Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Given the criticism of GOG 88 and in light of various other recent data, would you deliver definitive XRT in place of inguinal lymph node dissection?
Despite GOG 88 findings, a number of retrospective studies have suggested that regional prophylactic RT is an effective method of preventing groin recurrences with minimal morbidity when appropriately delivered. (Combined across retrospective series, the incidence of groin recurrence following treat...
Which PARP inhibitor do you recommend for maintenance therapy in BRCA mutated ovarian cancer after primary chemotherapy and why?
Given the abundance of both efficacy and safety data available for Olaparib in this setting, I use Olaparib for maintenance therapy in BRCA+ ovarian cancer patients after primary chemotherapy. The 5-year PFS data from SOLO-1, confirming sustained benefit beyond the end of treatment, further speaks t...
How would you evaluate the right inguinofemoral lymph nodes in a female patient in her 30s with a 4 mm midline SCC of the vulva (depth of invasion 1.45 mm) and a PET-positive enlarged left inguinal node, for whom you plan to debulk the left inguinofemoral lymph nodes?
Sentinel evaluation of right groin nodes at the same time as left groin debulking.
How would you manage a bulky primary exophytic vulvar SqCC in a patient with uncontrolled but very long standing HIV disease?
I would first optimize HIV management and then plan for definitive RT (chemo) based on the CD4 count.
When do you prefer to use bolus for treating superficial tumors adjacent to or involving the skin surface, especially for complex surface anatomy in the pelvis, head/neck, and extremity regions?
There is not a single answer to this question, as it depends on the specifics of the geometry, treatment technique (photons vs. electrons, beam angles, energy used, etc.), depth and size of the tumor, and other technical factors. Since almost no one has access to superficial or orthovoltage X-rays w...
How long would you continue second line maintenance PARP inhibitor in a patient with recurrent stage IV BRCA+ ovarian cancer who had CR and remains NED?
For patients with platinum-sensitive relapsed ovarian cancer with a partial or complete response to platinum-based chemotherapy, niraparib, olaparib, and rucaparib are approved by the FDA for maintenance therapy. While PFS outcomes are improved with these agents regardless of BRCA mutation status, t...
What is your dose-fractionation for cylinder-based vaginal cuff HDR brachytherapy for an isolated vaginal cuff recurrence after whole pelvis EBRT with residual thickness of disease <5 mm?
I usually prescribe 5Gy x5. I don't prescribe to a fixed thickness but treat based on residual thickness seen on MRI using multichannel applicator.I lesion at apex then treat upper 2-3 cm of vagina Here is out paper describing technique and outcome in detailhttps://www.ncbi.nlm.nih.gov/pubmed/299299...
Extrapolating from KEYNOTE-A18, would you consider adding pembrolizumab to chemoradiation for locally advanced vulvar cancer?
This is a very interesting and important question. Although we have no prospective data on vulvar cancer regarding this question, our treatments have invariably paralleled the cervix. PD-L1 expression is estimated to be ~50%. Similarly, in KEYNOTE-158, RR in PD-L1 + cervix cohort was 15%, while in t...
How would you counsel a young female patient who refuses to use contraception during radiotherapy?
A woman who refuses contraception needs careful psychological and psychiatric assessment and considerable time at the time of consultation to understand why she is refusing, especially since this response is neither rational nor logical. The practitioner needs to take the time to discuss the patient...
How do you approach radiation treatment of extramammary Paget's disease of vulva, diffusely involving the urothelium and the periurethral glands?
Very unusual case. Presuming it has invasive disease, would also check HER2/neu status to see if there is any value of indication with chemo and anti-HER2/neu therapy. Will plan definitive chemo RT treating vulva, vagina, urethra, and bladder (if involved) to 66-70 Gy to gross disease and prophylact...