Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Can you continue checkpoint inhibitor therapy in the setting of severe cutaneous irAE while concurrently treating the cutaneous reaction?
Cutaneous reactions from immune checkpoint inhibitors (ICPi) generally fit into 3 categories: rash/inflammatory dermatitis, bullous dermatoses, and severe cutaneous adverse reaction (SCAR). For grade 1-2 rash/inflammatory dermatitis, if symptoms can be managed with topical therapy or non-steroidal o...
Do you initiate management of new onset diabetes in a patient on immunotherapy or refer immediately to endocrinology given the risk of rapid worsening?
New onset hyperglycemia during ICPi therapy warrants careful review of potential risk factors for type 2 diabetes mellitus (T2DM) and close monitoring of symptoms and lab results to distinguish from the rare and typically more threatening checkpoint inhibitor-associated diabetes mellitus (CIADM). Ne...
What is your preferred steroid sparing therapy in a patient experiencing a severe checkpoint inhibitor toxicity and not responding to high dose IV steroids?
There are likely two different questions here: 1) For patients who have responded to steroids, but are unable to taper off (or to a minimally acceptable chronic dose), I have favored mycophenolate as a steroid sparing agent. 2) For patients with severe pneumonitis that is refractory to steroid ther...
How do you approach treatment for ovarian carcinosarcoma that has progressed during adjuvant carboplatin, paclitaxel, and bevacizumab following optimal tumor reductive surgery?
Recurrent ovarian carcinosarcoma (OCS) is a difficult clinical scenario with few evidence-based options. Clearly, a need exists for novel therapies, and a frank discussion on treatment goals and expectations is warranted. Ovarian carcinosarcoma (OCS) is a rare histologic subtype of ovarian cancer ac...
How would you treat an adenoid cystic carcinoma (well-diff, +extensive PNI) of the vulva s/p excision with positive margins?
Great question. I would not necessarily ask for re-excision, as I don't think it will change the recommendation for post-operative RT to the vulva. There does need to be some kind of inguinal node assessment, and PET is an acceptable approach if the nodes were not sampled or dissected. If PET is neg...
Would you administer pelvic radiation therapy to a post-menopausal patient with locally advanced carcinosarcoma with high risk features s/p TAH/BSO with a vesico-urethral fistula that would be in the radiation therapy field?
Although the role of adjuvant RT in uterine carcinosarcoma is unclear, it does appear that local control is enhanced. So my answer depends on "how high risk is high risk?". The question suggests that the risk of local recurrence is quite high ("locally advanced" is the descriptor), so I do think it ...
When would you hold anticoagulation medications in patients undergoing a tandem and ovoid/ring?
We usually don’t hold unless planned for hybrid with needle placement. We would make sure sonogram is available for placement of tandem to avoid false track.
What is the best way to approach adjuvant therapy for a FIGO Stage IIIB clear cell carcinoma of uterus s/p TAH BSO, with pathology showing extensive involvement of LUS, the cervix, and bilateral parametria with positive parametrial margins?
I wound get MRI imaging for pelvis to rule out gross disease and assuming staging is negative, would favor chemo RT to 50.4 Gy if not gross residual disease, followed by vaginal brachy boost and then additional chemo.
Are there known biomarkers predictive of IRAEs?
While there are no FDA-approved biomarkers predictive of iAEs, there is a growing body of preclinic and retrospective research trying to address this important question. Eosinophilia may be a potentially useful biomarker and this is supported by several retrospective studies 1,2. It is intriguing th...
Would you give checkpoint inhibitor therapy to a cancer patient with known dermatomyositis given the association of checkpoint inhibitor associated myocarditis, myasthenia gravis, and myositis?
I think the dermatomyositis could be more paraneoplastic that would actually benefit from controlling the cancer with ICI. I would give the treatment but I would carefully follow-up the patient for any irAEs. I will also document the rheumatological assessment, CPK, and myositis panel before startin...