Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
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...
What is optimal timing or sequencing of therapy for patients with synchronous locally advanced triple negative breast cancer and ovarian cancer with peritoneal carcinomatosis?
Because delays in surgical healing can affect initiation of chemotherapy in ovarian cancer, I would consider neoadjuvant therapy for both the ovarian and breast cancer. Alternatively, one could do debunking surgery and then chemotherapy. I would recommend carboplatin q 3 weeks with taxol weekly x 6 ...
For metastatic small cell cervix cancer, would you consider adding immunotherapy up front (per a small cell lung cancer paradigm)?
I agree that it is "not unreasonable." It is also reasonable NOT to give it. Given that these agents can have their own toxicities, which can be significant, and the potential benefit is certainly not a "home run" (and the cost is enormous) I would not add an immunotherapy agent at present.
Would there be any contraindication to whole pelvic RT for a patient with an ax-bifem bypass & the graft crosses the lower abdomen within the RT field?
I am not aware of any contradiction and have treated patients with peripheral bypass
Would you consider radiation therapy for ovarian dysgerminoma with residual lymphadenopathy after chemotherapy?
I would not as behavior like seminoma and most of the time turns out to be a desmoplastic reaction. You can consider a PET/CT as it has high negative predictive value. But if pet positive, it could be false positive and would monitor with serial imaging rather than treat and, if needed, consider for...