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OG33.1-5,OG34.1-5 | Gynaecological Oncology and Operative Gynaecology — PBL Case

CLINICAL SETTING

Mrs. Savitribai, a 56-year-old school teacher and mother of three, presents to the gynaecology outpatient department with a 4-month history of progressive abdominal distension and a vague sensation of fullness after eating. She also reports mild shortness of breath on exertion for the past 3 weeks. Her last menstrual period was 7 years ago. She has no significant past medical history, no family history of breast or ovarian cancer, and no prior abdominal surgeries. On examination, her abdomen is mildly distended with dullness on percussion in the flanks and shifting dullness, suggesting ascites. Bimanual pelvic examination reveals a hard, irregular, bilateral adnexal mass extending to the level of the umbilicus. She has no cervical lymphadenopathy. She asks the doctor: 'Doctor, I just thought it was weight gain — is this serious?'

Trigger 1: Initial Assessment and Differential Diagnosis

An urgent ultrasound pelvis and abdomen is performed. The report reads: 'Bilateral complex adnexal masses measuring 12 cm (right) and 9 cm (left); predominantly solid with irregular internal echoes, thick septations, and papillary projections; moderate ascites; no obvious metastatic deposits in the liver parenchyma on ultrasound.' Serum CA-125 is 1,840 U/mL. Full blood count and biochemistry are normal.

DISCUSSION POINTS

  • What is the differential diagnosis for bilateral complex adnexal masses in a 56-year-old postmenopausal woman? Rank your differentials by likelihood and justify your ranking.
  • Calculate the Risk of Malignancy Index (RMI) for this patient. What does the score imply and what should be the next step in management?
  • Why does a high CA-125 not by itself diagnose ovarian cancer? In which other conditions can CA-125 be elevated?
Click to reveal Trigger 2: Staging Laparotomy — Intraoperative Findings (discuss previous trigger first!)

Trigger 2: Staging Laparotomy — Intraoperative Findings

Mrs. Savitribai is referred to a gynaecological oncologist. CT chest, abdomen and pelvis reveals: bilateral adnexal masses, large-volume ascites, omental cake (thickened omentum with multiple deposits), multiple peritoneal implants throughout the upper abdomen, no pleural effusion, no parenchymal liver metastasis, and no inguinal or supraclavicular lymphadenopathy. She undergoes a midline laparotomy. Intraoperatively, the surgical findings include: both ovaries replaced by tumour, tumour implants over the uterine serosa, omentum grossly replaced by tumour (the 'omental cake'), peritoneal nodules in the paracolic gutters and right hemidiaphragm measuring up to 3 cm, and 1.5 litres of ascites drained. Retroperitoneal lymph nodes are sampled and sent for frozen section.

DISCUSSION POINTS

  • Using the FIGO 2014 surgical staging system for ovarian cancer, assign the stage for Mrs. Savitribai based on the intraoperative findings. Be precise about the sub-stage. Remember: this is the FIGO ovarian system — not cervical (FIGO 2018) or endometrial (FIGO 2023).
  • What is the surgical objective of debulking (cytoreductive) surgery in advanced ovarian cancer? What is the definition of 'optimal cytoreduction' and why does it matter for prognosis?
  • Which structures are typically removed or resected during a staging laparotomy + cytoreductive surgery for ovarian cancer? Explain why bilateral salpingo-oophorectomy, omentectomy, and lymph node sampling are all included.
Click to reveal Trigger 3: Histopathology, Tumour Markers, and Systemic Treatment (discuss previous trigger first!)

Trigger 3: Histopathology, Tumour Markers, and Systemic Treatment

The final histopathology report confirms: high-grade serous carcinoma (HGSC) of the ovary; bilateral involvement; omentum replaced by carcinoma; peritoneal implants positive for carcinoma; retroperitoneal lymph nodes: 3 of 12 pelvic nodes positive, 0 of 8 para-aortic nodes. Residual disease after cytoreduction: 1.5 cm nodule on the right hemidiaphragm not resected (suboptimal cytoreduction). The oncology multidisciplinary team (MDT) discusses chemotherapy options.

