Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How do you approach adjuvant radiation recommendations for low-risk endometrial cancer in which the patient was unable to undergo pelvic sentinel node mapping?
Nodal assessment would not change much for me, as it’s a low-risk disease, and PORTEC data have shown the risk of nodal recurrence is low. For focal LVSI, one may consider brachy alone.
How do you decide between neoadjuvant chemotherapy vs neoadjuvant radiation in a patient with endometrial cancer not amenable to surgical resection due to cervical involvement?
I'm not sure I have a perfect answer. For this case, the NCCN gives the following recommendations: -For suspected cervical involvement for patients who are not suitable for primary surgery, EBRT and brachytherapy are effective treatments (category 2A). If the patient is deemed operable 4-12 weeks po...
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
When practicing cervical brachytherapy with both intracavitary and interstitial approaches, do you obtain an MRI with each fraction of HDR BT?
Yes, we do obtain an MRI for every fraction. We are fortunate enough to have an MRI near the brachytherapy suite. Sometimes, though, if the patient has a small tumor and we're performing only intracavitary brachytherapy, then we do not do an MRI for every fraction, but typically do that for the firs...
How do you manage partial response following 6 cycles of carboplatin/paclitaxel/immunotherapy for advanced endometrial cancer with persistent peritoneal disease when surgical debulking is not an option?
A lot depends on the molecular makeup of the endometrial cancer. I would absolutely continue for dMMR or even TP53mut, but IO is unlikely to work in the NSMP subgroup. In that scenario, you could continue to progression or look at other markers, i.e., HER2. Trial is the next best option, and standar...
For patients on immune checkpoint inhibitors presenting with chest pain, dyspnea, fatigue, and troponin elevation, would you recommend early initiation of high dose steroids for empiric treatment of ICI myocarditis while pursuing workup with coronary angiogram, echocardiogram, and/or cardiac MRI, or wait until alternative etiologies have been ruled out?
This question raises an important point that the clinical presentation of ICI-associated myocarditis often overlaps with other cardiovascular disorders, including acute coronary syndrome, chronic CAD, congestive heart failure, and other nonischemic cardiomyopathies. Therefore, prompt initiation of w...
Should all patients with a remote history of immunotherapy, chemotherapy and/or radiation therapy have a baseline TTE regardless of ASCVD risk?
The current ASCVD risk assessment calculators we have available do not contain cancer-specific parameters and thus are inadequate for accurate assessment of a cancer survivor's risk of developing CHF and ischemic heart disease. If patients have received mediastinal radiation therapy or high-dose ant...
Given recent studies investigating ICI myocarditis biomarkers such as Temra CD8+ cells, is there now a growing selection of clinical biomarkers, besides BNP and troponin, being measured routinely in ICI myocarditis cases?
Since novel biomarkers are not yet clinically available in most practice settings, these are not yet routinely being checked though they certainly merit further investigation for diagnosis of ICI myocarditis. Currently, recommended biomarkers include indicators of cardiac injury (troponin, BNP or NT...
When would you consider tapering glucocorticoids in a patient with ICI-associated myocarditis?
Once troponins start to decrease, I start the steroid taper and follow troponin levels. If they rise, I slow the taper. I also get serial ECGs, esp if there were arrhythmia manifestations of myocarditis. Don't forget to assess for the need for PJP prophylaxis with Bactrim or pentamidine and PPI sinc...
What is your surveillance approach for outpatient monitoring of ICI myocarditis?
Screening and surveillance strategies for outpatient monitoring of ICI myocarditis are not well-defined. The best surveillance approach would be based on clinical risk assessment, followed by biomarker and imaging data. The risk factors for ICI myocarditis remain to be clarified, but the most valida...