Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Would you consider sentinel lymph nodes in a patient with a history of radiation for rectal cancer (no surgery) now with newly diagnosed endometrial cancer?
I do not perform sentinel node biopsy for patients who have undergone radiation for rectal cancer. The radiation field for rectal cancer usually includes the tumor plus a 2-5 cm margin. The presacral nodes and internal iliac nodes may also be included. (Kye and Cho, PMID 25210685)Radiation may also ...
Do you utilize GCSF during pelvic chemoradiation therapy for cervical cancer or avoid it due to concern for paradoxical neutropenia from concomitant radiation + GCSF?
Based on ANC count, duration, or fractions of RT completed, we have done neupogen to avoid delay of RT and keep total time within 7 to 8 weeks (timed administration of stimulant on Friday, Saturday, and Sunday).
How do you approach adjuvant chemotherapy for high risk/advanced endometrial cancer patients?
For patients with high risk/advanced endometrial cancer where adjuvant therapy is advised, I recommend paclitaxel (175 mg/m2) + carboplatin (AUC 6) (TC) every 3 weeks for 6 cycles. Data from GOG #209 strongly support this recommendation. In this large prospective study, TC demonstrated noninferiorit...
Do you recommend adjuvant treatment for nodal isolated tumor cells in an otherwise low-risk endometrial cancer?
Do you recommend adjuvant treatment for nodal isolated tumor cells in endometrial cancer?No, I don’t recommend adjuvant treatment for endometrial cancer patients based on the presence of isolated tumor cells (ITCs) alone, in the absence of other poor prognostic factors. A recent survey on sentinel l...
Would you recommend radiation for micrometastasis on sentinel lymph node biopsy in otherwise low risk endometrial cancer?
This is a great question! There really isn’t great data on what should be done with micrometastasis. At our tumor board, there is a clear consensus to treat macrometastasis on sentinel nodes. There is also a clear consensus that while we are capturing data to monitor our outcomes with isolated tumor...
What is your approach to a patient with locally advanced cervical cancer who presents with a fistula (rectal or bladder)?
For bladder fistula, we usually get a bilateral nephrostomy done for diversion and then treat patients with definitive intent with chemo RT with brachy using an interstitial device. We reassess the patient with PET/CT in 3 months and if complete responses, then they get urinary diversion with ideal ...
How aggressively do you approach pelvic treatment for patients with low volume metastatic cervical cancer, but bulky local disease?
For patients with minimal oligometastatic disease, for example, a single lung metastasis or a supraclavicular node, we will often treat all sides definitively. For patients with more significant metastatic disease, we would consider treating the primary with a shortened course of radiation. For exam...
Under what circumstance do you offer a definitive approach to local treatment of a patient with oligomestastatic cervical cancer found on initial staging PET/CT?
FIGO stage IVB Cervical CancerCervical cancer spreads in an orderly fashion predominantly via the lymphatic system and subsequently hematogenous spread to the lung and elsewhere.The FIGO stage IVB cervical cancer includes those with distant nodal metastases (para-aortic or supraclavicular lymph node...
How do you approach the adjuvant treatment for grade 1 endometrial cancer with micrometastasis in a sentinel lymph node if the tumor is otherwise low risk?
That is the problem with sentinel node vs full lymphadenectomy. One does not know the status of the other nodes vs knowing if they are involved or not. Is the micromets after multiple sections of the node? If a full lymphadenectomy is done, the micromets may not have been identified and no further t...
In light of new NCCN guidelines that state combination chemotherapy + pelvic RT should be reserved for endometrial cancer of at least stage IIIB, will you recommend EBRT in addition to chemotherapy for stage IIIA endometrial cancers?
Well, this is a little hard.I think it is pretty clear that chemotherapy is really the foundation for treatment of advanced disease. PORTEC-3 looked at women with high risk stage I, stage II, or stage III, or tumors with serous or clear cell histology (very diverse group!) and noted a survival benef...