Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What is your radiotherapy plan for stage IVA (cT4) cervical SCC with the tumor completely obliterating the bladder trigone?
I would follow the same schedule. After concurrent chemo RT, I would use HDR brachy with a hybrid applicator to achieve a D90 of 85 Gy or above to the HR-CTV and avoid any hotspot in the bladder wall. Part of the bladder wall in the trigone area receives a therapeutic dose.
Would you recommend adjuvant chemotherapy to a patient who has stage IB grade 1 endometrioid endometrial cancer with isolated tumor cells in two pelvic lymph nodes and extensive LVSI?
No. ITC is treated as n0. This patient should probably get whole pelvic RT +/- brachytherapy.
How do you approach endometrial cancer in the setting of multiple pelvic lymph nodes with ITCs and/or micromets, but no macrometastasis?
We are still learning how best to manage these patients as limited data suggests their outcome is much better and not the same as macromets. One caveat is that if only SNLN done with no dissection, than the data suggest there is risk of additional nodes which could be more than 20 percent and would ...
How does number of ITC influence your approach to adjuvant RT for a surgically staged 1B endometrial cancer meeting HIR criteria?
Management of ITC only in the setting of SNLN is not defined well. We know ITC has a much better prognosis than micromets and macromets. We also know that even with ITC after SNLN bx only, there is risk of additional residual nodal disease left behind which may need to be addressed. What we don’t k...
Do you recommend adjuvant treatment for nodal isolated tumor cells in an otherwise low-risk endometrial cancer?
Do you recommend adjuvant treatment for nodal isolated tumor cells in endometrial cancer?No, I don’t recommend adjuvant treatment for endometrial cancer patients based on the presence of isolated tumor cells (ITCs) alone, in the absence of other poor prognostic factors. A recent survey on sentinel l...
Would you recommend radiation for micrometastasis on sentinel lymph node biopsy in otherwise low risk endometrial cancer?
This is a great question! There really isn’t great data on what should be done with micrometastasis. At our tumor board, there is a clear consensus to treat macrometastasis on sentinel nodes. There is also a clear consensus that while we are capturing data to monitor our outcomes with isolated tumor...
What approach have you found works best in treating persistent acute radiation proctitis in patients undergoing pelvic EBRT?
Obviously, this is an important question, though I'm a little unclear on the meaning of "persistent acute" radiation proctitis. Though I am not certain, I believe @Dr. First Last's answer applies more to chronic (or at least sub-acute) radiation proctitis. As for the more traditionally "acute" radia...
In patients with PD-L1 negative metastatic cervical squamous cell carcinoma at primary diagnosis, do you add pembrolizumab, atezolizumab, or no immunotherapy to combination platinum/taxane/bevacizumab therapy?
You are correct that the data is not crystal clear in these patients, which means it is reasonable to consider doing either platinum/taxane/bev or platinum/taxane/bev/immunotherapy. Personally, I find that when giving all 4 agents at once, patients do experience more toxicity. So in my practice for ...
For a cervical cancer patient who had involved para-aortic lymph nodes, how much higher do you extend the superior edge of your field if there are nodes close to the renal vessels (i.e. usual superior extend of field)?
In this dataset from us, next station was retrocrural nodes with involvement more than 25% and for that reason, we extend CTV for 2-3 cm above renal vessel to include retrocrural nodal region and space.Kabolizadeh et al., PMID 23849691
Is there a role for definitive radiotherapy in patients with de-novo metastatic cervical cancer after achieving complete response with chemo-immunotherapy per KEYNOTE-826?
We don't know the true impact of local treatment or the durability of CR from chemo IO response. In situations like this, I have sometimes done brachy alone to treat the primary site for local control and prevent future symptomatology.