Case PresentationsHonduras 2011

Pedro T. Ramirez, M.D.Professor

Director of Minimally Invasive Research & EducationDepartment of Gynecologic Oncology

Cervix

Case Presentation

28 year old G0 with irregular bleeding and CIN-III Medical: NegativeSurgical History: NegativeOBGYN: Menses normal. Paps-History CINIIPelvic exam: No gross cervical lesion

Adnexa normalCone: 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

DFS OS

Case Presentation

34 year old G0 with history of stage IIB cervical cancer s/p chemotherapy and radiation

Presentation: Cough

Medical: NegativeSurgical History: NegativePelvic exam: Normal s/p radiation changes

Adnexa and rectal normal

Imaging Studies

Points of Discussion

• Discussion of prognosis

• Role of supportive care

• Options for treatmentGOG-179

GOG-204

• Ongoing trialsGOG-240

Uterine

Case Presentation

46 year old G3P2 obese female with irregular bleeding

Medical: Diabetes & HypertensionSurgical History: CholecystectomyPelvic exam: No gross cervical lesion

Adnexa normalDifficult 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: NegativeSurgical History: Myomectomy-FibroidPelvic exam: 26 cm irregular uterus

Adnexa non-palpableCervix 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: NegativeOBGYN: Menses normal. No STDs. Paps NormalPelvic 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, 2011Exploratory 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 emphysemaSurgical History: Bilateral salpingo-oophorectomyExam: Decreased breath sounds L

Abdomen distended and firmPelvis: 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: AppendectomyExam: Abdominal tenderness in R to deep palpation

Pelvis: Mobile palpable mass in pelvis ~12 cmsSocial: 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: HypertensionSurgical History: Cholecystectomy

Hystectomy-FibroidsExam: Chest-Normal

Abdomen distended & softFirm/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 CoursePOD # 4

Increasing acute abdominal pain and vomiting

Fever and elevated WBC count

Significant abdominal

tenderness

MD Anderson Cancer Center