Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How would you treat an isolated para-aortic recurrence while receiving adjuvant pembrolizumab after definitive chemoradiation for cervical cancer?
If the patient has failed while on pembro, I would favor holding/stopping IO and plan for definitive chemo-RT to the para-aortic region with SIB boost with weekly cisplatin.
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
What is your general approach to PARPi usage in the front-line and recurrent ovarian cancer setting in light of FDA label changes over the years?
In the frontline setting, I generally recommend PARP inhibition with olaparib x2 years for BRCAmut patients (1) and with niraparib x2-3 years for patients with HR-deficient tumors (I personally tend to do 2 years, based on SOLO1 data with olaparib) (2). For BRCAwt patients with HR-proficient tumors...
Do you routinely recommend completion hysterectomy with contralateral salpingo-oophorectomy for patients with a history of fertility-sparing staging for borderline tumor of the ovary who have since completed childbearing?
Borderline ovarian tumors, also known as atypical proliferative tumors by WHO classification, account for about 10-20% of epithelial ovarian tumors, have histologic subtypes similar to invasive ovarian cancer, and are characterized pathologically by a high degree of proliferation of the epithelial c...
When do you start a vaginal dilator after EBRT to the vaginal canal?
Although I have not reviewed the published data in a while, from my data review ~8 years ago and my own cumulative gynecologic specialty experience, I have fallen into the following paradigm: In the setting of standard EBRT or vaginal cuff brachy, for a patient, in reference to the use of a vaginal ...
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
I am a radiation oncologist and palliative care physician.I teach: "the hand that writes the opioids, writes the laxatives - or else it does the disimpaction". Opioid induced constipation is very common, can cause physical and psychological discomfort, and have a major impact on quality of life. It ...
In your practice, what is your goal dose for boosting positive PA nodes in either the adjuvant or definitive treatment for cervical cancer?
The dose of RT is based on the risk of tumor recurrence tempered by normal tissue constraints. In general, known or suspected gross nodal disease is treated to 60 Gy; higher doses of 62-66 Gy may be used for large nodes that are not immediately adjacent to the duodenum, particularly if a portion of ...
With the addition of pembrolizumab following chemoradiation per KEYNOTE-A18, would you be less likely to treat the paraaortic chain prophylactically?
I would favor the same volume of RT with or without pembro. If there is an indication to treat PA nodal chain, would treat as per plan.
How do you approach adjuvant radiation recommendations for low-risk endometrial cancer in which the patient was unable to undergo pelvic sentinel node mapping?
Nodal assessment would not change much for me, as it’s a low-risk disease, and PORTEC data have shown the risk of nodal recurrence is low. For focal LVSI, one may consider brachy alone.
Is there a role for leucovorin in a patient who is 3 days post her most recent treatment dose of methotrexate for GTN, who is experiencing grade 3 mucositis?
I would give it, but it has not been shown to be effective. I just feel like I should do something.