Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What situations do you use IMRT vs 4-field box technique (or visa versa) for patients with an intact cervix with no pelvic or para-aortic nodal involvement?
The main argument is sparing of small bowel and marrow dose. Comparing the dosimetry of the two plans would give the answer as to whether there is any advantage in a particular patient as it varies based on anatomy, BMI, size of uterus and disease
Which chemotherapy regimen (if any) do you recommend for palliative concurrent chemoradiation for a symptomatic patient with metastatic cervical carcinoma and CKD stage 4 (GFR 15-29)?
For patients who cant get cisplatin because of poor kidney function, we have used taxol at 45-50 mg/m2 weekly ( metabolized through liver) based on phase 2 data. In our experience it is tolerated well.
How would you manage an endometrial cancer with no (or minimal) myometrial invasion and only a very small focus of disease in a pelvic node?
Eventhough stage IIIC endometrial cancer is the most common sub-stage among locally advanced patients, patients with node positive disease have routinely been combined with other stages for clinical trial purposes (including high risk early stage disease, stage IV, and recurrent disease). This not o...
How would you manage treatment of a cervical cancer in a patient unable to tolerate chemotherapy or an HDR boost due to medical commodities?
The first step is to be absolutely certain that brachytherapy is not feasible. In our experience this is extremely rare. The patient should have a thorough medical evaluation and have their medical conditions optimized as much as possible before the decision is made to withhold these standard elemen...
Now that there are three FDA-approved PARP inhibitors for use in ovarian cancer (niraparib, rucaparib, olaparib), how do you decide which one to use?
One, niraparib is only approved for maintenance after treatment of platinum sensitive recurrence. Olaparib and rucaparib are approved for treating active, measurable disease. Olaparib for germline BRCA mutation carriers after 3 prior therapies, rucaparib for treating patients with germline or somati...
What is your recommended radiation field for early stage vulvar cancer with persistent positive margins (T1a-T1b)?
I agree that if the inguinal region has been adequately addressed with negative sentinel node biopsies or with an adequate inguinal node dissection that includes the femoral and superficial inguinal nodes, we would treat only the primary site. However, in these cases, we make an active attempt to li...
When would a completion inguinofemoral node dissection followed by adjuvant RT (+/- chemo) be favored over definitive RT (+/- chemo) for SLN+ vulvar cancer?
The interim analysis of the GROINSS-V II trial showed a recurrence in 12.2% (10/82) of patients treated with radiation in the setting of positive sentinel lymph node biopsy for vulvar cancer. On subset analysis the risk of nodal recurrence was 2.2% for micrometastases (< or = 2 mm) and 20% for macro...
For a young patient with stage 4 endometrial cancer with an excellent response to anthracyclines, would you continue to give anthracyclines beyond the standard dosage cap if cardiac function remains normal by echocardiogram?
A few things to consider in this case: What is the status of her stage IV disease/what response has she had to chemotherapy? How is she tolerating chemotherapy? If she has symptomatic disease and is contuning to respond to therapy, then it becomes a discussion of risk versus benefits (risk of cardio...
How soon after pelvic RT can a routine colonoscopy be completed?
I have had them get it done once acute side effects subside in 8 -12 weeks. I do inform them about avoiding rectal biopsy and informing endoscopist about it.
Given more restrictions on later line PARP inhibitor use for patients by BRCA status, would you consider repeat biopsy with somatic testing to identify candidates for second line maintenance therapy following platinum treatment for a patient who is gBRCAwt?
I would be comfortable deciding on the use of PARP maintenance in the second line based on initial somatic testing and would not feel a need to rebiopsy. Additionally, olaparib still has an indication for BRCAwt patients for maintenance post frontline regardless of biomarker status. Disclosure: No...