Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How do you approach treatment for isolated vaginal cuff recurrence of endometrial cancer in a patient previously treated with adjuvant vaginal cuff brachytherapy?
We take previous brachy dose into account. If the patients have a CT based plan from their previous brachy, then we calculate the 2 cc dose to rectum and bladder from previous RT. Based on that dose, we deliver 30-36 Gy to pelvis including entire vagina, paravagina and nodes with EBRT, and after tha...
How do you approach the nodal treatment of vaginal cancer using IMRT or more specifically in what situations do you modify elective nodal coverage?
The nodal target volume should reflect the distribution of disease in vagina and paravaginal tissues. All vaginal cancers generally require treatment of at least the internal and external iliac nodes. For apical cancers, the presacral nodes may be included. Cancers that involve the distal vagina (ne...
How is your institution incorporating MRI planning into cervical EBRT/brachy?
Our department began utilizing MRI-based cervical brachytherapy in 2014. An MRI-based brachytherapy program is multi-disciplinary effort that required support from all departments, and it took about 6 months for us to implement. We have since progressed from MRI-based intracavitary only implants to ...
How do you counsel premenopausal women with BRCA1 or BRCA2 mutations on the need for bilateral oopherectomy?
I typically mirror the NCCN guidelines in this area. For those with BRCA 1 mutations, I recommend RRBSO between age 35-40 after completion of childbearing. Because those with BRCA2 mutations typically have onset of ovarian cancer later, it is reasonable to delay until age 40-45. Counseling needs to ...
What dose schedule do you prescribe to the HRCTV when using interstitial technique for treating cervical cancer with HDR brachytherapy?
I follow the American Brachytherapy Society guidelines (Brachytherapy 11 (2012) 47-52) which uses doses of 5Gyx 5 to HR-CTV after 45 GY external beam and 4.5GY x5 fx after dose of 50.4GY extrenal beam radiationOne has to be aware of increased toxicity in this BID fractionationFor Vaginal - I will al...
What is your approach for, and in which situations would you use, an external boost in the management of gynecologic cancers?
The most important and consistent indication for external boosts is in the treatment of regional disease. In nearly all cases where there is evidence or suspicions of gross nodal involvement, we treat the sites of gross disease to at least 60 Gy, while areas of microscopic disease typically receive ...
When, if ever, would you consider adjuvant pelvic radiation after chemotherapy for a completely resected localized (Stage I - II) clear cell carcinoma of the ovary?
We do consider for early stage clear cell ovarian cancer after surgery and chemotherapy with Canadian data showing a survival advantage with WAR. We, in practice, consider pelvic RT only although these patients are still very infrequently referred by Gyn oncologist http://jco.ascopubs.org/content/ea...
What is your approach to uterine perforation during the time of brachytherapy implant for cervical cancer?
First off, I think uterine perforations occur a lot more frequently and easily than we previously accounted for. I learned how to perform brachytherapy using purely orthogonal X-rays, with dosing and dwell position times based on measured distances from the applicators, and all of the focus was plac...
Which pathologic features do you use to determine VCB vs pelvic RT in Stage IA/IB endometrial patients in the era of Sentinal Lymph node Biopsy?
The decision for adjuvant treatment type for us is based on similar pathological features for node negative endometrial cancer whether node negativity is based on SNL or dissection or sampling Recent randomsied study shows 99% negative predictive value in patients in whom sentinel node is identified...
What is your approach to managing patients with medically inoperable early stage endometrial adenocarcinoma who also cannot tolerate intracavitary brachytherapy (Rotte-Y, etc) as boost?
The curative-intent treatment of medically inoperable patients can be clinically challenging. Treatment is best individualized, taking into account their comorbidities, severity of disease, and other factors. Inoperability (unsuitable for hysterectomy) is largely due to serious medical comorbiditi...