Gynecologic Oncology
What this domain tests
Gynecologic items test upfront surgical management versus neoadjuvant chemotherapy in ovarian cancer, molecular classification of endometrial cancer, the chemoradiation paradigm in cervix cancer, and the germ cell and gestational trophoblastic entities that respond to chemotherapy alone.
Core rules
- Ovarian: high-grade serous carcinoma is the dominant histology. Maximal cytoreduction plus platinum–taxane is standard; neoadjuvant carboplatin–paclitaxel with interval debulking is equivalent in survival for bulky stage IIIC–IV disease (EORTC 55971, CHORUS). Germline and somatic BRCA and HRD testing are mandatory. Maintenance with a PARP inhibitor (olaparib, niraparib) is standard after response, with benefit greatest in BRCA-mutant and HRD-positive tumors. Bevacizumab is added to the chemotherapy backbone in high-risk disease.
- Endometrial: molecular classification into POLE-ultramutated (excellent prognosis), MMR-deficient, p53-abnormal (worst prognosis) and no specific molecular profile. Treatment is surgery with or without radiotherapy; advanced or recurrent disease gets carboplatin–paclitaxel, with dostarlimab or pembrolizumab for MMR-deficient tumors and lenvatinib plus pembrolizumab for proficient ones.
- Cervix: FIGO 2018 staging incorporates nodal status and tumor size. Stage IB3 to IVA disease is treated with concurrent chemoradiation using weekly cisplatin 40 mg/m² plus brachytherapy; add pembrolizumab in node-positive or advanced disease (KEYNOTE-826, KEYNOTE-A18). Metastatic disease first line: platinum/paclitaxel plus bevacizumab and pembrolizumab.
- Vulvar cancer: surgery with groin node assessment; chemoradiation for unresectable or node-positive disease.
- Gestational trophoblastic neoplasia: methotrexate or actinomycin-D for low-risk disease, EMA-CO for high-risk disease; surgery reserved for resistant disease.
Worked example
A 45-year-old with a 4 cm cervical squamous cell carcinoma and one enlarged pelvic node (stage IIIC1). She should receive definitive concurrent chemoradiation with weekly cisplatin plus image-guided brachytherapy, then adjuvant pembrolizumab if node-positive. Upfront radical hysterectomy is not appropriate for node-positive locally advanced disease.
Traps
- Offering neoadjuvant chemotherapy before surgery in cervix cancer - it worsens outcomes compared with chemoradiation.
- Missing that PARP maintenance is now offered beyond BRCA-mutant disease, based on HRD status.
- Relying on CA-125 for ovarian screening; it is not a screening test.
- Forgetting that cervical cancer is HPV-driven and that vaccination prevents it.