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Surgery_Schwartz_12002 | Surgery_Schwartz | remains an area of controversy. If a lymph node dissection is performed, it may be performed via laparotomy or laparoscopy. Generally, the bilateral pelvic and para-aortic lymph nodes are removed. The pelvic node dissection includes: bilateral removal of nodal tissue from the distal one-half of each common iliac artery, the anterior and medial aspect of the proximal half of the external iliac artery and vein, and the distal half of the obturator fat pad anterior to the obturator nerve. Most of the pelvic lymph nodes lie anterior, medially, and posteriorly to the external and internal iliac vessels and the obturator nerve. There are a few nodes that lie lateral to these structures, between the vessels and the pelvic sidewall, and these are generally removed in a complete dissection. The para-aortic lymph nodes include resection of nodal tissue over the distal vena cava from the level of the inferior mesenteric artery to the mid right common iliac artery and between the aorta and | Surgery_Schwartz. remains an area of controversy. If a lymph node dissection is performed, it may be performed via laparotomy or laparoscopy. Generally, the bilateral pelvic and para-aortic lymph nodes are removed. The pelvic node dissection includes: bilateral removal of nodal tissue from the distal one-half of each common iliac artery, the anterior and medial aspect of the proximal half of the external iliac artery and vein, and the distal half of the obturator fat pad anterior to the obturator nerve. Most of the pelvic lymph nodes lie anterior, medially, and posteriorly to the external and internal iliac vessels and the obturator nerve. There are a few nodes that lie lateral to these structures, between the vessels and the pelvic sidewall, and these are generally removed in a complete dissection. The para-aortic lymph nodes include resection of nodal tissue over the distal vena cava from the level of the inferior mesenteric artery to the mid right common iliac artery and between the aorta and |
Surgery_Schwartz_12003 | Surgery_Schwartz | The para-aortic lymph nodes include resection of nodal tissue over the distal vena cava from the level of the inferior mesenteric artery to the mid right common iliac artery and between the aorta and the left ureter from the inferior mesenteric artery to the left mid common iliac artery. Some also advocate resection of lymph nodes between the IMA and the gonadal vessels, as some uterine fundal tumors may drain directly into these lymph nodes.107The need for postoperative intervention is individualized based on the histology, stage, and risk factors such as age, lym-phvascular space invasion, and histology. Early-stage patients Table 41-92009 International Federation of Gynecology and Obstetrics staging of carcinoma of the uterine corpusI ATumor confined to the uterus, no or <½ myometrial invasionI BTumor confined to the uterus, >½ myometrial invasionIICervical stromal invasion, but not beyond uterusIII ATumor invades serosa or adnexaIII BVaginal and/or parametrial involvementIII | Surgery_Schwartz. The para-aortic lymph nodes include resection of nodal tissue over the distal vena cava from the level of the inferior mesenteric artery to the mid right common iliac artery and between the aorta and the left ureter from the inferior mesenteric artery to the left mid common iliac artery. Some also advocate resection of lymph nodes between the IMA and the gonadal vessels, as some uterine fundal tumors may drain directly into these lymph nodes.107The need for postoperative intervention is individualized based on the histology, stage, and risk factors such as age, lym-phvascular space invasion, and histology. Early-stage patients Table 41-92009 International Federation of Gynecology and Obstetrics staging of carcinoma of the uterine corpusI ATumor confined to the uterus, no or <½ myometrial invasionI BTumor confined to the uterus, >½ myometrial invasionIICervical stromal invasion, but not beyond uterusIII ATumor invades serosa or adnexaIII BVaginal and/or parametrial involvementIII |
