highly modernized, targeted technique, it is external being and you will get radiation to that bowel and then lower down, you would see it. I was spared much of the rectum here. And then this is the bladder here also getting largely spared by radiation. So I'm trying to spare all this bowel, this bladder, and then the rectum posteriorly for the technique.

00:37:45:15 - 00:38:10:24
Unknown
I think this is a little a little too detailed, but briefly for external beam radiation. You start with a CT simulation that's a planning scan where we make a bean bag mold for the patient to fly and to keep the hips and the legs in the same position every day. I put markers in the original cups. They're gold or platinum.

00:38:10:24 - 00:38:35:09
Unknown
They stand forever and I can see them every day on my planning machine so I can target to that area better. I fill the bladder with urine. Well, no, I don't do it. I have my patient drink water to bill for bladder with urine and I do a scan with a full bladder. Then I have her pee and I do an empty bladder because the organs move as bladder as the bladder fills and empties.

00:38:35:09 - 00:39:06:10
Unknown
And I want to go for that else's I.V. contrast to see to the different the lymph nodes better. And then I'm covering a bunch of different lymph nodes. We don't need to go into that too much. So I have a message here. Yes, we will talk about aspirate and our brachytherapy for recurrences in lymph nodes or other areas.

00:39:06:12 - 00:39:35:16
Unknown
This is more what I'm talking about with IMRT is where you do. You want to treat the whole process, all the lymph nodes that might be involved. So that includes the common iliac nodes, the pre sacral nodes, the external iliac, internal iliac and the operator lymph nodes. So I actually want to treat a bigger area. I don't want to be too targeted because then I'm going to miss areas where there might be lymph node disease that I can't see.

00:39:35:18 - 00:40:22:12
Unknown
So that's why we're we're treating it with an esoteric technique, but we will talk about that. So when do we add chemotherapy? First, did one and two disease and what are the studies? So we're going to look at a few studies here, not go into too many details, but this was a randomized study G 249 and it compared external beam radiation versus natural brachytherapy plus three cycles of carbon, taxol and what we learned was that external beam four for these patients was actually better than vaginal breaking or three cycles of chemotherapy in terms of overall survival and recurrence free survival, things were equivalent, but there was more toxicity with the chemotherapy arm.

00:40:22:14 - 00:40:48:12
Unknown
So for stage one, stage two patients, we still prefer external beam alone. The study was criticized, however, because many of us thought that there wasn't enough chemo, that perhaps if we had done vaginal breakage plus six cycles of chemo, that would have had greater benefit. We still haven't run that trial yet, so we are not sure if that's the case.

00:40:48:14 - 00:41:13:12
Unknown
Instead, going around this trial, which is part three, it's very exciting trial that came out while I was a resident, so was looking at higher risk endometrial cancers and included those one be grade three patient stage two or three, and it also included high risk studies such as Pearson Serous Carcinomas, and we compared external beam. That was the standard care for these patients at that time.

00:41:13:12 - 00:41:46:11
Unknown
And we compare that to external beam with radiation, sensitizing chemotherapy or cisplatin, followed by four cycles of carpal taxol overall survival and 3 to 3 survival were equal for all comers. But we saw an improvement in survival and failure survival without a recurrence in stage three patients. So what we learned from this study was for those stage two patients are those stage one, B grade three.

00:41:46:11 - 00:42:17:02
Unknown
External beam was still standard, but for stage three patients, those are patients with lymph node metastases. We do prefer a combination of chemo and radiation. Okay. So now we'll look at some of these which are positive patients and what to do. So we have a 70 year old patient here who had some had 50% engage in the cervix, was involved, and one out of ten pelvic lymph nodes was positive.

00:42:17:08 - 00:42:41:21
Unknown
This would make this a3c1 stage. And if a periodic lymph node is positive, that would make it a32. But we're going to treat this 3c1 patient and you have a lot of options on how to treat this patient. That's partially this isn't like a simple recipe where you put your ingredients in and get something out. There's a lot of different options.

00:42:41:21 - 00:43:04:13
Unknown
You have to think about a lot of different things. You are going to do some form of combination of chemotherapy and radiation for these patients, probably many different options. You can consider the protect three regimen that we mentioned here external to the chemo radiation and the carbon tax all times four, and that's randomized data that showed there was a benefit for stage three patients.

00:43:04:13 - 00:43:33:00
Unknown
So that is a good choice, but it is not our only choice. You can do a regimen called the sandwich regimen, which isn't done too much anymore, but was done while I was in training for a lot and that was doing three cycles of carbon Taxol then fitting external beam radiation in the middle and then doing three more cycles of Taxol, more common, is doing six cycles of carbo Taxol followed by external beam radiation.

00:43:33:02 - 00:44:02:23
Unknown
But in our recent trial, Georgi 258 Gel, we actually compared six cycles of cargo texel alone to the port three regimen, and we saw little benefit with the addition of radiation. So in some cases you can actually just do chemotherapy, six cycles of carbon dioxide alone and omit the radiation. But how do we decide? It's luckily, at least at UCLA, it's not just what we feel like doing or what we prefer.

