Ebook Gynecologic oncology clinical practice and surgical atlas: Part 2

Part 2 book “Gynecologic oncology clinical practice and surgical atlas” has contents: Perioperative and critical care, targeted therapy and immunotherapy, integrative oncology, quality of life, and supportive care, surgical instrumentation and sutures, uterine procedures, cervical procedures,… and other contents.

to 29% of tumors found in the reproductive organs may be non-gynecologic inorigin; in Thailand, where cholangiocarcinoma is quite prevalent, 7% of allmetastases to the genital tract may arise from the gallbladder or extrahepaticbiliary tract.1 A single-institution review from the United States of 445,000accessioned cases identified 325 metastatic tumors to the genital tract over a 32-year time period; 149 (45.8%) were from extragenital sites including the colonand rectum, breast, stomach, and appendix Additional primary sites included thebladder, ileum, and cutaneous melanoma The remaining sites of metastasesoriginated from other areas within the genital tract such as the endometrium.2The ovaries and vagina are, by far, the structures most commonly involvedwith nongenital tract metastases Although percentages may vary by geographicarea, the most common primary sites of disease metastatic to the ovariestypically arise from the gastrointestinal (GI) tract (large intestine and stomach,pancreas, biliary tract, and appendix) and breast These sites comprise 50% to90% of the metastatic cancers to the ovaries (Table 17-1) Although the histology

of a metastatic breast cancer may look uniquely like breast cancer, metastasesfrom other sites, such as the pancreas and appendix, are mucinous and can bedifficult to distinguish from a primary mucinous tumor of the ovary.Endometrioid-appearing histologies in the ovary can arise from metastatic coloncancer, and clear cell histology can be confused with signet ring cells from agastric cancer or a metastatic clear cell renal carcinoma In the case of breastcancer, metastases to the ovary may remain completely occult and are detectedonly at autopsy or when they become symptomatic to the patient or identified onexamination by her physician With mucinous tumors, the metastases in theovary can become quite large, leading to significant symptoms and typicallydominating the clinical picture for the patient and the clinician

Table 17-1 Metastatic Tumor to the Ovaries

Reproductive tract lesions are most likely to reflect metastatic disease whenthere is an established nongynecologic primary malignancy, especially if theprimary tumor is advanced or has poor prognostic factors This is true ofmetastatic breast, pancreatic, and colon cancer In the case of some metastatic GItract malignancies, however, the primary tumor may not be found for many yearsafter the metastasis The classic signet ring cell adenocarcinoma of the ovary iscalled a Krukenberg tumor, which represents fewer than 6% to 7% of all ovariantumors in Western countries The signet ring morphology was initially described

in 1896 by a German pathologist and gynecologist, Friedrich Krukenberg.However, the extragenital origin of the Krukenberg tumor was not describeduntil 6 years later The stomach is the primary site of malignancy in 70% ofcases of Krukenberg tumor The route of spread to the ovaries is believed to belymphatic due to the copious lymphatic plexus surrounding the gastric mucosaand submucosa This lymphatic plexus, which communicates with thelymphatics along the ovarian vessels, provides a direct conduit for even smallgastric cancers to spread to the hilum and cortex of the ovary.3

Primary appendiceal neoplasms, including low-grade mucinous neoplasms,signet ring adenocarcinomas, and mucinous carcinoid tumors, also may remainoccult until they present with symptomatic ovarian masses or disseminatedmucin consistent with pseudomyxoma peritonei The rupture site of a primarylow-grade appendiceal neoplasm may be small and contained with fibroticmucus.4 When this occurs, the resulting ovarian metastases are frequentlybilateral and occur as a result of implantation of tumor cells and mucin on thesurface of the ovaries, which can then invade into the stroma If there isunilateral involvement of the ovary, it is more frequently on the right side,adjacent to the appendix.5

Most patients with colorectal cancer, similar to those with breast cancer, willhave their primary malignancy detected before the diagnosis of metastaticdisease to the ovaries In colorectal cancers, only 3% of patients initially presentwith an ovarian mass In general, the majority of primary colon cancers occurdistally in the sigmoid or rectum In patients who develop ovarian metastases,most have a primary lesion in the colon that has full-thickness invasion of thebowel wall, direct invasion into adjacent structures, multiple positive lymphnodes, and/or involvement of other non-ovarian sites such as the omentum orliver.6 Although ovarian involvement can occur by direct extension, otherprocesses such as angio-genesis and stromal cell–cancer cell interaction havebeen proposed for the predilection of colorectal cancer to metastasize to the

ovaries In patients with pancreatic cancer, 4% to 6% will have ovarianmetastases during the course of their disease.4 In a small series of patients withmetastatic pancreatic cancer, all patients had other sites of intraperitonealdisease, such as the omentum and bowel mesentery, when the ovarianinvolvement was detected.7

Carcinomas of the extrahepatic bile ducts and gallbladder are far morecommon in Asian countries Ovarian metastases may present in a heterogenousmanner, with nearly equal number of patients presenting at the time of primarytumor diagnosis and before or after detection of the primary tumor site The vastmajority of metastases are bilateral and mucinous, but the tumor may beinfiltrative or primarily present on the surface of the ovaries and can be cystic,solid, or mixed in morphology.8

After the gastrointestinal tract, breast cancer is the most common site of origin

of metastatic disease, especially to the ovaries Because there are genetic

mutations in BRCA1, BRCA2, and the DNA mismatch repair genes that

predispose women to develop ovarian cancer, distinguishing a primary ovarianmalignancy from a metastatic breast or colon cancer in women who harbor thesegenetic mutations may create a diagnostic dilemma Nearly 10% of women whodevelop breast cancer before the age of 50 years will harbor a mutation in

BRCA1 or BRCA2 that will place them at risk for ovarian cancer.9 Distinguishingadvanced primary ovarian cancer from metastatic breast cancer is critical inproviding recommendations for the appropriateness of cytoreductive surgery,chemotherapy, or hormonal therapy

In a review of 79 women with a history of breast cancer who presented withcarcinomatosis and underwent surgery, the majority of patients (75%) werediagnosed with primary ovarian, tubal, or peritoneal cancers.10 Although notstatistically significant, the authors suggested a trend favoring a new primaryovarian cancer in women with longer intervals since their breast cancerdiagnosis and higher CA-125 values In autopsy studies, 10% of patients withbreast cancer have ovarian metastases.11 The most significant risk factor forovarian involvement is advanced-stage breast cancer In a series of 31 patientswith stage IV breast cancer who underwent laparoscopy for either an adnexalmass or therapeutic bilateral salpingo-oophorectomy, 21 patients (68%) werediagnosed with metastatic breast cancer.12 Conversely, women diagnosed withearly-stage breast cancer are more likely to have benign adnexal disease thanmetastatic disease in their ovaries In a series of 129 women with breast cancerwho underwent surgery for an adnexal mass, 88% were found to have benignovarian cysts; of the remaining patients with malignant lesions, the majority

