Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
For an elderly woman with a platinum-resistant recurrence of a high-grade serous ovarian cancer who has been rendered NED surgically, is observation a reasonable approach?
Based on her age, performance status, and goals of care, it is certainly reasonable to discuss all options with patients. With her being platinum resistant, I would counsel on prognosis and the need to consider quality of life. With the need for balance between QoL and OS, waiting until there is a m...
How do you manage patients with germline BRCA mutations who have STIC lesions found at the time of risk-reducing BSO?
How do you manage patients with germline BRCA mutations who have STIC lesions found at the time of risk-reducing BSO?Most experts agree these are worrisome lesions, likely precursors to high-grade serous carcinoma (HGSC). It is also biologically plausible that the presence of serous tubal intraepith...
How do you factor a decreasing but persistently elevated CA-125 into your decision regarding whether to proceed with interval cytoreductive surgery for PAX8+ high-grade serous cancer s/p neoadjuvant chemotherapy with minimal disease on imaging?
I don’t let the CA-125 influence my decision to perform interval debulking. If the patient has had a good radiologic response to neoadjuvant chemotherapy and has minimal disease on imaging, I proceed with interval debulking with the goal of an R0 resection regardless of the CA-125.
How would you evaluate the role for adjuvant radiation in a very young female (20s) with a localized vulvar SCC, HPV independent, status post hemivulvectomy?
Either re-excision or observation provided no dVin at margin and at least a 3 mm negative margin for invasive disease.
Would you offer systemic chemotherapy to a patient with at least 2023 FIGO stage IC high grade serous (p53-mut) endometrial cancer with extensive LVI for whom nodal assessment was not done?
This question was addressed in a large NCDB study in 2020 by Nasioudis et al (Nasioudis et al., PMID 32675056) who looked at USC confined to the endometrium, which found that 5-year OS was 91% for chemo alone, 91% for chemoRT, 85% for those who received radiation alone, and 82% who were observed. Ad...
Does the path length of vaginal cuff cylinder brachytherapy treatment as adjuvant therapy for endometrial cancer vary based on histology (serous, etc)?
There was some thought that treatment of high risk histologies, positive LVI, or high Grade required a longer vaginal length be treated. Including 2/3 or full length. That is largely unsupported by high-quality data and would increase distal vagina toxicity in this population. Our clinic treats uppe...
How would you approach a patient who is unable to undergo the recommended ophthalmologic examinations during treatment with mirvetuximab soravtansine?
Until more data are available regarding the ocular safety and reviewed by the agency, I follow the recommendations. I feel there is a decent chance real-world experience may change this but officially I follow the recommendations as stated. Having said this, the testing recommended (“Conduct an opht...
Would you ever consider pelvic exenteration followed by SBRT for a patient with recurrent cervical cancer (s/p chemoRT) who has disease only in the central pelvis and in a single hilar lymph node?
I think this is a tough question. The short of it would be that I would be very cautious with exent candidacy with extra-pelvic disease. The surgical morbidity and limited ability to get additional therapy are a reality. Scenarios where I might consider would be a long duration of time off therapy. ...
How do you manage a cervical cancer patient on anti-coagulation for pulmonary embolism requiring interstitial brachytherapy boost?
Have done with IVC filter and switch to heparin days prior to the procedure so that can hold anti coagulant for the procedure and epidural placement for analgesia.
With vaginal cuff brachytherapy, do you treat to the surface or a depth and why?
We prescribe to the surface of the vagina but also attend to the dose at depth. For patients receiving only vaginal cuff irradiation we use a prescription of 6 Gy VSD x 5 qod. Although this is a modest dose, it appears to be very effective in preventing vaginal recurrences, even in high-risk cases. ...