Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you consider MSI testing for nonserous ovarian cancer?
I do, but with the understanding that PD1/PDL1 expression, MSI/MMR is less well documented than in high grade serous cancers. Meagher et al has a nice article in Gyn Oncol 2018 looking at molecular profiling in 333 mucinous lesions. Common mutations noted were KRAS (60%), TP53 (38%), and HER2 in up ...
Should I wear gloves during a routine physical exam on an asymptomatic patient with no risk factors for COVID-19?
As per FAQ’s posted by ASTRO: There is no reason to do so at this time. Be vigilant re: hand hygiene and wiping down any equipment that touches the patient (stethoscope, etc.). Additionally, any equipment that touches mucosa/secretions of the patient must be sterilized (rhinolaryngoscope, etc.). For...
In the setting of vulvar cancer, do you perform complete inguinal lymphadnectomy when inguinal sentinel nodes demonstrate micrometastatic (<2mm) disease?
Knowing the status of the groin nodes is critical in vulva cancer, as it has important prognostic value and is considered when tailoring adjuvant therapy. Methods chosen to assess the groin must consider morbidity vs. accuracy. I favor imaging patients pre-operatively with PET/CT if and when possibl...
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 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...