Surgery_Schwartz_12004 | Surgery_Schwartz | invasionI BTumor confined to the uterus, >½ myometrial invasionIICervical stromal invasion, but not beyond uterusIII ATumor invades serosa or adnexaIII BVaginal and/or parametrial involvementIII C1Pelvic-node involvementIII C2Para-aortic involvementIV ATumor invasion bladder and/or bowel mucosaIV BDistant metastases including abdominal metastases and/or inguinal lymph nodesData from Pecorelli S: Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium, Int J Gynaecol Obstet. 2009 May;105(2):103-104.Brunicardi_Ch41_p1783-p1826.indd 181418/02/19 4:35 PM 1815GYNECOLOGYCHAPTER 41are typically cured with surgery alone, while patients with high-intermediate risk factors, as defined by collaborative tri-als groups, commonly receive intracavitary brachytherapy to decrease local recurrence.108,109 Patients with advanced disease and high-grade histologies commonly receive platinum-based chemotherapy with or without radiation.Similar to the case with vulvar cancer described | Surgery_Schwartz. invasionI BTumor confined to the uterus, >½ myometrial invasionIICervical stromal invasion, but not beyond uterusIII ATumor invades serosa or adnexaIII BVaginal and/or parametrial involvementIII C1Pelvic-node involvementIII C2Para-aortic involvementIV ATumor invasion bladder and/or bowel mucosaIV BDistant metastases including abdominal metastases and/or inguinal lymph nodesData from Pecorelli S: Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium, Int J Gynaecol Obstet. 2009 May;105(2):103-104.Brunicardi_Ch41_p1783-p1826.indd 181418/02/19 4:35 PM 1815GYNECOLOGYCHAPTER 41are typically cured with surgery alone, while patients with high-intermediate risk factors, as defined by collaborative tri-als groups, commonly receive intracavitary brachytherapy to decrease local recurrence.108,109 Patients with advanced disease and high-grade histologies commonly receive platinum-based chemotherapy with or without radiation.Similar to the case with vulvar cancer described |
Surgery_Schwartz_12005 | Surgery_Schwartz | recurrence.108,109 Patients with advanced disease and high-grade histologies commonly receive platinum-based chemotherapy with or without radiation.Similar to the case with vulvar cancer described earlier, sentinel node biopsy is becoming more prevalent in endome-trial cancer. A sentinel lymph node biopsy may be considered in apparent uterine-confined malignancy when there is no metasta-sis demonstrated by imaging studies or no obvious extrauterine disease at exploration. For this procedure, most frequently the cervix is injected with ICG dye, and the immunofluorescence detecting camera is used either robotically or laparoscopically to identify the sentinel node. If no node is mapped, a full lymph-adenectomy is generally advised.110Lynch Syndrome. Lynch syndrome, a cancer family syn-drome also known as hereditary nonpolyposis colorectal cancer (HNPCC), is an autosomal dominant inherited predisposition to develop colorectal carcinoma and extracolonic cancers, pre-dominantly including | Surgery_Schwartz. recurrence.108,109 Patients with advanced disease and high-grade histologies commonly receive platinum-based chemotherapy with or without radiation.Similar to the case with vulvar cancer described earlier, sentinel node biopsy is becoming more prevalent in endome-trial cancer. A sentinel lymph node biopsy may be considered in apparent uterine-confined malignancy when there is no metasta-sis demonstrated by imaging studies or no obvious extrauterine disease at exploration. For this procedure, most frequently the cervix is injected with ICG dye, and the immunofluorescence detecting camera is used either robotically or laparoscopically to identify the sentinel node. If no node is mapped, a full lymph-adenectomy is generally advised.110Lynch Syndrome. Lynch syndrome, a cancer family syn-drome also known as hereditary nonpolyposis colorectal cancer (HNPCC), is an autosomal dominant inherited predisposition to develop colorectal carcinoma and extracolonic cancers, pre-dominantly including |
Surgery_Schwartz_12006 | Surgery_Schwartz | also known as hereditary nonpolyposis colorectal cancer (HNPCC), is an autosomal dominant inherited predisposition to develop colorectal carcinoma and extracolonic cancers, pre-dominantly including tumors of the uterus and ovaries, now also including breast cancer.111 Genes involved in HNPCC are those required for proper single-strand DNA repair via the mismatch repair pathway; most commonly involved are MLH1, MSH2, MSH6, and PMS2. The risk of colorectal carcinoma is as high as 75% by age 75 years. Affected women have a 40% and 10% lifetime risk of developing uterine and ovarian cancers, respec-tively. Surveillance has not been proven to identify disease in early stage for these patients, though it is recommended and should include annual cervical cytology, mammography, trans-vaginal ultrasonography, CA-125 measurements, and an endo-metrial