Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How would you treat an isolated para-aortic lymph node endometrial cancer recurrence following a prolonged disease free interval previously treated with surgery, chemotherapy, and radiation therapy, if it is located outside of the previously irradiated field?
If no biopsy is done then surgery followed by adjuvant chemo and RT. If bx proven then based on nodal location and size, could be surgery and chemo RT or chemoRT without surgery.
Would you recommend adjuvant chemotherapy to a patient who has stage IB grade 1 endometrioid endometrial cancer with isolated tumor cells in two pelvic lymph nodes and extensive LVSI?
No. ITC is treated as n0. This patient should probably get whole pelvic RT +/- brachytherapy.
How would you treat a woman who has had a simple, extrafascial hysterectomy for a clinically occult, pathologically FIGO stage IB1 cervical cancer?
Standard would be to do some form of radical hysterectomy and if not done add adjuvant RT. That being said, the absolute risk of parametrial involvement for that size of disease is very low, and the benefit of RT if at all, is very small and requires a discussion of the pros and cons of intervention...
Given patients with substantial LVSI experience a pelvic recurrence rate of ~25%, how do you counsel patients with stage IA endometrioid endometrial cancer with LVSI regarding the relative risks/benefits of EBRT versus VBT alone?
Updated analysis of PORTEC-1 and 2 noted that 5-year pelvic lymph node recurrence was 26.3% when >4 vessels had LVSI involvement, compared to 6.7% with 1-3 foci and 3.3% with no LVSI1. Based on the data from PORTEC-2 which randomized patients to vaginal cuff brachytherapy or EBRT, on multivariable a...
Will you be changing your management of locally advanced cervical cancer based on the results of the recently published INTERLACE trial?
Absolutely NOT. INTERLACE results are in abstract form only, including early-stage disease I-II at 86%, and the details regarding radiation are minimal, stating it's prescribed to point A and recommend CT/MR planning (we do not know how many patients underwent image-guided brachytherapy). Also, ind...
For patients with advanced endometrial cancer, are the improved outcomes in PFS from DUO-E/RUBY/NRG-GY018 sufficient to move immunotherapy to the frontline for all presuming FDA approval?
The standard of care for metastatic endometrial cancer is systemic therapy with chemotherapy and now with or without immunotherapy. With this approach to therapy, there is a roughly 70% reduction in the risk of progression or death across three separate trials for the dMMR population (RUBY, GY018, A...
Do you have concerns about the validity of the INTERLACE data, considering the long study recruitment period (10 years) and evolution of radiation techniques that have occurred during that time frame?
The long recruitment period and change in the practice of brachytherapy do create some uncertainty in interpretation. As mentioned, 60% had point A-based brachytherapy in INTERLACE. Any modern cervical cancer trial needs to have current technology especially IMRT (helps with nodal boost, conformity,...
When do you transfuse cervical cancer patients undergoing chemoradiation?
Although we try to keep hemoglobin 10 gm and above for patients on chemo Rt, it is not clear whether it makes any difference to outcome. Anemia is associated with inferior treatment outcome in cervix cancer, but hemoglobin levels prior to and during treatment are strongly correlated with tumor size,...
Do you offer vaginal cuff brachy alone, vaginal cuff brachy and chemo, or WPRT for surgically staged IB grade 3 endometrial cancer?
All patients who have stage IBG3 fall into the GOG249 eligibility criteria. However, it is important to recognize that patients within this group have broadly varying risks. First of all, serous cancers (which have a greater propensity to spread intraperitoneally and may demand variant-specific appr...
Are there any situations in which you would offer brachytherapy alone instead of whole pelvis RT +/- brachytherapy for an endometrial cancer vaginal cuff recurrence?
Limited series in the past where only brachytherapy alone was done for salvage without EBRT reported high pelvic nodal relapse.One such series is Baek et al., PMID 27614661The only situation where I have done brachy alone is in patients who have had previous EBRT or have other contraindications to E...