Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What HDR dosing would you use in the neoadjuvant setting of endometrial cancer?
This is our experience: I use 5 Gy x 3 to 4 fractions based on response with EBRT with EQ2 dose of around 65 Gy.Vargo et al., 25218303Iheagwara et al., PMID 30802615
For newly diagnosed advanced cervical cancer, how soon after periaortic lymph node evaluation do you start definitive chemoradiation treatment?
It depends on the evaluation method: PET scanning, limited node biopsies, lymph node dissection. In general, 4-6 weeks is a reasonable waiting period, if post-op course is uneventful. I would use IMRT to decrease small bowel and kidney toxicity. Dose, about 5000 cGy and boost with limited volumes to...
What is the role of uterine artery embolization (UAE) in patients with locally advanced cervical cancer with emergent bleeding that persists through vaginal packing?
With packing and starting urgent chemo RT, the need for embolization is very limited in our practice. That being said, data suggest if embolization is done, it doesn’t affect efficacy or complication risk of subsequent chemo RT.
Is there a role for progestin therapy to temporize bleeding from endometrial cancer in a patient with an active venous thromboembolism?
In the setting of a newly diagnosed DVT in an otherwise surgically appropriate patient with known endometrial cancer, I would still consider keeping with the standard strategy of proceeding with surgical staging. I would place a filter and proceed with minimally invasive approach, if feasible. Posto...
What is your adjuvant therapy approach for stage II endometrioid endometrial cancer?
For patients with stage II endometrioid endometrial cancer, there are several considerations for adjuvant treatment. I recommend using the NCCN guidelines to guide your patient's case when possible. If there is visible tumor involvement of the cervix prior to surgery, I will perform a radical hyster...
Despite the paucity of strong data showing benefit of chemotherapy + radiotherapy in patients with stage I-II high risk histology endometrial cancer, if you recommend treatment with both modalities, how do you determine treatment schedule?
For the purpose of this answer, I'll define high risk as serous, carcinosarcoma, undifferentiated, and dedifferentiated. Clear cell carcinoma can be considered and likely treated more by its molecular profile. As you indicate, there is little data to support the routine use of chemotherapy for FIGO ...
How do you treat cervical cancer with an ovarian metastasis?
This is a data free zone but several papers report a very poor prognosis for these patients. For a limited ovarian met with pelvic localized disease, one may consider chemoradiation and add adjuvant chemotherapy (to follow) but these patients generally fail systemically. Hence, chemotherapy should b...
How would you approach diagnosis of residual ovarian tissue in a patient with ER positive breast cancer, history of BSO, and a rising estradiol level on tamoxifen?
Diagnosing elevated estrogen levels in a patient who has undergone BSO is difficult, since the symptoms are typically very non-specific (e.g., improvement in hot flashes, change in mood). There are multiple potential reasons for elevated estrogen levels following BSO, including an adrenal tumor that...
How do you manage the wide array of emotions like anger and disappointment patients may have when they first learn of an incurable relapse of an early stage cancer?
This is a really tough question and there is no easy or straight-forward answer. When I consider situations like this, however, I try to follow these guidelines: I use initial diagnostic uncertainty to my advantage. A diagnosis of relapse is almost never made instantaneously (a suspicious lesion on...
What is the maximum dose to small bowel you would allow in a single fraction with gynecologic brachytherapy?
There is no absolute number, but for a 5 fraction HDR schedule (5.5-6Gy x 5), we limit 2cc to less than 3 Gy and have accepted up to 4 Gy. We make sure that there is no hot spot touching small bowel loop by varying the filling of the bladder and sometimes using a hybrid applicator if needed to try t...