Managing Gynecologic Oncology

---
name: managing-gynecologic-oncology
description: Structures gynecologic cancer evaluation with staging, treatment planning, and surveillance. Use when managing gynecologic cancers, staging ovarian/uterine malignancies, or planning treatment.
tags:
  - management
  - obstetrics-and-gynecology
  - treatment
  - valuation
metadata:
  author: casemark
  practice_areas:
    - Obstetrics
    - Gynecology
    - Maternal-Fetal Medicine
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Gynecologic Oncology

Structures gynecologic cancer evaluation with FIGO staging, multidisciplinary treatment planning, and surveillance protocols for endometrial, ovarian, cervical, and vulvar malignancies.

## Why This Skill Exists

Gynecologic cancers — endometrial, ovarian, cervical, vulvar, and vaginal — collectively account for over 115,000 new cases and 34,000 deaths annually in the United States. Endometrial cancer is the most common gynecologic malignancy (incidence rising with the obesity epidemic), while ovarian cancer has the highest mortality due to late-stage diagnosis. FIGO staging is the international standard for all gynecologic malignancies and was updated for endometrial cancer in 2023 and cervical cancer in 2018.

Accurate staging determines treatment (surgery, chemotherapy, radiation, or combination), eligibility for clinical trials, and prognosis. Molecular classification (particularly for endometrial cancer — POLE, MSI-H, CN-low, CN-high/p53-abnormal) is now integrated into treatment planning. This skill ensures that evaluation, staging, and treatment planning follow NCCN and SGO/FIGO guidelines.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. **Cancer type** — endometrial, ovarian/fallopian tube/peritoneal, cervical, vulvar, vaginal, GTD? (Default: from pathology)
2. **Histologic type and grade** — specific histology (endometrioid, serous, clear cell, mucinous, squamous, etc.) and differentiation grade? (Default: from pathology report)
3. **FIGO stage** — current staging or pre-surgical estimated stage? (Default: from staging workup)
4. **Molecular markers** — MSI/MMR status, p53 IHC, POLE mutation, ER/PR status, HER2, BRCA1/2, PD-L1? (Default: from pathology/genetic testing)
5. **Imaging** — CT, MRI, PET-CT findings? (Default: from radiology reports)
6. **Tumor markers** — CA-125, HE4, AFP, βhCG, inhibin (depending on tumor type)? (Default: from lab results)
7. **Performance status** — ECOG performance status? (Default: from clinical assessment)
8. **Fertility preservation desire** — relevant for early-stage cancers in young patients? (Default: from patient discussion)

### Documents to Request

- Pathology reports (biopsy and surgical specimens) with molecular testing
- Operative reports (staging surgery, debulking)
- Cross-sectional imaging (CT chest/abdomen/pelvis, MRI pelvis, PET-CT)
- Tumor marker levels (serial if available)
- Genetic testing results (germline BRCA, Lynch/MMR, somatic profiling)
- Multidisciplinary tumor board recommendations
- Prior treatment records (chemotherapy, radiation)
- Performance status documentation

---

## Step 1: Endometrial Cancer — FIGO 2023 Staging and Management

### FIGO 2023 Staging (Surgical)

| Stage | Description |
|---|---|
| IA | Tumor limited to endometrium or < 50% myometrial invasion |
| IB | ≥ 50% myometrial invasion |
| IC | Invasion of cervical stroma (formerly stage II) |
| II | Tumor beyond uterus to ovaries, fallopian tubes, broad ligament, or vagina |
| IIIA | Tumor invading uterine serosa or adnexa |
| IIIB | Vaginal or parametrial involvement |
| IIIC1 | Pelvic lymph node metastasis |
| IIIC2 | Para-aortic lymph node metastasis |
| IVA | Invasion of bladder or bowel mucosa |
| IVB | Distant metastasis |

### Molecular Classification (The Cancer Genome Atlas — TCGA)

| Subtype | Prognosis | Treatment Implications |
|---|---|---|
| POLE ultramutated | Excellent (even if high-grade histology) | May de-escalate adjuvant therapy |
| MSI-high / MMR-deficient | Intermediate-favorable | Checkpoint immunotherapy (pembrolizumab) if advanced; Lynch syndrome screening |
| Copy-number low (CN-L) | Intermediate | Standard stage-based adjuvant therapy |
| Copy-number high (CN-H) / p53-abnormal | Poor | Aggressive adjuvant therapy (chemo + radiation); clinical trials |

### Standard Surgical Staging
- Total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO)
- Sentinel lymph node mapping (preferred) or full pelvic/para-aortic lymphadenectomy
- Peritoneal washings
- Omental sampling for serous, clear cell, or carcinosarcoma histology

---

## Step 2: Ovarian Cancer — FIGO Staging and Management

### FIGO Staging (Surgical)

| Stage | Description |
|---|---|
| I | Limited to ovaries/fallopian tubes |
| IA | One ovary, capsule intact, no surface involvement, negative washings |
| IB | Both ovaries, capsule intact |
| IC | Capsule rupture, surface involvement, or positive washings |
| II | Pelvic extension |
| III | Peritoneal metastasis beyond pelvis and/or retroperitoneal nodes |
| IIIC | Peritoneal metastasis > 2 cm and/or retroperitoneal nodes |
| IV | Distant metastasis (liver parenchymal, extra-abdominal) |