biopsy. Risk-reducing salpingo-oophorectomy with hysterectomy is now being recommended for women who have completed childbearing, ideally 5 to 10 | Surgery_Schwartz. also known as hereditary nonpolyposis colorectal cancer (HNPCC), is an autosomal dominant inherited predisposition to develop colorectal carcinoma and extracolonic cancers, pre-dominantly including tumors of the uterus and ovaries, now also including breast cancer.111 Genes involved in HNPCC are those required for proper single-strand DNA repair via the mismatch repair pathway; most commonly involved are MLH1, MSH2, MSH6, and PMS2. The risk of colorectal carcinoma is as high as 75% by age 75 years. Affected women have a 40% and 10% lifetime risk of developing uterine and ovarian cancers, respec-tively. Surveillance has not been proven to identify disease in early stage for these patients, though it is recommended and should include annual cervical cytology, mammography, trans-vaginal ultrasonography, CA-125 measurements, and an endo-metrial biopsy. Risk-reducing salpingo-oophorectomy with hysterectomy is now being recommended for women who have completed childbearing, ideally 5 to 10 |
Surgery_Schwartz_12007 | Surgery_Schwartz | CA-125 measurements, and an endo-metrial biopsy. Risk-reducing salpingo-oophorectomy with hysterectomy is now being recommended for women who have completed childbearing, ideally 5 to 10 years earlier than the first case of endometrial or ovarian cancer in the family. Dys-regulation of the mismatch repair pathway leads to the micro-satellite instability phenotype, now known be associated with susceptibility to select immunotherapy agents.Uterine Sarcomas. Uterine sarcomas arise from the uterine muscle and connective tissue elements and are typically aggres-sive tumors with a poorer prognosis compared to the more common endometrial carcinomas. The most common histopath-ologic types are endometrial stromal sarcomas, undifferentiated endometrial sarcomas, and leiomyosarcomas. Risk factors are challenging to assess but may include prior pelvic radiation and tamoxifen exposure. Patients typically present with bleeding or mass effects, although some are discovered incidentally at the time | Surgery_Schwartz. CA-125 measurements, and an endo-metrial biopsy. Risk-reducing salpingo-oophorectomy with hysterectomy is now being recommended for women who have completed childbearing, ideally 5 to 10 years earlier than the first case of endometrial or ovarian cancer in the family. Dys-regulation of the mismatch repair pathway leads to the micro-satellite instability phenotype, now known be associated with susceptibility to select immunotherapy agents.Uterine Sarcomas. Uterine sarcomas arise from the uterine muscle and connective tissue elements and are typically aggres-sive tumors with a poorer prognosis compared to the more common endometrial carcinomas. The most common histopath-ologic types are endometrial stromal sarcomas, undifferentiated endometrial sarcomas, and leiomyosarcomas. Risk factors are challenging to assess but may include prior pelvic radiation and tamoxifen exposure. Patients typically present with bleeding or mass effects, although some are discovered incidentally at the time |
Surgery_Schwartz_12008 | Surgery_Schwartz | challenging to assess but may include prior pelvic radiation and tamoxifen exposure. Patients typically present with bleeding or mass effects, although some are discovered incidentally at the time of hysterectomy for other indications. Leiomyosarcoma is the most common uterine sarcoma, and hysterectomy with salpingoophorectomy is the treatment of choice. Lymph node metastases are rare in sarcomas in general, and in the absence of palpable nodes or extrauterine disease. There are limited data to support cytoreduction when extrauterine disease is present. The benefits of adjuvant therapy are unknown. Advanced disease is typically treated with systemic chemotherapy.112Ovarian CancerEpithelial Ovarian, Tubal, and Primary Peritoneal Cancer. Ovarian cancer is a rare disease affecting 1 in 70 women with a median age at diagnosis of 62 years.96 Epithelial malignancies make up the vast majority of ovarian cancers. The majority of women (70%) are diagnosed at with advanced staged disease | Surgery_Schwartz. challenging to assess but may include prior pelvic radiation and tamoxifen exposure. Patients typically present with bleeding or mass effects, although some are discovered incidentally at the time of hysterectomy for other indications. Leiomyosarcoma is the most common uterine sarcoma, and