Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What upfront maintenance therapy would you recommend for a BRCA negative, advanced epithelial ovarian cancer patient after completing adjuvant carboplatin, paclitaxel, bevacizumab?
Without knowing the somatic genetics, I’d recommend niraparib. If she was BRCA+ or HRD+ by somatic testing, I’d consider Olaparib plus bevacizumab.
How would you treat metastatic squamous cell carcinoma arising from a mature cystic ovarian teratoma?
There is a lack of established guidelines to treat patients with metastatic squamous cell carcinoma arising from a mature cystic ovarian teratoma (MCT-SCC). In the absence of a clinical trial, this patient should be offered platinum-based chemotherapy. Next generation sequencing (NGS) should also be...
How do you manage intracranial metastases from gestational trophoblastic neoplasia?
High risk gestational trophoblastic neoplasia with brain metastases is rare, and treatment has evolved over the past few decades and centered on multi-agent chemotherapy. The most well-cited regimen is EP-EMA (etoposide, 150 mg/m; cisplatin, 75 mg/m, intravenous, day 1; etoposide, 100 mg/m; methotre...
Do you obtain somatic genomic testing for ovarian cancer patients that test negative for gBRCA mutation?
Yes. There are patients who will have somatic BRCA mutations, but not germ line mutations.
Do you routinely prescribe anticoagulation for patients on active chemotherapy?
This is dependent on the risk factors of the patient for the development of VTE. Recently published ASCO guidelines (JCO 2019) incorporated the additional recommendation of VTE prophylaxis for high risk outpatients receiving chemotherapy with either eliquis, xarelto, or LMWH. The Khorana scoring sys...
How are you counseling HR-proficient ovarian cancer patients about front line PARP inhibitor maintenance?
I think this is a tough decision, but I recommend observation for patients with HR proficient disease. In brief, I don't find a PFS advantage, without a proven OS advantage, enough to justify this long-term, expensive, and not non-toxic treatment.For BRCA carriers the answer is easier—with SOLO2 (20...
How do you clearly communicate to parents that the main purpose of a phase I trial is to find the best dose of a new drug with the fewest side effects rather than treating the patient's cancer?
Just with any communication, check first to see what their understanding is. Then, see if they are ready to hear what you have to say. Say it and then have them repeat it. When discussing trials, this conversation occurs over more than once. At the first conversation, one may be trying to lay out op...
Which modality of RT is most appropriate for a patient with pT3N0(sn) endometrial cancer?
For T3b, I favor EBRT plus brachy as to target disease extending to parametria or vagina. For T3a with isolated adnexal involvement and favorable intrauterine factor, she would get chemotherapy for stage IIIA disease. In the past I used to offer EBRT after chemotherapy but now, if the patient is su...
How do you approach the decision of whether and when to initiate therapy in patients who remain COVID-19 positive >2 weeks after infection but are asymptomatic from the virus?
If the patient is asymptomatic or minimally symptomatic, we have elected to initiate therapy for the patient. We have treated the patient in full PPE at the end of the day with no other patients in the clinic. Efforts should be made to minimize patient contact throughout the clinic. We have the pat...
Is there a role for minimally invasive surgery in patients undergoing an interval cytoreductive surgery?
Yes! There is data supporting the feasibility. In the MISSION trial 82 women showed a complete clinical response to neoadjuvant chemotherapy (NACT). Of that, 30 were excluded for BMI >40 and/or ASA category III/IV. Of the 52 patients enrolled, 22 were undergoing laparotomy approach to interval debul...