Middle ground.

Para-aortic nodal (PAN) failures are a big fear in locally-advanced cervical cancer, but adding large extended fields to include their coverage during definitive chemoradiation has been limited by significant GI toxicity. This Asian group got creative in their technique, and it didn’t call for advanced technology—important to note considering global incidence of locally-advanced cervical cancer is typically inversely correlated with regional resources. After treating the whole pelvis to 30-40 Gy, a midine block was introduced and the parametrium continued to 50 Gy. With this midline block began both intracavitary brachy and a sequential PAN field spanning T12 - S1 with inferior half-beam block treated to 36-40 Gy. This was all completed within 8 weeks and delivered with weekly cisplatin x 5. Trust us, just look at Figure 1. Among 90 women treated with these basic techniques, local control at 2 years was 96% and late grade 3+ GI toxicity was only 3%. TBL: Treating a sequential PAN field for locally-advanced cervical cancer may create a much needed therapeutic window. | Wakatsuki, Int J Radiat Oncol Biol Phys 2019