Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How have you incorporated ctDNA into the clinical management of patients with gynecologic cancers?
ctDNA certainly is increasing rapidly in oncology and has been led by several other disease sites. I think right now, GYN oncology is figuring out how to incorporate this in our care to meaningfully impact our patients. I have not incorporated ctDNA in my practice routinely, but do see the role of i...
What, if any, adjuvant treatment do you offer a a patient with stage I clear cell endometrial carcinoma?
Clear cell carcinoma is a rare tumor with sparse literature regarding its adjuvant treatment. There is a recent SGO review article on this topic that is a nice reference. For stage I uterine clear cell, there are no prospective studies to study the impact of adjuvant chemotherapy and/or radiation. H...
Have treatment recommendations changed for Stage I endometrial Cancer based upon PORTEC 4 results?
PORTEC-4a will almost certainly change recommendations for adjuvant treatment in high-intermediate risk stage I patients with endometrial cancer, and in at least 2 different ways, in my opinion. By following the molecular profiling guidelines, nearly half of these patients will avoid adjuvant treatm...
When do you consider re-irradiating patients with recurrent cervical cancer?
Because I have been seeing and treating a reasonable number of these cases for 35 years, I have some strong opinions on the matter. Although external beam re-irradiation in the setting of recurrent cervical cancer is fraught with great hazards and poor outcomes, interstitial re-irradiation has a hig...
Despite the paucity of strong data showing benefit of chemotherapy + radiotherapy in patients with stage I-II high risk histology endometrial cancer, if you recommend treatment with both modalities, how do you determine treatment schedule?
For the purpose of this answer, I'll define high risk as serous, carcinosarcoma, undifferentiated, and dedifferentiated. Clear cell carcinoma can be considered and likely treated more by its molecular profile. As you indicate, there is little data to support the routine use of chemotherapy for FIGO ...
How would you utilize brachytherapy boost in addition to EBRT for HPV-dependent invasive squamous cell carcinoma present as a large pelvic side wall mass, presumed to be of cervix primary, albeit the negative biopsies of the cervix?
I have had one P16+ SCC of Unknown Primary that presented as a solitary pelvic sidewall mass/node, no FDG avidity outside of that region, who had a full gynecological evaluation. First things first, ensure a thorough anorectal evaluation to rule out an anal primary. I would treat with a focus on uni...
How do you explain progression free survival to patients?
This is a really, really important question. I'd argue we often greatly undervalue the importance of communication with our patients and the impact the quality of our communication has on what they understand about their illness. I remember once having a long conversation with a patient where I outl...
How do you manage vaginal necrosis after pelvic radiation?
This is a broad topic that doesn't lend itself to a short answer format; however, I will offer a few thoughts. The first thing, of course, is to keep it from happening through judicious RT technique. Vaginal necrosis is most likely due to brachytherapy administration rather than external beam RT, an...
What radiation dose/fractionation would you consider for palliation of an unresectable vulvar cancer that received previous definitive radiation therapy?
For patients with recurrence after definitive vulvar irradiation, surgery is the best option, if possible.If this is not possible, then the retreatment with radiation can only be palliative to reduce pain or bleeding. Depending upon the extent of recurrent disease - a dose of 3000cgy in 10 fractions...
What are some considerations for planning T&O brachytherapy in a patient with bilateral hip replacements, where it is difficult to delineate disease on MRI and even surrounding structures on CT?
I have favored MRI-based contouring and planning in these patients. Dual-energy CT or simulation metal artifact reduction software can also help with better delineation and planning.