Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you perform routine pelvic exams on patients undergoing active treatment for gynecologic cancer without GYN symptoms?
I perform selective, NOT routine pelvic exams in asymptomatic patients undergoing active treatment for gynecologic cancers. The Pelvic Exam: When is there value?Screening for gynecologic cancers: There is an increasing body of literature supporting the lack of benefit of “screening” pelvic exams to ...
For gyn cancers receiving chemoradiation, how high can you boost grossly positive nodes with SIB if not near bowel?
I typically will give a simultaneous integrated boost (SIB) of 60 Gy in 30 fractions to the pelvic and para-aortic nodal CTV, which is the PET positive GTV plus a 3 mm margin. If possible I will boost the GTV of larger gross nodes (>1 cm) to 66 Gy (2.2 Gy/fx) with no margin, if constraints can be me...
Would you include the entire op bed (including flap) within the radiation field in a patient requiring a V-Y advancement flap for closure following a radical vulvectomy?
It depends on one's assessment of the risk of recurrence in the region of the flap. It sounds like the positive margin is pretty significant and situated at the vaginal introitus. Most likely, the area of the flap is at risk, but this assessment should be individualized. Assuming that the flap is he...
Does being on maintenance pembrolizumab change how you manage patients with partial metabolic response on PET/CT 3 months after chemoradiation for cervical cancer?
No, a good percentage of patients will not have a complete response by 3 months. Six months seems to be a reasonable cutoff. Persistent disease at 3 months does not seem to be a worse prognostic factor than completion at 6 months. At the 3-month mark, I would not manage differently. At 6 months, I w...
How do you approach adjuvant therapy of serous intraepithelial carcinoma of the endometrium?
I would favor no additional treatment as the risk of recurrence is low and no proven benefit of adjuvant RT.
When treating stage IVB cervical cancer with both systemic chemotherapy and local pelvic radiation therapy, do you incorporate the use of bevacizumab as in GOG 240?
I generally favor starting with multi-agent systemic therapy (Carbo/Taxol/Avastin +/- Pembro) upfront to confirm that the patient is going to respond appropriately and not blossom with metastatic disease prior to making a decision of radiating the pelvis in oligometastatic cervical cancer, similar t...
When do you use a vaginal cuff boost with pelvic RT for stage II endometrial cancer?
Most prospective studies studying the role of external beam in endometrial cancer have treated patients with pelvic radiation (46/2 Gy or 50.4/1.8 Gy) without any brachytherapy. These studies have reported very low rates (2-3%) of in field failure in the radiation arms, so recommending external beam...
Would you consider sentinel lymph nodes in a patient with a history of radiation for rectal cancer (no surgery) now with newly diagnosed endometrial cancer?
I do not perform sentinel node biopsy for patients who have undergone radiation for rectal cancer. The radiation field for rectal cancer usually includes the tumor plus a 2-5 cm margin. The presacral nodes and internal iliac nodes may also be included. (Kye and Cho, PMID 25210685)Radiation may also ...
Do you utilize GCSF during pelvic chemoradiation therapy for cervical cancer or avoid it due to concern for paradoxical neutropenia from concomitant radiation + GCSF?
Based on ANC count, duration, or fractions of RT completed, we have done neupogen to avoid delay of RT and keep total time within 7 to 8 weeks (timed administration of stimulant on Friday, Saturday, and Sunday).
How do you approach adjuvant chemotherapy for high risk/advanced endometrial cancer patients?
For patients with high risk/advanced endometrial cancer where adjuvant therapy is advised, I recommend paclitaxel (175 mg/m2) + carboplatin (AUC 6) (TC) every 3 weeks for 6 cycles. Data from GOG #209 strongly support this recommendation. In this large prospective study, TC demonstrated noninferiorit...