Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Would you consider staging lymph node dissection for a patient referred for stage IA endometrial cancer and MELF pattern on final pathology?
With no other risk factors like LVSI, grade 2 or 3, or outer half myometrial invasion, I recommend surveillance.
In which circumstances would you offer adjuvant brachytherapy to a surgically staged patient with endometrial cancer if they have received prior pelvic external beam radiation therapy for a non-gynecologic pelvic tumor?
Assuming that adjuvant treatment is clearly indicated based on pathology findings, I would likely offer it, with some caveats. Ideally, the previous RT would have been delivered on an adjuvant basis with a dose of 50 Gy or less to the vaginal cuff area. Rather than the typical 700 cGy x 3 fractions,...
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 ...
Do you offer surgery for patients with early stage cervical cancer who you suspect will need adjuvant radiation regardless of surgical pathology results?
Very exophytic tumors in very young women can be treated nicely even if greater than 5 cm without radiation if pet negative and careful patient selection by pelvic exam in my experience.
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...
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...
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.
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...