Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
In patients with advanced endometrial cancer who you plan to treat with chemotherapy + immunotherapy (per GY018 or RUBY), how and when do you utilize adjuvant EBRT and/or brachytherapy?
Reading the question at face value - does advanced endometrial cancer mean stage IVB? III/IVA? If IVB, there is not routinely a role of 'adjuvant' EBRT or BT.Given the discussion of adjuvant therapy, I presume the question is asking for the small fraction of RUBY and GY-018 patients who were stage I...
How would you utilize brachytherapy boost in addition to EBRT for HPV-dependent invasive squamous cell carcinoma present as a large pelvic side wall mass, presumed to be of cervix primary, albeit the negative biopsies of the cervix?
I have had one P16+ SCC of Unknown Primary that presented as a solitary pelvic sidewall mass/node, no FDG avidity outside of that region, who had a full gynecological evaluation. First things first, ensure a thorough anorectal evaluation to rule out an anal primary. I would treat with a focus on uni...
How do you explain progression free survival to patients?
This is a really, really important question. I'd argue we often greatly undervalue the importance of communication with our patients and the impact the quality of our communication has on what they understand about their illness. I remember once having a long conversation with a patient where I outl...
How do you decide between neoadjuvant chemotherapy vs neoadjuvant radiation in a patient with endometrial cancer not amenable to surgical resection due to cervical involvement?
I'm not sure I have a perfect answer. For this case, the NCCN gives the following recommendations: -For suspected cervical involvement for patients who are not suitable for primary surgery, EBRT and brachytherapy are effective treatments (category 2A). If the patient is deemed operable 4-12 weeks po...
How do you manage vaginal necrosis after pelvic radiation?
This is a broad topic that doesn't lend itself to a short answer format; however, I will offer a few thoughts. The first thing, of course, is to keep it from happening through judicious RT technique. Vaginal necrosis is most likely due to brachytherapy administration rather than external beam RT, an...
What radiation dose/fractionation would you consider for palliation of an unresectable vulvar cancer that received previous definitive radiation therapy?
For patients with recurrence after definitive vulvar irradiation, surgery is the best option, if possible.If this is not possible, then the retreatment with radiation can only be palliative to reduce pain or bleeding. Depending upon the extent of recurrent disease - a dose of 3000cgy in 10 fractions...
Is there data to support treating postoperative endometrial pelvic EBRT with a daily dilator in the vaginal canal?
Data is more for GI malignancies on using a vaginal dilator to reduce dose to the anterior vaginal wall and thus the risk of stenosis. With the vagina being a target for endometrial cancer, there is no study using it during RT to show any benefit.Arzola et al., PMID 37898354
What are some considerations for planning T&O brachytherapy in a patient with bilateral hip replacements, where it is difficult to delineate disease on MRI and even surrounding structures on CT?
I have favored MRI-based contouring and planning in these patients. Dual-energy CT or simulation metal artifact reduction software can also help with better delineation and planning.
What would be your radiation boost technique and dose levels for adjuvant treatment of endometrial cancer with high-grade disease or aggressive histology if there was a positive margin at the parametrium after TAH+BSO?
I usually consider 50.4 Gy with EBRT followed by an additional 5.4 Gy to the parametrial region. Whether this additional boost helps is not known.
Do you include pembrolizumab for metastatic/recurrent cervical cancer per KEYNOTE-826 regardless of PDL1 status?
PD-L1 expression is the biomarker currently approved for assessing potential responsiveness to immune checkpoint inhibitor (ICI) therapy in cervical and other malignancies. The search for better biomarkers is ongoing. With that caveat, KEYNOTE-826 was a randomized trial of chemotherapy +/- bevacizum...