Topics in Intraoperative Topics in Intraoperative Gynecologic - - PowerPoint PPT Presentation

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Topics in Intraoperative Topics in Intraoperative Gynecologic - - PowerPoint PPT Presentation

Jul 29, 2023 375 likes •1.1k views

Topics in Intraoperative Topics in Intraoperative Gynecologic Oncology Gynecologic Oncology Mark K. Dodson, M.D. Professor Department of OB/GYN Division of Gynecologic Oncology University of Utah I have no financial interests to disclose.

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Topics in Intraoperative Gynecologic Oncology Topics in Intraoperative Gynecologic Oncology

Mark K. Dodson, M.D. Professor Department of OB/GYN Division of Gynecologic Oncology University of Utah

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I have no financial interests to disclose.

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Learning Objectives Learning Objectives

Please See Provided Material

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Intraoperative Consult Intraoperative Consult

  • Cancer vs No Cancer
  • Gynecologic vs Other Cancer
  • Adenocarcinoma vs Squamous vs Sarcoma
  • Ovarian Cancer
  • Epithelial Adenocarcinoma
  • Germ Cell Cancer
  • Sex/Cord Stromal Cancer
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Cancer vs No Cancer Cancer vs No Cancer

  • Cervix: Radical Surgery vs Simple Surgery
  • Uterus: Radical vs Minimally Invasive
  • Ovaries/Tubes: Radical Debulking vs

Resect Primary Tumor

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Gynecologic vs Other Cancer Gynecologic vs Other Cancer

  • Uterus/Ovary/Tubes
  • Radical Resection of All Visible Tumor
  • Non-Gynecologic Cancer
  • Breast: Simple Resection then Chemotherapy
  • GI: Resect Primary Tumor then Chemo±Rads
  • Lymphoma: Simple Resection and Chemo
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Adenocarcinoma vs Squamous vs Sarcoma Adenocarcinoma vs Squamous vs Sarcoma

  • Adenocarcinoma
  • Radical Debulking of Tumor (except Cervix)
  • Squamous Cell Carcinoma
  • Resect Only if Localized
  • METS Typically Unresectable
  • Sarcoma
  • Resection of Primary Tumor
  • No Survival Benefit to Radical Debulking
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Ovarian Cancer Ovarian Cancer

  • Epithelial Adenocarcinoma
  • Radical Debulking

(TAH/BSO/Omentectomy/Bowel Resection/Splenectomy/Diaphragm)

  • Germ Cell Cancer
  • Young (USO/Omentectomy/Nodes/Biopsies)
  • Older (TAH/BSO/Omentecomy/ Nodes/Bx)
  • Sex Cord Stromal Cancer
  • Same as Germ Cell Cancer
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Topics in Intraop Gyn/Onc Topics in Intraop Gyn/Onc

  • Vulva
  • Vagina
  • Cervix
  • Uterus
  • Tube
  • Ovary
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Intraoperative Consultation Intraoperative Consultation

Communication is the Key

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Vulva Vulva

  • Should Have Preoperative Biopsy
  • Rare Need for a Frozen Section
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Vulva: Cancer vs No Cancer Vulva: Cancer vs No Cancer

  • Cancer
  • Excision
  • Simple
  • Radical
  • Dysplasia
  • Excision
  • Laser
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Vulvar Cancer Vulvar Cancer

  • All About the Depth
  • If ≤ 1mm Depth
  • Simple vulvectomy
  • If > 1mm Depth
  • Radical Vulvectomy + Nodes
  • To the Fascia of UG Diaphragm
  • Bulbospongiosis
  • Ischiocavernosus
  • Superficial Transverse Perineal
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Laser of VIN III Laser of VIN III

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Lipoma of Vulva Lipoma of Vulva

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Simple Vulvectomy Simple Vulvectomy

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Vulvar Cancer Vulvar Cancer

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Radical Vulvectomy Radical Vulvectomy

