Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
For vaginal cylinder HDR in the setting of adjuvant endometrial cancer radiation, do you routinely alter the prescription dose based on the diameter of the cylinder?
The prescription dose will remain the same regardless of the size of the cylinder that is used and should be specified to the vaginal surface (often 6 Gy x 5) or to 5 mm depth (often 7 Gy x 3). Because of the inverse square law, the dose to the non-prescription point will vary as a function of cylin...
How often do you believe para-aortic radiotherapy in addition to pelvic radiotherapy causes additional treatment breaks due to acute toxicity?
I would agree with @Dr. First Last that with IMRT and accurate definition of targets and organs at risk, that treatment can be delivered successfully. In patients who have had prior chemotherapy, attention to weekly blood counts is imperative. It is usually the platelet counts that pose a challenge....
How do you approach pre-operative chemoradiation for vulvar cancer?
Over time, the approach shifted from administering preoperative doses to delivering more doses in the mid-60s. Biopsies are now conducted at 8-12 weeks for persistent abnormalities to define pCR and persistent disease, thus enabling tailored management (Richman et al., PMID 32981696).Also this abstr...
In light of findings from GOG 258, is the benefit of adjuvant RT in IIIC endometrial cancer worth the potential acute and late risks of RT in the setting of significant autoimmune disease?
I agree with the thoughtful answers of others in terms of tailoring therapy and balancing risk/benefit. In this case, however, GOG 258 answered the value of doing radiation on top of chemotherapy for any patient that met its criteria. And in this case, it included 75% that indeed had stage IIIC dise...
How do you counsel patients and partners of patients with HPV+ cancers regarding the HPV vaccine?
The patient was likely exposed in their teens or twenties. The partner is likely too old to be vaccinated. Independent of the cancer, children should be vaccinated.
How would you approach an HPV+ retroperitoneal mass s/p resection involving the psoas/ureter, with uterus/cervix negative for any cancer?
When the PET and EUA are negative, I have treated HPV positive unknown primary with post-op or definitive chemo RT based on location. There is limited published data on HPV positive groin or pelvic nodes with occult primary. The last one I treated for unresectable RP mass had good response locally b...
What is the role of SBRT in recurrent oligometastatic ovarian cancer?
Ovarian granulosa cell tumor are not as chemo sensitive and respond more to local treatment and have long disease free interval and longer time to recur. Surgery where feasible and if not local treatment with fractionated IMRT or SBRT is reasonable based on location and extent of disease to prolong ...
What personnel does your department require to safely deliver vaginal cylinder brachytherapy, other than treating radiation oncologist and physicist?
We have dedicated nursing staff and specialized brachytherapy radiation therapists who are all integral for all of our procedures, including vaginal cylinder brachytherapy.
How do you approach adjuvant treatment of non-uterine leiomyosarcoma?
I do not offer adjuvant chemotherapy to persons with leiomyosarcoma. One can make a case that the large negative randomized study EORTC 62931 published in 2012 supplants the 2008 meta-analysis of smaller studies that showed survival benefit from adjuvant chemo. Woll et al., PMID 22954508Neither is t...
Would you offer adjuvant radiotherapy to a recurrent HPV-independent vulvar cancer located close to the anus, which was resected with very close (0.8 mm) margins?
I would favor RT and include the inguinal region as with local recurrence, there is about a 15% risk of nodal involvement.