Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
In patients treated with the KEYNOTE A-18 regimen who later recur, would you rechallenge with immunotherapy again?
Limited data in this clinical scenario. Per A18 (Lorusso et al., PMID 38521086), 32 patients received ICI as post-progression therapy, 25 of whom received Pembro. I am unable to find in the supplements whether those were patients from the placebo arm or from the pembro arm.I think if the patient rec...
If a patient with locally advanced cervical cancer cannot receive brachytherapy following 45Gy to the whole pelvis, how do you optimally deliver your boost?
One should be very cautious, as in our experience the situation where you can't do brachytherapy is very rare. There is a trend in the country to use a non-brachytherapy boost as it is more accessible but this approach can lead to worse outcomes. See Dr Viswanathan's paper recently published in the ...
For a patient who has vaginal cuff recurrence <6 months after adjuvant pelvic radiotherapy to a dose of 45 Gy, how would you approach management?
If amenable to a potentially curative brachytherapy approach, I would generally want to do this first and then give systemic treatment. The risk of local progression during systemic treatment is significant, and if this occurs, the patient has often lost the chance to be cured. However, if the decis...
Is there still a role of brachytherapy in uterine cancer if intensity-modulated radiation therapy is available?
Yes. Brachytherapy is still more conformal than optimally planned IMRT.
Would you offer post operative radiation for a patient who had findings of lymphovascular invasion on salvage resection of a recurrent obturator node after definitive chemoradiation for cervical cancer?
If no gross disease and has had previous RT, I would favor no additional RT.
What is your preferred adjuvant chemotherapy regimen after a completely resected stage IIIB Granulosa Cell tumor of the ovary?
Recommendation: Patients undergoing surgery with complete resection of tumor for an ovarian granulosa cell tumor (GCT) may be offered systemic chemotherapy or observation. If chemotherapy is offered, I prefer a combination of carboplatin and paclitaxel. Background: GCT of the ovary is the most commo...
For patients with ovarian cancer, do you order folate receptor-alpha testing at initial diagnosis, first recurrence, or first instance of platinum resistance?
I usually order at initial diagnosis because: We have tumor specimen to test on at the initial dx Most advanced ovarian cancer will recur initially as platinum-sensitive. But eventually, most of the patients will become platinum-resistant I have not seen convincing data that folate receptor changes...
What would you offer a patient with MSI-high metastatic endometrial cancer after disease progression on pembrolizumab?
It appears that it has been two years since the last platinum therapy (progressed after 1 year, then on immunotherapy for one year) so it's very reasonable to consider the use of platinum-based chemotherapy again, an option could include platinum + taxane + bevacizumab to add a targeted therapy to t...
How would you manage a recurrent cervical cancer previously treated with vaginal cuff brachytherapy and has had a complete response to chemo-immunotherapy?
Ling et al., PMID 30600093 -The paper gives our philosophy in this scenario. The total dose is the function of dose to target and cumulative dose to rectum and bladder. To be able to give a higher dose with brachy, generally would favor around 30.6 Gy with EBRT and then limit the last 14.4 Gy to the...
How would you treat a p16+ squamous cell carcinoma confined in the recto-vaginal septum with no suspicious adenopathy on PET or MRI?
Early vaginal or anal cancer still has relatively high rates of lymph node involvement. In vaginal cancer, T1 lesions have lymph node involvement rates of 5 - 15%. In anal cancer, T1 lesions have a higher rate of 5 - 50%. If there are no mucosal changes then it is possible this is an in-transit LN f...