Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
In light of the ongoing GOG 263 trial, do you consider adding concurrent chemo with RT for early stage cervical cancer as adjuvant after Rad Hyst off trial?
Adjuvant treatment is indicated after radical hysterectomy if pathologic risk factors are discovered. The GOG 92 trial with node negative intermediate risk patients had recurrence free survival rates of 88% for adjuvant RT versus 79% for the no treatment group. Longer term follow up shows PFS and tr...
In a patient metastatic recurrent endometrioid endometrial cancer who has a mixed response to carboplatin and paclitaxel, what is your next choice of therapy?
Understanding that there are no head to head trials comparing newer agents after failure of frontline platinum/taxane therapy, it is important to keep some issues in mind. Performance status and toxicity concerns are important given that all treatment will be palliative. 1) Patients should be offere...
Would you consider pembrolizumab plus lenvatinib for stage IV uterine carcinosarcoma after progression on chemotherapy as per Keynote-146 and now with Keynote-775?
Yes! Carcinosarcoma is considered a high-grade carcinoma (an epithelial neoplasm, and not a uterine sarcoma). The current FDA approved indication for lenvatinib and pembrolizumab is for those with advanced or recurrent disease that is not MSI-H or dMMR in patients who are not candidates for curative...
Would you change your approach to adjuvant radiation for an incompletely staged, at least IB, grade 1 endometrial cancer, if a uterine perforation occurred at time of surgery?
Similarly to the above authors, I agree with offering this patient vaginal brachytherapy. Though she does not definitively meet GOG99 criteria, given the situation with deep myometrial invasion and perforation, this is a reasonable and low-risk treatment opportunity to decrease local recurrence. The...
How would you approach unresectable pelvic side wall recurrence in cervical cancer with previous definitive chemoradiation?
I would start with palliative chemo and if good response, plan for SBRT for residual disease with the dose based on OAR.
In patients diagnosed with endometrial cancer who do not undergo SLNB or LND at the time of hysterectomy, what criteria is used to recommend completion surgery for LN assessment?
The value of nodal dissection was negative for survival in two trials and PORTEC 1 and 2 (no nodal staging), and GOG 99 (nodal staging) didn’t show any difference in nodal recurrence for most endometroid stage I cancer. Unless management would change, we usually limit redo surgical staging to advers...
What impacts your decision to use PET vs CT for radiographic staging of clinically locally advanced cervical cancer?
The quick of it: stage, histology, and availability are the major factors impacting my decision on PETCT vs. CT scan.In most cases of stage IB1-IVA (FIGO 2018 staging, Bhatla et al., PMID 30656645), any histology, I prefer a PETCT when possible to ensure that no distant disease as well as to evaluat...
Do you recommend the HPV vaccination for your young patients with HPV-associated cancers or pre-cancers who have not yet been vaccinated?
Yes, worth getting vaccinated to reduce risk for recurrent dysplasia. Lichter et al., PMID 32282601. Di Donato et al., PMID 33919003. Jentschke et al., PMID 32762871.
In patients with recurrent MSI-H endometrial cancer on immunotherapy with pembrolizumab, when do you discontinue therapy?
If they have no evidence of disease on their scan, I stop at 2 years.
How do you integrate ophthalmic exam and surveillance into routine visits for cervical cancer patients receiving tisotumab vedotin?
The key is to identify and intervene early; in my practice, I personally see patients each cycle (q3 weeks) and do office ophthalmic exams. Look for eye redness, irritation, corneal lesions. Key to avoiding tox is prevention with the vasoconstrictor, steroid, and lubricating drops as well as cool pa...