Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
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...
How do you discern whether elevated liver enzymes are from immunotherapy versus chemotherapy when a patient is on combination chemo/immunotherapy?
There is no consensus on the best method for distinguishing the cause of elevated liver enzymes in patients being treated with ICPi's when combined with various chemotherapies. Important considerations include time of onset, severity, and presence of hepatobiliary metastases. Hepatotoxicity from ICP...
Do you consider younger patients with NF2 to have a relative contraindication to radical pelvic RT due to risk of secondary malignancy?
Yes, I would consider NF2 to be a relative contraindication in a young patient. In the situation presented (borderline indications for post-op RT), I would likely lean toward up-front radical hysterectomy. However, if clear indications for post-op RT are present following surgery, I would not hesita...
How do you manage metastatic breast cancer to the uterus/ovaries that is symptomatic?
Management would be based on overall disease status, performance status, systemic treatment options, and expected survival. It tends to be seen more so in lobular carcinoma. Options could be from surgical debunking to quad shot based on the above.
When do you refer patients for germline testing when somatic tumor testing is negative for actionable mutations?
Somatic (tumor-only) testing should not be used to conclusively rule in or rule out the presence of a germline pathogenic/likely pathogenic alteration. While most germline sequence alterations (point mutations, small insertions/deletions) will be detected on tumor-only testing, this may miss chromos...