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Case Presentations Honduras 2011 Pedro T. Ramirez, M.D. Professor Director of Minimally Invasive Research & Education Department of Gynecologic Oncology
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Cervix
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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
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Points of Discussion Standard of care Options for fertility preservation Surgical approach Intraoperative decisions
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2010 NCCN Guidelines
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Surgery Exploratory laparotomy Radical trachelectomy Lymphatic mapping Bilateral pelvic lymphadenectomy Frozen: No residual tumor present
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Surgical Specimen
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Points of Discussion Risk of no chance of fertility Postoperative complications Obstetrical outcomes Oncologic outcomes Long-term follow up
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Conclusion: Radical trachelectomy has similar oncologic outcome to radical hysterectomy DFSOS
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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
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Imaging Studies
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Points of Discussion Discussion of prognosis Role of supportive care Options for treatment GOG-179 GOG-204 Ongoing trials GOG-240
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Uterine
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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
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Pathology & Imaging Studies Endometrial biopsy: Complex hyperplasia with atypia
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Surgery Robotic hysterectomy Bilateral salpingo-oophorectomy Frozen: G1 endometrioid adenocarcinoma No invasion FINAL:G1 endometrioid adenocarcinoma in CAH No invasion
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Points of Discussion Preoperative evaluation Discussion according to patient age Surgical approach Intraoperative options Postoperative hormone replacement
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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
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Imaging Studies
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Surgery Exploratory laparotomy Total abdominal hysterectomy Bilateral salpingo-oophorectomy Frozen: FINAL:Uterine leiomyosarcoma Tumor size: 24 cms R ovary-leiomyosarcoma
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Points of Discussion Preoperative evaluation Surgical approach Role of intraoperative frozen section Indications for lymphadenectomy Postoperative therapy
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Ovary
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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
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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)
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Surgery May 23, 2011 Exploratory laparotomy R salpingo-oophorectomy L cystectomy
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Points of Discussion Differential diagnosis Options for follow up vs. surgery Surgical approach Intraoperative options Postoperative counseling
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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
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Imaging and Laboratory Studies CA125: 1,043 U/mL (<35)
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Imaging and Laboratory Studies Video-assisted thoracoscopy (VATS) Thoracentesis: 600 mL
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Pathology CT-Guided biopsy: HG papillary serous carcinoma consistent with mullerian primary
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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
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Points of Discussion Considerations of work-up evaluation Options offered to the patient Treatment implementation Strategies for follow up
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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
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Imaging and Laboratory Studies CA125: 78 U/mL (<35)
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Surgery Exploratory laparotomy R salpingo-oophorectomy Pelvic and para-aortic lymphadenectomy Omental biopsy Peritoneal biopsies Frozen:
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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
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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
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Imaging and Laboratory Studies CA125: 1,565 U/mL (<35)
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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
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SPLEEN
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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
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Post-operative Course POD # 4 Increasing acute abdominal pain and vomiting Fever and elevated WBC count Significant abdominal tenderness
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MD Anderson Cancer Center
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