Case Presentations Honduras 2011 Pedro T. Ramirez, M.D. Professor Director of Minimally Invasive Research & Education Department of Gynecologic Oncology
Cervix
Case Presentation 28 year old G0 with irregular bleeding and CIN-III Medical: Negative Surgical History: Negative OBGYN: Menses normal. Paps-History CINII Pelvic exam: No gross cervical lesion Adnexa normal Cone: Adenocarcinoma 3mm invasion + margins
Points of Discussion Standard of care Options for fertility preservation Surgical approach Intraoperative decisions
2010 NCCN Guidelines
Surgery Exploratory laparotomy Radical trachelectomy Lymphatic mapping Bilateral pelvic lymphadenectomy Frozen: No residual tumor present
Surgical Specimen
Points of Discussion Risk of no chance of fertility Postoperative complications Obstetrical outcomes Oncologic outcomes Long-term follow up
Conclusion: Radical trachelectomy has similar oncologic outcome to radical hysterectomy DFSOS
Case Presentation 34 year old G0 with history of stage IIB cervical cancer s/p chemotherapy and radiation Presentation: Cough Medical: Negative Surgical History: Negative Pelvic exam: Normal s/p radiation changes Adnexa and rectal normal
Imaging Studies
Points of Discussion Discussion of prognosis Role of supportive care Options for treatment GOG-179 GOG-204 Ongoing trials GOG-240
Uterine
Case Presentation 46 year old G3P2 obese female with irregular bleeding Medical: Diabetes & Hypertension Surgical History: Cholecystectomy Pelvic exam: No gross cervical lesion Adnexa normal Difficult due to body habitus
Pathology & Imaging Studies Endometrial biopsy: Complex hyperplasia with atypia
Surgery Robotic hysterectomy Bilateral salpingo-oophorectomy Frozen: G1 endometrioid adenocarcinoma No invasion FINAL:G1 endometrioid adenocarcinoma in CAH No invasion
Points of Discussion Preoperative evaluation Discussion according to patient age Surgical approach Intraoperative options Postoperative hormone replacement
Case Presentation 38 year old G4P2 female with pelvic pain and bladder pressure Medical: Negative Surgical History: Myomectomy-Fibroid Pelvic exam: 26 cm irregular uterus Adnexa non-palpable Cervix normal
Imaging Studies
Surgery Exploratory laparotomy Total abdominal hysterectomy Bilateral salpingo-oophorectomy Frozen: FINAL:Uterine leiomyosarcoma Tumor size: 24 cms R ovary-leiomyosarcoma
Points of Discussion Preoperative evaluation Surgical approach Role of intraoperative frozen section Indications for lymphadenectomy Postoperative therapy
Ovary
Case Presentation 30 year old G0 with dyspareunia. Medical and Surgical History: Negative OBGYN: Menses normal. No STDs. Paps Normal Pelvic exam: Bilateral adnexal masses Cervix normal
Imaging and Laboratory Studies CA125: 13.3 U/mL (<35) AFP: 2.9 ng/mL (<5) Inhibin B: 123 pg/mL (<139) LDH: 449 IU/L ( )
Surgery May 23, 2011 Exploratory laparotomy R salpingo-oophorectomy L cystectomy
Points of Discussion Differential diagnosis Options for follow up vs. surgery Surgical approach Intraoperative options Postoperative counseling
Case Presentation 68 year old G0 with abdominal bloating and worsening shortness of breath. Medical: Congestive heart failure and emphysema Surgical History: Bilateral salpingo-oophorectomy Exam: Decreased breath sounds L Abdomen distended and firm Pelvis: Firm nodularity in cul-de-sac
Imaging and Laboratory Studies CA125: 1,043 U/mL (<35)
Imaging and Laboratory Studies Video-assisted thoracoscopy (VATS) Thoracentesis: 600 mL
Pathology CT-Guided biopsy: HG papillary serous carcinoma consistent with mullerian primary
Interval Cytoreductive Surgery Chemotherapy followed by surgery 3 cycles---Surgery---3 cycles Patients who are NOT good surgical candidates -Multiple liver or lung metastases -Suprarenal lymph nodes -Mesenteric adenopathy Recent European study shows NO difference in survival
Points of Discussion Considerations of work-up evaluation Options offered to the patient Treatment implementation Strategies for follow up
Case Presentation 32 year old G0 with R pelvic pain. Medical: History of breast cancer at age 30. Surgical History: Appendectomy Exam: Abdominal tenderness in R to deep palpation Pelvis: Mobile palpable mass in pelvis ~12 cms Social: Patient due to be married in 6 weeks
Imaging and Laboratory Studies CA125: 78 U/mL (<35)
Surgery Exploratory laparotomy R salpingo-oophorectomy Pelvic and para-aortic lymphadenectomy Omental biopsy Peritoneal biopsies Frozen:
Points of Discussion Considerations of work-up evaluation Options offered to the patient Risk factor discussion for ovarian cancer Subset of histopathologic subtypes: -non-invasive implants -invasive implants -micropapillary pattern Indications for treatment Discussions on recurrent disease
Case Presentation 60 year old G3P2 with new onset bloating & pain Medical: Hypertension Surgical History: Cholecystectomy Hystectomy-Fibroids Exam: Chest-Normal Abdomen distended & soft Firm/Irregular pelvic mass
Imaging and Laboratory Studies CA125: 1,565 U/mL (<35)
Surgery Exploratory laparotomy Bilateral salpingo-oophorectomy Omentectomy Splenectomy Partial liver resection Para-aortic radical lymphadenectomy Diaphragmatic stripping Recto-sigmoid resection with re-anastomosis Frozen: HG serous neoplasm
SPLEEN
Points of Discussion Role of gynecologic oncologist Preparation for surgery-Multidisciplinary Extent of surgery-Intraoperative decisions Treatment implementation-IV vs IP Role of consolidation therapy Strategies for follow up
Post-operative Course POD # 4 Increasing acute abdominal pain and vomiting Fever and elevated WBC count Significant abdominal tenderness
MD Anderson Cancer Center