hysterectomy with salpingoophorectomy is the treatment of choice. Lymph node metastases are rare in sarcomas in general, and in the absence of palpable nodes or extrauterine disease. There are limited data to support cytoreduction when extrauterine disease is present. The benefits of adjuvant therapy are unknown. Advanced disease is typically treated with systemic chemotherapy.112Ovarian CancerEpithelial Ovarian, Tubal, and Primary Peritoneal Cancer. Ovarian cancer is a rare disease affecting 1 in 70 women with a median age at diagnosis of 62 years.96 Epithelial malignancies make up the vast majority of ovarian cancers. The majority of women (70%) are diagnosed at with advanced staged disease |
Surgery_Schwartz_12009 | Surgery_Schwartz | 70 women with a median age at diagnosis of 62 years.96 Epithelial malignancies make up the vast majority of ovarian cancers. The majority of women (70%) are diagnosed at with advanced staged disease leading to the poor survival associated with this malignancy. Survival in advanced disease is due both to late diagnosis and lack of effective second-line cytotoxic therapy for the major-ity of patients who relapse following initial clinical complete response to platinum-based chemotherapy. Despite multiple pro-spective population based trials evaluating the use of CA-125, ultrasound, or combinations of these tests for early detection of disease, a mortality benefit to screening programs has not been demonstrated.113-116 Symptoms for either benign or malignant ovarian tumors are nonspecific but frequent, and they include bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency,117 which form the basis of an ovarian cancer | Surgery_Schwartz. 70 women with a median age at diagnosis of 62 years.96 Epithelial malignancies make up the vast majority of ovarian cancers. The majority of women (70%) are diagnosed at with advanced staged disease leading to the poor survival associated with this malignancy. Survival in advanced disease is due both to late diagnosis and lack of effective second-line cytotoxic therapy for the major-ity of patients who relapse following initial clinical complete response to platinum-based chemotherapy. Despite multiple pro-spective population based trials evaluating the use of CA-125, ultrasound, or combinations of these tests for early detection of disease, a mortality benefit to screening programs has not been demonstrated.113-116 Symptoms for either benign or malignant ovarian tumors are nonspecific but frequent, and they include bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency,117 which form the basis of an ovarian cancer |
Surgery_Schwartz_12010 | Surgery_Schwartz | frequent, and they include bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency,117 which form the basis of an ovarian cancer symptom index (Table 41-10). When newly developed and persistent, these symptoms should prompt an evaluation specifically targeted for identification of gynecologic malignancy.The histologic heterogeneity of ovarian cancer has long been recognized, but with the emergence of more robust clini-copathologic, molecular, and genetic data over the past decade these distinctions have become more clearly defined. Type I tumors consist of low-grade serous (LGS), low-grade endome-trioid, clear cell carcinomas (CCC), and mucinous carcinomas and are characterized by mutations in KRAS, BRAF, PTEN, PIK3CA, CTNNB1, ARID1A, and PPP2R1A. Type II ovarian cancers are the most common of the ovarian cancer histotypes, consisting of high-grade serous (70%), high-grade endometri-oid, carcinosarcoma, and | Surgery_Schwartz. frequent, and they include bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency,117 which form the basis of an ovarian cancer symptom index (Table 41-10). When newly developed and persistent, these symptoms should prompt an evaluation specifically targeted for identification of gynecologic malignancy.The histologic heterogeneity of ovarian cancer has long been recognized, but with the emergence of more robust clini-copathologic, molecular, and genetic data over the past decade these distinctions have become more clearly defined. Type I tumors consist of low-grade serous (LGS), low-grade endome-trioid, clear cell carcinomas (CCC), and mucinous carcinomas and are characterized by mutations in KRAS, BRAF, PTEN, PIK3CA, CTNNB1, ARID1A, and PPP2R1A. Type II ovarian cancers are the most common of the ovarian cancer histotypes, consisting of high-grade serous (70%), high-grade endometri-oid, carcinosarcoma, and |
