Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you have any advice when utilizing palliative radiation therapy in patients currently being treated with a PARP inhibitor?
This is an excellent question and certainly will become more of an issue with the recent FDA approval of olaparib for HR-defective (HRD) metastatic ovarian cancer. In addition, many other HRD metastatic cancers are being treated with this drug under compassionate use. Furthermore, the recent Phase I...
What is your approach to an optimally debulked patient with Stage Ia FIGO gr 3 serous carcinoma of the ovary?
For high grade serous early stage tumors, I use 6 cycles of carboplatin/paclitaxel. This is based on data from GOG 157 (Chan et al, Gyn Onc 2010). Single agent carbo would not be standard, but can be used in elderly or frail patients. This is a complicated situation, and treatment recommendations sh...
In what situations do you consider radiation to the pelvic and inguinal lymph nodes without treatment of the primary in vulvar cancer?
Good data in vulvar carcinoma is rare as there are not very many patients and not very many studies. Having said that, there is some data available.Among the literature is a 1994 Red Journal Article by Duesenberry et al. This is a study of 27 vulvar patients of which 13 patients had recurrences in t...
What dose is required to gross disease in the definitive treatment of vulvar cancer?
As with all gynecologic carcinomas, the optimal dose is at least to some extent dependent on the volume of disease. However, our experience suggests that a minimum of 60 Gy should always be given for gross diasease, even when concurrent chemotherapy is being given. That said, for gross disease that ...
How do you approach treatment for isolated vaginal cuff recurrence of endometrial cancer in a patient previously treated with adjuvant vaginal cuff brachytherapy?
We take previous brachy dose into account. If the patients have a CT based plan from their previous brachy, then we calculate the 2 cc dose to rectum and bladder from previous RT. Based on that dose, we deliver 30-36 Gy to pelvis including entire vagina, paravagina and nodes with EBRT, and after tha...
How do you approach the nodal treatment of vaginal cancer using IMRT or more specifically in what situations do you modify elective nodal coverage?
The nodal target volume should reflect the distribution of disease in vagina and paravaginal tissues. All vaginal cancers generally require treatment of at least the internal and external iliac nodes. For apical cancers, the presacral nodes may be included. Cancers that involve the distal vagina (ne...
How is your institution incorporating MRI planning into cervical EBRT/brachy?
Our department began utilizing MRI-based cervical brachytherapy in 2014. An MRI-based brachytherapy program is multi-disciplinary effort that required support from all departments, and it took about 6 months for us to implement. We have since progressed from MRI-based intracavitary only implants to ...
How do you counsel premenopausal women with BRCA1 or BRCA2 mutations on the need for bilateral oopherectomy?
I typically mirror the NCCN guidelines in this area. For those with BRCA 1 mutations, I recommend RRBSO between age 35-40 after completion of childbearing. Because those with BRCA2 mutations typically have onset of ovarian cancer later, it is reasonable to delay until age 40-45. Counseling needs to ...
What dose schedule do you prescribe to the HRCTV when using interstitial technique for treating cervical cancer with HDR brachytherapy?
I follow the American Brachytherapy Society guidelines (Brachytherapy 11 (2012) 47-52) which uses doses of 5Gyx 5 to HR-CTV after 45 GY external beam and 4.5GY x5 fx after dose of 50.4GY extrenal beam radiationOne has to be aware of increased toxicity in this BID fractionationFor Vaginal - I will al...
What is your approach for, and in which situations would you use, an external boost in the management of gynecologic cancers?
The most important and consistent indication for external boosts is in the treatment of regional disease. In nearly all cases where there is evidence or suspicions of gross nodal involvement, we treat the sites of gross disease to at least 60 Gy, while areas of microscopic disease typically receive ...