Mortality after the diagnosis of pancreatic ductal adenocarcinoma remains high for all patients. The role of multimodal therapy, including surgical resection and systemic chemotherapy, has been well established. Neoadjuvant treatment strategies continue to be used in resectable and borderline resectable PDAC. Results from ongoing or recently completed trials will continue to provide valuable insight into the management of patients with resectable and borderline resectable PDAC. Advances in the outcomes for this difficult disease and therefore the focus of futures studies should include a better understanding of tumor biology and markers, novel treatment agents, and combination treatment strategies.

Remote monitoring and telehealth platforms have been of increasing interest since the beginning of the Corona Virus disease-2019 pandemic, with rising rates of implementation. Surgical oncology patients are a unique population that may derive a particular benefit from the use of such technology, which has been shown to be feasible and acceptable to patients and providers. Previous studies have shown benefits in quality of life and symptom severity as well as a decreased readmission rate in select surgical oncology clinical settings; however, further research is ongoing to more specifically determine how the use of remote telemonitoring will affect clinical outcomes including complications and cost.

Hepatic artery infusion (HAI) chemotherapy is a regional, intra-arterial treatment of hepatic malignancies, delivering high-dose floxuridine directly to the liver. The rationale for HAI is based on the dominant blood supply of liver tumors from the hepatic arteries and near complete first-pass hepatic extraction of certain chemotherapeutic agents, which limits systemic toxicity. Although HAI chemotherapy is most commonly used among patients with colorectal liver metastases, it is now being more frequently employed for other disease processes such as intrahepatic cholangiocarcinoma and hepatocellular carcinoma as well. In addition, HAI chemotherapy is most often used in the setting of unresectable hepatic malignancies.

Neoadjuvant chemotherapy is now considered standard of care for most of the patients with clinically node-positive disease, and for a large proportion of triple-negative breast cancer and HER2-positive tumors. Here we reviewed the benefit of neoadjuvant chemotherapy on surgical de-escalation, the prognostic role of pathologic complete response, new therapeutic strategies across subtypes, and ongoing studies assessing locoregional treatment de-escalation according to treatment response. Thanks to the integration of new biomarkers, new ways to detect minimal residual disease after neoadjuvant chemotherapy, and new targeted therapies, the landscape of neoadjuvant therapy is evolving rapidly, and our ability to personalize breast cancer treatment is improving.

Adrenocortical carcinoma is a rare, aggressive cancer with a poor prognosis. Management of early-stage disease relies on surgical resection, which remains the only potentially curative therapy. Open surgery remains the standard of care, with minimally invasive approaches being appropriate in cases with smaller tumors and no evidence of local invasion. Advanced disease traditionally relies on mitotane-based chemotherapies to control disease progression. Clinical trials evaluating the potential efficacy of immunotherapy, checkpoint inhibitors, and tyrosine kinase inhibitors are ongoing but have yet to yield results that impact guideline-based therapies. Other therapies, such as radiation, are commonly used for recurrent or metastatic disease.

Retroperitoneal sarcoma is composed of a heterogeneous group of mesenchymal neoplasms that has poor prognosis. Although surgery remains the mainstay of treatment, achieving complete surgical resection with adequate margins is challenging, given anatomic constraints. Evidence on the use of adjunctive treatment modalities for retroperitoneal sarcoma is sparse, with the treatment rationale often based on data extrapolated from other soft tissue sarcomas. Recent studies demonstrate some benefits of neoadjuvant radiotherapy for histologic subtypes with high locoregional recurrence rates. Ongoing studies are evaluating various novel adjunctive treatment modalities.

Dermatofibrosarcoma protuberans is a rare, low-grade sarcoma characterized by lateral tentacle-like extensions into the surrounding subcutaneous tissue. Although surgical resection remains that mainstay of treatment, achieving negative margins is often challenging due to these irregular growth patterns and is similarly associated with high local recurrence. Different surgical approaches for dermatofibrosarcoma protuberans include wide local excision, Mohs micrographic surgery, and a multidisciplinary combined approach.

Standard use of adjuvant immunotherapy has significantly improved clinical outcomes in melanoma. Neoadjuvant immunotherapy has further enhanced these benefits in the setting of advanced disease. Lack of a reliable biomarker to monitor treatment response or disease progression has severely limited prognostication accuracy and the individualization of treatment regimens. A reliable biomarker that indicates treatment response or disease progression could guide clinical decision making to benefit patients with high-risk features or significant disease burden by enhanced activation of the innate antitumor immune response or altered gene expression are areas of active investigation to further improve clinical management of melanoma.

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a common entity with a prevalence in the general population that increases with age. Depending on the involvement of the main pancreatic duct, they can be divided into main-duct (MD), mixed-duct, and branch-duct (BD) variants. Most BD-IPMNs are low-risk and surveilled, while MD-IPMNs are generally resected. When necessary, a standard pancreatic resection with lymphadenectomy is recommended. The use of molecular profiling, intraoperative pancreatoscopy, and surveillance end points are discussed.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms originating in the mesenchyme of the gastrointestinal tract. An evolving treatment paradigm in the management of GISTs is the usage of neoadjuvant therapy (NAT). Prior to undergoing NAT, GISTs must be genetically tested. The main benefit of NAT is reduction of operative morbidity. Response to NAT is generally assessed by contrast-enhanced computed tomography or MRI at regular intervals. Patients are treated to maximal response, which is often 8 to 12 months. After resection, selected patients should continue systemic treatment, for a total of 3 years of therapy before entering posttreatment surveillance.