Metastatic melanoma and renal cell carcinoma frequently pose diagnosticproblems When metastatic to the ovaries or uterus, the majority of patients withmelanoma have disseminated disease in other areas The ovaries represent themajority (75%) of metastases Usually, there is a history of removal of acutaneous lesion or an ocular lesion The time span to the development ofmetastatic disease that involves the ovaries and becomes clinically significantmay be many years

Metastases to the uterus, cervix, vagina, and vulva are exceedingly rare, withindividual reports scattered throughout the literature Primary sites that canmetastasize to the uterine corpus or cervix include breast, stomach, colon,rectum, melanoma, lung, and kidney.13 In patients with a history of breastcancer, distinguishing between a primary uterine malignancy and metastaticbreast cancer can be challenging if the patient has received hormonal therapy forher breast cancer Tamoxifen is associated with known uterine pathology,including hyperplasias, highly irregular polyps, and primary endometrialcancers, all of which may also present with vaginal bleeding In general, womenwith metastatic breast cancer to the uterus have a poor prognosis, as the uterus israrely the only site of disseminated disease.14 Isolated metastases to the vaginahave been described in breast, renal, pancreatic, biliary tract, and colon cancer.Reports of metastases to the vulva are even more unusual

DIAGNOSIS

Key Points

1 Metastatic lesions to the reproductive organs typically present with similarsymptoms of primary gynecologic cancers and include abnormal bleeding,pelvic pain, and bloating

2 Ultrasound imaging may identify solid and bilateral ovarian masses that aresuggestive of metastatic disease

3 In women with pelvic masses or vaginal lesions, elevated serum markers, such

as carcinoembryonic antigen (CEA) or CA–19-9, may suggest anongynecologic primary malignancy

Whenever a patient has a history of cancer and presents with a mass or lesion inthe gynecologic tract, metastatic disease must be considered in the differential.Patients with metastatic disease to the ovaries are frequently younger thanpatients with primary ovarian cancer On average, patients with Krukenbergtumors are in the 40- to 50-year age range.15 Symptoms associated with ovarianinvolvement can include abdominal bloating, abdominal or pelvic pain, andweight loss Gastric cancers, because of luteinization of the ovarian stroma, mayproduce virilization or, on occasion, irregular vaginal bleeding.16 Occasionally,the patient may be asymptomatic and have a mass discovered on routine physicalexamination.17 This can occur with metastatic breast cancer In 30% of cases ofmetastatic disease to the ovaries, the mass may be the initial presenting featurebefore the diagnosis of the actual primary tumor site.16 Any metastatic tumorthat involves the uterus, cervix, vagina, or vulva may lead to symptoms ofirregular or postmenopausal bleeding, discomfort due to the presence of a mass,

or pain

Symptoms or the finding of an unexplained mass in the reproductive tractshould trigger a diagnostic work-up in the form of imaging and appropriatelaboratory studies Ultrasound or CT is usually the initial imaging studyperformed Features of ovarian tumors on ultrasound that suggest a metastaticorigin include bilateral involvement of the ovaries, a solid appearance, and adifferential in the size of the ovaries These features occur in 80% of patients ofKrukenberg tumor When there is a combined solid and cystic component, orcystic features only, distinction from a primary ovarian cancer becomeschallenging (Figure 17-1) On CT scan or MRI, many of the same features found

on ultrasound will be present, including a primarily solid component or solid andcystic components with septations (Figure 17-2) In the face of bilateral cysticovarian masses and copious fluid on imaging studies, a low-grade appendicealneoplasm resulting in pseudo-myxoma peritonei should be suspected

Serum markers may help to distinguish the primary site of disease CA-125 iselevated in 70% of advanced-stage ovarian cancers Although CA-125 may beelevated in a patient with a Krukenberg tumor, it may not be elevated to thedegree of epithelial ovarian cancers.18 CEA is a marker for colon, appendiceal,and gastric cancers, whereas CA–19-9 can be a marker for pancreatic cancer ACA-125 to CEA ratio of greater than 25 has also been used to help distinguishovarian from metastatic colorectal cancer with an overall test accuracy of 94%.19Metastatic lesions to the ovary from the breast frequently present as solidmasses or generalized ovarian enlargement in postmenopausal women Thisoccurs more frequently in women who have stage IV breast cancer When themasses are cystic and solid, however, differentiating a primary ovarian cancerfrom a metastasis is more difficult Positron emission tomography (PET)-CT,which is often used in breast cancer staging and restaging, can detect incidentallesions in the pelvis that require further investigation The sensitivity andspecificity of PET for metastatic lesions to the ovary is not well established.Although the standardized uptake value (SUV) is higher in breast cancermetastases to the ovaries compared with GI cancers, these results are based onvery limited numbers of patients with overlapping SUV levels and should not beused to distinguish primary cancers from metastatic disease at this time.20

may be challenging to distinguish a primary malignancy of the ovary from ametastatic tumor Metastatic colorectal cancers can mimic primary endometrioidovarian carcinomas, whereas metastatic appendiceal and pancreatic cancers can

be confused with primary mucinous or mucinous borderline tumors of the ovary.Frequently, however, primary mucinous or endometrioid cancers of the ovary areunilateral, not bilateral When the tumor is bilateral, or small (< 10 cm) andunilateral, metastatic disease should be suspected The classic Krukenberg tumorhas pathologic criteria defined by the World Health Organization to include thepresence of mucin-producing signet ring cells, stromal involvement, and ovarianstromal sarcomatoid proliferation.21 The intracytoplasmic mucin of the signetring cells typically stains with mucicarmine or a periodic acid-Schiff stain.Although Krukenberg tumors have typically been classified as metastatic gastriccancers, more recently the term has been applied to all metastatic GI cancers andcan include colon or pancreatic cancers as well as metastatic tumors of anynongenital tract origin When they result from metastatic gastric cancer, they aregrossly solid with a smooth nodular or bosselated outer surface (Figure 17-3A).When cut, the surface is white or tan with areas of red or brown discolorationand a firm or gelatinous appearance (Figure 17-3B) Histologically, the tumorshave an infiltrative, irregular growth pattern with single-cell invasion, signet ringcells, and surface mucin (Figure 17-4A, 4B).22 Metastatic mucinous cancers tend

to have a multinodular growth pattern that involves the ovarian surface Thepresence of necrotic debris or “dirty necrosis,” a higher degree of nuclear atypia

in the well-formed glands, and desmoplasia are features of metastatic coloncancer and can be used to distinguish a metastatic lesion from a primarymucinous or endometrioid cancer (Figure 17-5A-C).11 The size of the ovarianmetastasis does not seem to be a distinguishing factor in metastatic colorectalcancer, as the lesions can get quite large (> 10 cm) and be unilateral.6