00:44:03:00 - 00:44:26:16
Unknown
And we actually have a consensus that we make a consensus opinion among many physicians and we think about where is the patient most at risk of recurrence. If there's a lot of risk factors for a local recurrence or regional recurrence in those pelvic lymph nodes, then I am going to want to do radiation and I'm going to want to do radiation soon.

00:44:26:16 - 00:44:47:15
Unknown
And I might want to do a project three regimen. But if the risk is greater for distant metastasis, like with a high grade serious carcinoma, where we're more worried that patients are going to have disease outside the pelvis, then we're going to want to start with carbo, taxol, six cycles of carbon. Taxol, and then the radiation becomes less important there.

00:44:47:15 - 00:45:09:00
Unknown
Does it mean it's not important? No. But we want to start with what's most important. So that's how we're thinking about it. Where is the risk of recurrence? Where is it greatest? What do we need to get it? And also, what can the patient tolerate? We really need to think about all the whole picture. Can the patient tolerate six cycles of carbo taxol?

00:45:09:00 - 00:45:34:23
Unknown
Sometimes I get patients who really have a history of severe neuropathy, and one of the side effects of Taxol is severe neuropathy and they really can't tolerate it. So then we might want to focus more on radiation, other patients, or maybe have irritable bowel disease and can't really tolerate radiation in the pelvis. Of course we might want to prefer chemotherapy, so we're really looking at the whole whole picture.

00:45:34:23 - 00:46:17:23
Unknown
So from Jacquelyn is mentioning very correctly that molecular sequencing is needed. We do molecular sequencing for all endometrial cancers routinely, and the new staging system is has incorporated these molecular sequencing. What we don't have yet is data on how the molecular sequencing is really impacting survival in a randomized setting. We have where we've gone back and looked at patients who had, let's say MSA, MCI, we kind of see which treatments may have worked better or less good for those patients, but we don't have randomized data yet.

00:46:17:23 - 00:46:47:18
Unknown
But that study is coming. That's part tech for I love part sex trials. Project four is going to give us so much data, randomized data about how molecular sequencing affects patients and treatments. So we will have this data upcoming in the next 510 years. We just don't have it yet. So we have to be careful about using molecular information to choose our treatments because we really don't have randomized data.

00:46:47:20 - 00:47:09:11
Unknown
That doesn't mean we don't have any data. That doesn't mean we can never use it. We can always think about it. We do think about it. We do get the data, but we need to be careful. Cisplatin is used to boost the radiation or the way I think about it is it's a radiation sensitized, so it sensitizes cancer cells to radiation, making my radiation more effective.

00:47:09:13 - 00:47:45:24
Unknown
It's used in many different cancers, but particularly head and neck and cancers with radiation as another question. So moving on to case five, we have a 67 year old with a three centimeter vacinal recurrence status plus surgery for early stage endometrial cancer ten years ago. So basically this patient probably had an early stage endometrial cancer, got a hysterectomy, didn't require adjuvant treatment, but now has a recurrence in the vagina.

00:47:46:01 - 00:48:06:02
Unknown
What's the workup here? I think the most important thing is to restage where the PET scan. We want to make sure there's no disease anywhere else. And is this an isolated recurrence? I also will always get a pelvic hemorrhage. The uterus is gone now and now there's just a phase will cost. The bowel falls down into the pelvis.

00:48:06:02 - 00:48:25:16
Unknown
The rectum is right behind the vagina, bladders right in front. I to know how this tumor is inter playing with those other organs. Is it invading into the bladder, rectum or bowel, or is it free from those organs? So the pelvic camera so often the best way to look at that and of course going to get a biopsy, I need to believe that this is a cancer recurrence.

00:48:25:18 - 00:48:48:03
Unknown
We also want to get those molecular markers on this to see if there's any targeted therapies we can use. And then I'm asking myself, has the patient had prior radiation or not? Because that's going to help impact what I can with radiation. So this patient had not had prior radiation. We did a biopsy and it was consistent with a recurrent and a mutual cancer.

00:48:48:03 - 00:49:17:03
Unknown
And the imaging showed there was no regional or distant matter. So this is an isolated local recurrence of endometrial cancer. What's the treatment for that? That treatment is a combination of external beam radiation, brachytherapy, and I recommend concurrent cisplatin for these patients, even though there's little randomized data to support that. But from our clinical experience, we know that radiation will be more effective if we that cisplatin is.

00:49:17:05 - 00:49:45:13
Unknown
So the external beam radiation is very similar to previously. It's 45 grade to the whole pelvis. I want to cover any lymph node regions, but of course I also want to cover the vagina vaginal customer experience. The brachytherapy here is what is potentially very different than the fragile brachytherapy I talked before too. Before. If the tumor is greater than five millimeters thick in that vagina, I can't treat it with a cylinder.

00:49:45:15 - 00:50:10:00
Unknown
So what's very important is to do an exam to get an MRI sets that thickness after the external beam radiation is over. If it's five millimeters or greater, I to do what we call an interstitial brachytherapy implant I cannot treat from within the vagina itself. I actually have to put some needles directly into the tumor to cover that thickness gutter and safer.

