Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
When do you add chemotherapy to post operative RT for vulvar carcinoma?
We add for node positive disease treated with adjuvant RT especially if it is macromets (either after SNLN or INLND). Gill et al., PMID 25868965
When would a completion inguinofemoral node dissection followed by adjuvant RT (+/- chemo) be favored over definitive RT (+/- chemo) for SLN+ vulvar cancer?
The interim analysis of the GROINSS-V II trial showed a recurrence in 12.2% (10/82) of patients treated with radiation in the setting of positive sentinel lymph node biopsy for vulvar cancer. On subset analysis the risk of nodal recurrence was 2.2% for micrometastases (< or = 2 mm) and 20% for macro...
Do you give adjuvant RT to vulva in a patients with node positive vulvar cancer and no high risk features for vulvar recurrence?
There is variation in practice. I tend to treat primary also along with nodal volume as long term data shows a 25- 35% risk of LR and a low 65% salvage rate. Data unknown is how much would RT reduce this and if these are true recurrences or new primary. Te Grootenhuis et al., PMID 26428940
In what situations do you consider radiation to the pelvic and inguinal lymph nodes without treatment of the primary in vulvar cancer?
Good data in vulvar carcinoma is rare as there are not very many patients and not very many studies. Having said that, there is some data available.Among the literature is a 1994 Red Journal Article by Duesenberry et al. This is a study of 27 vulvar patients of which 13 patients had recurrences in t...
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.
How do you counsel patients regarding adjuvant therapy for stage IA uterine serous carcinoma confined to a polyp?
Observation, if fully staged is acceptable. Consider that, in the case with no residual we recommend no chemo. So, if this patient had a hysteroscopic polypectomy and then hyst with no residual we would say no chemo but, the same patient, no polypectomy, we say chemo? Biologically, are the same.
How do you manage early stage I uterine serous carcinoma?
The management of these patients remains controversial. The data are conflicting and treatment choices tend to be based more on impressions than solid data. Most clinicians advocate chemotherapy although randomized trials have not clearly shown benefit for this subset. For stage IA, we typically tre...
How long of a delay are you willing to accept for vaginal cuff brachytherapy either as primary therapy or as boost?
The absolute benefit of vaginal cuff HDR boost is small and 6 months delay would negate any such benefit.
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...
Do you believe the collective data support neoadjuvant chemotherapy or primary debulking surgery for patients with advanced ovarian cancer?
At this time, primary debulking surgery should be applied whenever feasible. However, I think we still do a poor job of selecting patients for PDS versus IDS. We neglect (or do not know) how tumor biology is really affected by surgery. For instance, BRCA-mutated tumors are likely easier to accomplis...