Krukenberg tumor, gastric cancer, cut surface

×40 B Krukenberg tumor, metastatic gastric cancer, AE1/AE3 stain ×400.

colon cancer in the stroma of the fallopian tube demonstrating desmoplasia C Metastatic colon cancer involving the ovary, low power D Metastatic colon

cancer involving the ovary, high power

and 17-6B) are another source of mucinous tumors Four to 6% of patients withpancreatic cancer will have metastases to the ovaries They more commonlyarise from the tail of the pancreas and may be confused with primary ovariancancers, especially when there is diffuse peritoneal and omental involvement.The ovaries may become quite large (average size, 12.5 cm) and contain largemucinous cysts with smaller glands in the intervening stroma.23

Metastatic cholangiocarcinoma to the ovary, high power

The classification of appendiceal mucinous tumors has gone through someevolution Tumors that are confined to the appendix have been called adenomas

or low-grade appendiceal mucinous neoplasms If there is a breach in themuscularis mucosa, the tumor has been called a mucinous tumor of uncertainmalignant potential Tumors with high-grade cytology or with destructiveinvasion of the appendiceal wall are called appendiceal adenocarcinomas orinvasive adenocarcinomas.24 Primary appendiceal carcinomas are quite rare,representing fewer than 1% of all GI tract cancers The primary tumor in theappendix may be small, or the appendix may rupture, leading to obliteration ofthe tumor altogether In pseudomyxoma peritonei, there is diffuse gelatinousmaterial present in the peritoneal cavity Mucinous low-grade appendicealneoplasms may produce secondary neoplasms in the ovary Most commonly,there is bilateral involvement of the ovaries; if unilateral involvement is found, it

is usually right sided On cut section of the ovary, there is mucinous material inthe stroma of the ovary (pseudo-myxoma ovarii) and multiple cysts lined bylow-grade, bland-appearing mucinous cells with minimal nuclear atypia In asmall number of cases, primary appendiceal carcinomas in the form of signetring histology can metastasize to the ovaries as a Krukenberg tumor

Application of an immunohistochemical profile using cytokeratin stains andother markers can distinguish the primary site of disease (Table 17-2) Primary

ovarian carcinomas are typically cytokeratin (CK) 7 positive and CK 20negative In contrast, colon cancer is typically CK 7 negative and CK 20positive Other GI primaries such as appendiceal, gastric, and small intestinalcancers, like ovarian cancer, can be CK 7 positive CA-125 is expressed in themajority of papillary serous ovarian cancers but is also positive in half ofmucinous ovarian cancers, making it a less useful immunostain for mucinoustumors Although CEA is positive in most mucinous tumors, this can occurregardless of whether the origin is ovarian or GI, also making it a less usefuldistinguishing marker CDX2 is a nuclear transcription marker that is frequentlypositive in lower GI tract cancers, which can be helpful in differentiating ametastatic GI primary from a primary mucinous ovarian cancer.25 Other studies

of mucinous markers such as MUC2 and MUC5AC have shown variable results.S100 is a marker for melanoma that is characteristically diffusely positive inmetastatic lesions Although immunostain profiles can be helpful, they are notmutually exclusive, and the patient’s entire clinical picture must be taken intoaccount when interpreting the results of stains

Table 17-2 Immunostain Profile of Primary Versus Metastatic Carcinomas Involving the Ovaries

In autopsy studies, metastatic breast cancer has been found in the ovaries in10% of patients Lobular carcinomas have a greater propensity to spread to theovaries than infiltrating ductal carcinomas; however, given the higher overallfrequency of ductal carcinomas, most metastases to the ovaries will be ductal innature The ovaries may be quite small when involved with metastatic disease Ifthe histology of the ovarian cancer is papillary serous, it is more likely to be aseparate primary ovarian cancer Lobular carcinomas can present with solid nests

of tumor that may appear similar to adult type ovarian granulosa cell tumors.Ductal carcinomas can be challenging to differentiate from adenocarcinomas ofthe ovary or peritoneum and often require further work-up, including specific

immunohistochemical stains Breast carcinomas tend to have a similarcytokeratin profile to ovarian cancers and are often CK 7 positive and CK 20negative CA-125, WT1, and gross cystic disease fluid protein 15 (GCDFP-15)may be helpful in distinguishing primary ovarian cancer from metastatic breastcancer In primary ovarian cancers, CA-125 is positive in 92% of cases, andWT1 is positive in 76% of cases, whereas GCDFP-15 tends to be negative incomparison with the breast cancer lesions.26 More recently, PAX8, atranscription factor necessary for organogenesis in the thyroid, kidney, andMullerian system, has been studied with WT1 to distinguish ovarian cancersfrom breast cancers PAX8 staining performed better than WT1 and wasdiffusely positive in 87% of known ovarian cancers, whereas none of the breastcancers stained positive for Pax8.27 Although it is a rare occurrence, when breastcancer metastasizes to the uterus, it often involves the myometrium and stromawhile sparing the endometrial glands.

Renal cell carcinoma metastatic to the ovaries is quite rare, but when it occurs,

it is invariably of the clear cell type Therefore, making a distinction between aprimary ovarian clear cell cancer from a metastatic renal cell carcinoma becomes

a dilemma In primary clear cell cancers of the ovary, there is a heterogeneity inthe appearance of the cells, as there is an admixture of flattened cells, hobnailcells, and cuboidal cells Primary clear cell cancers of the ovary may also beassociated with endometriosis In metastatic tumors, there is more homogeneity

to the clear cells, and there may be a sinusoidal vascular pattern Positive CK 7immunostaining may help to distinguish a primary ovarian cancer from ametastatic renal cell cancer, which tends to be CK 7 negative.28

Cutaneous malignant melanoma can metastasize to nearly any organ in thebody Approximately 20% of such patients develop recurrent disease However,metastases to the genital tract are exceedingly rare and represent only 2.5% ofcases Although the most frequent sites of recurrence are the primary site ofdisease followed by the regional lymph nodes, visceral spread can occur In thegenital tract, the ovaries are the most common metastatic site, but metastases tothe endometrium and myometrium of the uterus have also been described

Only 30% of ovarian metastases are pigmented Immunostains such as S-100,HMB-45, and MART1 are positive in most melanomas and may be helpful inidentifying the primary sites of disease.11

TREATMENT AND PROGNOSIS

1 Surgical resection of metastatic lesions should be considered in symptomaticpatients with good performance status and isolated masses

