Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
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...
How would you approach a primary small cell carcinoma of the vagina in a patient with an intact uterus and cervix?
We treat with the same principle as cervical small cell with combination of concurrent chemo with cis and RT (EBRT plus brachy) followed by adjuvant cis and etoposide. No pCI.
How would you manage an isolated port-site recurrence of grade 1 endometrioid endometrial cancer?
Isolated port site metastases in patients with endometrial cancer are rare. In a systematic review of published and unpublished data, Palomba and colleagues (PMID 22748961), only 1 of 4 patients with an apparently isolated port site metastasis was alive and free of disease 10 months after diagnosis ...
Do you perform routine pelvic exams on patients undergoing active treatment for gynecologic cancer without GYN symptoms?
I perform selective, NOT routine pelvic exams in asymptomatic patients undergoing active treatment for gynecologic cancers. The Pelvic Exam: When is there value?Screening for gynecologic cancers: There is an increasing body of literature supporting the lack of benefit of “screening” pelvic exams to ...
For gyn cancers receiving chemoradiation, how high can you boost grossly positive nodes with SIB if not near bowel?
I typically will give a simultaneous integrated boost (SIB) of 60 Gy in 30 fractions to the pelvic and para-aortic nodal CTV, which is the PET positive GTV plus a 3 mm margin. If possible I will boost the GTV of larger gross nodes (>1 cm) to 66 Gy (2.2 Gy/fx) with no margin, if constraints can be me...
Would you include the entire op bed (including flap) within the radiation field in a patient requiring a V-Y advancement flap for closure following a radical vulvectomy?
It depends on one's assessment of the risk of recurrence in the region of the flap. It sounds like the positive margin is pretty significant and situated at the vaginal introitus. Most likely, the area of the flap is at risk, but this assessment should be individualized. Assuming that the flap is he...
Does being on maintenance pembrolizumab change how you manage patients with partial metabolic response on PET/CT 3 months after chemoradiation for cervical cancer?
No, a good percentage of patients will not have a complete response by 3 months. Six months seems to be a reasonable cutoff. Persistent disease at 3 months does not seem to be a worse prognostic factor than completion at 6 months. At the 3-month mark, I would not manage differently. At 6 months, I w...
How do you approach adjuvant therapy of serous intraepithelial carcinoma of the endometrium?
I would favor no additional treatment as the risk of recurrence is low and no proven benefit of adjuvant RT.
When treating stage IVB cervical cancer with both systemic chemotherapy and local pelvic radiation therapy, do you incorporate the use of bevacizumab as in GOG 240?
I generally favor starting with multi-agent systemic therapy (Carbo/Taxol/Avastin +/- Pembro) upfront to confirm that the patient is going to respond appropriately and not blossom with metastatic disease prior to making a decision of radiating the pelvis in oligometastatic cervical cancer, similar t...