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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

Case PresentationsHonduras 2011

Pedro T. Ramirez, M.D.

Professor

Director of Minimally Invasive Research & Education

Department of Gynecologic Oncology

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
surgery
Surgery

Exploratory laparotomy

Radical trachelectomy

Lymphatic mapping

Bilateral pelvic lymphadenectomy

Frozen: No residual tumor present

points of discussion1
Points of Discussion
  • Risk of no chance of fertility
  • Postoperative complications
  • Obstetrical outcomes
  • Oncologic outcomes
  • Long-term follow up
slide16

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

points of discussion2
Points of Discussion
  • Discussion of prognosis
  • Role of supportive care
  • Options for treatment

GOG-179

GOG-204

  • Ongoing trials

GOG-240

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

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
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

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

ad