2 Limited evidence suggests a potential survival benefit with resection ofmetastatic disease in colorectal, pancreatic, and breast cancers

The treatment of patients with metastases to the genital tract depends on theperformance status of the patient, whether the patient has a known primary site

of disease, and whether the metastatic lesions are isolated or diffuselydisseminated Overall, the survival of patients with metastases to the ovaries ispoor Nearly 80% of patients succumb to their disease within 2 years Despitethis, metastatic tumor to the ovaries can create significant symptoms to warrantremoval for palliation In one recent retrospective series of patients, there was asignificant difference in survival if patients had isolated metastases to the ovaries

or disseminated disease In patients with isolated ovarian metastases, mediansurvival was 30.7 months as compared with those with extensive, disseminated

disease, for whom the median survival was 10 months (P = 02) Patients with

colon cancer had longer survivals compared with patients with gastric cancer(29.6 months vs 13 months, respectively), and patients who underwent surgeryand were left with microscopic disease also experienced longer survival ascompared with those left with visible residual disease.29 In another study ofmetastatic pancreatic cancer to the ovaries, the mean patient age was only 49years Those who underwent resection of their ovarian metastases had a mediansurvival of 16.5 months, as compared with 8.5 months in those who receivedchemotherapy alone In patients who received only chemotherapy, the ovarianmetastases did not respond to treatment.23 Patients with known ovarianmetastases from colon cancer also showed a lack of response to chemotherapy,which may suggest that the ovaries are a sanctuary for metastatic disease.30 In aKorean study of patients with a history of gastric cancer who developedKrukenberg tumors, the median age was also only 41 years Patients whounderwent either bilateral salpingo-oophorectomy or hysterectomy with bilateralsalpingo-oophorectomy had median survivals of 10.9 months if there was nogross residual disease or 7.5 months if left with gross residual disease Therewere 2 patients in this series of 34 patients who survived longer than 4 yearsafter complete resection of their Krukenberg tumors Additionally, there was asignificant difference if the patient had disease confined to the ovaries (median

survival, 13.1 months) as compared with disease in the pelvis (median survival,7.5 months) or intra-abdominal disease (median survival, 3.6 months).31Therefore, a reasonable approach in a patient with good performance status andisolated metastatic disease would be to consider surgery to remove the ovaries.Many of the same treatment strategies observed in metastatic GI cancer holdtrue for metastatic breast cancer Several retrospective studies have identified atrend toward longer progression-free survival in women who can be optimallydebulked even in the setting of metastatic breast cancer This typically occurs inthe setting of isolated metastatic disease and in patients without evidence ofother metastatic disease Garg et al32 showed that in 19 patients who were found

to have abdominal carcinomatosis due to breast cancer, those undergoingsuccessful cytoreductive surgery (5 patients) had a longer median survival timethan those with larger volume residual disease (14 patients; 34.4 vs 3.9 months;

P = 0001).32 In another small study of 29 patients, 62% underwent nonoptimalsurgery or biopsies and the remainder underwent complete resection ofmetastatic disease; median survival was 2 years in the former group and had notbeen reached at 2 years of follow-up in the latter group.33 The subsequentdevelopment of metastatic disease in other sites such as the pelvis and liveroccurred in the majority of patients after surgery This should be considered incounseling patients about the risks and benefits of undergoing surgery and effect

on palliation of symptoms As chemotherapy regimens improve fornongynecologic cancers, however, the survival of these patients may be expected

to improve

Management of metastases to other areas of the genital tract will clearlydepend on the patient’s overall prognosis and symptoms If a patient developssignificant problems with vaginal bleeding from uterine or cervical metastases, itwould be reasonable to perform a hysterectomy A complete hysterectomy alsoallows for definitive diagnosis of the disease Metastases to the vagina and vulvamust be managed individually and with attention paid to minimizingcomplications in the face of a disease with poor prognosis Primary resection andradiation have been described in the management of disease involving thevagina, but the numbers of patients treated are too small to provide anymeaningful conclusions about the effectiveness of treatment

FUTURE DIRECTIONS

In conclusion, patients who develop metastatic disease to the genital tract

frequently have primary malignancies arising from the GI tract or breast, and theprimary disease is usually advanced stage Ovarian metastases are frequentlybilateral; mucinous histologies, in particular, may be difficult to distinguish fromprimary mucinous ovarian cancers Surgery to cyto-reduce the metastatic lesionsappear to be associated with longer survival if the metastatic disease is isolatedand able to be completely cytoreduced As molecular markers improve, it maybecome easier to distinguish primary gynecologic malignancies fromnongynecologic malignancies Although it would be preferable to have serummarkers that could adequately determine the primary site of disease, often thedecision to operate or treat with chemotherapy or hormonal therapy tailored tothe primary site of disease becomes a function of patient performance status,symptoms, and the presence of other sites of disease.

4 Hart WR Diagnostic challenge of secondary (metastatic) ovarian tumors

simulating primary endometrioid and mucinous neoplasms Pathol Int.

2005;55:231-243

5 Young R, Gilks B, Scully R Mucinous tumors of the appendix associated withmucinous tumors of the ovary and pseudomyxoma peritonei: aclinicopathologic analysis of 22 cases supporting an origin in the appendix

9 Kwon JS, Gutierrez-Barrera AM, Young D, et al Expanding the criteria for

BRCA mutation testing in breast cancer survivors J Clin Oncol.

Tumour Biol 1992;13:18-26.

20 Kitajima K, Suzuki K, Senda M, et al FDG PET/CT features of ovarian

metastasis Clin Radiol 2011;66:264-268.

21 Serov SF, Scully RE Histologic typing of ovarian tumours, vol 9 Geneva,Switzerland: World Health Organization; 1973: 17-18

22 Lee KR, Young RH The distinction between primary and metastaticmucinous carcinomas of the ovary: gross and histologic findings in 50 cases

25 Vang R, Gown AM, Wu LSF Immunohistochemical expression of CDX2 inprimary ovarian mucinous tumors and metastatic mucinous carcinomasinvolving the ovary: comparison with CK20 and correlation with coordinate

expression of CK7 Modern Pathol 2006;19:1421-1428.

26

Tornos C, Soslow R, Chen S, et al Expression of WT1, CA125 and GCDFP-15 as useful markers in the differential diagnosis of primary ovarian

carcinomas versus metastatic breast cancer to the ovary Am J Surg Pathol.

In general, preoperative evaluation and testing are stratified based on apatient’s comorbidities All patients undergoing surgery for gynecologic cancershould undergo a thorough evaluation of other medical issues Such evaluationswill provide an individualized preoperative assessment In addition, theidentification of preoperative medical issues will allow these conditions to bemedically optimized.

