Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What is your approach to first line systemic treatment for low risk gestational trophoblastic neoplasia?
Patients with gestational trophoblastic disease and a WHO score < 6 are classified as low risk. In patients who desire retention of fertility, the first line treatment is chemotherapy which achieves typically very high remission rates/cure rates. The most frequently used first line regimens employ m...
Would you offer radiation to a patient with extensive vulvar dysplasia not amenable to surgical resection and previously resected micro-invasive vulvar cancer in the setting of immunosuppression for solid organ transplant?
I have never done RT for dysplasia alone in the absence of invasive disease so would avoid it and try other means and keep on close follow up.
How would you approach the primary treatment of a rapidly growing uterine carcinosarcoma with local extension through the anterior abdominal wall?
This patient needs multimodal therapy - surgical resection is a mainstay of treatment followed by adjuvant therapy (most likely chemotherapy +/- vaginal brachytherapy). In terms of chemotherapy agents - up front adjuvant treatment is usually carboplatin/paclitaxel or ifosfamide/paclitaxel. I would p...
How would you manage an endometrial adeno abdominal wall recurrence at the port site from prior laparoscopic surgery?
I agree with R0 resection and would echo postoperative RT if it is the only site of disease. Oncologic abdominal wall resections are not routine for most surgeons and don't have standardized approaches. Make sure that your surgeon and pathologist understand that you want it evaluated similarly to a ...
Do you have any precautions to your injury to the uterine artery when placing interstitial needles as ‘ovoid extenders’ to cover parametrial disease in cervical T&O procedures?
When using oblique needles, it does come close to parametrial vessel, and the risk of bleeding is increased. Some use Doppler ultrasound to identify and avoid needles in vessels. What we do is tend to usually not push the oblique needle beyond 2 cm and adjust later on CT if needed and take precautio...
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...
For cervical cancer intracavitary brachytherapy, do you use contrast when using CT-based planning to better visualize the ureters?
We normally do MRI based planning and the ureter can be identified and contoured on MRI. For only CT based, we do out diluted contrast in bladder for bladder contouring but do not go to the ureter. Rodríguez-López et al., PMID 33065181Koerner et al., PMID 34980569
For a patient obtaining significant benefit and no side effects from pentoxifylline/Vitamin E for radiation-induced vulvovaginal fibrosis, do you continue treatment longer than 6-7 months or discontinue?
I reassess these patients at 3 and 6 months, regardless of site (gyn or breast). If the patient is benefitting from the trental/vitamin E but still has significant fibrosis, I continue these meds for up to 2 years.
Would you cover presacral lymph-nodes in endometrial cancer patients with locally advanced disease (IIIC2 disease) who received neo-adjuvant chemotherapy prior to resection with no residual disease on pathology?
For IIIC2 endometrial cancer, we have included presacral lymph nodes routinely. There are no studies to compare with and without presacral lymph to my knowledge.
When, if ever, would you consider deep venous thrombosis prophylaxis for patients with advanced epithelial ovarian cancer undergoing neoadjuvant chemotherapy?
The Khorana scoring system is a great tool when this question comes up. I use it for all my ovarian cancer patients who have measurable disease in the neoadjuvant and adjuvant settings. I re-evaluate their score every 3 months to ensure they are still candidates for VTE ppx. Mulder et al., PMID 3060...