Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How would you approach HDR portion of cervical SCC with large area of fistula with sigmoid colon?
Consider using ultrasound every time a tandem is inserted or a Smit sleeve placed under ultrasound guidance (if not already part of routine practice) for tandem guidance, to ensure that a false tract into the fistulous bowel is not produced at the time of tandem placement. Otherwise, as noted by Dr....
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...
When treating locally advanced cervical cancer with concurrent chemoRT, do you contour the presacral LNs to the bottom of S3 or you stop your contour at S2-S3?
We contour up until we start seeing pyriform muscle like contouring guidelines for gynecological cancer. We address the differences between prostate and gyne in this letter Musunuru et al., PMID 33610294
How would you approach the adjuvant treatment of a stage IVA adenosarcoma of the ovary?
Adenosarcomas have a benign/low grade epithelial component, unlike carcinosarcoma/sarcomatoid carcinoma. The sarcomatous component is the high grade element driving prognosis, so therapy should be directed a'la sarcoma based on usual predictive factors of age, PS, organ function, etc.
How can oncologists be more collaborative with palliative care physicians?
First and foremost, for oncologists to be collaborative with palliative care physicians, a trusting relationship is a must (good communication amongst teams is key to optimal patient care). This is akin to PCP-Oncologist (or even PCP-any other specialist relationship). Before advances in science and...
How does depth of invasion factor into your decision making when considering postoperative radiotherapy for vulvar cancer?
I would not offer adjuvant RT for depth of invasion as only risk factor.
How do you manage post radiation chronic vaginitis with bleeding?
Limit trauma to the area. No biopsies unless absolutely necessary. Can use vaginal packs on a short term basis (don't leave in too long). Transfusions if indicated. Can try a course of metronidazole, which can treat an anaerobic infection, but also is purported to have oxygen-mimetic properties. Thi...
Do you recommend adjuvant radiation for a recurrent pT1bN0 vulvar carcinoma?
For recurrence disease, if the depth of invasion is more than 1 mm and nodal assessment is not done then would favor/discuss RT. Data shows with each recurrence, risk of nodal involvement (15%) goes up which is hard to salvage Grootenhuis et al., PMID 26428940.
How do you manage a patient with BRCA1 mutation with stage IVA high grade serous ovarian carcinoma following complete cytoreduction and adjuvant chemotherapy, currently on PARP inhibitor maintenance, found to have residual suprafascial disease on pathology following ostomy reversal?
This is a situation much like an elevated Ca125 where the patient is 1) asymptomatic and 2) has NED on imaging but has disease present. The decision to stop the PARP inhibitor and start traditional chemotherapy would have to be a risk/benefit decision with the patient. The evidence of disease at the...
How do you manage an inoperable T1b1 N1 M0 Cervix adenocarcinoma which developed 6 years after treatment of a rectal adenocarcinoma s/p LAR with adjuvant posterior pelvic radiation and chemotherapy?
There is no one answer but for central area, I would do brachy alone using IGBT with a dose of 7.5 Gy x 5 to HRCTV but aiming d98 GTV 95 Gy and above if possible based on rectal and bladder dosimetry.