Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What doses would you treat the primary and lymph nodes in node positive vulvar cancer patient with incidentally found focal SCC in a field of VIN3?
I would treat the primary and inguinal nodes if no additional surgery and SNLN planned. Dose to primary is a function of microscopic or macroscopic disease left behind: 54-56 Gy if microscopic but 60 or above if macroscopic.
What interventions besides lubricants do you advise to improve sexual satisfaction for patients s/p ChemoXRT for cervical cancer?
Advise a multimodal approach Additional strategies: 1) Vaginal dilator therapy. Additional visits outside of follow-ups may improve adherence 2) Vaginal moisturizers - Replens, Vitamin E oil, etc. This is outside of water-based lubricants during sexual activity 3) Topical estrogens (many of these pa...
How do you decide when to offer post-operative adjuvant treatment for a stage IC1 ovarian granulosa cell tumor?
The postoperative management of stage IC granulosa cell tumor of the ovary remains controversial. In early-stage granulosa cell tumors, the major factors that have been studied in terms of risk of relapse have included tumor size, nuclear atypia, mitotic count, and rupture. Unfortunately, there is n...
How do you manage BRCA wild-type patients with an incidental STIC found at the time of an opportunistic salpingectomy?
I would consider having the pathology reviewed to be sure they agree with STIC, and also that they do not see invasive cancer. I would make sure the patient has had comprehensive genetic testing, as we have seen STICs even with non-BRCA genes. Regardless of genotype, but depending on the age of the ...
How do you manage maintenance therapy in BRCA wild type patients who have undergone primary surgery and achieved an optimal/complete gross resection?
I do not personally utilize maintenance bevacizumab in the upfront setting for wtBRCA patients who had primary optimal resection as I do not think the small PFS benefit demonstrated in GOG 218 and ICON 7 (evaluating use of maintenance bev vs no maintenance) justifies the additional cost and morbidit...
Do you consider tumor mutation burden as a possible biomarker for response to immune checkpoint therapy in the second line setting for cervical cancer?
According to NCCN guidelines, pembrolizumab could be used as a second line therapy for tumors that are PDL1 positive, can be categorized as MSI-high (high microsatellite instability), or are deficiency in mismatch repair (Le DT, et al. Mismatch repair deficiency predicts response of solid tumors to ...
How long would a vulvar cancer s/p definitive chemoradiotherapy, how long should the lesion be followed for regression before initiating biopsy or salvage surgery?
There is no prospective data but our practice is to perform once the acute reactions subside, usually 6-8 weeks after chemo RT.
Would you recommend EBRT/brachythrapy for any patients with stage III- IV uterine ca in light of GOG-258 data?
GOG-258 will certainly change management approach. The recurrence pattern between the two arms (higher distant mets in chemo RT arm and higher locoregional recurrence in chemo alone arm) suggests that sequencing of treatment may also matter. Our current approach is to have chemotherapy first and con...
What is your preferred sequence of chemotherapy regimens after patients with metastatic endometrial cancer develop resistance to carboplatin + paclitaxel?
This is a bit of an 'it depends' answer. If the patient has large volume disease or is highly symptomatic I will generally switch to liposomal doxorubicin. However, if the patient has more minimal disease, disease that is not imminently dangerous (nodal disease, pulmonary nodules) I will use endocri...
Would you offer radiotherapy or chemotherapy a patient with cervical cancer s/p radical hysterectomy and now a delayed metastasis to the ovary that was completely resected without tumor spill?
I agree with everything said so far. Extremely rare situation. I suppose I would add that the devil is sometimes in the details. Age? How far out from hysterectomy? was the ovary large? Difficult dissection that might suggest disease left in adjacent tissues? Also important to check with the patholo...