Preoperative Testing

Many patients with gynecologic malignancies will be of older age As a result,they often have other medical comorbidities In 2007, the leading causes of death

in the United States were heart disease, cancer, stroke, chronic lower respiratorydisease, and accidents Given the prevalence of coronary artery disease, diabetes,peripheral vascular occlusive disease, and obesity in our population, manypatients will require some preoperative testing to assess their cardiopulmonary

In healthy patients, the likelihood of an unrecognized medical condition thatwill cause undue surgical risk is low A review of studies investigating routinepreoperative laboratory evaluations with subsequent likelihood of postoperativecomplications demonstrated that only hematocrit, creatinine, and electrolytesprovided a modest benefit to predict for postoperative complications.Preoperative tests should be selected judiciously, because the addition ofunnecessary tests has been found to add a significant cost burden.1 Additionally,

in patients who have had a recent laboratory evaluation, retesting will not likelylead to identification of new abnormalities Our anesthesiologists recommendthat preoperative laboratory tests be performed no more than 30 days beforesurgery to have an up-to-date baseline

There is also little utility in screening electrocardiograms (ECGs) and chestradiographs (CXRs) in otherwise healthy patients An abnormal preoperativeECG is not a useful predictor of postoperative cardiac complications, even inelderly patients However, a preoperative ECG can be helpful as a baseline forcomparison with postoperative ECG abnormalities The 2007 American College

of Cardiology/American Heart Association (ACC/AHA) guidelines onperioperative cardiac evaluation include a recommendation for a preoperative12-lead resting ECG prior to intermediate-risk noncardiac or vascular surgery forpatients with known cardiovascular disease, cerebrovascular disease, orperipheral artery disease.2 Intermediate-risk procedures include intraperitonealand intrathoracic procedures, which are commonly performed in the surgicalstaging and treatment of patients with gynecologic malignancies The ACC/AHAguidelines also recommend preoperative ECG in patients with other cardiac riskfactors, such as diabetes, renal insufficiency, compensated or prior heart failure,

or ischemic heart disease

Even in the healthiest of patients, the preoperative evaluation of patientsundergoing surgery for gynecologic cancer will typically include a CXR forstaging Such an evaluation can be helpful in the detection of subclinicalpulmonary disease, which may affect intra-and postoperative respiratoryfunction In addition, the presence of a preoperative pleural effusion is associatedwith a decreased likelihood of achieving optimal surgical cytoreduction

When the preoperative suspicion of malignancy is low, there is little evidencesupporting the benefit of preoperative CXR regardless of age, unless there is ahistory of prior or current cardiopulmonary disease In a meta-analysis of 21studies investigating the routine use of preoperative CXR, only 0.1% of allCXRs performed led to a change in management The American College of

Physicians recommends preoperative CXR in patients with knowncardiopulmonary disease and those older than 50 years of age undergoing upperabdominal/thoracic surgery.3 The AHA suggests a routine posteroanterior andlateral CXR prior to surgery in all patients with morbid obesity (body mass index[BMI] ≥ 40).4

Patients with suspected ovarian, fallopian tube, or peritoneal carcinomas arerecommended to have an ultrasound and/or an abdominopelvic computedtomography (CT) scan Preoperative imaging may also be of use in planningsurgery, in order to appropriately counsel patients as to the extent of surgery andpostoperative issues that may arise In the management of ovarian cancer, certainfeatures on CT scan have been associated with the feasibility of optimalcytoreduction In 2 prospective studies, Bristow et al5 and Ferrandina et al6 bothfound that a predictive index incorporating features of peritoneal thickening,number of peritoneal implants, involvement of bowel mesentery, suprarenalpara-aortic lymphadenopathy, omental extension to spleen and stomach, pelvicsidewall involvement, and/or hydroureter was accurate in the identification ofpatients unlikely to undergo optimal primary cytoreductive surgery For patientswith presumed ovarian or peritoneal cancer, a preoperative CT scan may allowfor counseling of patients as to the likelihood that all disease can be surgicallyremoved and potential selection of patients for primary chemotherapy

In uterine cancer, the role of lymphadenectomy remains controversial.Histology and depth of myome-trial invasion have been associated with thelikelihood of lymph node involvement Unfortunately, imaging techniques havenot been as reliable in the preoperative prediction of myometrial involvement orlymph node involvement Positron emission tomography (PET)/-CT, CT scan,and Doppler ultrasound have not been found to be sensitive means to assessdepth of myometrial involvement.7 However, magnetic resonance imaging(MRI) has been found to be sensitive in the assessment of cervical involvement8;preoperative knowledge of cervical involvement may indicate a need for radicalhysterectomy, which in some series has been shown to improve outcome.9 MRImay also play a role when trying to determine whether a tumor is originatingfrom the cervix or endometrium With the advent of more minimally invasivesurgery, preoperative imaging may help anticipate the presence of suspicious orbulky retroperitoneal disease

MRI and PET/CT are commonly used in the preoperative assessment ofcervical cancer In the American College of Radiology Imaging Network6651/Gynecologic Oncology Group (GOG) 183 series of early cervical cancerpatients, MRI was found to be superior to CT scan in the evaluation of uterine

body involvement, tumor size, and parametrial involvement.10 However, neithermodality was accurate in the preoperative assessment of cervical stromalinvasion Although MRI has been demonstrated to have increased sensitivitycompared with PET/CT in the preoperative assessment of patients with cervicalcancer,11 a retrospective study correlating pathology outcome of 38 patients withstage IB/II cervical carcinoma demonstrated a negative predictive value of 92%for PET/CT scan.12 Another small prospective study found that PET/CT wassuperior to MRI in the preoperative detection of lymph node metastases incervical cancer.13

1).14 The 2007 ACC/AHA Guidelines recommend that “high-risk” cardiacpatients, including those with unstable coronary syndromes, decompensatedheart failure, significant arrhythmias, and severe valvular disease, undergofurther evaluation.15 Patients deemed as being at “intermediate risk,” includingthose with factors described in Table 18-1, should undergo a clinical evaluation

to determine the need for preoperative noninvasive cardiac testing with methodssuch as transthoracic echocardiogram to evaluate left ventricular function ordobutamine stress echocardiography

Table 18-1 Revised Cardiac Risk Index

Preoperative heart failure can be an important determinant of postoperativecardiac complications The ACC/AHA recommends that during the preoperativehistory and physical examination, an effort be made to assess for unrecognizedheart failure.16 Impaired exercise tolerance, which can be a sign of heart failure,can also be a predictor of adverse postoperative cardiac outcome A prior study

of 600 patients undergoing noncardiac surgery showed that simple self-reportedmeasures (eg, ability to walk or climb stairs) were significantly predictive forpostoperative cardiac events However, adequate exercise tolerance may alsoobviate the need for additional perioperative cardiac testing

