Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
When is it too late to start PARP manitenance after adjuvant chemotherapy in BRCA mutated ovarian cancer who had a delay in completing genetic testing?
Niraparib's prescribing information specifies that in the first-line maintenance setting, patients should start treatment no later than 12 weeks after their most recent platinum-containing regimen. In the setting of maintenance after recurrent ovarian cancer, treatment should start no later than 8 w...
How would you approach post op management of a patient s/p BSO for cystic pelvic mass with fallopian STIC lesion on final pathology?
This is a great question! There are no definitive management criteria for patients with isolated serous tubal intraepithelial carcinoma (STIC) lesions. The incidence at the time of risk-reducing salpingo-oophorectomy (RRSO) ranges from 0.6 to 7% in women with BRCA1/BRCA2 mutations. In patients under...
How would you manage a patient with profound dyspareunia after pelvic radiation for anal cancer?
Thanks for bringing up this important topic that remains understudied, with historically widely underestimated incidences of post-radiotherapy dyspareunia. There is currently no standardized method or schedule for assessing post-treatment sexual dysfunction including vaginal stenosis and fibrosis (a...
Would you consider adjuvant chemotherapy in a young patient with stage IC1 Sertoli-Leydig cell tumor, moderately differentiated, with heterologous (rhabdosarcomatous) component and retiform elements?
This young patient has several high-risk criteria for recurrence. Thus, I favor offering her adjuvant systemic platinum-based chemotherapy with 6 cycles of carboplatin + paclitaxel.Background:Sertoli-Leydig cell tumors (SLCTs) are sex-cord stromal tumors and account for less than 0.5% of primary ova...
What adjuvant therapy would you offer for an incidental endometrioid adenocarcinoma of the ovary noted on LSO, who has only a 3mm residual disease on peritoneal biopsy from completion staging?
As I read your question, I interpret this as saying that besides the ovary, the only site of disease after complete surgical staging was a biopsy obtained of the peritoneum? If this is the case, i.e., the patient has > stage I disease, I would proceed with adjuvant platinum-based chemotherapy.
How do you approach the pharmacologic management of cancer-related fatigue?
After the above considerations mentioned in the question, management considerations regarding cancer-related fatigue depend on the stage of disease (advanced/metastatic disease vs not) and whether the patient is on active cancer therapy. For both groups, non-pharmacologic interventions have the high...
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...