Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Under what circumstances (if any) would you offer hysterectomy after completion of primary chemoradiation for locally advanced cervical cancer?
Very few. I have only done this once for someone with recurrence limited to the cervix. The patient refused exenterative surgery and we were lucky that the planes were preserved to perform the hysterectomy after full dose external beam and brachytherapy.
What dose is needed for salvage RT for recurrent endometrial cancer in untreated PA region (who has received pelvic RT) after good PET response to systemic therapy?
I usually treat 45 Gy in 25 fraction to chain, and 55 in 25 to residual normalized node.
How would you approach a diagnostic excisional procedure for a pregnant patient with exam concerning for carcinoma and cervical biopsies (x 2) suspicious for foci of invasive disease?
First of all, I am very conservative in the management of cervical ca in pregnancy. Having said that, it appears that with a lesion I assume it was what was biopsied and showed questionable invasivion. I would re-biopsy the lesion, getting a good bite out of the lesion. If this is cancer you should ...
How would you counsel a patient with incidental diagnosis of at least high intermediate risk endometrial cancer, found on robotic hysterectomy with non-contained uterine morcellation and no node sampling?
MELF pattern of invasion has a higher rate of LN involvement, reported as 18% in one series (Joehlin-Price et al., PMID 27740968) and as high as 54% in an older series (Pavlakis et al., PMID 21438907).In the setting of an unstaged patient, a discussion of lymphadenectomy vs whole pelvis RT would be ...
How would you manage a patient with 1B2 adenocarcinoma of the endocervix s/p TAH/BSO who was found to have bilateral metastasis to Fallopian tube, a 1 cm pelvic side wall metastasis, and no LN metastasis?
We treat these patients like high-risk post op cervical cancer with concurrent chemo RT with weekly cisplatinum. We also discuss the option of adding adjuvant chemo after chemo RT with taxol and carboplatinum.
What is your preferred management for a patient who was treated with definitive chemoradiation for locally advanced cervical cancer who now has a biopsy-proven isolated brain metastasis 5 years later?
This is a rare occurrence, and there is no prospective clinical trial data that I am aware of to guide recommendations. In the literature, most seem to advocate for multimodal therapy with resection or stereotactic radiosurgery followed by whole brain radiotherapy for solitary brain lesions without ...
What dose and target volume do you use for neoadjuvant chemoRT in a patient with a locally advanced uterine/endometrial cancer involving parametria, cervix, and the uterine fundus (no side wall involvement) requiring downstage to be eligible for surgery?
Presuming that this is an endometrioid cancer - I would start with RT +/- chemo. There is potential for there to be sufficient shrinkage to facilitate brachytherapy boost. I do appreciate the link Dr. @Dr. First Last published, and would consider doing SBRT with a neoadjuvant dose how we would as pe...
What are your image guidance instructions for post-op endometrial cancer EBRT?
We treat all these patients with IMRT now and they are simulated with full and empty bladder. We do not place any fiducials as they tend not to stay in place. Patients are always treated with full bladder and empty rectum (as much as possible). Daily CBCT is used for matching bladder and rectum an...
How would you manage a patient with FIGO 2018 IA G3 endometrioid adenocarcinoma with substantial LVSI, and was N- with adequate nodal staging?
I continue to treat based on the 2018 group staging system, although I acknowledge the valuable prognostic insights gained from histology and molecular features incorporated into the 2023 system.When discussing treatment options with the patient, I avoid framing them as 'more aggressive' or 'less ag...
What are you posterior field borders for endometrial and cervical cancer 3DCRT plans?
The idea behind placing the posterior border 5 mm behind the sacrum on the lateral fields is to include the presacral fossa where the presacral nodes reside. I recommend covering the presacral nodes for all definitive cervix patients, both for prescral node coverage as well as to cover the parametri...