Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you ever alter dose/fractionation for early stage endometrial cancer patients receiving vaginal brachytherapy alone?
There are several commonly used regimens for vaginal brachytherapy alone. In GOG 249, the following regimens were allowed:HDR 6-7 Gy x 3 fractions, weekly, prescribed at a depth of 0.5 cm from the surface of the vagina.HDR 10-10.5 Gy, x 3 fractions, weekly, prescribed at the vaginal surface.HDR 6 Gy...
In light of the ongoing GOG 263 trial, do you consider adding concurrent chemo with RT for early stage cervical cancer as adjuvant after Rad Hyst off trial?
Adjuvant treatment is indicated after radical hysterectomy if pathologic risk factors are discovered. The GOG 92 trial with node negative intermediate risk patients had recurrence free survival rates of 88% for adjuvant RT versus 79% for the no treatment group. Longer term follow up shows PFS and tr...
Do you recommend stopping olaratumab in patients receiving doxorubicin/olaratumab for treatment of advanced sarcoma?
Yes, we have stopped since this data came out. Am continuing either with single agent doxorubicin or addition of a second agent such as ifosfamide in select patients.
Would you consider a single insertion HDR scheme for T&O brachytherapy (BID fractionation over 3 days)?
One can use the Vienna scheme where they do 7 Gy x2 with each insertion (2 insertion). I have done 5.5 to 6 Gy x5 with some patients with logisticical challenges. An important thing is planning should be 3D image guided, each fraction should be planned to account for change in applicator positioning...
Would you consider pembrolizumab plus lenvatinib for stage IV uterine carcinosarcoma after progression on chemotherapy as per Keynote-146 and now with Keynote-775?
Yes! Carcinosarcoma is considered a high-grade carcinoma (an epithelial neoplasm, and not a uterine sarcoma). The current FDA approved indication for lenvatinib and pembrolizumab is for those with advanced or recurrent disease that is not MSI-H or dMMR in patients who are not candidates for curative...
In a patient metastatic recurrent endometrioid endometrial cancer who has a mixed response to carboplatin and paclitaxel, what is your next choice of therapy?
Understanding that there are no head to head trials comparing newer agents after failure of frontline platinum/taxane therapy, it is important to keep some issues in mind. Performance status and toxicity concerns are important given that all treatment will be palliative. 1) Patients should be offere...
Would you change your approach to adjuvant radiation for an incompletely staged, at least IB, grade 1 endometrial cancer, if a uterine perforation occurred at time of surgery?
Similarly to the above authors, I agree with offering this patient vaginal brachytherapy. Though she does not definitively meet GOG99 criteria, given the situation with deep myometrial invasion and perforation, this is a reasonable and low-risk treatment opportunity to decrease local recurrence. The...
How would you approach unresectable pelvic side wall recurrence in cervical cancer with previous definitive chemoradiation?
I would start with palliative chemo and if good response, plan for SBRT for residual disease with the dose based on OAR.
In patients diagnosed with endometrial cancer who do not undergo SLNB or LND at the time of hysterectomy, what criteria is used to recommend completion surgery for LN assessment?
The value of nodal dissection was negative for survival in two trials and PORTEC 1 and 2 (no nodal staging), and GOG 99 (nodal staging) didn’t show any difference in nodal recurrence for most endometroid stage I cancer. Unless management would change, we usually limit redo surgical staging to advers...
What impacts your decision to use PET vs CT for radiographic staging of clinically locally advanced cervical cancer?
The quick of it: stage, histology, and availability are the major factors impacting my decision on PETCT vs. CT scan.In most cases of stage IB1-IVA (FIGO 2018 staging, Bhatla et al., PMID 30656645), any histology, I prefer a PETCT when possible to ensure that no distant disease as well as to evaluat...