Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
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...
In patients with recurrent MSI-H endometrial cancer on immunotherapy with pembrolizumab, when do you discontinue therapy?
If they have no evidence of disease on their scan, I stop at 2 years.
How do you integrate ophthalmic exam and surveillance into routine visits for cervical cancer patients receiving tisotumab vedotin?
The key is to identify and intervene early; in my practice, I personally see patients each cycle (q3 weeks) and do office ophthalmic exams. Look for eye redness, irritation, corneal lesions. Key to avoiding tox is prevention with the vasoconstrictor, steroid, and lubricating drops as well as cool pa...
How do you proceed after a patient has a partial response following 6 cycles of cisplatin + paclitaxel + bevacizumab +/- pembrolizumab for metastatic SCC of the cervix?
For a patient with minimal toxicity and evidence of a partial response receiving pembrolizumab, it is reasonable to continue treatment with chemotherapy + bevacizumab + pembrolizumab for a few more cycles. For patients not receiving pembrolizumab, I would continue treatment until unacceptable toxici...
When, if ever, would you consider lenvatinib + pembrolizumab as first line therapy for patients with stage IV microsatellite stable endometrial cancer?
Outside of a clinical trial, I have not incorporated lenvatinib and pembrolizumab therapy as 1L therapy for pMMR endometrial cancer patients. This question will be answered by the LEAP-001 trial, which has completed accrual.
In a patient with previous cervix cancer treated with surgery and adjuvant EBRT who presents with recurrent HGSIL, status post vaginectomy, would you consider brachytherapy?
I would consider advanced imaging such as MRI with vaginal gel to rule out the presence of a supravaginal lesion. Otherwise, I would not treat following excision of the HSIL lesion, even if margins were positive for dysplasia. HPV testing can be done to risk stratify. However, excision/ablation is t...
Would you offer pelvic radiation in a patient with Stage IIIC endometrial cancer who has Crohn's disease and a permanent ileostomy?
I would avoid as the risk is more than the benefit and would consider brachy only.
Do you add pelvic RT for stage II gr 2 endometrial cancers with multiple high risk features?
I would treat with pelvic adjuvant RT.Musunuru et al., PMID 35248784
What pelvic fields do you treat for patients with FIGO IA2-IB cervical cancer patients who inadvertently get a simple hysterectomy but with lymph node sampling (for presumed endometrial carcinoma)?
This situation used to be referred to as a "cut-through" hysterectomy (even though the surgeon did not cut through tumor). The devil is in the details for something like this. How thorough was the dissection? How deep the invasion? However, some generalizations can be made. The upper 1/2 of the vagi...
For which patients with stage IA nonsurgically staged endometriod cancer would you add pelvic RT?
At present, for most of these patients we would not add EBRT irrespective of nodal staging.The only subset where would consider EBRT is stage IA, grade 3 with LVSI, as they were underrepresented in PORTEC 2. In the ongoing PORTEC 3, they are treated like high risk with randomization between EBRT or ...