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Kevin Holcomb, MD
KevinHolcombMD (Physician - OBGYN - Gynecologic Oncology (Verified) )| Communities: Uterine and Endometrial Cancer , Ovarian Cancer , Cervical Cancer | Answers: 6 |
| Member Since: Jun. 2012 |
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Professional Statement
Dr. Holcomb is a Gynecologic Oncologist at the New York Presbyterian Hospital-Weill Cornell Medical College and Associate Professor of Clinical Obstetrics and Gynecology Weill Cornell Medical College.
In addition to helping diagnose and treat gynecologic cancers, Dr. Holcomb continues to develop more effective techniques in chemical, radiological and surgical treatments for these pernicious conditions. He is also very interested and active in the development of robotic and laparoscopic surgical techniques for gynecologic cancers. Dr. Holcomb was recently appointed Director of Minimally Invasive Surgery.
Dr. Holcomb’s research contributions to the field of gynecologic oncology have included dozens of peer-reviewed journal articles, a book chapter, an interactive CD-ROM, and many presentations at regional and national conferences and symposia. His research activities include clinical trials of new chemotherapy regimens as well as research in endometrial cancers and lymph node sampling. Topics of his research articles and presentations have included treatment of locally advanced cervical cancer, pre-invasive cervical lesions in HIV-positive women, and analyses of cell characteristics in human ovarian cancers.
His dedication to medical education was recognized by the Council on Resident Education in Obstetrics and Gynecology, where he received the National Faculty Award in 2002 and 2004. He has been named one of New York’s Top Doctors by New York Magazine, one of the New York Metro Area’s Top physicians by Castle-Connolly Medical Ltd., and one of America’s Leading Doctors by Black Enterprise magazine. Dr. Holcomb served as the President of the Board of Advisors for the American Cancer Society Upper Manhattan Office as well as President of the Metropolitan Gynecologic Cancer Society.
Dr. Holcomb believes strongly in a humanistic approach to medicine and establishing a personal connection with his patients. He believes the quality of patient care is enhanced by the quality of the caregiver’s commitment to care. If the patient feels cared about as a person, it helps every aspect of that patient’s medical care.
In addition to helping diagnose and treat gynecologic cancers, Dr. Holcomb continues to develop more effective techniques in chemical, radiological and surgical treatments for these pernicious conditions. He is also very interested and active in the development of robotic and laparoscopic surgical techniques for gynecologic cancers. Dr. Holcomb was recently appointed Director of Minimally Invasive Surgery.
Dr. Holcomb’s research contributions to the field of gynecologic oncology have included dozens of peer-reviewed journal articles, a book chapter, an interactive CD-ROM, and many presentations at regional and national conferences and symposia. His research activities include clinical trials of new chemotherapy regimens as well as research in endometrial cancers and lymph node sampling. Topics of his research articles and presentations have included treatment of locally advanced cervical cancer, pre-invasive cervical lesions in HIV-positive women, and analyses of cell characteristics in human ovarian cancers.
His dedication to medical education was recognized by the Council on Resident Education in Obstetrics and Gynecology, where he received the National Faculty Award in 2002 and 2004. He has been named one of New York’s Top Doctors by New York Magazine, one of the New York Metro Area’s Top physicians by Castle-Connolly Medical Ltd., and one of America’s Leading Doctors by Black Enterprise magazine. Dr. Holcomb served as the President of the Board of Advisors for the American Cancer Society Upper Manhattan Office as well as President of the Metropolitan Gynecologic Cancer Society.
Dr. Holcomb believes strongly in a humanistic approach to medicine and establishing a personal connection with his patients. He believes the quality of patient care is enhanced by the quality of the caregiver’s commitment to care. If the patient feels cared about as a person, it helps every aspect of that patient’s medical care.
Professional Info
Credential: MD
Primary specialty: OBGYN - Gynecologic Oncology
Medical school: New York Medical College
Residency: New York-Presbyterian Hospital / Weill Cornell Medical Center
Internship: New York-Presbyterian Hospital / Weill Cornell Medical Center
Fellowship: Kings County Hospital
Areas of expertise:
Robotic Surgery
Laparoscopic Surgery
Uterine Cancer
Ovarian Cancer
Cervical Cancer
Vulvar Cancer
Chemotherapy
Hospital affiliation: New York-Presbyterian Hospital / Weill Cornell Medical Center
Practice address:
525 East 68th Street J-130
New York, NY
10065
Practice phone number: (212) 746-7553
KevinHolcombMD Activities
Removal of both tubes and ovaries is recommended for comprehensive staging of endometrial cancer for two reasons. The first reason is the concern for microscopic spread of tumor to the tubes or ovaries that would go undetected if the organs were left in place. The second concern is the potential stimulation of microscopic residual cancer cells by the continued estrogen production if the ovaries are retained. These risks are theoretical and prior studies suggest that both are low. One concern, however, is that the risk of a separate ovarian cancer at the time of the endometrial cancer diagnosis (termed a "synchronous ovarian tumor") is higher in younger women and can be as high as 30%. There is a growing literature suggesting the safety of retaining the ovaries in young women with low-grade endometrial cancers with minimal invasion of the uterine muscle, although further studies are needed to confirm this. This is an important finding as the incidence of endometrial cancer is increasing and approximately 10-15% will be diagnosed in premenopausal women.