The use of perioperative β-blockade for prevention of coronary events wasinitially studied in cardiovascular surgery, with subsequent application forpatients undergoing noncardiac surgery The initiation of perioperative β-adrenergic receptor blockade (atenolol or metoprolol) has previously beenrecommended to decrease perioperative myocardial infarction and mortality In arandomized controlled trial of 8000 patients undergoing noncardiac surgery,metoprolol therapy did reduce the risk of myocardial infarction, but actuallyincreased the risk of perioperative death and stroke.17 The ACC/AHA hasrecommended that patients who are on β-blocker medications preoperatively becontinued on the agent For patients undergoing noncardiac surgery, only thosewho have existing coronary artery disease or 1 risk factor for coronary arterydisease (as listed in Table 18-1) can be considered for perioperative β-blockers.18Many patients do have indications for long-term β-blocker use including patientswith known cardiac ischemia, and these patients may still be considered forinitiation of β-blockade at the discretion of their primary care provided orcardiologist at least 2 weeks prior to surgery Patients who are takingantihypertensive medications preoperatively should be continued on these drugs

if possible, with careful follow-up of their blood pressure and heart rate becausethese are affected by perioperative pain and fluid management Treatment withstatins has also been associated with improved mortality after noncardiacsurgery

Pulmonary Issues

Any surgical procedure requiring intubation for general anesthesia increases therisk of pulmonary complications The presence of an acute respiratory conditionposes significant concerns in the perioperative patient Acute infections should

be treated before surgery in most nonemergent situations Other patients withhigh-risk conditions, including asthma, bronchitis, emphysema, or smoking,should be optimized for their medical condition if possible Preparing for surgerycan also be a teachable moment to encourage a smoking patient to considersmoking cessation However, prior case-control studies have suggested that ashort period of smoking cessation may not abate and may actually increase therate of pulmonary complications Because a period of abstinence from smoking

of 8 weeks or greater is not always possible prior to cancer surgery, awareness of

an increased risk of pulmonary complications for smokers is necessary, even inthe absence of chronic lung disease Additionally, in the setting of a short period

of smoking cessation, the evidence surrounding the increased risk is insufficient

Similar to the cardiac preoperative risk indices, pulmonary multifactorial riskindices have been developed and validated to identify patients at increased riskfor postoperative pneumonia, so that appropriate respiratory interventions can bemade Age, poor functional status, upper abdominal surgery, general anesthesia,chronic obstructive pulmonary disease, transfusion, steroid use, and smoking allcontribute to perioperative pulmonary risks For patients with significant pleuraleffusions, consideration can be given to preoperative thoracentesis versusintraoperative chest tube placement to maximize pulmonary function during thetime of surgery

Endocrine Issues

The majority of gynecologic oncology patients with diabetes will have resistant, or type 2, diabetes mellitus However, patients with type 1 diabetes willalso be encountered With autoimmune destruction of the pancreatic islets, suchpatients have a complete lack of endogenous insulin production Type 1 diabeticsare susceptible to frank ketoacidosis All diabetic patients are also at risk ofmetabolic and wound complications following surgery Furthermore, patientswith type 2 diabetes have a higher incidence of concomitant coronaryatherosclerosis and are at risk for “silent ischemia.”19 Type 2 diabetics can also

insulin-be at risk for hyperosmolar nonketotic acidosis in the setting of extremehyperglycemia

Prior to surgery, baseline glucose levels should be assessed in diabeticpatients Consideration can be given for a glycosylated hemoglobin (HbA1c)serum test Elevated glucose values, as well as an abnormal HbA1c, areassociated with an increased risk of wound infections.20 In addition, themedications and/or insulin used in management of diabetes should be recorded.For patients with evidence of poor glycemic control, aggressive managementmay include acute hospitalization and subcutaneous (or intravenous) insulinpreoperatively Patients taking oral hypoglycemic medications should beinstructed to hold such medications(s) on the morning of surgery For patientswho require insulin and use long-acting insulin, one-third to one-half of theirusual dose should be given the night prior to surgery Scheduling diabeticpatients for surgery earlier in the day may help minimize their risk ofhypoglycemia while fasting

Numerous medical conditions benefit from treatment with steroids, includingpatients with chronic obstructive pulmonary disease, asthma, and rheumatoid

arthritis, and many organ transplantation survivors As a result, some patientswill be on chronic steroids prior to surgery The ingestion of more than 20 mg ofprednisone per day (or its equivalent) for ≥ 5 days leads to suppression of thehypothalamic-pituitary-adrenal (HPA) axis and subsequent inability of theadrenal gland to respond adequately to physiologic stress Such adrenalsuppression can result in hypotension and cardiovascular instability at the time

of surgery The use of 5 to 20 mg of prednisone a day is associated with variablesuppression of the HPA axis It is unclear whether high-dose steroids arenecessary in the prevention of adrenal insufficiency A summary of trialsconcluded that the use of a daily steroid dose (vs a high dose of hydrocortisone)did not result in any difference in the incidence of perioperative hypotension ortachycardia.21 Weighing against the concern for perioperative adrenal crisis, it isimportant to note that the chronic use of high-dose steroids can be associatedwith impaired glycemic control and wound healing

Renal Issues

Chronic kidney disease is defined as a glomerular filtration rate of 60 mL/min, inthe presence or absence of structural kidney disease In 2010, there wereestimated to be more than 600,000 patients with end-stage renal disease (ESRD)

in the United States In a large meta-analysis, patients with chronic kidneydisease undergoing noncardiac surgery were found to have higher rates ofcardiovascular events and perioperative death.22 Patients with ESRD on dialysishave significant fluid management issues and have been found to have increasedperioperative complications, including bleeding, infections, and electrolyteabnormalities, particularly hyperkalemia Although dialysis performedimmediately prior to and after surgery has been associated with improvedoutcomes in patients undergoing cardiac surgery, there has been no suchinvestigation in patients undergoing abdominal surgery Common goals inpatients with chronic kidney disease include a focus on intraoperative euvolemia

to maintain renal perfusion Coordination with nephrologists may help tooptimize the timing of perioperative dialysis

Hepatic Issues

Given the improved care of patients with chronic liver disease and the advancedstate of transplantation medicine, patients with chronic liver conditions maydevelop and require surgical intervention for staging of gynecologic

malignancies Patients with mild to moderate hepatitis, in the absence ofcirrhosis, have no additional surgical risk Cirrhotic patients are at significantrisk of increased postoperative complications such as coagulopathy,hypoglycemia, hepatic decompensation with encephalopathy, and even death.23

