Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you give adjuvant RT to vulva in a patients with node positive vulvar cancer and no high risk features for vulvar recurrence?
There is variation in practice. I tend to treat primary also along with nodal volume as long term data shows a 25- 35% risk of LR and a low 65% salvage rate. Data unknown is how much would RT reduce this and if these are true recurrences or new primary. Te Grootenhuis et al., PMID 26428940
How would you approach a vulvar cancer with para-aortic and pelvic nodes?
I have treated a few patients with curative intent if ECOG 0-1. Especially if HPV positive. Below is the link to outcome for anal cancer with pa node involvement.Holliday et al., PMID 29907489
For adjuvant radiation decision making purposes, how is the "Lower Uterine Segment" (LUS) defined?
We have always used the pathologist's description of LUS (fundus, body, LUS, and cervix). That being said, I don’t use LUS as risk factor for deciding adjuvant treatment except in borderline cases where may lean towards brachytherapy if otherwise a candidate for observation.
What adjuvant radiation modality would you select for a grade 2 endometrial cancer with small nodule in the fallopian tube?
She would get chemotherapy for stage IIIA disease. For RT, in the past, used to offer EBRT after chemotherapy but now, if surgically staged with nodal assessment, would favor brachy alone.
How do you manage rectal or bowel perforation from interstitial brachytherapy needles?
One additional step I take other than the one highlighted is at the time of CT simulation if I notice that, I would pull those needles out either completely or to the point they are not into the wall of OARs.
What are your top takeaways in Gynecologic Cancers from ASCO 2022?
1. ATHENA (LBA5500)- Consistent efficacy signal with PARPi maintenance therapy in the front line- Another potential option for our patients with greater dosing flexibility- The BICR PFS difference in the HRP population really caught my attention. Nearly a 6 month improvement with median PFS in the r...
What is your institutional approach to a restrictive “neutropenic diet”?
Simple answer: never. The "neutropenic diet" has no efficacy and may actually be nutritionally AND microbially inferior to normal diet. This has been shown by multiple studies. I like the title of the review, "Things We Do For No Reason: Neutropenic Diet." Ma et al., PMID 35356218. Radhakrishnan et ...
What is the appropriate time interval to assess treatment response in primary vaginal SCC?
I would favor biopsy before any intervention. If positive, would need surgical salvage (similar principle as cervical cancer).Beaty et al., PMID 34455989 This review gives some biological differences between cervical and other HPV-associated malignancies.
In the setting of platinum resistant ovarian cancer, do you consider repeat use of bevacizumab with subsequent lines of chemotherapy following prior treatment with chemotherapy + bevacizumab with bevacizumab maintenance?
I typically do reuse bevacizumab. Now that bevacizumab is approved for front-line, maintenance, and recurrent settings, many patients with recurrence may not be bev-naive, to begin with, and I still use bev+chemo.In breast cancer (von Minckwitz et al., PMID 25273342) and colon cancer (Bennouna et al...
What are various positioning and treatment techniques you use to help reduce bowel dose?
Prone position IMRT/VMAT I tend to use both concurrently for rectal/anal/some gyn. There is a "myth" that prone position is difficult to reproduce. Studies do not show this, or if there is an effect, it can be mitigated by image guidance. Here is another study showing this.