Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Would you consider radiation alone or chemoradiation therapy for a small vulvar cancer near the urethra or clitoris?
Yes, I think radiation is worth considering in this situation. However, the morbidity of radiation is also significant with potential for edema and fibrosis in high dose volume. The consequence of that may arguably be worse than surgery. If we do treat with radiation, I would still add chemotherapy ...
What dose is required to gross disease in the definitive treatment of vulvar cancer?
As with all gynecologic carcinomas, the optimal dose is at least to some extent dependent on the volume of disease. However, our experience suggests that a minimum of 60 Gy should always be given for gross diasease, even when concurrent chemotherapy is being given. That said, for gross disease that ...
Which patients with locally advanced cervical cancer would you consider as candidates for moderately hypofractionated pelvic chemoradiation before brachytherapy?
At present, would not offer outside clinical trials, as data are limited, with some suggesting a higher risk of acute morbidity also. Doses of EBRT in these studies are also not similar, varying from 37.5 in 15, 40 in 16, 44 in 20, and 43.3 in 17.
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.
How do you decide between neoadjuvant chemotherapy vs neoadjuvant radiation in a patient with endometrial cancer not amenable to surgical resection due to cervical involvement?
I'm not sure I have a perfect answer. For this case, the NCCN gives the following recommendations: -For suspected cervical involvement for patients who are not suitable for primary surgery, EBRT and brachytherapy are effective treatments (category 2A). If the patient is deemed operable 4-12 weeks po...
When practicing cervical brachytherapy with both intracavitary and interstitial approaches, do you obtain an MRI with each fraction of HDR BT?
Yes, we do obtain an MRI for every fraction. We are fortunate enough to have an MRI near the brachytherapy suite. Sometimes, though, if the patient has a small tumor and we're performing only intracavitary brachytherapy, then we do not do an MRI for every fraction, but typically do that for the firs...
How do you manage partial response following 6 cycles of carboplatin/paclitaxel/immunotherapy for advanced endometrial cancer with persistent peritoneal disease when surgical debulking is not an option?
A lot depends on the molecular makeup of the endometrial cancer. I would absolutely continue for dMMR or even TP53mut, but IO is unlikely to work in the NSMP subgroup. In that scenario, you could continue to progression or look at other markers, i.e., HER2. Trial is the next best option, and standar...
For patients on immune checkpoint inhibitors presenting with chest pain, dyspnea, fatigue, and troponin elevation, would you recommend early initiation of high dose steroids for empiric treatment of ICI myocarditis while pursuing workup with coronary angiogram, echocardiogram, and/or cardiac MRI, or wait until alternative etiologies have been ruled out?
This question raises an important point that the clinical presentation of ICI-associated myocarditis often overlaps with other cardiovascular disorders, including acute coronary syndrome, chronic CAD, congestive heart failure, and other nonischemic cardiomyopathies. Therefore, prompt initiation of w...
Should all patients with a remote history of immunotherapy, chemotherapy and/or radiation therapy have a baseline TTE regardless of ASCVD risk?
The current ASCVD risk assessment calculators we have available do not contain cancer-specific parameters and thus are inadequate for accurate assessment of a cancer survivor's risk of developing CHF and ischemic heart disease. If patients have received mediastinal radiation therapy or high-dose ant...
Given recent studies investigating ICI myocarditis biomarkers such as Temra CD8+ cells, is there now a growing selection of clinical biomarkers, besides BNP and troponin, being measured routinely in ICI myocarditis cases?
Since novel biomarkers are not yet clinically available in most practice settings, these are not yet routinely being checked though they certainly merit further investigation for diagnosis of ICI myocarditis. Currently, recommended biomarkers include indicators of cardiac injury (troponin, BNP or NT...