In patients with large esophageal varices, consideration should be given todelaying laparotomy until variceal banding or shunting can be performed.Although the overall risk of surgery to the varices is unclear, minimally invasivesurgery has been performed safely in patients with varices and splenomegaly; in

a recent series of 52 laparoscopic procedures in patients with cirrhosis, 4%required conversion to laparotomy.24

The Child-Pugh classification of hepatic cirrhosis has been found to bepredictive of surgical outcome, and such clarification should be made inconjunction with the patient’s hepatologist Unfortunately, preoperative testingmay not be helpful in assessing hepatic dysfunction, because transaminases may

be normal even in the setting of cirrhosis.23 Thrombocytopenia, prolongedprothrombin time, and hypoalbuminemia may portend increased perioperativerisk as well Although cirrhotic patients often share findings of ascites andsplenomegaly with ovarian cancer patients, superficial vascular skin changessuch as spider telangiectasias are unique to cirrhotic patients

Nutritional Issues

Prior to surgery, many gynecologic oncology patients will have compromisednutrition This can be due to prior chemotherapy and/or radiation, medicalcomorbidities, or the advanced nature of their disease Perioperative nutritionalassessment may help identify patients who are most likely to benefit fromnutritional support Preoperative weight loss should be quantitated, and thedegree of malnutrition should be assessed The presence of malnutrition has beendemonstrated to be associated with prolonged hospitalization in gynecologiccancer patients,25 as well as poor postoperative outcome in other surgicalspecialties Albumin, a serum protein marker produced by the liver, is a widelyused indicator of malnutrition and has been shown in numerous studies to beassociated with increased complications during the postoperative period,26 evenwhen not associated with malnutrition cachexia Extremely poor preoperativenutrition, as demonstrated by a prealbumin < 10 mg/dl, was shown to besignificantly associated with intraoperative blood loss and perioperativemorbidity in a series of more than 100 patients undergoing surgicalcytoreduction.27 Patients with poor nutrition, in conjunction with complicated

Special Considerations

Prior to surgery for gynecologic malignancies, patients should be made aware ofpossible complications in the postoperative period Following surgery forovarian cancer, 20% to 30% of patients will require admission to an ICU Themost common reasons for admission include respiratory support and fluidmanagement Consideration of such disposition in the preoperative period willalso allow for appropriate resource allocation following surgery

An important part of counseling prior to surgery for gynecologic cancerinvolves a discussion of postoperative sexual function and body image.Procedures that are unique to the surgical treatment of gynecologic malignanciesare also associated with unique care issues in the intraoperative andpostoperative period

Patients may inquire as to the impact of cervical removal on sexual function; aprior randomized trial of supracervical versus total hysterectomy in benigngynecologic disease showed that there was no difference in postoperative sexualfunction.28 However, the extent of pelvic dissection in radical hysterectomy mayalter postoperative sexual function Issues with sexual function, such aslubrication and arousal, have been noted after radical hysterectomy for cervicalcarcinoma.29 In a series of 38 patients, the rate of postoperative sexual functionwas similar between those who underwent the procedure via laparotomy orlaparoscopy.30 “Nerve-sparing” radical hysterectomy has been suggested tominimize rates of postoperative sexual dysfunction Radical vulvectomy andpelvic exenteration can both affect body image and sexuality, yet both surgeriesare performed with a goal of cure and prolongation of life Counseling with afocus on psychosexual issues may also help in the adjustment period

The rates of urinary tract dysfunction following radical hysterectomy areestimated to be between 50% and 75% Patients should be made aware of thepossibility of prolonged catheterization The mode of catheterization can beeither by transurethral or suprapubic catheterization

Depending on the type of surgery and the extent of cancer involvement,patients may require either a temporary or permanent fecal ostomy Preoperativediscussion of the likelihood and nature of such diversion is essential for both theshort-term and long-term adaptation of patients and families to such devices.Furthermore, preoperative marking for stoma placement can allow for marking

Preparing both the patient and involved family for home care coordination inthe postoperative period is also helpful, particularly if the need for a skillednursing facility is anticipated

lists possible antimicrobial regimens Patients with a history of a hypersensitivityreaction to penicillins and/or cephalosporins are recommended to receiveclindamycin or metronidazole, plus gentamicin or aztreonam or a quinolone.31Antimicrobial prophylaxis should be given within 60 minutes prior to thesurgical incision to ensure that appropriate tissue levels are present Manygynecologic debulking procedures will also include intestinal resection;coverage of gram-negative and anaerobic bacterium must be incorporated.According to the Surgical Care Improvement Project, cefazolin may still beconsidered for preoperative antibiotic prophylaxis32; cefoxitin or cefotetan can

be considered given the improved coverage of bowel anaerobes Recently, arandomized trial comparing ertapenem to cefotetan in elective colorectal surgeryshowed that ertapenem was associated with a significantly decreased rate ofsurgical site infectious; it was, however, associated with an increased risk of

Clostridium difficile–associated diarrhea.33

Table 18-2 Prophylactic Antimicrobial Regimens

Endocarditis Prophylaxis

of endocarditis is now only recommended in patients with prosthetic valves, aprior history of infective endocarditis, unrepaired cyanotic congenital heartdisease, repaired congenital heart disease with prosthetic material, and valvulardisease in a transplanted heart Such patients should receive endocarditisprophylaxis prior to invasive genitourinary procedures with ampicillin andgentamicin, substituting vancomycin for ampicillin in penicillin-allergic patients

Thromboembolic Prophylaxis

Among cancer patients, those with gynecologic malignancies have the highestrisk of thromboembolic disease Prior to surgery, in addition to assessing thelikelihood of malignant disease, patients should also be assessed for other riskfactors for venous thromboembolism.35 Patients with known cancer, or those inwhom the preoperative suspicion is high, should be considered for preoperativethromboprophylaxis with unfractionated heparin (UFH) or low molecular weightheparin 2 hours prior to surgery, as recommended by the 2008 American College

of Chest Physician guidelines.36 Some gynecologic oncologists have expressedconcern regarding preoperative administration of anticoagulants before majorsurgery, but continuous assessment for change in practice is indicated Einstein

et al37 reported that a recent change in protocol that included administration ofUFH 1 to 2 hours prior to surgery led to a significant decrease in the rate ofthromboembolic events In the event that patients should be interested in the use

of regional anesthesia or neuroaxial blockade, discussion should be made withthe anesthesia team before administration of preoperative heparin Continuation

of pharmacologic prophylaxis may also be indicated in high-risk patients

Some patients may have a pre-existing diagnosis of thromboembolism oratrial fibrillation or have a mechanical heart valve in place and be onanticoagulation therapy, prior to surgery Because there is a risk ofhypercoagulability with discontinuation of warfarin, patients at significantlyhigh risk for thrombosis should be transitioned to intravenous or low molecularweight heparin before and after surgery.38 The international normalized ratioshould decrease to less than 1.3 to 1.5 before elective surgery Intravenousheparin should be stopped 6 hours prior to incision Low molecular weightheparin should be stopped 12 hours prior to incision Consultation with thepatient’s hematologist or cardiologist is also indicated