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Vulvar Reconstruction Vulvar Reconstruction

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Vulvar Cancer and Nodes (> 1mm) Vulvar Cancer and Nodes (> 1mm)

  • Sentinel Lymph Node
  • If ≤ 4cm
  • Inguinofemoral Lymphadenectomy
  • If > 4cm
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Lymphedema Lymphedema

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Vulvar Cancer Vulvar Cancer

  • When is Frozen Section Necessary?
  • If Suspicious Node On Sentinel Resection
  • If Positive: Formal Lymphadenectomy
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Vulvar Cancer Vulvar Cancer

  • Margins Important
  • If High Risk of Positive Margin: 1° Radiation
  • Periurethral
  • Perianal
  • If Positive Resection Margin
  • Re-Resect
  • Radiation
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Any Excised Vulvar Lesion Any Excised Vulvar Lesion

Encourage Surgeon to Mark Specimen at 12 O'clock

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Marking Specimen Marking Specimen

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Paget’s Disease of Vulva Paget’s Disease of Vulva

  • 15 – 20% with Adenocarcinoma
  • Positive Margins Typical
  • Mark Specimen at 12 O'clock

Black et al. Gynecol Oncol. 2007

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Paget’s and Marking Specimen Paget’s and Marking Specimen

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Paget’s and Marking Specimen Paget’s and Marking Specimen

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Vulvar Melanoma Vulvar Melanoma

  • 2 cm Margin Grossly
  • Sentinel Nodes
  • Treated as Systemic Disease
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Cervical Disease Cancer vs No Cancer Cervical Disease Cancer vs No Cancer

  • Cervical Dysplasia: High Grade/CIS
  • CKC/LEEP
  • Cervical Cancer
  • Depth and Width Determine Treatment
  • CKC/LEEP
  • Simple Hysterectomy
  • Radical Trachelectomy/Hysterectomy + Nodes
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Cervix Disease Cervix Disease

  • Cold Knife Conization or LEEP
  • Equivalent for CIN, ACIS and Early Cancer
  • LEEP Considerably Cheaper
  • Frozen is a Bad Idea
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Cervix Cancer Cervix Cancer

  • < 3mm Depth & < 7 mm Width
  • Stage IA1 Disease
  • CKC/LEEP (If desires to maintain fertility)
  • Simple Hysterectomy
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Simple Hysterectomy Simple Hysterectomy

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Cervix Cancer Cervix Cancer

  • 3 – 5 mm Depth & < 7 mm Width
  • Stage IA2 Disease
  • Radical Trachelectomy + Nodes (Fertility

Sparing)

  • Modified Radical Hysterectomy + Nodes
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Radical Trachelectomy Radical Trachelectomy

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Cervix Cancer Cervix Cancer

  • > 5mm Depth or > 7mm Width
  • Stage IB1: < 4cm Size
  • Radical Trachelectomy + Nodes (≤ 2cm Best)
  • Radical Hysterectomy + Nodes
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Cervix Cancer Cervix Cancer

  • If > 4 cm : Stage IB2
  • Radiation + Chemotherapy
  • If Stage II, III, IV
  • Radiation + Chemotherapy
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Uterine Disease Cancer vs No Cancer Uterine Disease Cancer vs No Cancer

  • Benign
  • Hormones vs Minimally Invasive Surgery
  • Hyperplasia
  • Without Atypia: Hormonal Therapy
  • With Atypia/EIN: Hysterectomy
  • Cancer
  • Surgery : Hysterectomy ± Nodes ±

Omentectomy and Biopsies

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Uterine Cancer Important Factors Uterine Cancer Important Factors

  • Grade 3
  • Nodes and At Least Vaginal Cuff Rads
  • Depth (> ½ Invasion)
  • Nodes and at Least Vaginal Cuff Rads
  • Histologic Subtype
  • Serous and Clear Cell
  • Omentectomy/Abdominal Biopsies
  • Likely Chemo
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Fibroids vs Sarcoma