00:50:10:02 - 00:50:35:20
Unknown
And I do have a picture of that here. So this was one of my patients years ago. And she had this very sick recurrence and it turned out to the left. Celtic Sidewall actually obstructed her daughter and caused hydro necrosis and these black little holes here, these are the tubes I put directly into the tumor. And I delivered the radiation through it.

00:50:35:20 - 00:50:56:11
Unknown
So you can see this is stuff 100% and the yellow is the 90% dose. It's not even touching the bladder and the rectum here in the bowels here and the segments here and everything's right around. But I can get all of that dose in safely. If I had just used the cylinder to treat it, you could see I would.

00:50:56:13 - 00:51:17:19
Unknown
Well I don't know. I would just build a treat like right here and I wouldn't be able to cover the thickness of this tumor involved with that. Be an inpatient procedure. So there's many different ways to do interstitial brachytherapy. At UCLA, we often do it as an outpatient because we just have a lot of resources and can do it quickly and efficiently.

00:51:17:19 - 00:51:42:09
Unknown
So I would do multiple procedures, typically three procedures once or twice a week as an outpatient takes about three or 4 hours total. But I also have patients who come from far and at most other institutions who don't have our resources. It is often done as an inpatient inpatient stay in the hospital and my patients would come from over like 3 hours away.

00:51:42:09 - 00:52:03:22
Unknown
I'm not going to make them drive in L.A. three times. It's a so I keep them in the hospital and get all the treatment and what are our curates with cell so in there. Yeah Yes Cure rates are pretty good. This is one of the few recurrent cancers where we have a good chance of cure a local control of 60 to 90%.

00:52:03:24 - 00:52:28:04
Unknown
I'd say it's closer to that 90% when I put those interstitial needles in really gives me good coverage. Overall survival, unfortunately, is a little bit lower because often we think that the recurrence is isolated. We can't see it on the PET scan, we can't see it anywhere else. But there might be microscopic cells elsewhere in the body. This is where those molecular markers really come into play.

00:52:28:06 - 00:52:58:10
Unknown
So we can think about combining that radiation with treatments such as pembrolizumab or immunotherapy to really help with that systemic control of disease. This in this setting, the patient hadn't had prior radiation. So I did external being an advisor on brachytherapy patients. And all of you often asked what if the patient had radiation before? Can we do brachytherapy again?

00:52:58:10 - 00:53:30:24
Unknown
Yes. Yes, we can. So if a patient has already had external beam or even basilar brachytherapy during their initial treatment stage and then they recur afterwards, can I do radiation again? I can, but I would only do that interstitial brachytherapy like this because I really am able to get good dose into this area, sparing those normal structures. So we typically will do 6 to 8 treatments of brachytherapy in this instance.

00:53:30:24 - 00:53:57:16
Unknown
And then of course I would definitely keep the patient overnight to get those multiple nights to get all that radiation in. And then I know we're running out of time. This is actually my last night. So I think it this is a patient who had a hysterectomy and then had a final cut for Current. And despite being in Los Angeles and having access to good care, the tumor was allowed to regrow.

00:53:57:16 - 00:54:24:12
Unknown
And she came to me with this tumor. This is a uterus. This is actually a tumor that grew back. And it was involving the sigmoid colon right here. So we actually I recommended a colostomy to move the colon out of the way, and that allowed me to deliver curative radiation dose despite the shouldn't have had prior radiation. And I was able to control all this tumor.

00:54:24:12 - 00:54:51:24
Unknown
And she has no evidence of disease about the year after. I think she's over a year out from this. And when she came to me, she couldn't even sit up because she was in so much pain from this tumor. And since treatment, she's able to enjoy her life in a very meaningful, wonderful way. So I think brachytherapy can be an option when other physicians tell you there are no options.

00:54:51:24 - 00:55:24:00
Unknown
Sometimes we can do these very large implants. I put probably put almost 15 or 20 catheters into this tumor delivered radiation. So now that I have a minute left, I'm going to open it up to more questions, although I think I answered many questions during that talk. I can open it up if people want to unmute themselves and ask questions out loud or keep typing.

00:55:24:00 - 00:55:53:17
Unknown
Or I can also answer the questions that were sent to me as well. But do we prefer I think maybe you answered the questions that we sent and maybe people can add to the chat. So while you're answering questions, they can type. So the first question is, is it important to get a bone density scan after treatment? I think all women over the age of 50 should be getting bone density scans every two years, I believe is the recommendation.

00:55:53:17 - 00:56:27:16
Unknown
Although don't quote me on it. Talk to your primary care doctor. I recommend all of our patients get a bone density scan after treatment. When we do external beam radiation. That's an external beam on. When do external beam radiation? All this bone does get some dose of radiation. Even though I am pushing that dose off of that, the lymph nodes live right in front of your your spine and it's going to get dose also the femoral heads here you see I pushed the dose off of them, but they're still getting some radiation.

00:56:27:21 - 00:56:56:00
Unknown
We do weaken those bones. So women are at risk of sacral insufficiency, fractures. That's where the sacrum just fractures on its own without really any inciting event. That can be extremely painful. So gets bone density is important and and I also strongly recommend all women, including myself. Hypocrite. Here take vitamin D and calcium every day. You take them together, you absorb them better.

