Case presentations honduras 2011
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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

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Case Presentations Honduras 2011

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Case presentations honduras 2011

Case PresentationsHonduras 2011

Pedro T. Ramirez, M.D.

Professor

Director of Minimally Invasive Research & Education

Department of Gynecologic Oncology


Cervix

Cervix


Case presentation

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

Points of Discussion

  • Standard of care

  • Options for fertility preservation

  • Surgical approach

  • Intraoperative decisions


2010 nccn guidelines

2010 NCCN Guidelines


Surgery

Surgery

Exploratory laparotomy

Radical trachelectomy

Lymphatic mapping

Bilateral pelvic lymphadenectomy

Frozen: No residual tumor present


Surgical specimen

Surgical Specimen


Points of discussion1

Points of Discussion

  • Risk of no chance of fertility

  • Postoperative complications

  • Obstetrical outcomes

  • Oncologic outcomes

  • Long-term follow up


Case presentations honduras 2011

DFS

OS

Conclusion:

Radical trachelectomy has similar oncologic outcome to radical hysterectomy


Case presentation1

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

Imaging Studies


Points of discussion2

Points of Discussion

  • Discussion of prognosis

  • Role of supportive care

  • Options for treatment

    GOG-179

    GOG-204

  • Ongoing trials

    GOG-240


Uterine

Uterine


Case presentation2

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

Pathology & Imaging Studies

Endometrial biopsy: Complex hyperplasia with atypia


Surgery1

Surgery

Robotic hysterectomy

Bilateral salpingo-oophorectomy

Frozen: G1 endometrioid adenocarcinoma

No invasion

FINAL:G1 endometrioid adenocarcinoma in CAH

No invasion


Points of discussion3

Points of Discussion

  • Preoperative evaluation

  • Discussion according to patient age

  • Surgical approach

  • Intraoperative options

  • Postoperative hormone replacement


Case presentation3

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 studies1

Imaging Studies


Surgery2

Surgery

Exploratory laparotomy

Total abdominal hysterectomy

Bilateral salpingo-oophorectomy

Frozen:

FINAL:Uterine leiomyosarcoma

Tumor size: 24 cms

R ovary-leiomyosarcoma


Points of discussion4

Points of Discussion

  • Preoperative evaluation

  • Surgical approach

  • Role of intraoperative frozen section

  • Indications for lymphadenectomy

  • Postoperative therapy


Ovary

Ovary


Case presentation4

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

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)


Surgery3

Surgery

May 23, 2011

Exploratory laparotomy

R salpingo-oophorectomy

L cystectomy


Points of discussion5

Points of Discussion

  • Differential diagnosis

  • Options for follow up vs. surgery

  • Surgical approach

  • Intraoperative options

  • Postoperative counseling


Case presentation5

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 studies1

Imaging and Laboratory Studies

CA125: 1,043 U/mL (<35)


Imaging and laboratory studies2

Imaging and Laboratory Studies

Video-assisted thoracoscopy (VATS)

Thoracentesis: 600 mL


Pathology

Pathology

CT-Guided biopsy:

HG papillary serous carcinoma consistent with mullerian primary


Interval cytoreductive surgery

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 discussion6

Points of Discussion

  • Considerations of work-up evaluation

  • Options offered to the patient

  • Treatment implementation

  • Strategies for follow up


Case presentation6

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 studies3

Imaging and Laboratory Studies

CA125: 78 U/mL (<35)


Surgery4

Surgery

Exploratory laparotomy

R salpingo-oophorectomy

Pelvic and para-aortic lymphadenectomy

Omental biopsy

Peritoneal biopsies

Frozen:


Points of discussion7

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 presentation7

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 studies4

Imaging and Laboratory Studies

CA125: 1,565 U/mL (<35)


Surgery5

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


Case presentations honduras 2011

SPLEEN


Points of discussion8

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

Post-operative Course

POD # 4

Increasing acute abdominal pain and vomiting

Fever and elevated WBC count

Significant abdominal

tenderness


Case presentations honduras 2011

MD Anderson Cancer Center


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