Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Would you recommend PARP inhibitor maintenance for a BRCA wild-type, HRD+ advanced ovarian cancer?
We have a better understanding of ovarian cancer biology now, including the importance of germline and somatic BRCA mutations, as well as the role of homologous recombination deficiency (HRD) in tumors and the potential benefit of new therapies in the maintenance.Considerations for maintenance thera...
Should special precautions be taken patients with Ehlers-Danlos syndrome receiving radiation therapy?
Not all EDS is the same. Most commonly, an EDS patient these days is a clinically diagnosed patient with hypermobile joints, possibly stretchy skin, and possibly chronic pain syndrome. That is a very different picture from vascular EDS with a COL3A1 mutation, which is rare and would have the extreme...
Would you use immunotherapy in patients with HIV and a positive viral load?
Current guidelines do not recommend universal HIV screening before starting immune checkpoint inhibitors (ICIs). However, if HIV is known or suspected, patients should ideally be on antiretroviral therapy (ART) before initiating immunotherapy.Safety:Retrospective data from the CATCH-IT Consortium (E...
How do you sequence chemotherapy with radiotherapy for advanced endometrial cancer?
Unfortunately, we don’t even know for sure if we need RT for stage III disease.GOG 258 showed early concurrent chemo RT is no better than chemotherapy alone (delaying chemo increased distant mets, which probably negated locoregional control benefit of RT). For this reason, chemotherapy has become st...
Is there any role for PARPi maintenance in BRCA-/HRD- patients after response to front line chemotherapy +/- bevacizumab?
This is a more complex question, and relies on a conversation with the patient and shared decision making. Unfortunately, the benefit seen with PARPi maintenance in BRCA-/HRD- patients was limited (PRIMA 8.1 vs. 5.4 months; PAOLA-1 16.9 vs. 16 months). I am also sensitive to implications of incorpor...
If an anatomical defect forms due to rapid disease response from pelvic radiation for large gynecological tumors, is it safe to proceed with a further radiotherapy boost?
I would proceed with brachytherapy as planned. For a fistula, if symptomatic, would consider diversion - bilateral nephrostomy or diversion colostomy as needed. Brachytherapy would treat the involved bladder or rectal wall to a therapeutic dose without any needles in the tissue, thereby avoiding any...
How would you treat an isolated para-aortic recurrence while receiving adjuvant pembrolizumab after definitive chemoradiation for cervical cancer?
If the patient has failed while on pembro, I would favor holding/stopping IO and plan for definitive chemo-RT to the para-aortic region with SIB boost with weekly cisplatin.
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
What is your general approach to PARPi usage in the front-line and recurrent ovarian cancer setting in light of FDA label changes over the years?
In the frontline setting, I generally recommend PARP inhibition with olaparib x2 years for BRCAmut patients (1) and with niraparib x2-3 years for patients with HR-deficient tumors (I personally tend to do 2 years, based on SOLO1 data with olaparib) (2). For BRCAwt patients with HR-proficient tumors...
Do you routinely recommend completion hysterectomy with contralateral salpingo-oophorectomy for patients with a history of fertility-sparing staging for borderline tumor of the ovary who have since completed childbearing?
Borderline ovarian tumors, also known as atypical proliferative tumors by WHO classification, account for about 10-20% of epithelial ovarian tumors, have histologic subtypes similar to invasive ovarian cancer, and are characterized pathologically by a high degree of proliferation of the epithelial c...