00:56:56:00 - 00:57:21:02
Unknown
Bone strength is important and weight bearing exercises. We should all be doing that. Let's improve our bone health diet for radiation. I don't have a specific diet for radiation because every patient's digestive system is very different. I kind of take it one day at a time. We see our patients once a week at minimum during external beam radiation.

00:57:21:04 - 00:57:44:17
Unknown
Plus you're here every day. We're here every day. So there's a lot of communication. So I kind of say I talk to my patient before if their bowels are working. Okay, I say, let's continue what you're doing. And then as affects start, we adjust the diet accordingly. Most side effects from external beam don't start till week three or week four of radiation, So we have time to kind of address things as they come.

00:57:44:19 - 00:58:08:08
Unknown
In general, the thought is to decrease the fruits and the vegetables that might cause gassy ness or cause diarrhea. The thing is, not everyone is the same and those foods are good. So I tell my patients, just eat a healthy diet. Don't try to don't try to lose weight. That's not what I want you to do. Proteins really encourage staying hydrated.

00:58:08:08 - 00:58:36:21
Unknown
Great. It's encourage just being healthy is good, but don't go crazy. This isn't the time to start a new new diet and make your digestive system goes crazy. Let's just take it one step at a time. What can we do to minimize side effects, short term or long term? I think number one thing you can do as it's at all possible, go to an academic center for your radiation guy.

00:58:36:21 - 00:59:18:21
Unknown
And cancers are not well taught in residency. Some residency programs don't see a lot of gland cancers. It's not something that our country prioritizes. Unfortunately, I fight for time with my residents and I'm at an academic institution. I think also they're not the most common cancers that are radiated. So I do think coming to someone like me or another academic institution is preferred, someone who treats a lot of external being given for brachytherapy or 100%.

00:59:18:21 - 00:59:43:16
Unknown
Please can't go to an academic center if at all possible. I know not everyone can travel, but these are short treatments and it is your life and these side effects will will last forever. Once radiation is given, it can't be taken back. Brachytherapy is very specialized. These are high doses of radiation given in a surgical manner and should not be taken lightly.

00:59:43:18 - 01:00:04:16
Unknown
Dose for vitamin D Please talk to your primary care doc on that. Everyone's a little different there and I don't I'm not up to date on those recommendations. I didn't get to talk about that. You know, I want to talk about meds and. Okay, great question. So let's talk about mats. I thought I had slides in here.

01:00:04:16 - 01:00:34:11
Unknown
I must have taken them up because I knew it was getting too hot. So I'm not just going to talk about liver mats. Let's talk about mats. In general, if someone has less than five, five or less sites, whether it's lymph nodes or in the lung or in the liver, we consider that a legal metastatic disease. We think of that as a different entity than if you have like just diffuse mats all over the body.

01:00:34:11 - 01:01:23:02
Unknown
Anything greater than five is considered diffuse. We have this belief that we can still offer long term control for patients with five or fewer mats if we give local treatments to those lesions. And those local treatments are typically given in two ways. But I'll talk about three. The most common is stereotactic body radiotherapy. That is what one of our members thought for her for a node recurrence and I do this all the time and it's it's usually delivered in five treatments every other day or every day can be fine and it's targeted radiation just to that side of disease, wherever it is, and it can be done anywhere in the body.

01:01:23:04 - 01:01:49:09
Unknown
Another option is to actually do brachytherapy to those mats. You can put a needle just like you're when you get a biopsy. The intervention radiologist puts a needle in to take tumor out. You can put a needle in to put radiation in and I can treat a metastasis from inside out. I can get higher doses and less radiation to surrounding structures than even with a spirited downside.

01:01:49:09 - 01:02:13:06
Unknown
Of course, it's a surgical procedure you have to put that needle in. You often have to do it maybe three times. And there's sometimes it's not possible to get the needle and sometimes there's no benefit to break you versus a spirit. I like to do both. I do both. So I I'm always thinking about both options violators. Okay, let's get started.

01:02:13:06 - 01:02:37:12
Unknown
I got questions. I love it. So for a dilator, this is individual. You should use your dilator till Dr. Venkat tells you to stop. So I tell my patients, basically, depending on what radiation you get and your own body, some women do not get scar tissue. And we can I can clean them off very quickly in 3 to 6 months post-treatment.

01:02:37:15 - 01:02:59:06
Unknown
They're sexually active and everything seems normal. They really don't need it. Other women get scar tissue and we have to continue it for life. That is that possibility. So every follow up, I talk to my patient. All right, The dilator is going. Are you doing that? How sexual activity Is it painful? Is there bleeding? I do the exam.

01:02:59:06 - 01:03:18:07
Unknown
I look for scar tissue. If there's no scar tissue, everything's good. I decreased the frequency. Maybe they were doing it every other day. I just sit two, two times a week. But then let's say we decrease it and side effects get worse. Maybe sexual intercourse becomes painful. We go back to the more common ones. So I have my whole my own protocol.