DISCUSSION POINTS

  • What is the standard first-line chemotherapy regimen for advanced epithelial ovarian cancer? Name the drugs, route, and schedule. What are the main adverse effects of this regimen?
  • What does 'platinum-sensitive' versus 'platinum-resistant' recurrence mean in the context of ovarian cancer management? Why is this distinction clinically important?
  • Mrs. Savitribai's family asks if her daughters are at increased risk of ovarian cancer. What genetic testing would you recommend? How does BRCA1/BRCA2 status influence treatment decisions (including targeted therapy with PARP inhibitors)?
Click to reveal Trigger 4: Post-operative Complications and Monitoring (discuss previous trigger first!)

Trigger 4: Post-operative Complications and Monitoring

On post-operative day 5, Mrs. Savitribai develops fever (38.8°C), right flank pain, and reduced urine output. Her serum creatinine has risen from a baseline of 0.9 to 2.4 mg/dL. Catheter urine output is reduced. A CT urogram is requested.

DISCUSSION POINTS

  • What is the most likely cause of the rising creatinine and right flank pain following this major gynaecological surgery? How would you confirm this clinically and radiologically?
  • What is the anatomical basis for ureteric injury during major pelvic surgery? At which point in the operation is the ureter most vulnerable, and what surgical technique reduces this risk?
  • Outline the immediate management steps if the CT urogram confirms right ureteric obstruction secondary to inadvertent ligation. What are the short-term and long-term options for urinary tract reconstruction?
Click to reveal Trigger 5: Prognosis, Surveillance, and Holistic Care (discuss previous trigger first!)

Trigger 5: Prognosis, Surveillance, and Holistic Care

After completing 6 cycles of carboplatin-paclitaxel chemotherapy, repeat CT scan shows complete radiological response. CA-125 normalises to 18 U/mL. Mrs. Savitribai is relieved but anxious about recurrence. During the follow-up consultation, she asks: 'When will I know if the cancer is coming back? What should I watch for? And what happens if it comes back?'

DISCUSSION POINTS

  • What is the approximate 5-year survival rate for the FIGO stage you assigned to Mrs. Savitribai? What intraoperative and pathological factors most significantly influence her prognosis?
  • Outline a structured surveillance protocol for Mrs. Savitribai following completion of first-line chemotherapy. Include the frequency of visits, investigations at each visit (including the role and limitations of serial CA-125 monitoring), and duration of surveillance.
  • How would you counsel Mrs. Savitribai about the possibility of recurrence in a way that is honest, empathetic, and empowering? What specific 'alarm symptoms' should she report immediately?

Group Task Assignments

  • Construct a diagnostic algorithm for a postmenopausal woman presenting with an adnexal mass — starting from clinical assessment, through RMI calculation, to definitive staging.
  • Draw a management flow diagram for advanced ovarian cancer (FIGO Stage IIIC) from surgical staging through adjuvant chemotherapy to surveillance, annotating the decision points at each stage.
  • Prepare a two-minute explanation of the diagnosis and surgical plan for Mrs. Savitribai (role-play: one student is the doctor, one is the patient) — focusing on what the operation involves, what the risks are, and what the expected recovery will be.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OG34.2] What are the FIGO 2014 surgical staging criteria for ovarian cancer, and how do Stage IIIC criteria (macroscopic peritoneal metastasis >2 cm beyond the pelvis) differ from Stage IIIA and IIIB?
  2. [OG34.2] What is the Risk of Malignancy Index (RMI), how is it calculated (U × M × CA-125), and what score threshold prompts specialist gynaecological oncology referral?
  3. [OG34.2] What is the standard first-line chemotherapy for advanced epithelial ovarian cancer (carboplatin-paclitaxel), and what is the definition of platinum-sensitive vs platinum-resistant recurrence?
  4. [OG34.5] At which anatomical point is the ureter most vulnerable during a total abdominal hysterectomy, and what is the surgical technique to avoid ureteric injury ('water under the bridge')?
  5. [OG34.5] What constitutes optimal cytoreduction in advanced ovarian cancer, and how does residual tumour burden (<1 cm vs >1 cm) affect prognosis?
  6. [OG34.2] How does BRCA1/BRCA2 mutation status influence treatment decisions in ovarian cancer, including the role of PARP inhibitors as maintenance therapy?