Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you recommend sentinel lymph node dissection or full lymphadenectomy for high grade and type II uterine cancers?
Sentinel lymph node (SLN) biopsy is the preferred method for detection of lymph node metastases (LNM) for both type I and type II endometrial cancers. Current studies comparing SLN biopsy vs. lymphadenectomy favor its safety and effectiveness in high-risk patients as long as experienced surgeons con...
When, if ever, would you recommend hysterectomy after chemoradiation for patients with locally advanced cervical cancer?
We would never offer a routine hysterectomy unless a planned dose of RT can’t be derived for various reasons (very rare). If the patient has persistent disease after chemo RT, then they are considered for hysterectomy or exenteration based on extent of residual disease and surgical feasibility.
What is optimal therapy for a 5 year delayed recurrence of uterine cancer, rendered NED by solitary pulmonary metastasis resection?
I favor “pseudoadjuvant” therapy with carboplatin + paclitaxel chemotherapy for 6 cycles. I make this recommendation in the absence of strong data to suggest an improvement in outcome with chemotherapy over observation vs. hormonal therapy. The optimal therapy for this patient with recurrent endomet...
How would you approach second isolated vaginal cuff recurrence in a young patient with FIGO IA Grade 2 endometrioid endometrial adenocarcinoma who received EBRT+ interstitial brachy for her initial recurrence?
The dose delivered initially was on the lower side which may be a reason for recurrence. Normally we aim for 75 Gy EQ2 dose. This is our series for reradiation if exenteration is not an option Ling et al., PMID 30600093.
For a patient with cervical cancer s/p chemoRT, would you consider brachytherapy to downstage tumor to allow for hysterectomy rather than pelvic exenteration?
I am not clear as have not encountered this situation. I would complete chemo RT including brachy to definitive dose and reserve surgery as salvage if there is persistent disease 12-16 weeks after treatment.
If a patient with HER2+ uterine serous carcinoma recurs while on maintenance trastuzumab, would you continue trastuzumab with second line chemotherapy?
I advise against extrapolating data from breast cancer therapies to endometrial cancer. There is no clinical trial supporting the administration of trastuzumab (or other anti-HER2 therapy) with second line chemotherapy after progression on maintenance trastuzumab in serous endometrial cancer. Rather...
When do you include the presacral nodes in post-operative XRT of endometrial cancer?
Cervical stromal invasion (pT2) or for definitive radiation for nodal or vaginal recurrence when treating the whole pelvis.The new Gyn postop atlas recommends if in including presacral to treat down to the pyriformis muscle. Historically, RTOG/GOG recommended S1-S3. PORTEC-3 used a 10mm in front of ...
How would you treat a recurrent endometrial cancer at the vaginal cuff that was initially FIGO 1A with no adj treatment, in a patient with actively treated scleroderma?
I would favor brachytherapy alone using MRI based planning with either a multichannel or hybrid applicator. Dose 6 Gy x 6 to CTV and higher dose (hot spots) to GTV.
How would you treat completed resected rectosigmoid recurrence of endometrial adenocarcinoma?
We have equally treated with chemotherapy for recurrence followed by involved site with RT in a few cases for isolated extended pelvic relapse. Overall outcome has been mixed.
How do you manage a distal vaginal recurrence of endometrial adenocarcinoma in a patient who had adjuvant external beam and cylinder brachytherapy boost to the top 4 cm of the vaginal cuff?
I would treat with EBRT to primary plus both inguinal regions followed by image based brachytherapy. Would add concurrent chemo if bulky disease. Dose of EBRT adjusted based on overlapLing et al., PMID 30600093