New answer by KevinHolcombMD (Physician - OBGYN - Gynecologic Oncology (Verified))
1
Answer |
10 months ago
Presently there are no standard recommendations for follow-up of patients who have completed primary treatment for endometrial cancer and are in a clinical remission. No specific intervention (ie blood tests, CT scans, chest x rays) has been shown to affect overall survival in this patient population and because of this there is wide variation in practice. Women with a history of endometrial cancer remain at risk for local, regional, and distant recurrences and an ideal follow up plan should take each possibility into account. The level of risk, however, is determined by their tumor cell type and the stage of their disease following comprehensive surgical staging.
The tools frequently used to screen women with no symptoms of recurrence include routine pelvic examinations with or without vaginal Pap smears, pelvic and abdominal imaging tests, chest x ray, and the CA 125 blood test. It is my practice to see patients for scheduled visits every three months for the first two post-treatment years and then semi-annually thereafter. During these scheduled visits patients undergo careful full physical examination and a Pap smear of the upper vagina. I use CT scans of the abdomen and pelvis and chest x ray to rule out distant recurrence in patients who offer new complaints suggestive of recurrence. In the absence of symptoms, my use of CT scans and chest x ray is restricted to the minority of patients with advanced stage disease or those at increased risk of recurrence by nature of an aggressive tumor cell type.
The tools frequently used to screen women with no symptoms of recurrence include routine pelvic examinations with or without vaginal Pap smears, pelvic and abdominal imaging tests, chest x ray, and the CA 125 blood test. It is my practice to see patients for scheduled visits every three months for the first two post-treatment years and then semi-annually thereafter. During these scheduled visits patients undergo careful full physical examination and a Pap smear of the upper vagina. I use CT scans of the abdomen and pelvis and chest x ray to rule out distant recurrence in patients who offer new complaints suggestive of recurrence. In the absence of symptoms, my use of CT scans and chest x ray is restricted to the minority of patients with advanced stage disease or those at increased risk of recurrence by nature of an aggressive tumor cell type.
New answer by KevinHolcombMD (Physician - OBGYN - Gynecologic Oncology (Verified))
1
Answer |
10 months ago
The term “adnexa” refers to the area of the fallopian tubes and ovaries. Therefore, an adnexal mass is usually a mass involving the ovary or tube. Masses arising from the uterus or other nearby structures can be referred to as an adnexal mass on physical examination or imaging studies as well. Adnexal masses are typically found either as an abnormality of the pelvic examination or by pelvic imaging ( ie pelvic sonograms, CT scans, or MRI). Some masses cause symptoms such as pelvic pain or increasing girth of the abdomen while others may cause no symptoms at all. Adnexal masses may be fluid-filled (“cystic”), solid, or mixed with cystic and solid areas. The risk of malignancy is heavily influenced by the age of the woman, the imaging characteristics, and the family history of cancer. Ovarian and fallopian tube cancer is largely a disease of postmenopausal women (average age is approximately 61 years) so an adnexal mass in a postmenopausal woman carries a higher risk of malignancy than a mass in a premenopausal woman. It should be noted, however, that the majority of adnexal masses in postmenopausal women are benign. Malignant adnexal masses share some common characteristics on pelvic sonograms. They tend to be larger than benign masses, contain both solid and cystic components with vascular flow in the solid areas, are more often bilateral, and occasionally are associated with free fluid (ascites). Many benign masses share these characteristics and this lack of specificity limits the accuracy of pelvic sonograms for determining the risk of malignancy. A strong family history of breast, ovarian, uterine, and/or colon cancer should alert the gynecologist to the possibility of a familial cancer syndrome that would also increase the risk of malignancy in an adnexal mass. Lastly, the majority of ovarian cancers produce a glycoprotein called CA-125 that can be measured in the blood and used to monitor the progress of an ovarian cancer patient during chemotherapy. Many clinicians will also use this serum tumor marker in an attempt to assess the risk of malignancy in an adnexal mass. It should be noted that its lack of sensitivity (only 50% of early stage ovarian cancer patients have an elevated CA 125 level) and specificity (many benign gynecologic and non-gynecologic conditions can elevate CA 125) limits its usefulness in this setting. Despite these limitations, the American Congress of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists have issued guidelines that instruct a general Gynecologist when it is appropriate to refer a woman with an adenxal mass to a Gynecologic Oncologist. These guidelines vary for pre and postmenopausal women and consider the physical findings, sonographic findings, the CA 125 levels. Recently, the Food and Drug Administration approved 2 new blood tests that have been proven to increase the accuracy of adnexal mass cancer risk assessment above the previously available tools. These tests are meant to aid in the triage of patients that are already scheduled for surgery to a Gynecologic Oncologist if they are determined to be at increased risk for cancer.
