Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
When do you consider the insertion of nephrostomy tubes for gynecologic malignancies without fistulas?
Indication of nephrostomy for gyn cancer depends on the stage of cancer and renal function. If creatinine is normal range, nephrostomy may not be needed but if abnormal, nephrostomy is indicated. In the early stage of cancer, nephrostomy is more likely indicated than late stage of cancer.
When the initial diagnosis of stage I uterine leiomyosarcoma is made via a non-intact resection such as a myomectomy or supracervical hysterectomy, what factors, if any, might push you to consider adjuvant chemotherapy after completion surgery?
Great question. Delivering a non-intact uterus has been investigated and reported over the past several years. Specifically, it has been reported in the context of uterine morcellation and the prognosis of those surgeries that morcellated sarcomas compared to those that the uterus was delivered inta...
What elective nodal areas do you cover in medically inoperable endometrial cancer?
Gebhardt et al., PMID 28923412 Schwarz et al., PMID 26186975 For early stage grade low volume grade 1 and 2 treated with brachy alone like the above reference. For those who need EBRT (for large volume or high grade), I usually treat common iliac, external, internal, and obturator nodal regions.
What is the treatment strategy for a resected atypical endometriosis mass in the parametrium that has grade 1 endometrioid adenocarcinoma, in patient who had prior elective hysterectomy/BSO?
Based on the information, would favor pelvic RT unless high risk from adhesions from endometriosis as adjuvant treatment.
What is your approach to first line systemic treatment for low risk gestational trophoblastic neoplasia?
Patients with gestational trophoblastic disease and a WHO score < 6 are classified as low risk. In patients who desire retention of fertility, the first line treatment is chemotherapy which achieves typically very high remission rates/cure rates. The most frequently used first line regimens employ m...
Would you offer radiation to a patient with extensive vulvar dysplasia not amenable to surgical resection and previously resected micro-invasive vulvar cancer in the setting of immunosuppression for solid organ transplant?
I have never done RT for dysplasia alone in the absence of invasive disease so would avoid it and try other means and keep on close follow up.
How would you approach the primary treatment of a rapidly growing uterine carcinosarcoma with local extension through the anterior abdominal wall?
This patient needs multimodal therapy - surgical resection is a mainstay of treatment followed by adjuvant therapy (most likely chemotherapy +/- vaginal brachytherapy). In terms of chemotherapy agents - up front adjuvant treatment is usually carboplatin/paclitaxel or ifosfamide/paclitaxel. I would p...
How would you manage an endometrial adeno abdominal wall recurrence at the port site from prior laparoscopic surgery?
I agree with R0 resection and would echo postoperative RT if it is the only site of disease. Oncologic abdominal wall resections are not routine for most surgeons and don't have standardized approaches. Make sure that your surgeon and pathologist understand that you want it evaluated similarly to a ...
Do you have any precautions to your injury to the uterine artery when placing interstitial needles as ‘ovoid extenders’ to cover parametrial disease in cervical T&O procedures?
When using oblique needles, it does come close to parametrial vessel, and the risk of bleeding is increased. Some use Doppler ultrasound to identify and avoid needles in vessels. What we do is tend to usually not push the oblique needle beyond 2 cm and adjust later on CT if needed and take precautio...
How do you approach hormone replacement therapy for premenopausal patients following pelvic radiation therapy?
Most patients who undergo pelvic radiation will become menopausal. Physiologically, the outcome is similar to surgical menopause because sufficient doses of radiation result in complete loss of ovarian function. In contrast, after natural menopause, the ovaries continue some types of endocrine funct...