Gyne tumor board crown plaza

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Gyne tumor board crown plaza

  1. 1. Gynecology Tumor Board Cases
  2. 2. First session
  3. 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. 4. Case 1 1. Close follow up 2. Chemotherapy (BEP) 3. Complete surgery with hysterectomy ,remove other ovary followed by chemotherapy
  5. 5. Case 1 • This patient refuse chemotherapy and elected to have follow up • Q- How frequent need to do AFP? 1. Weekly 2. Q 2 weeks 3. Monthly 4. Q 3 months
  6. 6. 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…
  7. 7. Case 2 1-Close follow up 2-Cemotherapy with BEP 3-Chemotherapy with VAC 4-Chemotherapy + radiotherapy 5-Radiotherapy alone 6-Hysterectomy followed by chemotherapy
  8. 8. 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….
  9. 9. Case 3 1-Follow up with radiology every 3 month 2-Trachelectomy + pelvic lymphadenectomy 3-Chemotherapy (platinum and doxorubicin ) 4-Radiotherapy (EBRT&brachytherapy )
  10. 10. Case 3 • Patient under went robotic radical trachelectomy and pelvic lymphadenectomy • Histopathology : positive disease in parametrium other specimens negative for cancer • Stage III liomyosarcoma of the uterus • What's next 1-Follow up with radiology test every 3 month 2-Chemotherapy (Cisplatinum with doxorubicin ) 3-Radiotherapy (EBRT) 4-Aromatase inhibitors
  11. 11. 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…
  12. 12. Case 4 1-Radiotherapy with cisplatinum 2-Radiotherapy with 5FU 3-Exentration and exision of groin nodes 4-Excision of groin nodes followed by radiotherapy and chemotherapy 5-Radiotherapy with (cisplatinum and 5FU)
  13. 13. Cases 4 • She received radiotherapy concomitant with 5 FU • Re examine after treatment ,still she had 1cm vulvar lesion and • She had vulvectomy + lower vaginectomy + Maritus flap • Final histopathology , squamous cell carcinoma-negative margin
  14. 14. 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….
  15. 15. Case 5 1. Taxane & platinum base chemotherapy 2. Taxane & platinum + Avastin 3. IP chemotherapy (IV taxol and IP cisplatin) 4.Dose-dense weekly paclitaxel with carboplatin
  16. 16. Second Session
  17. 17. 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?
  18. 18. Case 6 1-Radiotherapy 2-Chemotherapy (VAC) and Radiotherapy 3-Chemotherapy (VAC)
  19. 19. Case 6 • Received VAC, Six months later, no evidence of recurrence clinically and radiologically • Closure of rectovaginal fistula done with Maritus flap • Plane for closure of colostomy …….
  20. 20. 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….
  21. 21. Case 7 1-Hysterectomy followed by EMA-CO 2-Switch to EMA_EP 3-Give more cycle of EMACO 4-Hystrectomy followed by EMA-EP 5-Switch to taxane and platinum based chemotherapy
  22. 22. 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…
  23. 23. Case 8 1-Palliative radiation 2-Chemotherapy- (taxane &paltinum ) 3-Palliative care 4-Chemotherapy (cisplatinum ,taxol ,ifosfamide )
  24. 24. Case 8 • This patient received six cycle carboplatinum /taxol • Radiology : She had a good response locally with complete radiological response distally • What could be next step…. 1-Close follow up 2-Radical radiation ( EBRT, Brachytherapy) 3-Radical hysterectomy
  25. 25. 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…
  26. 26. Case 9 1-Close follow up 2-Chemotherapy (VAC) 3-Radiotherapy 4-Aromatose inhibitor 5-Progesterone 6-Ifosfamide & doxyrubicin
  27. 27. 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 ??
  28. 28. Case 10 1. Large Cold knife cervical conization 2. Radiotherapy concomitant with weekly cisplatinum 3. Radical tracheolectomy and pelvic lymphadenectomy 4. Radical hysterectomy + pelvic lymphadenectomy
  29. 29. Third session
  30. 30. 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…?
  31. 31. Case 11 1-Close follow up 2-Chemotherapy (Ifosfamide , doxorubicine ) 3-Radiotherapy 4-Aromatose inhibitors
  32. 32. Case 11 One year later patient came after losing follow up She developed ascitis and 10 × 12 cm omental mass Radiologically : no evidence of distal or local recurrence. Next step?
  33. 33. Case 11 1-Palliative care 2-Debulking surgery followed by chemotherapy 3-Chemotherapy
  34. 34. 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…
  35. 35. Case 12 1-Chemotherapy with EBRT (Sandwich technique ) 2-Six cycle chemotherapy (taxane ,platinum)follow up by EBRT 3-External beam Radiotherapy alone 4-External beam Radiotherapy ,bracytherapy 5-Chemotherapy (taxane ,paltinum ) and progestrone
  36. 36. 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…
  37. 37. Case 13 1-Chemotherapy (VAC) 2-Chemotherapy ( Ifosfamide,doxorubicine ) 3-Radiotherapy 4-Chemotherapy followed by Radiotherapy 5-Close follow up (no further treatment ) 6-Aromatase inhibitor
  38. 38. 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…
  39. 39. Case 14 1-Close Follow up every 3 month with tumor marker 2-Full surgical staging 3-Chemotherapy (BEP) 4-Radiotherapy
  40. 40. 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
  41. 41. 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…
  42. 42. Case 15 1.Abort radical hysterectomy and refer to radiotherapy 2. Radical hysterectomy and removal of bulky pelvic node 3.Remove the bulky nodes , abort the radical hysterectomy and refer to radiotherapy
  43. 43. Case 15 • The patient had radical hysterectomy + bilateral pelvic and para-ortic lymphadenectomy. • Histopathology showed - GII squamous cell carcinoma, negative margin • 1/20 pelvic node was positive • Next step…. 1-EBR + brachytherapy 2-EBR + concomitant chemotherapy and brachytherapy 3-Chemotherapy only

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