  • n Frozen Section

Fibroids vs Sarcoma

  • n Frozen Section
  • Very Difficult Position for Pathologist
  • Encourage Communication
  • Lymphadenectomy Not Absolute
  • Laparoscopic Lymphadenectomy at Later

Date if Necessary

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Ovarian Pathology Gynecologic vs Other Origin Ovarian Pathology Gynecologic vs Other Origin

  • Metastatic Disease
  • GI
  • Breast
  • Lymphoma
  • Communication is Key
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Krukenberg Tumor Krukenberg Tumor

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Ovarian Pathology Cancer vs No Cancer Ovarian Pathology Cancer vs No Cancer

  • Benign
  • Cystectomy/Oophorectomy
  • LMP/Borderline
  • Cystectomy/Oophorectomy
  • Cancer
  • Staging/Debulking
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Borderline Ovarian Tumor (LMP) Borderline Ovarian Tumor (LMP)

  • Cystectomy
  • 20% Recurrence
  • Unilateral Oophorectomy
  • 5% Recurrence
  • No Staging Necessary

Shazly et al. Am J Obstet Gynecol. 2016

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LMP LMP

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LMP with Cystectomy LMP with Cystectomy

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LMP Following Cystectomy LMP Following Cystectomy

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Ovarian Cancer Ovarian Cancer

  • Epithelial Adenocarcinoma
  • Germ Cell Cancer
  • Sex Cord/Stromal Cancer
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Epithelial Ovarian Cancer Epithelial Ovarian Cancer

  • Acceptable to Retain Uterus and Unaffected

Ovary

  • Often Bilateral Ovarian Disease
  • Optimal Debulking is the Goal
  • Each Lesion < 1cm
  • Typical: TAH/BSO/Omentectomy/Nodes
  • Often: Bowel

Resection/Splenectomy/Diaphragm Resection

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Ovarian Cancer in Pregnancy Ovarian Cancer in Pregnancy

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Ovarian Cancer Ovarian Cancer

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Germ Cell Cancer Ovary Germ Cell Cancer Ovary

  • Typically Unilateral
  • If Young: Retain Uterus and Opposite Tube

& Ovary (Even with METS)

  • Oophorectomy/Omentectomy/Nodes/Biopsi

es (Debulking if Necessary)

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Sex Cord/Stromal Cancer Ovary Sex Cord/Stromal Cancer Ovary

  • If Young: Retain Uterus and Opposite Tube

& Ovary (Even with METS)

  • Oophorectomy/Omentectomy/Nodes/Biopsi

es (Debulking if Necessary)

  • If Granulosa Cell Cancer and Retained

Uterus: Endometrial Biopsy (25% Cancer)

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Mucinous Ovarian Mass Mucinous Ovarian Mass

  • Pathologists: Appendectomy
  • Gyn/Onc Literature: No Appy

Lin et al. Am J Obstet Gynecol. 2013 Jan

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Pseudomyxoma Peritonei Pseudomyxoma Peritonei

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BRCA Abnormality BRCA Abnormality

  • Gonadal Vessels to Pelvic Brim
  • Submit Entire Tube & Ovary
  • Pelvic and Abdominal Washings
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BRCA1 Abnormality and Aggressive Endometrial Cancer BRCA1 Abnormality and Aggressive Endometrial Cancer

  • High Grade Serous Cancers
  • 2.6% Risk if BSO Only
  • Recommend Hysterectomy at time of

Prophylactic Oophorectomy

Shu et al. JAMA Oncol Jun 2016

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Fallopian Tube Cancer Fallopian Tube Cancer

  • 40% – 70% Of All Ovarian Cancers
  • Prophylactic Salpingectomy Now Common
  • Most Arise in Fimbria
  • No Need to Distinguish from Ovarian

Cancer (Staged and Treated the Same)

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