01:03:18:07 - 01:03:50:08
Unknown
I'm happy to share with the group. My protocol. My protocol comes from my patients, from talking to my patients and working with them and learning about how vaginas react to this treatment. There's not a lot of data out there. I'm working on a paper that talks about the limited data there is out there and then ends with my protocol and also doing the study, looking at the microbiome can post radiation and correlating that to side effects.

01:03:50:10 - 01:04:22:05
Unknown
So there will be data. It's just this isn't something the medical community cared about for generations, but that is changing. I am here. I'm doing doing some of this work microbiome. So that is a very good question. I'll read the question just so everyone has it. It's basically asking does my the microbiome gut health can impact the effectiveness of immunotherapy?

01:04:22:05 - 01:05:06:01
Unknown
And given that the radiation impacts the gut, will radiation impact the effectiveness of immunotherapy? That's a very good question. Very reasonable. In general, we find that radiation makes immunotherapy more effective, however, is what we've seen in most studies, often in the brain with melanoma, but also within the pelvis. I often combine more targeted types of treatments like aspirate or brachytherapy with immunotherapy, because we think that as we kill the cancer cells, that's going to release cancer proteins into the bloodstream, allowing the immune system and that immunotherapy to find these cancer proteins and then attack it elsewhere.

01:05:06:01 - 01:05:31:14
Unknown
There's many studies that have shown this synergy. I do think it's a very good question. If you're doing more or less targeted radiation, like when I'm treating the full pelvis for a cervical cancer trial that was just published, we combined external beam with chemotherapy, with immunotherapy, and there was a small benefit in disease free survival, but not as big of a benefit as we expected.

01:05:31:14 - 01:05:53:19
Unknown
And perhaps that is because we messed up the the gut microbiome. I don't think that's an unreasonable supposition. I think we still need to do more research on that. But I think combining immunotherapy with the more targeted types of radiation is really the way to go. And we're really seeing we have we did a trial with brachytherapy and immunotherapy on there studies coming out.

01:05:53:19 - 01:06:44:17
Unknown
We're getting more and more data every day. So, okay. So if you decide not to do adjuvant radiation, what you should do and follow up is and this is actually probably true whether you do it or not, final exams are the most important one for endometrial cancer. That is because people are like, why don't I get a PET scan or MRI or some teachers most early stage endometrial cancer recurrence is greater than 75% occur in the vagina and we can see and feel a vaginal recurrence long before it'll show up on that imaging study.

01:06:44:19 - 01:07:11:03
Unknown
So those exams are critical. The recommendations for follow up exams are every 3 to 6 months post-treatment. I strongly encourage you to do them every three months for the first two years. That's what I do for all my patients. About 3 to 6 months. That's a big difference. So I don't really appreciate that recommendation by the National Cancer Center guidelines.

01:07:11:03 - 01:07:36:16
Unknown
Just do it every three months for two years. Then I start spreading it out to four months for a year three, and then I do every six months for year four and five, and then I do annually. That's if everything is normal, no side effects. If someone has viral bleeding or pain with intercourse or any bowel or bladder changes, that should trigger an earlier pelvic exam.

01:07:36:18 - 01:08:38:23
Unknown
I do think those exams are much more important than the imaging studies. Okay, So this is this is a tough one. So it sounds like there was a reference on the label looks at China and what we underwent external beam showed a date time you treat themselves. So the label or the external area or skin in general there is going to be that that burn your skin epithelium is a fast responding and so when you radiate it basically scrapes off the surface of the skin over and over again and regrows and scrapes off and grows.

01:08:39:00 - 01:09:10:02
Unknown
So that's very common when I treat vulvar cancer to have those reactions one way to minimize those reactions is to do a little less external beam and do a little bit of breaking because the break is just treating less skin so there's less of that burn. That being said, that should only be done by people like me who do brachytherapy for of our cancer.

01:09:10:02 - 01:09:35:23
Unknown
It's very specialized and there's actually not a lot of data to support doing brachytherapy for cancer. So this does sound like it was probably standard treatment. It's just really, really hard treatment sometimes. Like if all of our cancer is my least favorite thing to treat because it does cause so much pain and there's this burning reaction to patients.

01:09:35:23 - 01:10:03:11
Unknown
I really hate it. I love this question from our I guided radiation. So am I. Guided radiation is great, but it's only helpful if an MRI is going to help you see your target better. That's actually not always the case. We have an MRI guided machine here. I'm always thinking about whether I can use it or not. There's some downsides of it.

01:10:03:11 - 01:10:27:18
Unknown
Yes, the imaging is better, but the treatment is actually a little limiting because of that MRI and the electron linear accelerator. We're not able to do some of the cool manipulation of our photon beams with our MRI machine that we can do with a CT guided machine. So I really think you should use that MRI only when it's needed.

01:10:27:20 - 01:10:53:03
Unknown
When is that Typically with pelvic diseases, if you're targeting and like a small lymph node that's near bowel, you can probably see the lymph node on your CT guide and machines and your MRI guided machines. But what you can see better on the MRI machine is the bowel, so you can actually adapter treatment daily to get it off the ball as the ball moves.

