Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How do you incorporate diagnostic laparoscopy for interval debulking surgery?
The goal at interval debulking is to optimally cytoreduce disease burden. My patients undergo standard workup prior to planning interval debulking surgery, which includes a physical exam, measurement of CA125, and imaging. These standard diagnostic tests are useful but are not always predictive of t...
In a patient with squamous vulvar cancer previously treated with cisplatin and radiotherapy and now with widely metastatic recurrence, would you initiate treatment with chemotherapy or consider immunotherapy?
This is a difficult case, and the literature on systemic treatment options in metastatic vulvar cancer is sparse. I would check for PDL1, MMR as you have done. In addition, I would also test for NTRK gene fusion. A next general sequencing panel such as CARIS or Foundation One is useful in these sett...
Is radiation therapy a treatment option for refractory Paget's disease of the vulva extending onto skin of buttocks and anal margin?
I have treated localized peri-anal Paget's Disease with good outcomes, and there is some data to support this. I have not treated a patient with such widespread vulvar Paget's and I suspect that the morbidity would be significant given the doses required, and the volume to be treated in the case you...
How do you approach treatment of vulvar cancer with bulky lymph node metastasis?
PET CT. Plan definitive chemo (weekly cisplatinum) with IMRT, with a dose of about equivalent dose of 66 Gy to GTVs. Reassess after 6-8 weeks for excision or bx of any residual disease. Dose-Escalated Intensity Modulated Radiation Therapy in Patients with Locally Advanced Vulvar Cancer- Does It Incr...
Are you offering PARP inhibitor alone or both PARP inhibitor and bevacizumab maintenance for HRD+ ovarian cancer patients after upfront treatment?
If already giving bevacizumab for tumor-related reasons at initial presentation, would continue to maintain and add parp inhibitor, however, otherwise would use avastin later at recurrence, typically.
Is it safe to treat checkpoint inhibitor-induced arthritis with methotrexate or biologics?
How the safety of methotrexate or biologics compares to long term steroid use to treated checkpoint-inhibitor inflammatory arthritis has not been determined. With that said, steroids can have deleterious effects on the tumor response in addition to all the other known side effects. Therefore, for pa...
Would you offer adjuvant therapy for a patient with stage I high risk invasive mole after hysterectomy?
Great question! For this patient’s unique situation, although adjuvant chemotherapy is entirely appropriate, I believe it may not be necessary. The decision to offer adjuvant therapy may be cautiously delayed pending her immediate post-hysterectomy hCG levels. If there is a rapid decline in hCG, obs...
How do you approach interval cytoreductive surgery in patients with epithelial ovarian cancer requiring 6 or more cycles of neoadjuvant chemotherapy?
I think this is a really hard question. It obviously depends on why they've gotten 6 cycles of neoadjuvant chemotherapy. If they had medical problems that delayed surgery, then an interval debulking procedure makes sense. If they have progressive disease, then they are unlikely to ever be a candidat...
What is your treatment approach to a young woman with widely metastatic low grade endometrial stromal sarcoma not amenable to complete cytoreduction?
Widely metastatic low-grade ESS in a young woman is quite rare - would suggest pathology confirmation as a first step along with cytogenics/to evaluate for diagnostic fusions in this entity. Is the pattern in the abdm/pelvis? Or are there lung or other mets as well? The most effective approach/guide...
What pre-treatment findings on CT scan (if any) influence your concern for GI perforation risk with bevacizumab use in ovarian cancer patients?
This is really a two parts question. The first question would be, do you offer bevacizumab to all your ovarian cancer patients and the second question would be what patients would you not recommend bevacizumab because of concern for bowel perforation? Based on findings from GOG218 and ICON7, I only ...