Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
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...
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).
How do you counsel a cervical cancer patient s/p definitive chemoRT who is not sexually active and refuses to use vaginal dilators to improve compliance?
There isn't much you can do except talk with them about the reasons for non-compliance (has it been painful, embarrassing, discuss rationale and encourage them. Are they unsure how to use it?- having them insert it during their clinic exam may help. If the dilator is causing pain, lubricants or vagi...
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...
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.