Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How would you approach adjuvant therapy for a fully resected vulvar carcinoma with a single positive lymph node?
There is not a simple answer to this question. In most cases, omitting adjuvant therapy is appropriate, but in certain cases, adjuvant radiation therapy + chemotherapy is advised, even in the presence of only a single positive lymph node. It has been over 30 years since Homesley and co-workers’ 1986...
Would you ever consider pelvic exenteration followed by SBRT for a patient with recurrent cervical cancer (s/p chemoRT) who has disease only in the central pelvis and in a single hilar lymph node?
I think this is a tough question. The short of it would be that I would be very cautious with exent candidacy with extra-pelvic disease. The surgical morbidity and limited ability to get additional therapy are a reality. Scenarios where I might consider would be a long duration of time off therapy. ...
How do you manage a cervical cancer patient on anti-coagulation for pulmonary embolism requiring interstitial brachytherapy boost?
Have done with IVC filter and switch to heparin days prior to the procedure so that can hold anti coagulant for the procedure and epidural placement for analgesia.
How would you palliate a large, symptomatic vaginal melanoma recurrence with limited small pelvic lymph node metastases?
Palliation. Treat problems that are symptomatic. No expensive systemic work up. Pall RT to the pelvis if it’s symptomatic. 30 Gy/10 fractions, 25 Gy/5 fractions, or 20 Gy/2 fractions with a 1 week inter-fraction interval. Apologize for the lengthy response.
Between KEYNOTE A-18 and INTERLACE, for which patients would you recommend using one protocol over another?
We currently favor A-18 for stage III disease (clinical or node-positive). A-18 had a more modern RT technique both for EBRT and brachytherapy while in INTERLACE, 60% had a prescription to point A for brachytherapy. In comparison with the EMBRACE 3D brachytherapy series, pelvic recurrence rate seems...
With vaginal cuff brachytherapy, do you treat to the surface or a depth and why?
We prescribe to the surface of the vagina but also attend to the dose at depth. For patients receiving only vaginal cuff irradiation we use a prescription of 6 Gy VSD x 5 qod. Although this is a modest dose, it appears to be very effective in preventing vaginal recurrences, even in high-risk cases. ...
How do you logistically incorporate a "scope and score" of a patient with newly diagnosed advanced ovarian cancer into a busy OR schedule?
This can definitely be tricky. In my practice, I typically scope and score the same day as I plan to do their debulking surgery, booking cases like this as the last case of the day. While I do have block time in the OR, it is hard to take a patient for scope and score to then return in a short inter...
Is there a role for definitive radiotherapy in patients with de-novo metastatic cervical cancer after achieving complete response with chemo-immunotherapy per KEYNOTE-826?
We don't know the true impact of local treatment or the durability of CR from chemo IO response. In situations like this, I have sometimes done brachy alone to treat the primary site for local control and prevent future symptomatology.
How would you proceed after complete response to carboplatin/paclitaxel/bevacizumab in a patient who presented with distantly recurrent SCC of the cervix?
I favor treating this patient in accordance with patients on GOG 240 where the patients were treated until disease progression, unacceptable toxicity, or complete response. In this pivotal prospective study, combination platinum doublets with bevacizumab were shown to have high response rates, compl...
What is your preferred treatment regimen for locally advanced (IIB-IVA) high-grade neuroendocrine carcinoma of the cervix (small cell type)?
Tempfer et al., PMID 29728073 There is no prospective randomized trial, but the most common modality of therapy for this patient would be platin-etoposide chemotherapy followed by radiation therapy. With respect to PET AVID nodes and tissue confirmation. Would extend radiation therapy to include nod...