Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How would you counsel a patient with incidental diagnosis of at least high intermediate risk endometrial cancer, found on robotic hysterectomy with non-contained uterine morcellation and no node sampling?
MELF pattern of invasion has a higher rate of LN involvement, reported as 18% in one series (Joehlin-Price et al., PMID 27740968) and as high as 54% in an older series (Pavlakis et al., PMID 21438907).In the setting of an unstaged patient, a discussion of lymphadenectomy vs whole pelvis RT would be ...
What is your preferred management for a patient who was treated with definitive chemoradiation for locally advanced cervical cancer who now has a biopsy-proven isolated brain metastasis 5 years later?
This is a rare occurrence, and there is no prospective clinical trial data that I am aware of to guide recommendations. In the literature, most seem to advocate for multimodal therapy with resection or stereotactic radiosurgery followed by whole brain radiotherapy for solitary brain lesions without ...
How would you manage a patient with 1B2 adenocarcinoma of the endocervix s/p TAH/BSO who was found to have bilateral metastasis to Fallopian tube, a 1 cm pelvic side wall metastasis, and no LN metastasis?
We treat these patients like high-risk post op cervical cancer with concurrent chemo RT with weekly cisplatinum. We also discuss the option of adding adjuvant chemo after chemo RT with taxol and carboplatinum.
What are your image guidance instructions for post-op endometrial cancer EBRT?
We treat all these patients with IMRT now and they are simulated with full and empty bladder. We do not place any fiducials as they tend not to stay in place. Patients are always treated with full bladder and empty rectum (as much as possible). Daily CBCT is used for matching bladder and rectum an...
What dose and target volume do you use for neoadjuvant chemoRT in a patient with a locally advanced uterine/endometrial cancer involving parametria, cervix, and the uterine fundus (no side wall involvement) requiring downstage to be eligible for surgery?
Presuming that this is an endometrioid cancer - I would start with RT +/- chemo. There is potential for there to be sufficient shrinkage to facilitate brachytherapy boost. I do appreciate the link Dr. @Dr. First Last published, and would consider doing SBRT with a neoadjuvant dose how we would as pe...
How would you manage a patient with FIGO 2018 IA G3 endometrioid adenocarcinoma with substantial LVSI, and was N- with adequate nodal staging?
I continue to treat based on the 2018 group staging system, although I acknowledge the valuable prognostic insights gained from histology and molecular features incorporated into the 2023 system.When discussing treatment options with the patient, I avoid framing them as 'more aggressive' or 'less ag...
What is your strategy to deliver EBRT, brachytherapy, and a parametria/lymph node boost in less than 7-8 weeks for cervical cancer?
These are the things we do to accomplish this: 1) Up-front planning for the entire course. Schedule brachys before the start of external beam, particularly if you are dependent on an OR, gyn oncologist or anyone else who might require advance notice. The first brachy should be scheduled no later tha...
What are you posterior field borders for endometrial and cervical cancer 3DCRT plans?
The idea behind placing the posterior border 5 mm behind the sacrum on the lateral fields is to include the presacral fossa where the presacral nodes reside. I recommend covering the presacral nodes for all definitive cervix patients, both for prescral node coverage as well as to cover the parametri...
Do you recommend concurrent chemotherapy with XRT for inoperable patients with stage I-II high-risk endometrial carcinoma?
For inoperable patients due to medical comorbidities, we have been reluctant to add chemotherapy because of the concern about side effects. For inoperable patients due to disease extent, we routinely add concurrent chemotherapy.https://www.ncbi.nlm.nih.gov/pubmed/25218303/
How do you decide on adjuvant therapy in a patient with a Stage IA uterine carcinosarcoma without any myometrial invasion?
There is no good prospective study. Our approach, based on outcome and retrospective data (including NCDB), is brachy plus chemo. https://www.ncbi.nlm.nih.gov/pubmed/30170976This is paper I was referring to. With all the caveats of NCDB studies, it givess some objective information where prospective...