New answer by KevinHolcombMD (Physician - OBGYN - Gynecologic Oncology (Verified))
1
Answer |
10 months ago
The risk of lower extremity lymphedema from surgical staging of a gynecologic malignancy varies depending on the site of the nodal dissection (ie pelvic versus groin), the number of lymph nodes removed, the use of postoperative radiation therapy, and the incidence of postoperative infection at the site of the nodal dissection. The risk of lymphedema resulting from pelvic and paraaortic lymph node biopsies in cervical, endometrial, and ovarian cancer surgery ranges from 2-40% in the literature while the risk in women undergoing groin node dissection for vulvar cancer can be as high as 60%.
Efforts to develop techniques that identify the first lymph node group involved by a cancer (the “sentinel node”) have been underway for years in vulvar cancer and, more recently, for endometrial and cervical cancers. Sentinel node sampling involves injection of a dye, a radioactive tracer, or both into the tumor or organ and a directed biopsy of the first nodal group with uptake. Studies have proven that sentinel node sampling in vulvar cancer significantly reduces postoperative complications, including lymphedema, compared to the traditional groin node dissection. Unfortunately, the technique is best suited for women with small tumors that are limited to one side of the vulva, leaving a significant number of women who still require full nodal dissection. With regard to sentinel node sampling in endometrial and cervical cancer, emerging technologies are being developed to extend the technique to this setting as well.
One effort that has been suggested to limit the risk of lower extremity lymphedema in women undergoing pelvic node dissection is sparing of the most distal pelvic node group (commonly referred to as the circumflex iliac nodes). Retrospective studies support the efficacy of this practice. Limiting the use of postoperative radiation and the prevention of infection with preoperative antibiotics has also been employed with varying results.
Efforts to develop techniques that identify the first lymph node group involved by a cancer (the “sentinel node”) have been underway for years in vulvar cancer and, more recently, for endometrial and cervical cancers. Sentinel node sampling involves injection of a dye, a radioactive tracer, or both into the tumor or organ and a directed biopsy of the first nodal group with uptake. Studies have proven that sentinel node sampling in vulvar cancer significantly reduces postoperative complications, including lymphedema, compared to the traditional groin node dissection. Unfortunately, the technique is best suited for women with small tumors that are limited to one side of the vulva, leaving a significant number of women who still require full nodal dissection. With regard to sentinel node sampling in endometrial and cervical cancer, emerging technologies are being developed to extend the technique to this setting as well.
One effort that has been suggested to limit the risk of lower extremity lymphedema in women undergoing pelvic node dissection is sparing of the most distal pelvic node group (commonly referred to as the circumflex iliac nodes). Retrospective studies support the efficacy of this practice. Limiting the use of postoperative radiation and the prevention of infection with preoperative antibiotics has also been employed with varying results.
New answer by KevinHolcombMD (Physician - OBGYN - Gynecologic Oncology (Verified))
1
Answer |
10 months ago
The role of routine lymph node sampling in endometrial cancer care remains hotly debated. As I mentioned previously, the determinants of recurrence and survival in endometrial cancer include the tumor grade and depth of invasion of the uterine muscle (myometrium). These factors also predict the risk of spread to the pelvic and para-aortic lymph nodes. For example, a woman with a grade I endometrial cancer with invasion of only the inner 1/3 of the myometrium carries a 3% risk of a pelvic node metastases. Comparatively, a woman with a grade 3 tumor and myometrial invasion to the outer third carries a 30% risk of pelvic node metastases. These risks, however, are base on postoperative pathology findings and not an intra-operative assessment of tumor grade and myometrial invasion. As in any medical decision, the risk of missing a lymph node metastasis must be weighed against the risks of lymph node sampling, which include bleeding and postoperative lymphedema (swelling of the lower extremities).
There are three schools of thought with regard to the role of lymph node sampling in endometrial cancer. Some surgeons perform routine sampling of the pelvic and paraaortic lymph nodes for all patients, others biopsy only suspicious lymph nodes found at surgery or identified on preoperative imaging studies, while the remaining surgeons utilize some form of pre and intra-operative risk assessment to determine which patients are at risk for nodal spread and should undergo the procedure. Presently, I perform some level of lymph node sampling on all patients that are safe surgical candidates because I believe that lymph node data is useful for determining the need for postoperative therapy and I question the ability to accurately predict the risk of nodal spread pre or intra-operatively. The available literature has not brought clarity to this debate with some studies suggesting a benefit to lymph node sampling and others showing no benefit.
