Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What is your approach to uterine perforation during the time of brachytherapy implant for cervical cancer?
First off, I think uterine perforations occur a lot more frequently and easily than we previously accounted for. I learned how to perform brachytherapy using purely orthogonal X-rays, with dosing and dwell position times based on measured distances from the applicators, and all of the focus was plac...
In light of the SHAPE trial results, how would you manage a patient with an incidentally diagnosed FIGO IA1 cervical cancer after simple extrafascial hysterectomy/BSO?
Without question, I would recommend that this patient receive pelvic RT and probably cuff brachytherapy as well. The SHAPE trial (NCT01658930) enrolled "low risk" patients, but they allowed LVSI patients into the trial, even though this is a high risk feature for local recurrence. There were approxi...
What is your approach to recurrent metastatic high-grade uterine carcinosarcoma with rhabdomyoblastic differentiation?
Carcinosarcomas (even with rhabdomyoblastic differentiation) are still considered to be derived from endometrial tissue. I would treat it as endometrial cancer and not as uterine or soft tissue sarcoma.
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...
How does positive peritoneal washings factor into your treatment decisions regarding pelvic radiation and/or chemotherapy?
At this point, for patients who lack other adverse factors, we do not change management based on positive cytology for endometrioid histology.
How do you manage refractory radiation cystitis status post pelvic EBRT/BT?
Thankfully chronic radiation cystitis and specifically radiation-induced hemorrhagic cystitis is relatively rare (2-8%) [1]. However, it can be a chronic and debilitating complication after pelvic radiotherapy. In managing these patients, first, I make sure to rule out another cause of cystitis – in...
How do you decide until what age to offer ovarian preservation for patients with biopsy-proven grade 1 or grade 2 endometrial cancer without evidence of metastatic disease on imaging or at the time of surgery?
I often reference Jason Wright's article evaluating the safety of ovarian preservation up to age 45 regarding cancer-related mortality. Granted, this doesn't measure recurrence rates. I also reference Dr. Barakat's incomplete GOG study (a casualty of the WHI study) that found only ~2-3% of patients ...
How would you treat bilateral groin recurrence of vulvar small cell neuroendocrine carcinoma in a patient who has previously had pelvic and groin radiation?
I would start with chemo-immunotherapy, like in pulmonary small cell, as this is likely to be the tip of the iceberg. If no prior groin surgical exploration, this can be considered by gyn/onc. If not, I would consider focal reirradiation of any residual disease after chemotherapy during IO maintenan...
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In general, how do you manage patients with early-stage endometrioid endometrial cancer who have concomitant POLE and TP53 mutations?
Based on published outcome data, double mutation is uncommon, and the outcome is driven by the better of the two mutations. So in the above situations, POLE type and not TP53 type will drive outcome and treatment decisions. That’s why in molecular-based decisions, it is important that the POLE type ...