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
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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
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Risk of no chance of fertility
Postoperative complications
Obstetrical outcomes
Oncologic outcomes
Long-term follow up
DFS
OS
Conclusion:
Radical trachelectomy has similar oncologic
outcome to radical hysterectomy
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
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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
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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 (313-618)
Surgery
May 23, 2011
Exploratory laparotomy
R salpingo-oophorectomy
L cystectomy
Points of Discussion
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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
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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
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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
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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