There are three schools of thought with regard to the role of lymph node sampling in endometrial cancer. Some surgeons perform routine sampling of the pelvic and paraaortic lymph nodes for all patients, others biopsy only suspicious lymph nodes found at surgery or identified on preoperative imaging studies, while the remaining surgeons utilize some form of pre and intra-operative risk assessment to determine which patients are at risk for nodal spread and should undergo the procedure. Presently, I perform some level of lymph node sampling on all patients that are safe surgical candidates because I believe that lymph node data is useful for determining the need for postoperative therapy and I question the ability to accurately predict the risk of nodal spread pre or intra-operatively. The available literature has not brought clarity to this debate with some studies suggesting a benefit to lymph node sampling and others showing no benefit.
New answer by KevinHolcombMD (Physician - OBGYN - Gynecologic Oncology (Verified))
1
Answer |
10 months ago
In the 1980’s, a large study was performed to identify the pathologic findings that truly influenced the risk of recurrence and the overall survival in endometrial cancer. Some easily determined uterine and extra-uterine factors were identified including the cell type, tumor grade, depth of invasion of the uterine muscle (myometrial invasion), metastases to the pelvic and para-aortic lymph nodes, and metastases to the fallopian tubes and ovaries. These findings ushered in the era of “surgical staging” of endometrial cancer, which had previously been staged by physical examination alone. Complete surgical staging requires a careful exploration of the abdomen and pelvis, a total hysterectomy, removal of both tubes and ovaries, and selective biopsy of the pelvic and para-aortic lymph nodes.
At the time, the only available mode of surgery to accomplish this staging was traditional open surgery (laparotomy). However, in the 1990’s improvements in laparoscopic equipment made it feasible to perform comprehensive staging without the large incision required for a laparotomy. Laparoscopic procedures (sometimes referred to as “keyhole” surgery) allow the surgeon to access the abdomen and pelvis through small incisions (usually 5-10 mm in diameter each). Because the uterus, cervix, tubes and ovaries can be removed through the vagina, there is no need for a larger incision. The first minimally invasive surgery to comprehensively stage endometrial cancer was a laparoscopic-assisted vaginal hysterectomy with removal of the tubes and ovaries and laparoscopic nodal sampling. Techniques for total laparoscopic hysterectomy and staging quickly followed. Presently, approximately 60% of endometrial cancers in the United States are managed via minimally invasive surgery, many utilizing robotic-assisted laparoscopy. Laparoscopy has been proven superior to laparotomy with regard to postoperative pain and recovery time in a number of clinical scenarios including endometrial cancer staging. The three to four day hospital stay following a laparotomy is typically reduced to one postoperative day for women that undergo minimally invasive staging. More importantly, the typical 6 week home recovery for laparotomy is routinely shortened to approximately 2 weeks for laparoscopy. Many studies have proven the equivalence of laparotomy and laparoscopy with regard to the risk of recurrence and survival in patients with endometrial cancer.
At the time, the only available mode of surgery to accomplish this staging was traditional open surgery (laparotomy). However, in the 1990’s improvements in laparoscopic equipment made it feasible to perform comprehensive staging without the large incision required for a laparotomy. Laparoscopic procedures (sometimes referred to as “keyhole” surgery) allow the surgeon to access the abdomen and pelvis through small incisions (usually 5-10 mm in diameter each). Because the uterus, cervix, tubes and ovaries can be removed through the vagina, there is no need for a larger incision. The first minimally invasive surgery to comprehensively stage endometrial cancer was a laparoscopic-assisted vaginal hysterectomy with removal of the tubes and ovaries and laparoscopic nodal sampling. Techniques for total laparoscopic hysterectomy and staging quickly followed. Presently, approximately 60% of endometrial cancers in the United States are managed via minimally invasive surgery, many utilizing robotic-assisted laparoscopy. Laparoscopy has been proven superior to laparotomy with regard to postoperative pain and recovery time in a number of clinical scenarios including endometrial cancer staging. The three to four day hospital stay following a laparotomy is typically reduced to one postoperative day for women that undergo minimally invasive staging. More importantly, the typical 6 week home recovery for laparotomy is routinely shortened to approximately 2 weeks for laparoscopy. Many studies have proven the equivalence of laparotomy and laparoscopy with regard to the risk of recurrence and survival in patients with endometrial cancer.
New answer by KevinHolcombMD (Physician - OBGYN - Gynecologic Oncology (Verified))
1
Answer |
10 months ago
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