Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How do you decide until what age to offer ovarian preservation for patients with biopsy-proven grade 1 or grade 2 endometrial cancer without evidence of metastatic disease on imaging or at the time of surgery?
I often reference Jason Wright's article evaluating the safety of ovarian preservation up to age 45 regarding cancer-related mortality. Granted, this doesn't measure recurrence rates. I also reference Dr. Barakat's incomplete GOG study (a casualty of the WHI study) that found only ~2-3% of patients ...
How would you treat bilateral groin recurrence of vulvar small cell neuroendocrine carcinoma in a patient who has previously had pelvic and groin radiation?
I would start with chemo-immunotherapy, like in pulmonary small cell, as this is likely to be the tip of the iceberg. If no prior groin surgical exploration, this can be considered by gyn/onc. If not, I would consider focal reirradiation of any residual disease after chemotherapy during IO maintenan...
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In general, how do you manage patients with early-stage endometrioid endometrial cancer who have concomitant POLE and TP53 mutations?
Based on published outcome data, double mutation is uncommon, and the outcome is driven by the better of the two mutations. So in the above situations, POLE type and not TP53 type will drive outcome and treatment decisions. That’s why in molecular-based decisions, it is important that the POLE type ...
How have you incorporated ctDNA into the clinical management of patients with gynecologic cancers?
ctDNA certainly is increasing rapidly in oncology and has been led by several other disease sites. I think right now, GYN oncology is figuring out how to incorporate this in our care to meaningfully impact our patients. I have not incorporated ctDNA in my practice routinely, but do see the role of i...
What, if any, adjuvant treatment do you offer a a patient with stage I clear cell endometrial carcinoma?
Clear cell carcinoma is a rare tumor with sparse literature regarding its adjuvant treatment. There is a recent SGO review article on this topic that is a nice reference. For stage I uterine clear cell, there are no prospective studies to study the impact of adjuvant chemotherapy and/or radiation. H...
When do you consider re-irradiating patients with recurrent cervical cancer?
Because I have been seeing and treating a reasonable number of these cases for 35 years, I have some strong opinions on the matter. Although external beam re-irradiation in the setting of recurrent cervical cancer is fraught with great hazards and poor outcomes, interstitial re-irradiation has a hig...
Despite the paucity of strong data showing benefit of chemotherapy + radiotherapy in patients with stage I-II high risk histology endometrial cancer, if you recommend treatment with both modalities, how do you determine treatment schedule?
For the purpose of this answer, I'll define high risk as serous, carcinosarcoma, undifferentiated, and dedifferentiated. Clear cell carcinoma can be considered and likely treated more by its molecular profile. As you indicate, there is little data to support the routine use of chemotherapy for FIGO ...
How would you utilize brachytherapy boost in addition to EBRT for HPV-dependent invasive squamous cell carcinoma present as a large pelvic side wall mass, presumed to be of cervix primary, albeit the negative biopsies of the cervix?
I have had one P16+ SCC of Unknown Primary that presented as a solitary pelvic sidewall mass/node, no FDG avidity outside of that region, who had a full gynecological evaluation. First things first, ensure a thorough anorectal evaluation to rule out an anal primary. I would treat with a focus on uni...
How do you explain progression free survival to patients?
This is a really, really important question. I'd argue we often greatly undervalue the importance of communication with our patients and the impact the quality of our communication has on what they understand about their illness. I remember once having a long conversation with a patient where I outl...