Surgery_Schwartz_12011 | Surgery_Schwartz | PIK3CA, CTNNB1, ARID1A, and PPP2R1A. Type II ovarian cancers are the most common of the ovarian cancer histotypes, consisting of high-grade serous (70%), high-grade endometri-oid, carcinosarcoma, and undifferentiated carcinomas. Type II tumors are defined by TP53 mutations, which are rare in type I cancers.118-121 Each of these types have distinct risk factors and potential precursor lesions.121Risk factors for development of ovarian cancer include hormonal factors such as early menarche, late menopause, and nulliparity. The use of oral contraceptives reduces risk of ovar-ian carcinoma—this risk reduction persists for up to 30 years after cessation of use.122 Additionally, tubal ligation and hyster-ectomy decrease population level epithelial ovarian cancer risk. Genetic predisposition to breast or ovarian cancer is the most important known risk for the development of ovarian cancer, and 18% to 24% of ovarian carcinomas may arise in conjunction with a hereditary predisposition.123-128 | Surgery_Schwartz. PIK3CA, CTNNB1, ARID1A, and PPP2R1A. Type II ovarian cancers are the most common of the ovarian cancer histotypes, consisting of high-grade serous (70%), high-grade endometri-oid, carcinosarcoma, and undifferentiated carcinomas. Type II tumors are defined by TP53 mutations, which are rare in type I cancers.118-121 Each of these types have distinct risk factors and potential precursor lesions.121Risk factors for development of ovarian cancer include hormonal factors such as early menarche, late menopause, and nulliparity. The use of oral contraceptives reduces risk of ovar-ian carcinoma—this risk reduction persists for up to 30 years after cessation of use.122 Additionally, tubal ligation and hyster-ectomy decrease population level epithelial ovarian cancer risk. Genetic predisposition to breast or ovarian cancer is the most important known risk for the development of ovarian cancer, and 18% to 24% of ovarian carcinomas may arise in conjunction with a hereditary predisposition.123-128 |
Surgery_Schwartz_12012 | Surgery_Schwartz | breast or ovarian cancer is the most important known risk for the development of ovarian cancer, and 18% to 24% of ovarian carcinomas may arise in conjunction with a hereditary predisposition.123-128 Germline genetic muta-tions are far more common among type II ovarian cancers, while endometriosis and hormonal factors predispose to type I ovarian malignancies.121,126,129Since 2007, the National Comprehensive Cancer Network guidelines began recommending that all women diagnosed with ovarian cancer receive genetic testing as up to 20% of ovarian cancer patients are BRCA1/2 mutation carriers.127,130-134 Although family history of breast and/or epithelial ovarian cancer is one of the strongest factors for lifetime risk of having breast or epithelial ovarian cancer, up to 50% of women with ovarian cancer who test positive for a BRCA mutation have no fam-ily history of either malignancy, supporting the importance of testing all women with a personal diagnosis of ovarian cancer, regardless | Surgery_Schwartz. breast or ovarian cancer is the most important known risk for the development of ovarian cancer, and 18% to 24% of ovarian carcinomas may arise in conjunction with a hereditary predisposition.123-128 Germline genetic muta-tions are far more common among type II ovarian cancers, while endometriosis and hormonal factors predispose to type I ovarian malignancies.121,126,129Since 2007, the National Comprehensive Cancer Network guidelines began recommending that all women diagnosed with ovarian cancer receive genetic testing as up to 20% of ovarian cancer patients are BRCA1/2 mutation carriers.127,130-134 Although family history of breast and/or epithelial ovarian cancer is one of the strongest factors for lifetime risk of having breast or epithelial ovarian cancer, up to 50% of women with ovarian cancer who test positive for a BRCA mutation have no fam-ily history of either malignancy, supporting the importance of testing all women with a personal diagnosis of ovarian cancer, regardless |
