Fi nal gyne tumour board symposium may 10 2013 syllibas pdf

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  • 1. Gynecology Tumor Board Cases
  • 2. First session
  • 3. Case 1 • 21 year old • Presented with pelvic mass . • Pelvic Ultra sound : 15 × 20x15cm solid right ovarian mass • Alphafetoprotein – 5000 mg/ml • She had laparotomy- uni lateral Salpingo oophrectomy staging lymphadenectomy • HP - Endodermal Sinus Tumor confirmed to the • ovary capsule was free • lymph nodes & pelvic washing negative • Stage Ia Endodermal Sinus Tumor • What most appropriate next step?..
  • 4. Case 2  15 year old single patient  ECOG 0  Presented with heavy vaginal bleeding • On inspection : 7x8cm fleshy mass protrude from the vagina • biopsy showed emberyonal sarcoma • She underwent Examination under anesthesia • Finding : the mass was attached to the posterior cervix by small pedicle, the vagina was free • Procedure : Excision of the tumor with negative margin(LEEP) • Radiology : no distance metastasis , no lymphadenopathy • What next step…
  • 5. Case 3 • 34 year old Po + 0 • Presented with menorrhagia • ECOG 1 • Referred to gynecology oncology after subtotal hysterectomy for uterine mass • Final histopathology – Uterine leiomyosarcoma • Radiology – negative for metastasis • Next step….
  • 6. Case 4  56 year old  Presented with vulvar itching and pain  On examination : she had 3 cm vulvar lesion extending to posterior fourchette • 1cm close to the anus ,with 2 cm inguinal lymph node • Vulvar Biopsy : squamous cell carcinoma ,grade II • ECOG 2 • Radiology , no distance metastasis  stage III vulvar cancer(squamous cell carcinoma). • What is your next step…
  • 7. Cases 5 • 45 year old diagnosed to have papillary serous ovarian cancer, stage III c. • She had debulking. TAHBSO • Residual disease < 1cm. • ECOG : 2 • Next step….
  • 8. Second Session
  • 9. Case 6 • 28 year old female patient • Presented with 2 cm lesion in upper vagina , ressected and found to have PNET in private hospital • Developed Rectovaginal fistula required colostomy • Referred to gynecology oncology found to have no residual disease with Rectovaginal fistula and colostomy • Radiological , no metastasis • ECOG 1 • Histopathology reviewed confirm diagnosis (Primitive neuroectodermal tumor ) • Stage II Primitive neuroectodermal tumor of the Vagina • What is your next step of management?
  • 10. Case 7  25 Year old had three kids ,last delivery was seven month ago  ECOG 1  Presented with excessive nausea and vomiting  Bhcg 70,000 IU/ml,no intra uterine pregnancy in pelvic ultrasound  Radiology : positive for multiple chest metastasis  Diagnosis : high risk gastational trophoblastic neoplasm Modified by (WHO Score- 7)  She received EMA-CO • After 4 cycle EMACO – BHCG increase • BHCG Graph • Radiology CT – same lung lesions size ,no new metastasis • Ultra sound pelvis : hypervascular lesion in endometrium • What next step….
  • 11. Case 8  40 year old  Presented with heavy vaginal bleeding  Found to have 5 cm exophytic cervical mass  Cervical biopsy – squamous cell carcinoma ,grade II  Cystoscopy ,Segmoidoscopy were negative  Radiology : multiple bilateral lung metastasis  No pelvic lymphadenopathy  stage IV squamous cell carcinoma of the cervix. • What is the next step…
  • 12. Case 9  50 year old female patient  ECOG 2  Presented with pelvic pain  Radiology :Bulky uterus ,heterogeneous mass in the uterus measuring 18× 18× 10 cm  MRI , no distance metastasis  Serum Creatinin : normal  underwent laparotomy  Finding : mass in the fundus of the uterus invading the right ureter and partially invading the right side of the bladder  Procedure : total abdominal hysterectomy ,bilateral salpingo oophrectomy ,excision of distal right ureter, partial cystectomy with re implant of right ureter • side to side ureter anastomosis , with microscopic residual disease • Histpathology - Low grade stromal Sarcoma of the uterus • What next step…
  • 13. Case 10 • 32 year old married for the last three years, no children • Presented with post coital bleeding • ECOG 1 • On pelvic examination : 2cm exophytic cervical lesion • Biopsy –GII adenocarcinoma • MRI- pelvis + abdomen negative (no parametrium or vaginal involvement nor L-node enlargement) • Stage IB adenocarcinoma of the cervix ,grade II • What is next ??
  • 14. Third session
  • 15. Case 11 • 59 year old • Presented with heavy vaginal bleeding • ECOG 1 • She under went hysteroscopic resection of endometrial polyp. • Histopathology High Grade Stromal Sarcoma • Radiology No distant metastasis • Subsequently she underwent total abdominal hysterectomy ,bilateral salpingo-oophrectomy , pelvic and para aortic lymphadenectomy • Histopathology : no residual disease in the uterus • Total of 32 pelvic and para aortic lymph nodes removed all were negative ,pelvic washing negative for cancer • stage Ia uterine High Grade Stromal Sarcoma • Next step…?
  • 16. Case 12 • 37 year old newly married • Presented with heavy vaginal bleeding • Endometrial sampling -- grade II endometriod adenocarcinoma of the uterus • ECOG 1 • She underwent laparotomy • Finding : bulky uterus ,both ovaries and tubes normal ,2 cm deposit in the right uterosacral ligament • Procedure : pelvic washing , hystrectomy ,removing both ovaries and fallopian tubes Pelvic and Para aortic lymphadenectomy , resection of uterosacral implant • Histopathology  G1 endometriod adenocarcinoma of the uterus  >50 % myometrial invasion  Negative nodes (total 30)  The uterosacral implant positive for metastasis  Cervix free • Stage IIIb , G1 endometriod adenocarcinoma of the uterus • Next Step…
  • 17. Case 13  52 year old nulliparus  ECOG 1  Presented with postmenopausal bleeding (endometrial biopsy negative)  Pelvic ultrasound : bulky uterus with multiple fibroid • She underwent laprotomy • Finding : peritoneal and omental seedling ,4 cm para aortic node • Procedure : hysterectomy bilateral salping oophrectomy ,omentectomy excision of bulky Paraortic lymph node with microscopic residual disease • Final histopathology : Rhabdomyosarcoma metasatic to omentum and Paraortic lymph node • Radiology : no distal recurrence • Stage IV Rhabdomyosarcoma • What next step…
  • 18. Case 14 • 11 year old presented with pelvic mass • Ultrasound : 20 cm solid with cystic ovarian mass • LDH : 5000 , other tumor marker normal • ECOG 1 • She under went left Oophorectomy- cyst ruptured intra operative (general gynecologist) • Histopathology : ovarian dysgerminoma • Next step…
  • 19. Case 15 • 52 year old patient • Presented with post menopausal bleeding • Pelvic examination: 2cm exophytic cervical mass • Clinically: stage I B cervical acncer • ECOG 1 • What next step… 1. CT abdomen, chest and pelvis 2. MRI pelvis + abdomen 3. PET Scan
  • 20. Case 15 Radical hysterectomy, pelvic lymphadenectomy • This patient had laparotomy. Intraoperative was found to have 2 cm Bulky 2cm right pelvic nodes, send for frozen section which showed squamous cell carcinoma • What next step…