Merkel cell carcinoma is a rare, aggressive cutaneous neuroendocrine tumor, often diagnosed in later stages. Most of cases are related to either ultraviolet exposure or infection with the Merkel cell polyomavirus. Immunocompromised patients are at higher risk for the development of the disease. Treatment in the initial stages consists of resection and radiotherapy. Metastatic disease has a very poor prognosis and shows a limited durable response to chemotherapy. Combination of surgery, radiation therapy, and systemic therapy is used for the treatment of metastatic disease. Recently, the advent of programmed cell death protein 1 axis agents has improved outcomes in metastatic disease. There are ongoing clinical trials evaluating these agents in resected disease.

Approximately 10% of patients with melanoma develop in-transit disease (ITM). Although resection may be performed in patients with limited, fully resectable disease, many patients with ITM present with bulky, unresectable disease, which can pose a significant therapeutic challenge. Regional perfusion chemotherapy procedures and intralesional therapy have high response rates and can provide durable locoregional control while limiting systemic toxicity. Systemic therapies, including immune checkpoint inhibitors and targeted therapies, may also be used especially in patients with concomitant distant metastatic disease. In this article, we review the available treatment options for ITM.

The use of secondary cytoreductive surgery before standard chemotherapy in recurrent ovarian cancer is controversial. Several groups have identified patient and disease factors that correlate with benefit from surgery. Complete gross resection of disease is the most important factor, and selection criteria have been developed and validated to predict this outcome. Recently, 3 parallel multicenter randomized controlled trials of secondary cytoreduction were reported and have shown mixed results but a meta-analysis suggests a benefit, particularly, in those with complete gross resection of disease.

Recurrent platinum-resistant ovarian cancer represents a significant therapeutic challenge, characterized by poor responses to standard chemotherapy and limited survival outcomes. This chapter comprehensively reviews the biological mechanisms underlying platinum resistance, including alterations in DNA repair pathways, intracellular drug transport, evasion of apoptosis, tumor microenvironment adaptations, and cancer stem cell dynamics. Emerging therapies targeting these mechanisms are discussed in detail, along with promising strategies that combine these therapies. Clinical trial data are discussed to highlight advances in overcoming platinum resistance and the potential for biomarker-driven treatment approaches. The chapter emphasizes the importance of targeting tumor heterogeneity and resistance mechanisms through novel therapies and personalized strategies to improve outcomes in patients with recurrent platinum-resistant ovarian cancer.

The mitogen-activated protein kinase (MAPK) cascade is a critical pathway involved in cancer cell survival as well as resistance to drug therapy. Phosphorylation of extracellular signal-regulated kinase 1 (ERK1) and extracellular signal-regulated kinase 2 (ERK2), the final effectors of the MAPK pathway, results in activation of multiple substrates that are responsible for cellular proliferation, differentiation, survival, and migration. This review will focus on our current understanding of 2 types of rare gynecologic cancers that frequently harbor MAPK alterations, low-grade serous ovarian cancer and mesonephric/mesonephric-like gynecologic neoplasms, and how this understanding may change our future treatment of these diseases.

Antibody-drug conjugates are a class of novel antineoplastic drugs that deliver potent cytotoxic agents directly into tumor cells by targeting tumor-specific antigens. Two of these drugs are currently approved for treatment of gynecologic cancers and many more are under investigation. Along with the expected toxicities associated with chemotherapy drugs, antibody-drug conjugates can cause more atypical adverse events; the treating oncologist should be aware of these toxicities and their management.

Gynecologic malignancies are a heterogenous group of tumors driven by a wide variety of molecular alterations. Molecular profiling has become increasingly useful in the development of novel biomarkers, screening tools, and targeted therapeutic agents. The purpose of this article is to provide an overview of the current usage of personalized medicine in the field of gynecologic oncology.

Cervical cancer continues to represent an immense burden worldwide. Fortunately, in all stages of the disease and therapeutic modalities there have been significant advances in the past 5 years with the promise of improving oncologic outcomes and decreasing morbidity. The introduction of immunotherapy into the care of patients with metastatic and recurrent cervical cancer, a disease with a historically poor prognosis and limited treatment options, has altered the standard of care.

The surgical staging of endometrial cancer has changed in recent years to include sentinel lymph node (SLN) biopsy as a tool to replace regional lymphadenectomy. This has afforded surgeons the ability to preserve surgical staging information, valuable for adjuvant therapy prescription, while minimizing associated morbidities, such as lymphedema. Although SLN biopsy has been established as being highly accurate in detecting metastatic disease, including in patients with high-grade cancers, future studies should focus on establishing the value of this technique with respect to patient survival and its role in concert with molecular markers to individualize and optimize treatment outcomes.

A significant amount of the literature on health disparities in gynecologic cancer care has focused on descriptively identifying disparities with a particular focus on the dichotomous care received by black and white patients. Although there are actionable improvements that can be made to improve research within this field as it is currently conceived, it is critical to broaden the academic approach to these difficult issues in order to develop frameworks in which both the medical factors and social and environmental factors are treated as an integrated system.

Gynecologic cancer treatments often lead to increased sexual concerns, which often are not addressed. Screening should be performed in a standardized fashion both routinely and frequently. Various treatment options are available and should be offered to improve quality of life. Referrals to specialty clinics can be made when available.