Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How would you approach adjuvant therapy for a fully resected vulvar carcinoma with a single positive lymph node?
There is not a simple answer to this question. In most cases, omitting adjuvant therapy is appropriate, but in certain cases, adjuvant radiation therapy + chemotherapy is advised, even in the presence of only a single positive lymph node. It has been over 30 years since Homesley and co-workers’ 1986...
For a BRCA1+ patient with a history of stage IVB endometrioid ovarian carcinoma s/p upfront surgery and adjuvant chemotherapy who has now completed 3 years of maintenance niraparib and is NED, how would you counsel about discontinuing vs continuing PARPi therapy?
Recommendation: I recommend that this patient with Stage IVB ovarian cancer, with a complete response to surgery, chemotherapy, and 3 years of maintenance PARPi, be counseled to discontinue niraparib.Background:The duration of therapy for primary maintenance PARPi should be tailored based on the ass...
Are there circumstances where you would recommend every 6 week dosing schedule for pembrolizumab monotherapy?
FDA approval for q 6 week dosing of pembrolizumab is awaited but has yet to occur; this would represent a welcome change for our patients, as just happened with the recent approval of q 4 week dosing of atezolizumab. Without FDA approval we are not using pembrolizumab 6 week dosing at this time, and...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
In light of DESKTOP III, how will you approach secondary debulking for platinum sensitive epithelial ovarian cancer patients?
Well, it certainly does make things interesting. GOG 213, reported in the NEJM (Coleman RL et al., NEJM 2019), was a similar randomized phase III trial and included patients with resectable platinum sensitive recurrence who were randomized to secondary cytoreduction + chemo, vs chemo alone. The inve...
How should you manage a COVID-19 infected/suspected patient who is receiving chemotherapy and cannot interrupt or delay their cancer treatment?
This is difficult to answer specifically without further details. There certainly is accumulating evidence that patients with cancer, especially those receiving immunosuppressive chemotherapy, are at greater risk of COVID-19 infection if exposed, and a greater risk of serious and life-threatening co...
Is pembrolizumab considered standard of care in the 2nd line treatment of recurrent cervical cancer?
The phase II Keynote-158 indication is based on objective response of 14% in patients with PD-L1+ tumors. The US FDA approval is accelerated approval meaning that there needs to be a confirmatory trial - this is Keynote 826 which is ongoing.
For early-stage vulvar cancer that is clinically/radiographically node negative with no surgical lymph node evaluation (e.g., patient or surgeon refusal), would elective nodal irradiation be reasonable in the absence of risk factors warranting treatment to the primary site?
It depends on the a priori risk of nodal involvement based on tumor size, depth of invasion, LVSI, etc. If the risk is high enough, we can consider vs close observation with ultrasound or PET/CT.
When do you recommend PD-L1 testing for patients with recurrent cervical cancer?
I think getting the testing done as soon as possible is best because very few patients will only need first line therapy. This way, there is less of a delay at the time of progression following/during first-line therapy.
When do you choose dose-dense chemotherapy v. q3 week therapy in advanced epithelial ovarian cancer?
In our recent OGR, we suggested an approach to deciding which patients might be appropriate for considering the dose-dense regimen in the first line setting (Figure 2). The dose-dense JGOG regimen was shown to confer an overall survival advantage in newly-diagnosed patients with advanced disease (es...