Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Would you recommend adjuvant chemotherapy to a patient who has stage IB grade 1 endometrioid endometrial cancer with isolated tumor cells in two pelvic lymph nodes and extensive LVSI?
No. ITC is treated as n0. This patient should probably get whole pelvic RT +/- brachytherapy.
How do you approach endometrial cancer in the setting of multiple pelvic lymph nodes with ITCs and/or micromets, but no macrometastasis?
We are still learning how best to manage these patients as limited data suggests their outcome is much better and not the same as macromets. One caveat is that if only SNLN done with no dissection, than the data suggest there is risk of additional nodes which could be more than 20 percent and would ...
How does number of ITC influence your approach to adjuvant RT for a surgically staged 1B endometrial cancer meeting HIR criteria?
Management of ITC only in the setting of SNLN is not defined well. We know ITC has a much better prognosis than micromets and macromets. We also know that even with ITC after SNLN bx only, there is risk of additional residual nodal disease left behind which may need to be addressed. What we don’t k...
Do you recommend adjuvant treatment for nodal isolated tumor cells in an otherwise low-risk endometrial cancer?
Do you recommend adjuvant treatment for nodal isolated tumor cells in endometrial cancer?No, I don’t recommend adjuvant treatment for endometrial cancer patients based on the presence of isolated tumor cells (ITCs) alone, in the absence of other poor prognostic factors. A recent survey on sentinel l...
Would you recommend radiation for micrometastasis on sentinel lymph node biopsy in otherwise low risk endometrial cancer?
This is a great question! There really isn’t great data on what should be done with micrometastasis. At our tumor board, there is a clear consensus to treat macrometastasis on sentinel nodes. There is also a clear consensus that while we are capturing data to monitor our outcomes with isolated tumor...
What approach have you found works best in treating persistent acute radiation proctitis in patients undergoing pelvic EBRT?
Obviously, this is an important question, though I'm a little unclear on the meaning of "persistent acute" radiation proctitis. Though I am not certain, I believe @Dr. First Last's answer applies more to chronic (or at least sub-acute) radiation proctitis. As for the more traditionally "acute" radia...
In patients with PD-L1 negative metastatic cervical squamous cell carcinoma at primary diagnosis, do you add pembrolizumab, atezolizumab, or no immunotherapy to combination platinum/taxane/bevacizumab therapy?
You are correct that the data is not crystal clear in these patients, which means it is reasonable to consider doing either platinum/taxane/bev or platinum/taxane/bev/immunotherapy. Personally, I find that when giving all 4 agents at once, patients do experience more toxicity. So in my practice for ...
In a patient with locally advanced cervical cancer that has extensive residual disease (>7 cm in greatest dimension) after chemoradiation, how do you weigh the geometric advantages of a Syed-Neblett template against the superior toxicity profile and outpatient feasibility of an advanced hybrid applicator?
Kilar et al., PMID 41737510, explains applicator selection. If residual disease is less than 4 cm on either side (still a total of 7 cm), a hybrid with straight and oblique needles can help to cover the disease. However, if it is more than 4 cm on one side, then you have to look at geometry, and som...
For early-stage vulvar cancer that is clinically/radiographically node negative with no surgical lymph node evaluation (e.g., patient or surgeon refusal), would elective nodal irradiation be reasonable in the absence of risk factors warranting treatment to the primary site?
It is tempting to skip elective nodal irradiation in this setting, especially if the radiographic evaluation includes a PET-CT, where the negative predictive value is probably close to 90%. However, if the risk of groin LN involvement is at least 15%, based on primary tumor characteristics such as s...
For a cervical cancer patient who had involved para-aortic lymph nodes, how much higher do you extend the superior edge of your field if there are nodes close to the renal vessels (i.e. usual superior extend of field)?
In this dataset from us, next station was retrocrural nodes with involvement more than 25% and for that reason, we extend CTV for 2-3 cm above renal vessel to include retrocrural nodal region and space.Kabolizadeh et al., PMID 23849691