01:10:53:03 - 01:11:20:01
Unknown
So that's something I like to do a lot here. Where else is liver health? Sorry, MRI is really helpful for liver. That is way better than CT. And then for any sort of pancreas tumor, you're not really, really relevant to this group, hopefully, but that's where it's extremely beneficial. So yes, it's cool and it's sometimes better, but not always so.

01:11:20:01 - 01:11:43:16
Unknown
Yes. Barbara, Yes, you always continue with casual examples, basically, always continue with vaginal exams over. If you ever get radiation to the pelvis, you should be getting basil exams. Highly important not only to look for tumor, but also in this setting you've got external beam and brekky. We need to look for scar tissue, for ulcerations, radiation effects. So yes, please.

01:11:43:18 - 01:12:11:16
Unknown
I really am a believer in that. You can't do too many vaginal. It's not really true. You can, but nobody does. I just I don't like all these guidelines, particularly for pap smears. So moving it to every five years, I really think we should be doing more exams for women because we can prevent cancer. That's strongly biased opinion.

01:12:11:18 - 01:12:37:23
Unknown
Okay, I have more questions on the page, so I'm just going to keep reading. Okay. Go for this one type of radiation more tolerable. Most hard question to answer. So many different types of radiation. Let's talk about external beam versus brachytherapy. Definitely brachytherapy is typically more tolerated because you're just treating a smaller volume, it's more targeted, less dose to normal structures.

01:12:37:23 - 01:13:08:22
Unknown
So yes, typically much better tolerated. Of course, it's more of a procedure in a very sensitive area. The vagina's not an easy place to get treatment. So mentally, emotionally, it can be tougher to get brachytherapy. And then there's other special types of brachytherapy that maybe cause more pain or discomfort or more of an invasive procedure. So it somewhat depends on the situation.

01:13:08:24 - 01:13:30:20
Unknown
So when you think about re or radiation, yes, it can be done. What matters is time and between radiation, normal tissues do heal over time. So the longer you are from the previous radiation, the better. Also in general, brachytherapy is the preferred type of radiation because it's going to be more targeted. Stay off those normal tissues as much as possible.

01:13:30:20 - 01:14:06:00
Unknown
So there's not really a limit to how much radiation a person can get, but there's a limit to how much radiation a structure can get. So bowel one specific loop of bowel can only get so much radiation. That doesn't mean all the bowel can't get that. So it's really anatomically driven and time driven. But yes, I do generally recommend brachytherapy for re irritation and also definitely be something that should be discussed at an academic center if possible.

01:14:06:02 - 01:14:35:12
Unknown
And can you have additional brachytherapy? Yes, I think we've discussed that recent developments in radiation technology. So brachytherapy is not Neil. I still think it's the most technologically developed and advanced and. We do change our techniques on the daily. It is patient specific or we're doing the same. Every procedure is specific. The anatomy of that time and that moment.

01:14:35:12 - 01:15:00:24
Unknown
We do live imaging. So there's it's going to be hard to be more advanced than brachytherapy, but we have the cool MRI guidance for imaging. We are doing adaptive re external beam radiation where we can adapt the plan on the day of treatment based on where that anatomy is in that moment. What else do we have on proton therapy and even talk about photons?

01:15:00:24 - 01:15:25:00
Unknown
Protons are cool and generally asked about. So most of the external beam radiation I talked about photon treatments. Photons are the same as packets of light or energy. They go in, they go out there like X-rays. Protons are heavy, heavy and they can because they're heavy and they have weight, they can be stopped within a patient. So we think we can stop them.

01:15:25:02 - 01:15:47:23
Unknown
So they have a feel that say you have a tumor and then you have the spinal cord and we can stop the dose right in front of the spinal cord. It sounds great in theory, and it does very good for children because it decreases the total radiation dose in the body, the integral radiation dose. And it could be something that becomes more generally utilized in the future.

01:15:48:00 - 01:16:06:20
Unknown
The problem with protons is they're so heavy, they're hard to manipulate. So in theory, we're like, yes, we can stop our dose, but it's hard to get the protons where we want them to go to stop them. They're very hard to manipulate all of the new fancy technologies where we can block things and treat from 360 degrees is really hard to do with protons.

01:16:06:20 - 01:16:37:08
Unknown
So definitely some downsides. Strongly don't recommend protons for most adults unless you're talking about brain or spinal cord. There's really minimal benefit and there may be some downsides. We also don't understand how they really work in the body that well. So there's we're still learning and we understand how photons deposit their dose in body. The proton is not as well defined also as air protons.

01:16:37:08 - 01:16:58:24
Unknown
When they go through air versus soft tissue, that dose is going to change a lot. So as ball moves around, that dose you think you're delivering is probably not what you're delivering in. Makes me a little nervous in the focus. So I don't think we're quite there yet. In general. Okay. I think that's it for developments in radiation oncology.

01:16:59:01 - 01:17:19:18
Unknown
For now, there'll be the hospital stay for breaking only if needed. Like I said, we do a lot of outpatient. Frankly, the vaginal cylinder breaking stuff like outpatient takes about 20 minutes total. You're in and out of the department. Real quick for us for interstitial break, you are putting those tubes in. Often we do it as outpatient, but we also do it as inpatient.