### Management Principles
- **Primary debulking surgery (PDS):** Goal is R0 (no visible residual disease) — complete cytoreduction is the strongest predictor of survival
- **Neoadjuvant chemotherapy (NACT):** Carboplatin + paclitaxel × 3 cycles → interval debulking surgery → 3 more cycles (for patients unlikely to achieve R0 at PDS)
- **BRCA-mutated or HRD-positive:** PARP inhibitor maintenance (olaparib, niraparib) after platinum response
- **CA-125 monitoring:** Serial values during and after treatment; GCIG criteria for progression (doubling from nadir and above upper limit of normal)

---

## Step 3: Cervical Cancer — FIGO 2018 Staging and Management

### FIGO 2018 Staging (Now Allows Imaging and Pathology)

| Stage | Description |
|---|---|
| IA1 | Stromal invasion ≤ 3 mm depth |
| IA2 | Stromal invasion > 3 mm and ≤ 5 mm depth |
| IB1 | Clinically visible ≤ 2 cm |
| IB2 | Clinically visible > 2 cm and ≤ 4 cm |
| IB3 | Clinically visible > 4 cm |
| IIA | Upper 2/3 vagina, no parametrial invasion |
| IIB | Parametrial invasion |
| IIIA | Lower 1/3 vagina |
| IIIB | Pelvic sidewall / hydronephrosis |
| IIIC1 | Pelvic lymph node metastasis |
| IIIC2 | Para-aortic lymph node metastasis |
| IVA | Bladder or rectal mucosal invasion |
| IVB | Distant metastasis |

### Treatment by Stage
- **IA1 (no LVSI):** Cone biopsy with negative margins (fertility-sparing) or simple hysterectomy
- **IA2–IB1:** Radical hysterectomy + pelvic lymphadenectomy; or radical trachelectomy (fertility-sparing)
- **IB2–IIA:** Radical hysterectomy vs. primary chemoradiation (equivalent outcomes)
- **IIB–IVA:** Primary chemoradiation (cisplatin weekly + external beam + brachytherapy)
- **IVB:** Systemic chemotherapy ± pembrolizumab (PD-L1 positive or MSI-H); bevacizumab per GOG 240

---

## Step 4: Surveillance Protocols

| Cancer Type | Surveillance Schedule | Key Assessments |
|---|---|---|
| Endometrial | Q3–6 months × 2 years, then Q6–12 months × 3 years | Symptom review, pelvic exam, vaginal cuff cytology (if risk factors), imaging only if symptomatic |
| Ovarian | Q2–4 months × 2 years, then Q3–6 months × 3 years | CA-125, exam, CT if rising markers or symptoms |
| Cervical | Q3–4 months × 2 years, then Q6 months × 3 years | Pap smear (if treated with surgery), pelvic exam, imaging if indicated |
| Vulvar | Q6 months × 2 years, then annually | Vulvar exam, biopsy any suspicious lesions |

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. **Is the FIGO stage correctly assigned** using the most current staging system (endometrial 2023, cervical 2018)?
2. **Is histologic type and grade documented** with molecular classification for endometrial cancer?
3. **Does the treatment plan align** with NCCN guidelines for the stage and histology?
4. **Are molecular markers documented** — MSI, p53, BRCA, PD-L1 as applicable?
5. **Is the surveillance schedule specified** with appropriate intervals and assessments?

---

## Quality Audit

- [ ] Cancer type and histologic subtype documented from pathology
- [ ] FIGO stage assigned with supporting evidence (imaging, surgical findings, pathology)
- [ ] Tumor grade (well, moderately, poorly differentiated) documented
- [ ] Molecular markers documented (MSI/MMR, p53, POLE, BRCA, HER2, PD-L1 as applicable)
- [ ] Imaging staging documented (CT, MRI, PET-CT findings)
- [ ] Tumor markers documented (CA-125, HE4, others as applicable)
- [ ] Surgical staging completeness documented (LN assessment, washings, omentum)
- [ ] Residual disease status documented for ovarian cancer (R0, R1, R2)
- [ ] Multidisciplinary tumor board discussion documented
- [ ] Adjuvant therapy plan specified with regimen and cycle count
- [ ] Genetic counseling referral documented (Lynch, BRCA, when indicated)
- [ ] Performance status documented (ECOG)
- [ ] Surveillance plan documented with intervals and assessments
- [ ] Fertility preservation discussion documented (if applicable)

---

## Guidelines

1. **Use the correct FIGO staging year** — endometrial 2023, cervical 2018, ovarian 2014. Misapplying staging systems leads to incorrect treatment.
2. **Molecular classification is now standard for endometrial cancer** — POLE, MSI, p53, and CN status must be obtained to guide adjuvant therapy decisions.
3. **Optimal cytoreduction is the goal in ovarian cancer** — document residual disease status (R0, < 1 cm, > 1 cm) as it drives prognosis.
4. **Test all endometrial cancers for MMR/MSI** — per NCCN, universal screening identifies Lynch syndrome and eligibility for immunotherapy.
5. **Do not skip genetic referral** — all ovarian cancer patients should be offered germline BRCA testing; all endometrial cancer patients with MSI-H or age < 50 should be evaluated for Lynch.
6. **Document tumor board decisions** — multidisciplinary review is standard of care and should be recorded with attending specialties and recommendations.
7. **Fertility-sparing options exist** — for early-stage endometrial (grade 1, IA) and cervical (IA1–IB1) cancers, conservative management can be offered after thorough counseling.