Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
When performing GYN HDR brachytherapy with freehand needles, what strategies do you employ to immobilize the needles and prevent changes to your implant?
For over two decades, we have employed a technique using dental putty and friction collars to secure brachytherapy catheters. Initially developed to address needle migration issues in HDR prostate brachytherapy, we have successfully applied this technique to various other sites, including gynecologi...
In clinically node positive vulvar cancer, are you recommending bilateral inguinal LND or nodal debulking followed by adjuvant radiotherapy?
I am sure there is wide variation in practice as there is no prospective study to guide care. Our approach is definitive chemo RT with the removal of only residual persistent node. Richman et al., PMID 32981696
When is it appropriate to use adjuvant whole pelvis radiotherapy for Stage I endometrial adenocarcinoma?
The indications have been changing with the publications of GOG 99, PORTEC 1 and 2 , the Swedish and ASTEC studies, and the interpretation of data with the confounding factor of nodal dissection.At present, I would/do consider pelvic RT for Stage IB with grade 3 disease and Stage Ia with grade 3 and...
How often should you re-plan interstitial brachytherapy for gynecologic malignancies?
Ideally one should scan before each fraction to ensure needle position and account for changes in critical organ anatomy. That being said, because of logistic constraints we do QA before each fraction to check for needle displacement and if measurements are off by 2 mm or more, then we do rescanning...
What instructions do you give patients to optimize bladder filling and rectal emptying for GU and GYN simulation and treatment?
For prostate cancer treatment with external beam, IGRT is standard, so pretreatment localization of the target takes place. Because of IGRT, I don't recommend rectal filling/emptying instructions. To reduce bladder exposure, simulation and treatment with a "comfortably full bladder" is recommended.
What dose constraint do you use for the female urethra in gynecologic brachytherapy?
In our experience the tolerance is very different as the prostatic urethra and membranous urethra are very different. We have published our limited experience in Brachytherapy. When we do interstitial HDR brachy we limit 0.1 cc to 100 percent or less of what we prescribed. The 2cc concept is not app...
What is the likelihood of a successful pregnancy following pelvic irradiation?
This is a very important question. The risks on future fertiltiy from radiation therapy to the abdomen/pelvis are twofold.1) Dose to the ovaries. The LD-50 to the ovaries may be as low as 2 Gy, thus the risk of ovarian dysfunction and premature menopause, is high. 2) Dose to the uterus leading to po...
After pelvic irradiation, how often do you recommend that female patients use a vaginal dilator and for how long?
The need for a vaginal dilator is dependent on the degree of stenosis, and related to the total dose, dose per fraction for HDR brachy patients, and patients underlying tendency to form scar tissue. In general we suggest evaluation by the physician every 3 months. If it appears that scar tissue con...
What is the appropriate dose for a patient with recurrent vulva VIN III?
I have never treated VIN III by itself without any evidence of invasion, although I have had patients with diffuse VIN with invasion who responded well to RT with regression of both invasive disease and VIN changes. Dose is hard to answer but all these pts get at least 50Gy for invasive disease.
Do you treat inguinal lymph nodes for patients with low lying vaginal cancers?
Yes we do. For distal vaginal cancers (not involving vulva) that have no enlarged nodes, we treat the medial inguinal nodes (e.g. nodes medial to the common femoral and saphenous veins) to 45 Gy. We do not treat the nodes lateral to the femoral vein (i.e., along the circumflex v) unless there are su...