Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How do you discern whether elevated liver enzymes are from immunotherapy versus chemotherapy when a patient is on combination chemo/immunotherapy?
There is no consensus on the best method for distinguishing the cause of elevated liver enzymes in patients being treated with ICPi's when combined with various chemotherapies. Important considerations include time of onset, severity, and presence of hepatobiliary metastases. Hepatotoxicity from ICP...
Do you consider younger patients with NF2 to have a relative contraindication to radical pelvic RT due to risk of secondary malignancy?
Yes, I would consider NF2 to be a relative contraindication in a young patient. In the situation presented (borderline indications for post-op RT), I would likely lean toward up-front radical hysterectomy. However, if clear indications for post-op RT are present following surgery, I would not hesita...
How do you manage metastatic breast cancer to the uterus/ovaries that is symptomatic?
Management would be based on overall disease status, performance status, systemic treatment options, and expected survival. It tends to be seen more so in lobular carcinoma. Options could be from surgical debunking to quad shot based on the above.
When do you refer patients for germline testing when somatic tumor testing is negative for actionable mutations?
Somatic (tumor-only) testing should not be used to conclusively rule in or rule out the presence of a germline pathogenic/likely pathogenic alteration. While most germline sequence alterations (point mutations, small insertions/deletions) will be detected on tumor-only testing, this may miss chromos...
How do you approach RT coverage of an abdominopelvic lymph node in the oligometastatic or oligorecurrent setting?
Speaking specifically about prostate cancer, after treating a number of these with SBRT and having them fail in an adjacent node, me and everyone in our group will tend to treat the entire nodal chain with an SIB to the grossly involved LNs. The only exceptions are in those patients where prior RT p...
In uterine cancer, how does positive peritoneum biopsy influence your recommendation for adjuvant RT?
It is stage IV disease and routine value of any adjuvant RT is very limited.
When do you consider the insertion of nephrostomy tubes for gynecologic malignancies without fistulas?
Indication of nephrostomy for gyn cancer depends on the stage of cancer and renal function. If creatinine is normal range, nephrostomy may not be needed but if abnormal, nephrostomy is indicated. In the early stage of cancer, nephrostomy is more likely indicated than late stage of cancer.
When the initial diagnosis of stage I uterine leiomyosarcoma is made via a non-intact resection such as a myomectomy or supracervical hysterectomy, what factors, if any, might push you to consider adjuvant chemotherapy after completion surgery?
Great question. Delivering a non-intact uterus has been investigated and reported over the past several years. Specifically, it has been reported in the context of uterine morcellation and the prognosis of those surgeries that morcellated sarcomas compared to those that the uterus was delivered inta...
What elective nodal areas do you cover in medically inoperable endometrial cancer?
Gebhardt et al., PMID 28923412 Schwarz et al., PMID 26186975 For early stage grade low volume grade 1 and 2 treated with brachy alone like the above reference. For those who need EBRT (for large volume or high grade), I usually treat common iliac, external, internal, and obturator nodal regions.
What is the treatment strategy for a resected atypical endometriosis mass in the parametrium that has grade 1 endometrioid adenocarcinoma, in patient who had prior elective hysterectomy/BSO?
Based on the information, would favor pelvic RT unless high risk from adhesions from endometriosis as adjuvant treatment.