Surgery_Schwartz_12013 | Surgery_Schwartz | cancer who test positive for a BRCA mutation have no fam-ily history of either malignancy, supporting the importance of testing all women with a personal diagnosis of ovarian cancer, regardless of family history. The identification of deleterious mutations allows for cascade testing. Relatives of the affected patient are referred for genetic testing limited to the identified mutation. The lifetime risk for the development of ovarian can-cer for carriers of mutations in the BRCA1 and BRCA2 genes Brunicardi_Ch41_p1783-p1826.indd 181518/02/19 4:35 PM 1816SPECIFIC CONSIDERATIONSPART IIis estimated to be between 20% and 45% and 10% and 20%, respectively.123,130,135One of the challenges associated with early detection of ovarian cancer has historically been the lack of an identifiable precursor lesion. In 2001, however, “dysplastic changes” in the fallopian tubes removed from women with increased risk of developing ovarian carcinoma were first described.136 Subse-quent careful | Surgery_Schwartz. cancer who test positive for a BRCA mutation have no fam-ily history of either malignancy, supporting the importance of testing all women with a personal diagnosis of ovarian cancer, regardless of family history. The identification of deleterious mutations allows for cascade testing. Relatives of the affected patient are referred for genetic testing limited to the identified mutation. The lifetime risk for the development of ovarian can-cer for carriers of mutations in the BRCA1 and BRCA2 genes Brunicardi_Ch41_p1783-p1826.indd 181518/02/19 4:35 PM 1816SPECIFIC CONSIDERATIONSPART IIis estimated to be between 20% and 45% and 10% and 20%, respectively.123,130,135One of the challenges associated with early detection of ovarian cancer has historically been the lack of an identifiable precursor lesion. In 2001, however, “dysplastic changes” in the fallopian tubes removed from women with increased risk of developing ovarian carcinoma were first described.136 Subse-quent careful |
Surgery_Schwartz_12014 | Surgery_Schwartz | precursor lesion. In 2001, however, “dysplastic changes” in the fallopian tubes removed from women with increased risk of developing ovarian carcinoma were first described.136 Subse-quent careful microscopic examination using a newly developed “sectioning and extensively examining of the fimbriated end” protocol (SEE-FIM) of the grossly normal fallopian tubes and ovaries from women with BRCA1/2 mutations revealed occult tubal cancer and precancers designated as serous tubal intraepi-thelial carcinoma. The relationship between serous tubal intraep-ithelial carcinomas and high-grade serous and endometrioid cancers is supported by the ubiquitous presence of TP53 muta-tions and their typical location within the fimbriated end of the fallopian tube.118,121,137 High-grade, serous epithelial cancers of the ovary, fallopian tube, and peritoneum are now recognized to have a common fallopian tubal precursor lesion and often com-bined under the rubric of epithelial ovarian cancer (HGSOC).For | Surgery_Schwartz. precursor lesion. In 2001, however, “dysplastic changes” in the fallopian tubes removed from women with increased risk of developing ovarian carcinoma were first described.136 Subse-quent careful microscopic examination using a newly developed “sectioning and extensively examining of the fimbriated end” protocol (SEE-FIM) of the grossly normal fallopian tubes and ovaries from women with BRCA1/2 mutations revealed occult tubal cancer and precancers designated as serous tubal intraepi-thelial carcinoma. The relationship between serous tubal intraep-ithelial carcinomas and high-grade serous and endometrioid cancers is supported by the ubiquitous presence of TP53 muta-tions and their typical location within the fimbriated end of the fallopian tube.118,121,137 High-grade, serous epithelial cancers of the ovary, fallopian tube, and peritoneum are now recognized to have a common fallopian tubal precursor lesion and often com-bined under the rubric of epithelial ovarian cancer (HGSOC).For |
Surgery_Schwartz_12015 | Surgery_Schwartz | cancers of the ovary, fallopian tube, and peritoneum are now recognized to have a common fallopian tubal precursor lesion and often com-bined under the rubric of epithelial ovarian cancer (HGSOC).For women at increased risk of ovarian cancer, the only confirmed prevention strategy is risk-reducing salpingo-oopherectomy.138,139 The lifetime risk of HGSOC is reduced to under 3% with risk-reducing salpingo-oopherectomy. A modern understanding of the fallopian tube as the site of origin for many ovarian cancers has led to the suggestion that opportunistic salpingectomy could be implemented as a potential cancer prevention strategy in the general population. Scandinavian population-based cohort studies have demon-strated a significant decrease in epithelial ovarian cancer following salpingectomy.140,141 Opportunistic salpingectomy is feasible among women undergoing tubal