Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Would you recommend adjuvant therapy for a non-invasive Grade 3 endometrioid endometrial cancer that is P53 wild-type and MMR deficient (due to methylation)?
I would not give adjuvant therapy. The risk of nodal met is low based on GOG 33 and all other known data. Given that the tumor is p53 negative, I am going to assume it will not behave as a serous tumor.So, would observe.
What is your strategy for treatment of FIGO IIB cervical cancer in a patient who poorly tolerated the first insertion and refuses subsequent insertions?
Not other equivalent options. That being said, I would plan IMRT/IGRT boost with total dose to HRCTV (75-80 Gy) based on dose to rectum, bladder, and small bowel with tight PTV margin.
Would you consider maintenance therapy in a recurrent endometrial cancer that is MSI-H and ER/PR+ that achieved a complete response after pelvic RTx and 4 cycles of Carbo/Taxol?
Great question! Before answering, we must first answer the pivotal question: is there maintenance therapy that has been demonstrated to be beneficial for such a patient? (e.g. endometrial cancer patient after an excellent response to radiation and chemotherapy for recurrent disease)? If so, are thos...
How do you approach a patient with recurrent endometrial cancer within the field of prior primary radiation who is not a surgical or cytotoxic chemotherapy candidate?
There are several things to consider here.Assuming that there is truly no potential for surgery or cytotoxic chemotherapy then the remaining options are: targeted therapy, hormonal therapy, discussing with radiation oncology any role for additional radiation, or best supportive care.First, though, I...
Is adjuvant treatment recommend for a 0.8cm serous endometrial CA confined to polyp s/p hysterectomy + surgical staging?
For surgically staged IA confined to polyp, the risk of recurrence reported in literature varies but on average, appears to be low and recent ESGO guidelines favor no treatment.
What is the longest interval to proceed with brachytherapy boost for cervical CA after EBRT?
I would proceed with brachytherapy even after a delay of 2-3 months as that is still better than no brachy and if local recurrence occurs, then the patient would need exenteration. Another option to consider, if imaging and scan show great response to EBRT, it is the possibility of a hysterectomy. I...
Would you add olaparib to maintenance immunotherapy for a patient with recurrent MMR-proficient, HER2-negative serous endometrial carcinoma?
I think it is reasonable to treat HER2 non-amplified USC with anti-PD-1 in addition to chemotherapy as long as they are TP53 mutated (90-95%) of tumors. This was looked at in a survival sub-analysis in RUBY. Other considerations would be bevacizumab, as there is evidence this works in TP53 mutated t...
In a patient with HER2+ advanced endometrial cancer, do you include IO(+/- olaparib) in their treatment regimen, or only trastuzumab in addition to carboplatin/paclitaxel?
This is a data-free zone and an excellent question. We don't yet know the efficacy of checkpoint inhibitor therapy in pMMR, HER2-positive, p53 mutated tumors, although the ad hoc RUBY data presented at ESMO suggest that p53 mutated tumors are responsive to immunotherapy. I eagerly await the histolog...
What is your technique to calculate the vaginal surface dose in gyn intracavitary brachytherapy?
The limited published data on image based brachytherapy has not found any dosimetric correlate of upper vaginal morbidity. The traditional point dose tolerence has underassessed tolerence of the upper vaginaThe recent multi-institutional EMBRACE study with different techniques and dose of cervical b...
What is your approach to a cervical SCC patient in which you're unable to properly place a T&O, due to obliterated cervical os, after completion of EBRT?
In our experience this is an extremely rare circumstance if the implant is done with ultrasound guidance--certainly <1% of cases. Depending on your level of experience and confidence, it may be worth referring the patient to a more experienced brachytherapist. That said, there are rare cases, partic...