Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Can you omit the vulva from the radiation field in isolated LN recurrence several years after initial vulvectomy/nodal dissection without adjuvant RT?
In my opinion, yes, assuming the patient has had a recent well-done pelvic examination with close inspection of the vulva and vagina. A more difficult question, I think, is whether to treat the ipsilateral pelvic LN's. In general I would favor treating ipsilateral pelvic LN's to microscopic disease ...
Do you recommend probiotics to patients receiving pelvic radiotherapy?
I have not routinely recommended a probiotic to patients receiving abdominal or pelvic radiation but I did learn early on in my career to suggest it if they continued to have symptoms beyond the usual 2 weeks following radiation and found that it often helped a great deal. I have no idea which is th...
Is adenocarcinoma of the vulva more radioresistant than squamous cell carcinoma?
In general, SCC responds better to radiotherapy than adenocarcinoma, therefore I agree with @Dr. First Last that I would advocate for surgery (if possible) for these entities - however, given their location (close to introitus), often they will warrant adjuvant radiotherapy.
How do you approach ITCs in sentinel lymph node biopsy in a vulvar cancer patient?
If only SNLN bx is done, then based on GROINNS data, there is a 5% risk of additional node. Since nodal recurrences have a low salvage rate, I would treat with adjuvant RT.
What special considerations do you take when treating cancer patients with severe intellectual disabilities?
Caring for patients with any type of disability is both a privilege and a challenge. Severe intellectual disability poses additional challenges due to logistical, ethical, and moral dilemmas. Additional factors including patients' socioeconomic status, support system, language spoken to individuals ...
Would you offer adjuvant systemic therapy for recurrent fallopian tube leiomyosarcoma after resection of an isolated liver metastasis that presented within 1 year from primary surgery?
If this was an R0 resection, then I would not offer adjuvant therapy. It would be beneficial to understand if this is a high-grade or a low-grade leiomyosarcoma and also the ER/PR status. If strongly positive, then perhaps maintenance aromatase inhibitor can be considered, however, there is no good ...
How do approach palliation of local symptoms in the setting of metastatic vulvar cancer?
If patient's PS status doesn't allow definitive treatment, for local palliation, you can treat 4 Gy x 5 and then reassess in 2-4 weeks for further treatment.
How do you determine duration of anticoagulation for an ovarian vein thrombosis following a provoking event?
This specific question has not been addressed in a clinical trial to my knowledge. If the patient is symptomatic, I would anticoagulate for 3 months in the absence of a contraindication, just as I would for most other provoked VTE events. One might consider a watch and wait approach without anticoag...
How often do you believe para-aortic radiotherapy in addition to pelvic radiotherapy causes additional treatment breaks due to acute toxicity?
I would agree with @Dr. First Last that with IMRT and accurate definition of targets and organs at risk, that treatment can be delivered successfully. In patients who have had prior chemotherapy, attention to weekly blood counts is imperative. It is usually the platelet counts that pose a challenge....
How do you approach pre-operative chemoradiation for vulvar cancer?
Over time, the approach shifted from administering preoperative doses to delivering more doses in the mid-60s. Biopsies are now conducted at 8-12 weeks for persistent abnormalities to define pCR and persistent disease, thus enabling tailored management (Richman et al., PMID 32981696).Also this abstr...