ligation, hysterectomy, or other pelvic surgery.142 Early Staged Ovarian Cancer. Early stage epithelial ovarian cancer | Surgery_Schwartz. cancers of the ovary, fallopian tube, and peritoneum are now recognized to have a common fallopian tubal precursor lesion and often com-bined under the rubric of epithelial ovarian cancer (HGSOC).For women at increased risk of ovarian cancer, the only confirmed prevention strategy is risk-reducing salpingo-oopherectomy.138,139 The lifetime risk of HGSOC is reduced to under 3% with risk-reducing salpingo-oopherectomy. A modern understanding of the fallopian tube as the site of origin for many ovarian cancers has led to the suggestion that opportunistic salpingectomy could be implemented as a potential cancer prevention strategy in the general population. Scandinavian population-based cohort studies have demon-strated a significant decrease in epithelial ovarian cancer following salpingectomy.140,141 Opportunistic salpingectomy is feasible among women undergoing tubal ligation, hysterectomy, or other pelvic surgery.142 Early Staged Ovarian Cancer. Early stage epithelial ovarian cancer |
Surgery_Schwartz_12016 | Surgery_Schwartz | Opportunistic salpingectomy is feasible among women undergoing tubal ligation, hysterectomy, or other pelvic surgery.142 Early Staged Ovarian Cancer. Early stage epithelial ovarian cancer has an excellent outcome. Low grade, stages IA and B disease can be cured in up to 90% to 95% of cases by a complete surgical procedure. The prevailing position in the United States is that such patients do not benefit from chemotherapy.143 8The standard of care for women with stages IC and II, and all women with grade 3 or clear cell histology, is adjuvant che-motherapy with 3 to 6 cycles of platinumand taxane-based chemotherapy.144Advanced Ovarian Cancer. A pelvic mass with ascites, an omental cake, and an elevated CA-125 is pathognomonic for advanced ovarian cancer. CT scan is the imaging modality of choice to evaluate the upper abdomen and potential resect-ability of disease. Concerning physical or radiographic exam findings should prompt referral to a gynecologic oncologist (Table 41-10), as | Surgery_Schwartz. Opportunistic salpingectomy is feasible among women undergoing tubal ligation, hysterectomy, or other pelvic surgery.142 Early Staged Ovarian Cancer. Early stage epithelial ovarian cancer has an excellent outcome. Low grade, stages IA and B disease can be cured in up to 90% to 95% of cases by a complete surgical procedure. The prevailing position in the United States is that such patients do not benefit from chemotherapy.143 8The standard of care for women with stages IC and II, and all women with grade 3 or clear cell histology, is adjuvant che-motherapy with 3 to 6 cycles of platinumand taxane-based chemotherapy.144Advanced Ovarian Cancer. A pelvic mass with ascites, an omental cake, and an elevated CA-125 is pathognomonic for advanced ovarian cancer. CT scan is the imaging modality of choice to evaluate the upper abdomen and potential resect-ability of disease. Concerning physical or radiographic exam findings should prompt referral to a gynecologic oncologist (Table 41-10), as |
Surgery_Schwartz_12017 | Surgery_Schwartz | of choice to evaluate the upper abdomen and potential resect-ability of disease. Concerning physical or radiographic exam findings should prompt referral to a gynecologic oncologist (Table 41-10), as studies demonstrate inferior patient outcome for women who have had primary surgery by nongynecologic oncologists.The objectives of surgery in ovarian cancer are threefold. The first is to make the histologic diagnosis. The second is to assess the extent of disease through complete surgical staging (Tables 41-11 and 41-12). When epithelial ovarian cancer is identified on frozen section and disease is grossly limited to the pelvis, complete staging with node dissection will upstage nearly one-third of patients.145 The third objective is (when feasible) surgical cytoreduction or debulking. The extent of disease upon entering the abdomen and the residual disease upon completion of the debulking surgery are independent prognostic variables for patient outcome. The Gynecologic Oncology Group | Surgery_Schwartz. of choice to evaluate the upper abdomen and potential resect-ability of disease. Concerning physical or radiographic exam findings should prompt referral to a gynecologic oncologist (Table 41-10), as studies demonstrate inferior patient outcome for women who have had primary surgery by nongynecologic oncologists.The objectives of surgery in ovarian cancer are threefold. The first is to make the histologic diagnosis. The second is to assess the extent of disease through complete surgical staging (Tables 41-11 and 41-12). When epithelial ovarian cancer is identified on frozen section and disease is grossly limited to the pelvis, complete staging with node dissection will upstage nearly one-third of patients.145 The third objective is (when feasible) surgical cytoreduction or debulking. The extent of disease upon entering the abdomen and the residual disease upon completion of the debulking surgery are independent prognostic variables for patient outcome. The Gynecologic Oncology Group |
