Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you ever offer minimally invasive surgery for treatment of early stage cervical cancer?
I do not offer minimally invasive surgeries to cervical cancer patients regardless of tumor size based on the RCT data. I think there is also sufficient retrospective data to question this approach in even smaller tumor sizes and do not feel comfortable offering this to patients given the concern fo...
How would you treat cervical stump SCC involving bladder, pelvic nodes, and port-site metastasis in a patient post-laparoscopic hysterectomy?
No standard approach. If good KPS, would favor treating with definitive chemo RT with EBRT plus interstitial plus weekly cisplatinum. For port site recurrence depending on volume, would favor local excision vs. definitive RT dose.
Would you offer brachytherapy for a patient with metastatic cervical cancer s/p 30Gy/10 fx to the pelvis followed by chemotherapy who only has isolated disease in the cervix?
Control of central pelvic disease in cervical cancer is a main goal of treatment, regardless of whether the patient has metastatic disease or not. This is important for maintaining quality of life. Death from central pelvic disease is very unpleasant. Therefore, I recommend brachytherapy in this pop...
Do you modify your treatment for a patient with ulcerative colitis needing vaginal brachytherapy?
For adjuvant treatment, I switch to 6 Gy x 5 to surface to reduce total dose to rectum instead of 7 Gy x 3 at 5 mm. Also, sometimes I have used a multichannel cylinder to off load Isodose line from rectum based on anatomy. By doing as above d2cc of rectum is usually in the 10 Gy range which is way l...
When, if ever, would you consider ovarian preservation in a premenopausal patient with high grade endometrial carcinoma?
It depends on the extent of disease i.e., is it superficial invasion or deep invasion? Were the nodes evaluated? How old is the patient? The answer could be yes or no depending on the above.
Do you offer adjuvant treatment for patients with early-stage cervical cancer and isolated tumor cells identified in sentinel lymph nodes, if they would otherwise not meet criteria for adjuvant radiation therapy?
ITCs are treated as n0 in all cancers and thus in the absence of all other risk factors, I would recommend observation. I may have a lower threshold re: the discussion of RT for patients that have 1 or 2 risk factors or are otherwise close to meeting Sedlis criteria.
Now that the INTERLACE trial is published, do you plan to do induction chemotherapy prior to chemoRT or chemoRT with immunotherapy (per KEYNOTE-A18) for locally advanced cervical cancer?
Read this editorial by the EMBRACE group on INTERLACE.I always emphasized that modern clinical trials for cervix need to mandate IGBT, otherwise we don’t know if progress is true improvements or compensating for poor brachytherapy.Lindegaard et al., PMID 38986568
Do PORTEC-3 and GOG-258 change your approach to managing patients with high-risk or node positive endometrial cancer?
The ambiguous answer is "yes and no." The positive impact of RT on vaginal and nodal failure rates cannot be ignored and argues for a continued role for RT, probably external RT. There are a number of caveats relative to the interpretations of GOG 258. These include (but may not be limited to) high...
Would you consider BID treatment for a patient with a pelvic SCC (e.g. cervix or anal) if a significant amount of treatment days have been missed?
We frequently bid patients for up to 3 fractions to make up for holidays or other breaks in treatment--we have not found this to be a problem, particularly if the bid treatments are space out a bit. We generally require a 6 hour interfraction minimum interval. The maximum number of days we are willi...
How do you manage bladder fullness during cervical T&O brachytherapy to minimize OAR dose?
We usually treat with empty bladder as it is reproducible. But if at first fraction any loop of small bowel close by then for remaining fractions we simulate and treat with full bladder to decrease dose to small bowel (usually 120-180 cc fluid).