2. Gynecology Tumor Board Cases

3. First session

4. 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?..

5. 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…

6. 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….

7. 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…

8. 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….

9. Second Session

10. 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?

11. 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….

12. 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…

13. 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…

14. 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 ??

15. Third session

16. 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…?

17. 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…

18. 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…

19. 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…

20. 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

21. 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…