Elective surgery is traditionally to be avoided in the first month after acute

in situations of acute venous thromboembolism to minimize the incidence ofperioperative pulmonary emboli or if the risk of bleeding on intravenous heparin

is high If planned in advance with interventional radiology, an IVC filter can beremoved within 2 weeks after surgery, even after a patient has resumedanticoagulation A recent retrospective study from Adib et al39 demonstrated notonly that the use of perioperative IVC filters was feasible without a significantincrease in the rate of recurrent venous thromboembolism or surgicalcomplications, but also that surgery could be performed relatively soon after theplacement of an IVC filter After surgery, intravenous heparin should be restartedwithout bolus after at least 12 hours and potentially longer if there is continuedconcern for surgical bleeding A temporary vena caval filter can be removedwithin 2 weeks after surgery, even after a patient has resumed anticoagulation

Bowel Preparation

For decades, mechanical bowel preparation has been included in the surgicalpreparation process; the goal of such preparation is to evacuate stool, allowingfor improved visualization and reduction of endogenous intestinal bacteria.Increasing evidence has suggested that such preparations not only lead to anincrease in anastomotic leaks, but also are associated with an increase in surgicalsite infections This was shown in a meta-analysis involving 13 randomizedtrials as well as a 2009 Cochrane review.40,41 Magnesium citrate may also haverisk in patients with renal impairment Small volumes of polyethylene glycolmay be considered if a bowel preparation is necessary

In minimally invasive surgery, the use of mechanical bowel preparation maytheoretically aid in surgical visualization through decompression of the bowels.However, in a series of patients undergoing gynecologic laparoscopy, the use ofpreoperative bowel preparation did not have a significant impact on the surgicalfield, operative difficulty, or operative time; however, preoperative discomfortwas significantly elevated in the bowel preparation group.42 In open tumordebulking cases, bowel preparation may help to eliminate solid boluses of stoolthat may potentially confound intra-abdominal exploration for tumor resection

A recent Cochrane review found that the use of oral and intravenousantibiotics, in the setting of colorectal surgery, was superior to intravenousantibiotics alone.43 This theoretical benefit is not seen in all series; furthermore,

in a small series, the use of preoperative oral antibiotics was actually shown to

use of oral antibiotics may still be considered in gynecologic oncology patientswho are likely to have intestinal surgery incorporated into surgery; however,given the gastrointestinal (GI) distress that may accompany oral antibiotics,parenteral antimicrobial prophylaxis may be preferred

Surgery on the Obese Patient

The prevalence of obesity in the United States is increasing every year; 65% ofthe American population can now be classified as overweight (BMI ≥ 25) orobese (BMI ≥ 30) In addition to being at risk of multiple other malignances due

to obesity, obese women are at particular risk of developing cancer of theendometrium The practicing gynecologic oncologist is therefore extremelylikely to operate upon patients with morbid obesity and should be familiar withthe physiology and comorbidities that may be present

The AHA recommends obtaining a preoperative 12-lead ECG and CXR in allmorbidly obese patients prior to surgery.4 The AHA proposes additional testingwhen signs of right ventricular hypertrophy or left bundle branch block are seen

on preoperative ECG, because these may be indicative of existing pulmonaryhypertension and occult coronary artery disease, respectively Obese patientswith no risk factors for coronary heart disease, such as hypertension, heartfailure, vascular disease, or pulmonary hypertension, may not require any furthertesting However, patients with 3 risk factors or those with current coronary heartdisease will likely require additional invasive testing with exertional cardiactesting Exercise stress testing is an appropriate assessment of functionalcapacity and can be predictive of postoperative cardiovascular complications.44

If the patient’s functional capacity is poor or cannot be assessed due to extremeobesity, a dobutamine stress echocardiogram can be considered

In the presence of morbid obesity, the sheer weight of the chest wall can lead

to a restrictive lung physiology, leading to a decreased functional residualcapacity and expiratory reserve volume.45 In addition, these patients may alsohave concomitant or unrecognized sleep apnea.4 If patients are on ambulatorycontinuous positive airway pressure, this should be continued in the hospital.The GOG LAP 2 trial demonstrated that minimally invasive surgery in obesepatients was feasible; although a higher BMI was associated with an increasedlikelihood of conversion to laparotomy, this randomized trial demonstrates thefeasibility of this technique.46 In addition, a recent case-control studydemonstrated that robotic-assisted laparoscopy in obese patients may also be

feasible.47 Minimally invasive surgery in the obese population is associated withunique risks Prolonged steep Trendelenburg positioning, combined with carbondioxide pneumoperitoneum, will lead to increased airway pressure and decreasedairway compliance In addition, careful positioning is necessary to preventpressure necrosis given extremes of body weight.48 Furthermore, prolongedsurgical procedures may also increase the possibility of rhabdomyolysis If this

is a concern, a creatine kinase level may be obtained

When minimally invasive approaches are not available or when the obesepatient cannot tolerate the necessary positioning, the patient may be consideredfor a simultaneous panniculectomy, which may facilitate exposure duringlaparotomy Such patients are at risk of wound breakdown, and wound infectionrates following panniculectomy during gynecologic surgery have ranged from3% to 33% However, this procedure has been described in several series to be abeneficial addition to improve visualization in a morbidly obese patient; further,

a long-term follow-up study of 42 such patients revealed that 91% of patientswere pleased with their surgical outcome.49

CRITICAL CARE/POSTOPERATIVE

EVALUATION

The ICU is an essential resource for the management of the most critically illgynecologic cancer surgery patients ICU utilization for gynecologic oncologypatients ranges between 6% and 33%.50 A multivariate analysis of ovariancancer patients admitted to the ICU for short (< 24 hours) versus longer staysfound that the patients’ preoperative medical condition was less important thanperioperative factors in utilization of ICU resources Patients requiring bowelresection, placement of a pulmonary artery catheter, and ventilator dependencewere most likely to require ICU care Preoperative factors such ashypoalbuminemia and significantly elevated CA-125 have also been associatedwith an increased likelihood of extensive disease and need for ICU admission.26Severity of illness by the Acute Physiology and Chronic Health Evaluation(APACHE) classification system has also been correlated with survival ofcritically ill gynecologic oncology patients.50 Most patients admitted to the ICUafter gynecologic oncology surgery have a short critical care course, although insingle-institution reports, the 30-day postoperative mortality rate ranges between11% and 27% Identification of patients who may be at greatest risk for needing