Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Given patients with substantial LVSI experience a pelvic recurrence rate of ~25%, how do you counsel patients with stage IA endometrioid endometrial cancer with LVSI regarding the relative risks/benefits of EBRT versus VBT alone?
Updated analysis of PORTEC-1 and 2 noted that 5-year pelvic lymph node recurrence was 26.3% when >4 vessels had LVSI involvement, compared to 6.7% with 1-3 foci and 3.3% with no LVSI1. Based on the data from PORTEC-2 which randomized patients to vaginal cuff brachytherapy or EBRT, on multivariable a...
Will you be changing your management of locally advanced cervical cancer based on the results of the recently published INTERLACE trial?
Absolutely NOT. INTERLACE results are in abstract form only, including early-stage disease I-II at 86%, and the details regarding radiation are minimal, stating it's prescribed to point A and recommend CT/MR planning (we do not know how many patients underwent image-guided brachytherapy). Also, ind...
Do you have concerns about the validity of the INTERLACE data, considering the long study recruitment period (10 years) and evolution of radiation techniques that have occurred during that time frame?
The long recruitment period and change in the practice of brachytherapy do create some uncertainty in interpretation. As mentioned, 60% had point A-based brachytherapy in INTERLACE. Any modern cervical cancer trial needs to have current technology especially IMRT (helps with nodal boost, conformity,...
When do you transfuse cervical cancer patients undergoing chemoradiation?
Although we try to keep hemoglobin 10 gm and above for patients on chemo Rt, it is not clear whether it makes any difference to outcome. Anemia is associated with inferior treatment outcome in cervix cancer, but hemoglobin levels prior to and during treatment are strongly correlated with tumor size,...
Are there any situations in which you would offer brachytherapy alone instead of whole pelvis RT +/- brachytherapy for an endometrial cancer vaginal cuff recurrence?
Limited series in the past where only brachytherapy alone was done for salvage without EBRT reported high pelvic nodal relapse.One such series is Baek et al., PMID 27614661The only situation where I have done brachy alone is in patients who have had previous EBRT or have other contraindications to E...
Do you take patients off anticoagulation for tandem and ovoid or tandem and ring procedures?
We don't take them off anti coagulant for intracaviatry alone unless using a hybrid applicator
For a patient with carcinosarcoma of the uterus and an allergic reaction to paclitaxel, would you have any reservations about using docetaxel instead?
While there is no clear data for this in carcinosarcoma, Yes, I would be comfortable using Docetaxel in this scenario. I am extrapolating from ovarian cancer, where the two drugs have similar activity; The SCOTROC trial in ovarian cancer compared Carbo-Paclitaxel vs. Carbo-Docetaxel and found simila...
Would you recommend maintenance therapy with a PARP inhibitor for BRCA+ patients with advanced uterine serous cancer?
This is a data free zone, so I would hesitate to make a recommendation to use a PARP in this setting. Although, theoretically this should work if the patient has BRCA gene mutation. This would be an excellent question to answer in the form of a clinical trial similar to what Fader et al did for HER2...
Do you routinely discuss HRT with patients that have undergone surgical menopause due to treatment of cervical cancer?
Yes, I routinely discuss it with premenopausal patients and it is an important part of their care. If they will be having chemoradiation for a locally advanced cancer, I will discuss pros/cons of ovarian transposition. With adenocarcinomas, some patients do opt for oophorectomy if a radical hysterec...
How would the presence of micro-metastatic disease in multiple sentinel pelvic lymph nodes change your recommendation for adjuvant therapy in a patient with otherwise stage I endometrioid adenocarcinoma?
Currently, we treat like stage III disease with chemotherapy followed by adjuvant EBRT for decreasing LRR and control any residual nodal disease (could be 30% based on FIRES) left behind as had only SNLN done. The outcome appears to be better than macrometastases.If only ITC then no chemo for now bu...