Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How do you treat cervical cancer with an ovarian metastasis?
This is a data free zone but several papers report a very poor prognosis for these patients. For a limited ovarian met with pelvic localized disease, one may consider chemoradiation and add adjuvant chemotherapy (to follow) but these patients generally fail systemically. Hence, chemotherapy should b...
How would you approach diagnosis of residual ovarian tissue in a patient with ER positive breast cancer, history of BSO, and a rising estradiol level on tamoxifen?
Diagnosing elevated estrogen levels in a patient who has undergone BSO is difficult, since the symptoms are typically very non-specific (e.g., improvement in hot flashes, change in mood). There are multiple potential reasons for elevated estrogen levels following BSO, including an adrenal tumor that...
How do you manage the wide array of emotions like anger and disappointment patients may have when they first learn of an incurable relapse of an early stage cancer?
This is a really tough question and there is no easy or straight-forward answer. When I consider situations like this, however, I try to follow these guidelines: I use initial diagnostic uncertainty to my advantage. A diagnosis of relapse is almost never made instantaneously (a suspicious lesion on...
What is the maximum dose to small bowel you would allow in a single fraction with gynecologic brachytherapy?
There is no absolute number, but for a 5 fraction HDR schedule (5.5-6Gy x 5), we limit 2cc to less than 3 Gy and have accepted up to 4 Gy. We make sure that there is no hot spot touching small bowel loop by varying the filling of the bladder and sometimes using a hybrid applicator if needed to try t...
How do you treat severe vaginal stenosis after radiation in a patient that is already compliant with dilators?
Local estrogen helps a lot. Compliance can be a problem. I suggest that the patient will cover their applicator with estrogen and insert after she goes to bed at night and just leave it in. It will usually come out during the night but this usually beats the patient having to take time out during th...
What is your surveillance approach for outpatient monitoring of ICI myocarditis?
Screening and surveillance strategies for outpatient monitoring of ICI myocarditis are not well-defined. The best surveillance approach would be based on clinical risk assessment, followed by biomarker and imaging data. The risk factors for ICI myocarditis remain to be clarified, but the most valida...
How will you treat an uterine embryonal rhabdomyosarcoma with regional node involvement resected to involved parametrial margins?
It's hard for me to say how I would treat the patient as described without a bit more information and review of the case. So, I will make a few general comments. One major question is, "What is the age of the patient?". And I assume from the question that the parametrial margins were involved. Two t...
How would you manage a patient diagnosed with squamous carcinoma involving the entire length of the vagina and extends into the vulva (introitus), who has severe vaginal stenosis?
If this is a vaginal lesion involving the vulva, it should be classified as vulva cancer and treated like so. Typically with ext beam boost to 66 to 70 Gy.
What dose would you use to treat unresectable basal cell carcinoma of the vulva?
I would make sure not mixed pathology like basosquamous. If pure basal then would treat primary alone with dose and volume like BCC of skin.
Is there evidence to support or argue against intermittent fasting for cancer patients?
This is a complex topic with many permutations of dietary interventions similar to fasting such as calorie restriction and “fasting mimicking”, but as it pertains to pure fasting, I know of a few small studies which characterize fasting around the time of chemotherapy infusions (Raffaghello et al., ...