Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What is the longest interval to proceed with brachytherapy boost for cervical CA after EBRT?
I would proceed with brachytherapy even after a delay of 2-3 months as that is still better than no brachy and if local recurrence occurs, then the patient would need exenteration. Another option to consider, if imaging and scan show great response to EBRT, it is the possibility of a hysterectomy. I...
Would you add olaparib to maintenance immunotherapy for a patient with recurrent MMR-proficient, HER2-negative serous endometrial carcinoma?
I think it is reasonable to treat HER2 non-amplified USC with anti-PD-1 in addition to chemotherapy as long as they are TP53 mutated (90-95%) of tumors. This was looked at in a survival sub-analysis in RUBY. Other considerations would be bevacizumab, as there is evidence this works in TP53 mutated t...
In a patient with HER2+ advanced endometrial cancer, do you include IO(+/- olaparib) in their treatment regimen, or only trastuzumab in addition to carboplatin/paclitaxel?
This is a data-free zone and an excellent question. We don't yet know the efficacy of checkpoint inhibitor therapy in pMMR, HER2-positive, p53 mutated tumors, although the ad hoc RUBY data presented at ESMO suggest that p53 mutated tumors are responsive to immunotherapy. I eagerly await the histolog...
What is your technique to calculate the vaginal surface dose in gyn intracavitary brachytherapy?
The limited published data on image based brachytherapy has not found any dosimetric correlate of upper vaginal morbidity. The traditional point dose tolerence has underassessed tolerence of the upper vaginaThe recent multi-institutional EMBRACE study with different techniques and dose of cervical b...
What is your approach to a cervical SCC patient in which you're unable to properly place a T&O, due to obliterated cervical os, after completion of EBRT?
In our experience this is an extremely rare circumstance if the implant is done with ultrasound guidance--certainly <1% of cases. Depending on your level of experience and confidence, it may be worth referring the patient to a more experienced brachytherapist. That said, there are rare cases, partic...
How do you treat endometrial cancer in the setting of a pCR after neoadjuvant chemotherapy?
There is no data to guide. I would favor pelvic RT based on initial stage IIIB disease. We, at our institution, usually treat these patients with neoadjuvant chemo RT followed by surgery.https://www.ncbi.nlm.nih.gov/pubmed/25218303
How do you match a para-aortic field to a previously irradiated whole pelvis field in a woman with PA nodal failure after definitive chemoRT for cervical cancer?
We try to treat entire PA region and match to pelvic field (match two 50 percent isodose line) with .5 to 1 cm of safety factor based on nodal location
What alternative boost methods (techniques / dose) do you recommend for a vaginal cuff boost after whole pelvis when imaging shows bowel adherent to the vaginal cuff?
I usually prescribe to surface in these scenario rather than thickness. 6Gy x2
Are you using the new FIGO 2018 staging or waiting until it is incorporated into the next AJCC edition?
It will take 6-8 months for the incorporation into AJCC. Since our tumor registry follows AJCC, we are waiting for it to be done for uniformity of reporting.
If a patient with recurrent endometrial cancer experiences minimal or slow disease progression on pembrolizumab or pembro/lenvatinib, would you consider continuing or would you change agents?
Great question with unfortunately no perfect answer. There are several things that need to be considered if there is slow or minimal progression. Is this true progression (patient is on immunotherapy)? How well is the patient tolerating the therapy (are toxicities worth the benefit in this patient)...