Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What small bowel dose constraints do you use in gyn brachytherapy?
I agree with all of Sushil's comments. One thing I also like to stress is that there are two components that contribute to long term bowel health---the maximum dose received and the overall average bowel dose. Although we try to keep the 2 cc max to less than 60-65, some patients (particularly those...
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...
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 ...
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.
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...
How would you manage a Stage IB endometrioid endometrial cancer, status post staging surgery, with a rapid vaginal recurrence <1 month post operatively?
A rapid recurrence like this is unusual, but we have definitely seen it. Cuff recurrences require multidisciplinary management. The most worrisome feature of this patient is the rapidity of recurrence. For the initial management, I would probably have recommended some kind of adjuvant treatment afte...
Would uterine serosal involvement change your adjuvant treatment recommendation for a patient with Stage II grade 2 endometrial cancer?
Would recommend chemotherapy and vaginal brachytherapy. Had the patient had Stage II, Grade 2 disease (ignore the ITC for a moment), we would offer the patient pelvic radiation therapy alone based on GOG 249 and PORTEC 3 results, the latter of which showed a benefit of chemotherapy largely driven by...
How would you manage a clinically inoperable, stage IIIB, MMR deficient uterine cancer?
Tough situation and uncommon case. If definitely inoperable, your options are to do preoperative systemic therapy or preoperative radiation therapy. I often advocate for preoperative radiation therapy as these tumors tend to respond well to radiation, and you can save the standard-of-care chemothera...
What chemotherapy regimen would you utilize for a metastatic, poorly differentiated carcinoma of the cervix with neuroendocrine features?
I would work with pathology to define if this is a true neuroendocrine cervical cancer versus a poorly differentiated cervical carcinoma with neuroendocrine features. This could potentially impact treatment decisions. I treat patients with poorly differentiated metastatic cervical carcinoma with the...
How would you approach treatment for a locally advanced cervical cancer in the context of a completely prolapsed uterus in a non-surgical candidate?
In the few cases I have done, it was reducible and would have it pushed in daily during the course of EBRT, and also made brachytherapy feasible. One which is not reducible is a challenge with both EBRT and brachytherapy. One can treat with chemo RT and hope regression of tumor would make brachyther...