Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
For early-stage vulvar cancer that is clinically/radiographically node negative with no surgical lymph node evaluation (e.g., patient or surgeon refusal), would elective nodal irradiation be reasonable in the absence of risk factors warranting treatment to the primary site?
It is tempting to skip elective nodal irradiation in this setting, especially if the radiographic evaluation includes a PET-CT, where the negative predictive value is probably close to 90%. However, if the risk of groin LN involvement is at least 15%, based on primary tumor characteristics such as s...
How do you approach hormone replacement therapy for premenopausal patients following pelvic radiation therapy?
Most patients who undergo pelvic radiation will become menopausal. Physiologically, the outcome is similar to surgical menopause because sufficient doses of radiation result in complete loss of ovarian function. In contrast, after natural menopause, the ovaries continue some types of endocrine funct...
How do you prevent radiation induced colitis?
My primary strategy to prevent radiation-induced acute large bowel injury is to try to minimize the dose delivered to the bowel as much as possible. In patients who I think might be at high risk of developing this problem, I will give them written instructions about diet modifications (low fiber, lo...
Now that the INTERLACE trial is published, do you plan to do induction chemotherapy prior to chemoRT or chemoRT with immunotherapy (per KEYNOTE-A18) for locally advanced cervical cancer?
Read this editorial by the EMBRACE group on INTERLACE.I always emphasized that modern clinical trials for cervix need to mandate IGBT, otherwise we don’t know if progress is true improvements or compensating for poor brachytherapy.Lindegaard et al., PMID 38986568
After an optimal tertiary cytoreduction for recurrent granulosa cell tumor previously treated with BEP and hormonal therapy, would you recommend systemic chemotherapy?
If it was R0 with no residual disease, then - no - I would not treat. If there was some disease left (even if optimal) - I would consider chemo - Carbo/taxol - not BEP. Observation is also very reasonable in order to reserve further systemic chemo for when the disease is no longer resectable.
Is radiation therapy a treatment option for refractory Paget's disease of the vulva extending onto skin of buttocks and anal margin?
I have treated localized peri-anal Paget's Disease with good outcomes, and there is some data to support this. I have not treated a patient with such widespread vulvar Paget's and I suspect that the morbidity would be significant given the doses required, and the volume to be treated in the case you...
Would you offer cisplatin concurrent with radiation to a patient with p53-mutated stage III endometrial cancer if she has adult-onset hearing loss and uses a cochlear implant?
Cisplatin is commonly used for radiosensitization in patients being treated for gynecologic cancer. Ototoxicity is a common side effect of cisplatin. It is caused by the death of outer hair cells in the inner ear. Cochlear implants are used to treat hearing loss in patients with severe hearing loss ...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
If a patient meets criteria for extrafascial hysterectomy for early-stage cervical cancer, how do you determine your surgical approach (abdominal vs laparoscopic)?
For FIGO 1A1-1A2 (i.e., microinvasion which means no visible lesion) - I would perform a vaginal hysterectomy with bilateral salpingectomy (IA1) or robotic hysterectomy with bilateral salpingectomy-nodes (IA2); for FIGO 1B1 with no visible lesion (eg., post-conization), I would perform a robotic cys...
What adjuvant therapy do you recommend, if any, for a vaginal margin that is positive for HSIL/VAIN3 following radical hysterectomy but negative for invasive cancer and otherwise does not meet Sedlis criteria for adjuvant radiation?
I usually perform standard surveillance for cervical cancer recurrence with exams, review of symptoms, and at least yearly pap as outlined by the NCCN. If the surveillance pap shows HSIL, then I perform colposcopy and treat and detect VAIN according to biopsy results.