01:17:19:18 - 01:17:43:08
Unknown
Whatever works for the patient on the situation. So the burns from external beam in the pelvis area, that really shouldn't happen if we're treating just endometrial cancer because that all of this is inside the body. There's actually skin sparing effect when we use photon radiation. But when you're treating the vulva and the labia and the skin, that's when you get those burns.

01:17:43:11 - 01:18:03:00
Unknown
If you're treating the groin, that's that we feel will solve our cancer and have to treat the the inguinal femoral nodes in the groin that's very close to the skin surface. That's where you get those burns, where if the distal vagina's involved with either a cervical or endometrial or fragile cancer, I have to treat those groins. That's when you get those burns.

01:18:03:00 - 01:18:50:05
Unknown
Otherwise you really shouldn't get them in this country. With our technology, with some of the older technologies like cobalt 60 machine, but that really shouldn't exist anywhere in this country. And I don't think it does anymore. It's not 100% basically. So hopefully that's not a thing. Okay, I'm still going. That's a little to treating lung and liver. I think we talked about there was a specific question about hemorrhoids, but I will say about hemorrhoids is external being radiation aggravates hemorrhoids in some people find out they have hemorrhoids for the first time during radiation.

01:18:50:07 - 01:19:12:17
Unknown
What can you do about that? You really can't change the radiation to avoid that area we're always pushing on The rectum is pushing off the rectum as much as possible anyways, so we really have to manage them medically. So warm baths, sit spots, hemorrhoid creams. I like the hemorrhoid wipes, the preparation h wipes. Just being really gentle with that area.

01:19:12:18 - 01:19:45:08
Unknown
Talk to your provider technique. Definitely don't want to skip radiation because of hemorrhoids, so we should be managing those medically. I love tomo. Well, Tomo therapy is a machine. So that's we have a machine here. It's a type of linear accelerator that uses C.T. guidance. So very typical, but it delivers the radiation in a helical or a form.

01:19:45:08 - 01:20:08:14
Unknown
So basically you have a donut like you do for a T scanner and the patient moves through the tomo machine rather than the machine moving around the patient. And it does deliver really great plan sometimes for pelvic lymph nodes. I do love my tumor, but it's just kind of like another brand name. It has some benefits, definitely has some downsides.

01:20:08:14 - 01:20:48:24
Unknown
A lot of people find the tumor unit quite hard to use personally. Love it. It's we are replacing our tumor with a newer machine called E cells. And my heart is breaking inside. But all machines have pluses and minuses. It's a good machine, though, for IMRT or pelvic radiation. It's okay. So, Julie, I understand your questions to me, what do you need other than vaginal exams for an early stage cancer that didn't get adjuvant treatment?

01:20:48:24 - 01:21:17:13
Unknown
So the recommended follow up is just fragile exams every three months for two years and then extend it out to five years and then annually. Imaging is not recommended because the data has shown that it really doesn't show us recurrences before, those vaginal exams. So it won't be covered by insurance and really is not recommended to be ordered or done.

01:21:17:15 - 01:21:42:14
Unknown
So those are just recommendations by the National Cancer Center guidelines and I know that can be frustrating. Like, can I get a PET scan or can I look at the whole body? Really, the reasons are many a financial medical. The way I think about it is we do a PET scan, everybody will find questionable findings. Everyone has questionable findings on a PET scan.

01:21:42:14 - 01:22:05:10
Unknown
We really do a PET scan say, there's nothing there's always this but this brightness here. That might be something, but it isn't. And it leads to unnecessary concern, anxiety, biopsies that biopsies do have risks with them. I've had many patients who've had a lung biopsy because they got a PET scan which showed something, and then they have a pneumothorax and they end up in the hospital with a chest tube.

01:22:05:10 - 01:22:31:11
Unknown
There are real risks to all these procedures, and then we shouldn't be doing imaging from less. It's indicated unless you have a side effect of bleeding the do an exam if the exams normal. No, I would still I would get an MRI at that point. But there should be something you're looking for because these cancers do bleed when they return and they do cause we should see them and feel them before I often can see and feel a recurrence.

01:22:31:11 - 01:22:52:15
Unknown
That's biopsy proven that I can't see on a PET scan. I can't see on an MRI. I definitely can't see on a CT scan. So our eyes and our fingers are better than imaging. Imaging is just like it's not a picture. It's it's much inferior than a picture or a camera. Because it's tricky because technology to reproduce the inside of the body and the imaging.

01:22:52:15 - 01:23:27:16
Unknown
Yes, it's amazing. And the technology's improved, but it is still less good than my eyes, than my fingers. So those exemptions continuing. Yeah. So just a little more maybe a couple more questions, but so lymphedema came up a few times. So radiation induced lymphedema in the pelvis is pretty rare unless you're treating vulvar cancer because you're typically not treating those groins, which is what causes it is rare, but not never.

