Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What is your institutional approach to a restrictive “neutropenic diet”?
Simple answer: never. The "neutropenic diet" has no efficacy and may actually be nutritionally AND microbially inferior to normal diet. This has been shown by multiple studies. I like the title of the review, "Things We Do For No Reason: Neutropenic Diet." Ma et al., PMID 35356218. Radhakrishnan et ...
What is the appropriate time interval to assess treatment response in primary vaginal SCC?
I would favor biopsy before any intervention. If positive, would need surgical salvage (similar principle as cervical cancer).Beaty et al., PMID 34455989 This review gives some biological differences between cervical and other HPV-associated malignancies.
In the setting of platinum resistant ovarian cancer, do you consider repeat use of bevacizumab with subsequent lines of chemotherapy following prior treatment with chemotherapy + bevacizumab with bevacizumab maintenance?
I typically do reuse bevacizumab. Now that bevacizumab is approved for front-line, maintenance, and recurrent settings, many patients with recurrence may not be bev-naive, to begin with, and I still use bev+chemo.In breast cancer (von Minckwitz et al., PMID 25273342) and colon cancer (Bennouna et al...
What are various positioning and treatment techniques you use to help reduce bowel dose?
Prone position IMRT/VMAT I tend to use both concurrently for rectal/anal/some gyn. There is a "myth" that prone position is difficult to reproduce. Studies do not show this, or if there is an effect, it can be mitigated by image guidance. Here is another study showing this.
Can you continue checkpoint inhibitor therapy in the setting of severe cutaneous irAE while concurrently treating the cutaneous reaction?
Cutaneous reactions from immune checkpoint inhibitors (ICPi) generally fit into 3 categories: rash/inflammatory dermatitis, bullous dermatoses, and severe cutaneous adverse reaction (SCAR). For grade 1-2 rash/inflammatory dermatitis, if symptoms can be managed with topical therapy or non-steroidal o...
Do you initiate management of new onset diabetes in a patient on immunotherapy or refer immediately to endocrinology given the risk of rapid worsening?
New onset hyperglycemia during ICPi therapy warrants careful review of potential risk factors for type 2 diabetes mellitus (T2DM) and close monitoring of symptoms and lab results to distinguish from the rare and typically more threatening checkpoint inhibitor-associated diabetes mellitus (CIADM). Ne...
What is your preferred steroid sparing therapy in a patient experiencing a severe checkpoint inhibitor toxicity and not responding to high dose IV steroids?
There are likely two different questions here: 1) For patients who have responded to steroids, but are unable to taper off (or to a minimally acceptable chronic dose), I have favored mycophenolate as a steroid sparing agent. 2) For patients with severe pneumonitis that is refractory to steroid ther...
How do you approach treatment for ovarian carcinosarcoma that has progressed during adjuvant carboplatin, paclitaxel, and bevacizumab following optimal tumor reductive surgery?
Recurrent ovarian carcinosarcoma (OCS) is a difficult clinical scenario with few evidence-based options. Clearly, a need exists for novel therapies, and a frank discussion on treatment goals and expectations is warranted. Ovarian carcinosarcoma (OCS) is a rare histologic subtype of ovarian cancer ac...
How would you treat an adenoid cystic carcinoma (well-diff, +extensive PNI) of the vulva s/p excision with positive margins?
Great question. I would not necessarily ask for re-excision, as I don't think it will change the recommendation for post-operative RT to the vulva. There does need to be some kind of inguinal node assessment, and PET is an acceptable approach if the nodes were not sampled or dissected. If PET is neg...
Would you administer pelvic radiation therapy to a post-menopausal patient with locally advanced carcinosarcoma with high risk features s/p TAH/BSO with a vesico-urethral fistula that would be in the radiation therapy field?
Although the role of adjuvant RT in uterine carcinosarcoma is unclear, it does appear that local control is enhanced. So my answer depends on "how high risk is high risk?". The question suggests that the risk of local recurrence is quite high ("locally advanced" is the descriptor), so I do think it ...