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

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

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

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

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

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

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

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

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