Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What is your approach to an incidental diagnosis of low risk endometrial cancer in a patient who underwent minimally invasive hysterectomy with uterine morcellation with gross intra-operative tumor spillage?
Little guidance is available in the literature on the optimal management of a patient with a low grade endometrial cancer who had a minimally invasive procedure with uterine morcellation and gross tumor spillage. Fortunately, this situation is not common. Wright et al. estimated the risk of occult m...
Would you recommend adjuvant chemotherapy for a patient with serous endometrial cancer initially treated with neoadjuvant radiation due to cervical involvement precluding surgical resection who is now s/p hysterectomy/BSO/LND/omentectomy with only small amount of residual disease confined to the endometrium?
Yes, assuming adequate performance status and no contraindications, I would recommend adjuvant postoperative chemotherapy for any patient requiring neoadjuvant treatment with uterine serous carcinoma that has any residual disease found at the time of hysterectomy.For the patient in this case, she in...
What resources/ancillary staff do you utilize for school re-entry after cancer treatment to decrease anxiety, improve self-confidence, and support emotional functioning?
Facilitating school re-entry for children and adolescents undergoing cancer treatment is an important component of comprehensive care. Maintaining engagement in school can help preserve a sense of normalcy and mitigate feelings of isolation and loneliness. However, the transition back to school may ...
What is the best treatment for a medically inoperable endometrial adenocarcinoma of the uterus FIGO 1, grade 1, type 1?
I would get a pelvic MRI to assess tumor size and myometrial involvement. If small volume (2 cm or smaller) with superficial invasion then use brachy alone, otherwise EBRT plus brachy. The type of brachy is based on uterine width: If the width is less than 5 cm: single tandem and cylinder. Otherwise...
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...