Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What are some considerations for planning T&O brachytherapy in a patient with bilateral hip replacements, where it is difficult to delineate disease on MRI and even surrounding structures on CT?
I have favored MRI-based contouring and planning in these patients. Dual-energy CT or simulation metal artifact reduction software can also help with better delineation and planning.
What would be your radiation boost technique and dose levels for adjuvant treatment of endometrial cancer with high-grade disease or aggressive histology if there was a positive margin at the parametrium after TAH+BSO?
I usually consider 50.4 Gy with EBRT followed by an additional 5.4 Gy to the parametrial region. Whether this additional boost helps is not known.
Do you include pembrolizumab for metastatic/recurrent cervical cancer per KEYNOTE-826 regardless of PDL1 status?
PD-L1 expression is the biomarker currently approved for assessing potential responsiveness to immune checkpoint inhibitor (ICI) therapy in cervical and other malignancies. The search for better biomarkers is ongoing. With that caveat, KEYNOTE-826 was a randomized trial of chemotherapy +/- bevacizum...
Would you favor giving mirvetuximab before paclitaxel/bevacizumab?
Given some lag time for tests to be completed, I have personally started ordering folate testing early in a patient's care so that I have the information available for when we are making decisions like which regimen to move to. Prior to this when waiting for results, I would give treatments like tax...
Would you consider radiation alone or chemoradiation therapy for a small vulvar cancer near the urethra or clitoris?
Yes, I think radiation is worth considering in this situation. However, the morbidity of radiation is also significant with potential for edema and fibrosis in high dose volume. The consequence of that may arguably be worse than surgery. If we do treat with radiation, I would still add chemotherapy ...
Does lymphovascular invasion trump POLE mutation in early-stage uterine cancer adjuvant therapy decisions?
In the current ESGO guidelines, stage I and II POLE types are always low risk, irrespective of substantial LVSI, with a predicted risk of recurrence being less than 10 percent, and favoring observation. That being said, in practice, I do offer brachytherapy, as I feel it is a low morbidity procedure...
Would you offer cisplatin concurrent with radiation to a patient with p53-mutated stage III endometrial cancer if she has adult-onset hearing loss and uses a cochlear implant?
Cisplatin is commonly used for radiosensitization in patients being treated for gynecologic cancer. Ototoxicity is a common side effect of cisplatin. It is caused by the death of outer hair cells in the inner ear. Cochlear implants are used to treat hearing loss in patients with severe hearing loss ...
How do you modify the management of an SLE patient with active systemic lupus for a gynecological cancer that normally requires pelvic radiation and brachytherapy?
I have not done any specific modification for SLE. I would treat with VMAT and IGRT with a 5 mm PTV margin and ensure EBRT and HDR meet ideal dose constraints for OARs.
How would you treat a small cell carcinoma with a 4 cm right Bartholin's gland primary and a single small right inguinal adenopathy?
It’s like limited-stage SCLC would be treated with cis plus etoposide and RT (60-66 Gy). Will favor no elective pelvic node RT if pure small cell carcinoma and no mixed component.
How would you treat a high intermediate risk stage IA grade 2 endometrial ca?
If it is Stage IA, Grade 2 without additional risk factors, we recommend observation. It is not considered high intermediate risk.If it is Stage IA, Grade 2 with additional risk factors such as LVI or age 60+, we recommend a referral to radiation oncology to discuss. Anecdotally, most patients will ...