Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you perform pap smears as part of the surveillance of patients with a history of cervical or vaginal cancers who had radiation as part of their treatment?
I personally do not routinely perform pap testing for patients with a prior history of cervical or vaginal cancer who have had prior radiation. The main driver for me in this decision is that the results we receive from Pap testing often show abnormalities that are not reflective of recurrence or de...
How do you manage refractory radiation cystitis status post pelvic EBRT/BT?
Thankfully chronic radiation cystitis and specifically radiation-induced hemorrhagic cystitis is relatively rare (2-8%) [1]. However, it can be a chronic and debilitating complication after pelvic radiotherapy. In managing these patients, first, I make sure to rule out another cause of cystitis – in...
How do you decide until what age to offer ovarian preservation for patients with biopsy-proven grade 1 or grade 2 endometrial cancer without evidence of metastatic disease on imaging or at the time of surgery?
I often reference Jason Wright's article evaluating the safety of ovarian preservation up to age 45 regarding cancer-related mortality. Granted, this doesn't measure recurrence rates. I also reference Dr. Barakat's incomplete GOG study (a casualty of the WHI study) that found only ~2-3% of patients ...
How would you treat bilateral groin recurrence of vulvar small cell neuroendocrine carcinoma in a patient who has previously had pelvic and groin radiation?
I would start with chemo-immunotherapy, like in pulmonary small cell, as this is likely to be the tip of the iceberg. If no prior groin surgical exploration, this can be considered by gyn/onc. If not, I would consider focal reirradiation of any residual disease after chemotherapy during IO maintenan...
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In patients with PD-L1 negative metastatic cervical squamous cell carcinoma at primary diagnosis, do you add pembrolizumab, atezolizumab, or no immunotherapy to combination platinum/taxane/bevacizumab therapy?
You are correct that the data is not crystal clear in these patients, which means it is reasonable to consider doing either platinum/taxane/bev or platinum/taxane/bev/immunotherapy. Personally, I find that when giving all 4 agents at once, patients do experience more toxicity. So in my practice for ...
In general, how do you manage patients with early-stage endometrioid endometrial cancer who have concomitant POLE and TP53 mutations?
Based on published outcome data, double mutation is uncommon, and the outcome is driven by the better of the two mutations. So in the above situations, POLE type and not TP53 type will drive outcome and treatment decisions. That’s why in molecular-based decisions, it is important that the POLE type ...
How have you incorporated ctDNA into the clinical management of patients with gynecologic cancers?
ctDNA certainly is increasing rapidly in oncology and has been led by several other disease sites. I think right now, GYN oncology is figuring out how to incorporate this in our care to meaningfully impact our patients. I have not incorporated ctDNA in my practice routinely, but do see the role of i...
What, if any, adjuvant treatment do you offer a a patient with stage I clear cell endometrial carcinoma?
Clear cell carcinoma is a rare tumor with sparse literature regarding its adjuvant treatment. There is a recent SGO review article on this topic that is a nice reference. For stage I uterine clear cell, there are no prospective studies to study the impact of adjuvant chemotherapy and/or radiation. H...
Have treatment recommendations changed for Stage I endometrial Cancer based upon PORTEC 4 results?
PORTEC-4a will almost certainly change recommendations for adjuvant treatment in high-intermediate risk stage I patients with endometrial cancer, and in at least 2 different ways, in my opinion. By following the molecular profiling guidelines, nearly half of these patients will avoid adjuvant treatm...