1. Case PresentationsHonduras 2011 Pedro T. Ramirez, M.D. Professor Director of Minimally Invasive Research & Education Department of Gynecologic Oncology

2. Cervix

3. 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

4. Points of Discussion • Standard of care • Options for fertility preservation • Surgical approach • Intraoperative decisions

5. 2010 NCCN Guidelines

6. Surgery Exploratory laparotomy Radical trachelectomy Lymphatic mapping Bilateral pelvic lymphadenectomy Frozen: No residual tumor present

9. Surgical Specimen

10. Points of Discussion • Risk of no chance of fertility • Postoperative complications • Obstetrical outcomes • Oncologic outcomes • Long-term follow up

16. DFS OS Conclusion: Radical trachelectomy has similar oncologic outcome to radical hysterectomy

17. 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

18. Imaging Studies

19. Points of Discussion • Discussion of prognosis • Role of supportive care • Options for treatment GOG-179 GOG-204 • Ongoing trials GOG-240

20. Uterine

22. 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

23. Pathology & Imaging Studies Endometrial biopsy: Complex hyperplasia with atypia

24. Surgery Robotic hysterectomy Bilateral salpingo-oophorectomy Frozen: G1 endometrioid adenocarcinoma No invasion FINAL: G1 endometrioid adenocarcinoma in CAH No invasion

25. Points of Discussion • Preoperative evaluation • Discussion according to patient age • Surgical approach • Intraoperative options • Postoperative hormone replacement

26. 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

27. Imaging Studies

28. Surgery Exploratory laparotomy Total abdominal hysterectomy Bilateral salpingo-oophorectomy Frozen: FINAL: Uterine leiomyosarcoma Tumor size: 24 cms R ovary-leiomyosarcoma

29. Points of Discussion • Preoperative evaluation • Surgical approach • Role of intraoperative frozen section • Indications for lymphadenectomy • Postoperative therapy

32. Ovary

33. 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

34. 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)

35. Surgery May 23, 2011 Exploratory laparotomy R salpingo-oophorectomy L cystectomy

36. Points of Discussion • Differential diagnosis • Options for follow up vs. surgery • Surgical approach • Intraoperative options • Postoperative counseling

37. 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

38. Imaging and Laboratory Studies CA125: 1,043 U/mL (<35)

39. Imaging and Laboratory Studies Video-assisted thoracoscopy (VATS) Thoracentesis: 600 mL

40. Pathology CT-Guided biopsy: HG papillary serous carcinoma consistent with mullerian primary

41. 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

42. Points of Discussion • Considerations of work-up evaluation • Options offered to the patient • Treatment implementation • Strategies for follow up

43. 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

44. Imaging and Laboratory Studies CA125: 78 U/mL (<35)

45. Surgery Exploratory laparotomy R salpingo-oophorectomy Pelvic and para-aortic lymphadenectomy Omental biopsy Peritoneal biopsies Frozen:

46. 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

47. 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

48. Imaging and Laboratory Studies CA125: 1,565 U/mL (<35)

49. 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