Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Do you alter treatment in high grade serous ovarian cancer patients receiving neoadjuvant chemotherapy with stable disease after 3 cycles?
This is always a challenging clinical situation, as the intent of neoadjuvant chemotherapy is to reduce disease burden sufficiently to enable cytoreduction to microscopic residual disease. If disease remains stable despite administration of neoadjuvant therapy, it often denotes a biologically aggres...
Do you consider MSI testing for nonserous ovarian cancer?
I do, but with the understanding that PD1/PDL1 expression, MSI/MMR is less well documented than in high grade serous cancers. Meagher et al has a nice article in Gyn Oncol 2018 looking at molecular profiling in 333 mucinous lesions. Common mutations noted were KRAS (60%), TP53 (38%), and HER2 in up ...
Should I wear gloves during a routine physical exam on an asymptomatic patient with no risk factors for COVID-19?
As per FAQ’s posted by ASTRO: There is no reason to do so at this time. Be vigilant re: hand hygiene and wiping down any equipment that touches the patient (stethoscope, etc.). Additionally, any equipment that touches mucosa/secretions of the patient must be sterilized (rhinolaryngoscope, etc.). For...
In the setting of vulvar cancer, do you perform complete inguinal lymphadnectomy when inguinal sentinel nodes demonstrate micrometastatic (<2mm) disease?
Knowing the status of the groin nodes is critical in vulva cancer, as it has important prognostic value and is considered when tailoring adjuvant therapy. Methods chosen to assess the groin must consider morbidity vs. accuracy. I favor imaging patients pre-operatively with PET/CT if and when possibl...
What upfront maintenance therapy would you recommend for a BRCA negative, advanced epithelial ovarian cancer patient after completing adjuvant carboplatin, paclitaxel, bevacizumab?
Without knowing the somatic genetics, I’d recommend niraparib. If she was BRCA+ or HRD+ by somatic testing, I’d consider Olaparib plus bevacizumab.
How would you treat metastatic squamous cell carcinoma arising from a mature cystic ovarian teratoma?
There is a lack of established guidelines to treat patients with metastatic squamous cell carcinoma arising from a mature cystic ovarian teratoma (MCT-SCC). In the absence of a clinical trial, this patient should be offered platinum-based chemotherapy. Next generation sequencing (NGS) should also be...
How do you manage intracranial metastases from gestational trophoblastic neoplasia?
High risk gestational trophoblastic neoplasia with brain metastases is rare, and treatment has evolved over the past few decades and centered on multi-agent chemotherapy. The most well-cited regimen is EP-EMA (etoposide, 150 mg/m; cisplatin, 75 mg/m, intravenous, day 1; etoposide, 100 mg/m; methotre...
Do you obtain somatic genomic testing for ovarian cancer patients that test negative for gBRCA mutation?
Yes. There are patients who will have somatic BRCA mutations, but not germ line mutations.
Do you routinely prescribe anticoagulation for patients on active chemotherapy?
This is dependent on the risk factors of the patient for the development of VTE. Recently published ASCO guidelines (JCO 2019) incorporated the additional recommendation of VTE prophylaxis for high risk outpatients receiving chemotherapy with either eliquis, xarelto, or LMWH. The Khorana scoring sys...
How are you counseling HR-proficient ovarian cancer patients about front line PARP inhibitor maintenance?
I think this is a tough decision, but I recommend observation for patients with HR proficient disease. In brief, I don't find a PFS advantage, without a proven OS advantage, enough to justify this long-term, expensive, and not non-toxic treatment.For BRCA carriers the answer is easier—with SOLO2 (20...