Explain：Ovarian cancer
Clinical Information:
The patient had {{ progressive abdomen distension, GI symptoms,
irregular menstruation, lower abdominal pain, no symptom}}.
Oncologic survey
including pelvic and abdominal tomography, color doppler sonography, and tumor
marker.
color doppler
sonography: RI: _______
Pelvic and abdominal
CT shows retroperitoneal lymph node {{enlarged, not
enlarged}}.
The biochemical data
are: CEA:_______, CA-125:________, AFP:_______, beta-hCG:_______, CA19.9:_______, LDH:_______,
Operative Procedures:
Type of operation: Maximal
debulking: {{hysterectomy, BSO, tumor debulking,
BPLD, multiple peritoneal excision, omentectomy, appendectomy, enterolysis,
cytology}}.
After meticulous evaluation
of the pelvic and abdominal cavity to rule out the possible evidence of
metastatic tumor and the intestinal loops were placed in the upper abdominal
cavity by gauze pads and the uterus and adnexae were well-exposed. There was
yellowish ascites at the opening of peritoneum, which was tapped out and sent
for cytological study. Several metastatic nodules was suspected over the
uterine serosa and the cul-de-sac with dense adhesion to the lower sigmoid.
Coalescent nodules around the hepatic flexture and over the posterior
sub-phrenic region with dense adhesion to the liver surface were noted also. As
gross appearance showed a picture of ovarian cancer, the incision wound was
extended up to the sub-xiphoid and down to 1cm above the symphysis pubis. The
left ovarian tumor and fallopian
tube was removed by lysis of adjacent adhesion, and double ligate the
infundibular ligament, and then the ovarian ligament, and sent for frozen
section. Most of its surface are smooth, but scattered nodules of tumor seeding
were noted around the lower pole. As the frozen section confirmed it was a
ovarian malignant, hysterectomy along with right salpingo-oophorectomy and
segmental resection of lower sigmoid were performed. The uterus and sigmoid,
along with cul-de-sac tumor seedings and sigmoid metastatic lesions were
removed en-bloc by retroperitoneal approach which began at the pelvic brim,
near the ovarian vessels. Bilateral ureters were identified and were separated
away from the specimen site. The round ligament is then divided, the uterine
and superior vesicle vessels are ligated, and the peritoneal covering of the
bladder is removed as it was involved with the cancer. Carefully dissection for
en-bloc removal of primary tumor and pelvic metastatic nodules was undertaken.
Pelvic lymphadnectomy was
performed after the main tumor was removed. The procedures started from the
left common iliac and lower para-aortic lymph nodes, then down to the left
lower pelvic nodes that including the external iliac, internal iliac, external
and internal inguinal, and obturator nodes, and then over the right upper and
lower lymph nodes. Enlarged and indurated lymph nodes over bilateral obturator
areas were noted. However, no enlarged nodes were palpable over the lower
para-aortic and common-iliac regions. All the accessible lymph nodes were
dissected.
Subcolic omentectomy was
undertaken at the initiation of procedure since the lower margin of omentum was
adherent to the left ovarian tumor. For the total removal of the omentum, the
gastroepiploic vessels and their branches were exposed for a direct separation
from the stomach. The confluent nodules over the hepatic flexture of colon were
excised by sharp dissection. The spleen was small and no palpable/visible tumor
nodules over its parenchyma and its surface.
After the above procedures,
the severed sigmoid was end-to end anastomisized by protologist. The tumor
nodularies over the sub-phrenic area was excised by a general surgeon. A chest tube was inserted for drainage of
pleural effusion that may caused by patch excision of diaphragm.
The resection of intra- and
retroperitoneal tumor was optimal and no gross residual tumor present after the
operation Significant reduction of tumor mass and total cancer cell burden
accomplished
Two J-P tubes and vacuum
balls were placed over both pelvic fossa for drainage.
The adhesion tissues were
removed, and the intestine, omentum, ovary. tube, uterus, and peritoneum were separated into original location. All the
adhesion band and any suspicious malignant tissue over the whole abdominal
peritoneum were removed and sent for pathologic reading.
The mesoappendix and
appendix artery were clamped, cut
and ligated with 2-0 catgut. The appendix was removed. The appendix cut
surface was clean with betaiodine and normal saline.
Optimal debulking was
performed.
The abdominal wall was
closed layer by layer. The peritoneum below the umbilicus was approximated by
1-0 chromic catgut, the abdominal fascia was closed by 1-0 PDS continuous
suture, the sub-cutaneous fat was approximated by 1-0 vicryl, and the skin was
approximately by 3-0 vicryl subcutaneously.
Operative Findings:
ascite: _________ml
carcinomatosis {{ yes, no}}.
tumor size: _________cm.
frozen pathology: _________
Lymph node status: [[node not enlarged, R’t pelvic nodes enlarged, L’t node
enlarged, paraaortic node not enlarged, Paraaortic node metastasis]]
Complication: [[massive
bleeding, ureter injury, bladder injury, intestine injury, _______________]].
Pathology:
Cytology: [[ negative, positive ]] for malighancy
Histology: [[epithelial: [[serous cystadenocarcinoma, mucinous
cystadenocarcinoma, endometrioid cystadenocarcinoma, clear cell
cystadenocarcinoma, malignant brenner tumors, mixed epithelial carcinomas,
undifferentiated adenocarcinoma]]; germ cell tumor:[[dysgerminoma, immature
teratoma, endodermal sinus tumors, embryonal carcinoma, nongestational
choriocarcinoma, polyembryoma, mixed germ cell tumors; gonadal stromal
tumor:[[thecomas, Sertoli-Leydig cell tumors, lipoid cell tumors,
gynandroblastomas; nonspecific mesenchymal tumors:[[lymphoma, sarcoma]] ]].
Stage: {{Ia, Ib, Ic, IIa, IIb, IIc, IIIa, IIIb, IIIc, IV}}
R’t pelvic nodes: {{ negative, positive _______}}.
L’t pelvic nodes: {{ negative, positive _______}}.
R’t paraaortic nodes: {{ negative, positive _______}}.
R’t paraaortic nodes:
{{ negative, positive _______}}.
Dr:________________. Date: _______________.