1. Case Presentations Honduras 2011 Pedro T. Ramirez, M.D. Professor Director of Minimally Invasive Research & Education Department of Gynecologic Oncology

2. Cervix

3. 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

4. Points of Discussion Standard of care Options for fertility preservation Surgical approach Intraoperative decisions

5. 2010 NCCN Guidelines

6. Surgery Exploratory laparotomy Radical trachelectomy Lymphatic mapping Bilateral pelvic lymphadenectomy Frozen: No residual tumor present

9. Surgical Specimen

10. Points of Discussion Risk of no chance of fertility Postoperative complications Obstetrical outcomes Oncologic outcomes Long-term follow up

16. Conclusion: Radical trachelectomy has similar oncologic outcome to radical hysterectomy DFSOS

17. 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

18. Imaging Studies

19. Points of Discussion Discussion of prognosis Role of supportive care Options for treatment GOG-179 GOG-204 Ongoing trials GOG-240

20. Uterine

22. 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

23. Pathology & Imaging Studies Endometrial biopsy: Complex hyperplasia with atypia

24. Surgery Robotic hysterectomy Bilateral salpingo-oophorectomy Frozen: G1 endometrioid adenocarcinoma No invasion FINAL:G1 endometrioid adenocarcinoma in CAH No invasion

25. Points of Discussion Preoperative evaluation Discussion according to patient age Surgical approach Intraoperative options Postoperative hormone replacement

26. 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

27. Imaging Studies

28. Surgery Exploratory laparotomy Total abdominal hysterectomy Bilateral salpingo-oophorectomy Frozen: FINAL:Uterine leiomyosarcoma Tumor size: 24 cms R ovary-leiomyosarcoma

29. Points of Discussion Preoperative evaluation Surgical approach Role of intraoperative frozen section Indications for lymphadenectomy Postoperative therapy

32. Ovary

33. 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

34. 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 (313-618)

35. Surgery May 23, 2011 Exploratory laparotomy R salpingo-oophorectomy L cystectomy

36. Points of Discussion Differential diagnosis Options for follow up vs. surgery Surgical approach Intraoperative options Postoperative counseling

37. 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

38. Imaging and Laboratory Studies CA125: 1,043 U/mL (<35)

39. Imaging and Laboratory Studies Video-assisted thoracoscopy (VATS) Thoracentesis: 600 mL

40. Pathology CT-Guided biopsy: HG papillary serous carcinoma consistent with mullerian primary

41. 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

42. Points of Discussion Considerations of work-up evaluation Options offered to the patient Treatment implementation Strategies for follow up

43. 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

44. Imaging and Laboratory Studies CA125: 78 U/mL (<35)

45. Surgery Exploratory laparotomy R salpingo-oophorectomy Pelvic and para-aortic lymphadenectomy Omental biopsy Peritoneal biopsies Frozen:

46. 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

47. 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

48. Imaging and Laboratory Studies CA125: 1,565 U/mL (<35)

49. 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

52. SPLEEN

56. 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

57. Post-operative Course POD # 4 Increasing acute abdominal pain and vomiting Fever and elevated WBC count Significant abdominal tenderness

58. MD Anderson Cancer Center