01:23:27:18 - 01:23:59:12
Unknown
Compression stockings are good, but there's also usually lymphedema clinics you can go to, which is a mix of physical therapy and massage, and that can really, really help. So I definitely think you should either ask to go to a lymphedema clinic or get some specialized care for that visit happens happening during urination. Yes. That doesn't go away. The burning after urination should go away if it's caused by radiation.

01:23:59:12 - 01:24:36:20
Unknown
That's not typically a long term side effect. It can happen with dryness due to lack of estrogen that I've seen linger longer. And also if someone's having recurrent UTIs, which can also be increased because of that lack of estrogen and dryness. So I just think if you're having burning that is still there three months after radiation, when you urinate, if that does warrant more workup, I would recommend a urology consult, probably do a cystoscopy to look in there and see what's going on.

01:24:36:22 - 01:25:23:10
Unknown
Yeah, because that's not typical. It's the second checked. So yes, when do you start getting checked? So the way I think about it is after your last treatment, whether it's, you know, usually get surgery, then chemo and radiation or than chemo or just surgery, whatever the last treatment is, you should get an exam three months after that. At minimum, some surgeons, the dynamics will do the first exam three months after the surgery, regardless of what subsequent treatments you're getting.

01:25:23:10 - 01:25:56:07
Unknown
That's also okay. But you typically can wait until that adjuvant treatment, that treatment that happens right after surgery is complete to start plus three mg I did want to mention something about Serious Carcinomas because there was a question about it. High grade serous carcinomas are more aggressive type of uterine cancer. They're often at risk of distant metastasis. And we also think of them as more aggressive.

01:25:56:13 - 01:26:26:02
Unknown
So people often think maybe they don't respond to radiation or they actually do they respond very well to radiation in the local region. Wherever I'm radiating, they respond well. The concern is that they may recur outside my radiation field, wherever I am that field, the risk is they will recur outside. So that's why we do like to do chemotherapy for those patients as the primary treatment and radiation tends to be either added after or or concurrently.

01:26:26:02 - 01:26:56:02
Unknown
But I often plant chemotherapy first for high grade serous cancers like I did want to talk about side effects of radiation. In general, you have to think of short term side effects of long term side effects. Short term side effects are side effects that recur during radiation or up to three months and after. Those are generally transient, Those aren't what we're worried about long term for a pelvic radiation or bracket therapy.

01:26:56:02 - 01:27:20:04
Unknown
We're worried about the things in the pelvis, bladder, bowel mostly. So increased frequency of urination, burning with urination, low stools, diarrhea, urgency to go to the bathroom. That's a big one that I don't think I mentioned earlier the urgency. But we do not cause incontinence. We're not cutting the nerves, we're not damaging the nerves, but we're just kind of slowing down the function of those nerves.

01:27:20:04 - 01:27:57:22
Unknown
So there's a lot of urgency to go that should get better with time, but may not go away completely. So what are those long term side effects? Long term side effects are anything that happens from three months till life, and that's chronic side effects. That's the vaginal stenosis is prior tissue or any chronic bowel or bladder irritation. So those long term increase frequency urination or diarrhea or sensitivity to different foods, the risk of small bowel obstruction, the surgery on the radiation can cause scar tissue in the pelvis and bowel can get entrapped in that scar tissue.

01:27:57:22 - 01:28:37:20
Unknown
So that does an increased risk. But any treatment to the pelvis. Okay. And then there's quite clear. So I'm sorry to ignore a clear cell carcinoma. Those are very important high risk. They tend to occur locally or distantly. One thing that's important with clear cells is they don't respond to chemotherapy very well. So I often end up radiating their cells quite a bit like the Protect three regimen for these patients where we do that chemo and radiation first, then to the systemic chemo, because often the systemic isn't as effective.

01:28:37:20 - 01:29:09:14
Unknown
So let's do the radiation. These are very these are responsive to radiation. So definitely something we think about and clear cells tend to refer anywhere really. So we're thinking about the whole body, but we do radiation for those pretty frequently. Okay. Okay. You covered so much. And I feel like I feel like we went to went to the class at UCLA.

01:29:09:16 - 01:29:36:16
Unknown
You went to school today, not to give you all homework, which is to follow up with your primary care doctors about vitamin C and vitamin D and calcium. And also make sure if you've had a G Y in cancer that you are getting your appropriate every three month or every six month exams. Yeah, well, thank you so much, Dr. Venkat.

01:29:36:16 - 01:30:03:00
Unknown
We really appreciate your time and it's is definitely my pleasure. Real quickly, I do not radiate the whole body that would kill a person. It should not be done as the last question. But but I do radiate all over the body, literally from the top of the head to the bottom of the foot and everything in between. I've done it so it can be done.

01:30:03:02 - 01:30:26:01
Unknown
Really. My pleasure. Thank you all for for joining and staying. I will share resources as requested from if that would be interested. Interesting to everyone. I think the vaginal dilator protocol I've developed is unique and special and I would love to share it with the group. Yes. And then I'll think about other things and I'll send them your way that we would really like that.

01:30:26:04 - 01:30:38:00
Unknown
Thank you. Also. Thank you all. It was a pleasure meeting everybody and thanks for your time and attention and I wish you all the best. Thank you. Thank you. Thank you.