Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What is your approach to the adjuvant treatment for stage IA grade 2 endometrioid adenocarcinoma without LVSI whose molecular classification is p53 abnormal (MMR intact, POLE wild type)?
These attached guidelines recommend consideration of chemo if IA with myometrial invasion. From a radiation perspective, I do brachy alone with consideration of chemotherapy. Concin et al., PMID 33397713
When, if ever, would you perform Her2 testing in serous intraepithelial neoplasia of the endometrium?
It's not known whether HER2 expression or amplification is definitely prognostic for EIN, but I suspect it is and we know it is for stage I uterine serous carcinoma. Seeing HER2 expression in EIN makes me concerned about the possibility of a more aggressive disease. We're currently studying this at ...
What are your top takeaways from SGO 2023?
There were many great presentations at SGO 2023 along with a few practice changing presentations. Two pivotal randomized phase III clinical trials enrolled advanced, metastatic endometrial cancer patients. Each demonstrated dramatic benefit with the addition of immunotherapy to chemotherapy (followe...
How would you treat a patient with synchronous locally advanced cervical and ovarian cancers?
At a minimum, I would favor removing the ovarian mass and peritoneal and omental bx to get an idea about ovarian cancer (stage 1 or stage III). Based on that, you may start with chemo first (like carbo and taxol) for the ovarian cancer, and assess local response of cervical cancer then definitive ch...
For a patient with IIIC endometrial adenocarcinoma diagnosed and treated with 6 cycles of Carboplatin/Paclitaxel two years prior, would you consider maintenance therapy with PD-L1 inhibition, given results of GY018 and RUBY?
Endometrial cancer incidence is increasing in the United States, and very little improvement in survival has been noted for advanced disease until recently. Monotherapy with immune checkpoint inhibitors have offered hope for patients with recurrence, and the recent publication of GY018 and the RUBY ...
What small bowel dose constraints do you use in gyn brachytherapy?
There is no good outcome data available with this, although some dosimetric studies have limited 2 cc to 60-65 Gy (EQ2). That being said, it is important to monitor at each fraction the closest loop of small bowel and attempts should be made to avoid any hot spots and to spread out that dose to diff...
When do you use a brachytherapy vaginal cuff boost in postoperative cervical cancer treatment?
I limit use to close or positive margins, or if the patient has had an incidental simple hysterectomy done instead of a radical hysterectomy.
In a surgically staged Stage II Grade 1 endometrial adenocarcinoma, with no other high risk factors, would you treat with brachytherapy alone or add on the pelvic RT?
Yes, the current stage II was excluded from PORTEC 1 and 2 and were part of GOG 99 and GOG 249. With stromal invasion there is risk of nodal, vaginal, and parametrial (if only simple hysterectomy was done) recurrence, and for that reason we offer pelvic EBRT. That being said, if stromal invasion is ...
Is there a role for elective para-aortic nodal irradiation in endometrial cancer?
We treat in two scenarios:One is for patients who have had surgery done, have positive pelvic nodes on pathology, and PA nodes have not been dissected. For these patients, surgical series report a risk of pa nodal involvement of 40-50% and we treat pelvic and PA region after adjuvant chemotherapy.Th...
For a patient with vaginal adhesions/stenosis, do you recommend any other therapy besides a dilator?
Yes! In patients who have received radiation and have stenosis I frequently given topical estrogen cream with their dilators to help prevent or treat vaginal stenosis. My patents report that it helps with the pain associated with vaginal atrophy when they try to use their dilator. I treat a lot of c...