Surgery_Schwartz_12018 | Surgery_Schwartz | extent of disease upon entering the abdomen and the residual disease upon completion of the debulking surgery are independent prognostic variables for patient outcome. The Gynecologic Oncology Group has defined optimal residual disease as residual tumor ≤1 cm in the largest diameter. However, more contemporary data suggest that the most favorable survival outcomes are associated with complete cytoreduction to no gross residual disease.146 Decisions about the benefits and risks of radical debulking for individual presentations and diverse pathology depend on the age and medical stability of the patient, as well as the pathologic type of the cancer.The publication of two randomized prospective trials of neoadjuvant chemotherapy (NACT) for ovarian cancer has led to a questioning of the dogma of maximum surgical effort. Both trials revealed no survival difference compared to primary deb-ulking.147,148 In a patient who is medically compromised or in whom complete primary cytoreduction is | Surgery_Schwartz. extent of disease upon entering the abdomen and the residual disease upon completion of the debulking surgery are independent prognostic variables for patient outcome. The Gynecologic Oncology Group has defined optimal residual disease as residual tumor ≤1 cm in the largest diameter. However, more contemporary data suggest that the most favorable survival outcomes are associated with complete cytoreduction to no gross residual disease.146 Decisions about the benefits and risks of radical debulking for individual presentations and diverse pathology depend on the age and medical stability of the patient, as well as the pathologic type of the cancer.The publication of two randomized prospective trials of neoadjuvant chemotherapy (NACT) for ovarian cancer has led to a questioning of the dogma of maximum surgical effort. Both trials revealed no survival difference compared to primary deb-ulking.147,148 In a patient who is medically compromised or in whom complete primary cytoreduction is |
Surgery_Schwartz_12019 | Surgery_Schwartz | of maximum surgical effort. Both trials revealed no survival difference compared to primary deb-ulking.147,148 In a patient who is medically compromised or in whom complete primary cytoreduction is unlikely, neoadjuvant Table 41-10Ovarian cancer symptom index (2007) and ACOG guidelines for patient referral to gynecologic oncologyOVARIAN CANCER SYMPTOM INDEXACOG GUIDELINES FOR REFERRAL OF PREMENOPAUSAL WOMEN WITH MASS SUSPICIOUS FOR OVCAACOG GUIDELINES FOR REFERRAL OF POSTMENOPAUSAL WOMEN WITH MASS SUSPICIOUS FOR OVCADevelopment of, change in, and/or persistence in:1 or more of:1 or more of:BloatingCA-125 >200 U/mLElevated CA-125Pelvic or abdominal painAscitesAscitesDifficulty eating or feeling full quicklyEvidence of abdominal or distant metastasisNodular or fixed pelvic massUrinary symptoms of urgency or frequencyFamily history of 1 or more first degree relatives with ovarian or breast cancerEvidence of abdominal or distant metastasisFamily history of one or more first-degree | Surgery_Schwartz. of maximum surgical effort. Both trials revealed no survival difference compared to primary deb-ulking.147,148 In a patient who is medically compromised or in whom complete primary cytoreduction is unlikely, neoadjuvant Table 41-10Ovarian cancer symptom index (2007) and ACOG guidelines for patient referral to gynecologic oncologyOVARIAN CANCER SYMPTOM INDEXACOG GUIDELINES FOR REFERRAL OF PREMENOPAUSAL WOMEN WITH MASS SUSPICIOUS FOR OVCAACOG GUIDELINES FOR REFERRAL OF POSTMENOPAUSAL WOMEN WITH MASS SUSPICIOUS FOR OVCADevelopment of, change in, and/or persistence in:1 or more of:1 or more of:BloatingCA-125 >200 U/mLElevated CA-125Pelvic or abdominal painAscitesAscitesDifficulty eating or feeling full quicklyEvidence of abdominal or distant metastasisNodular or fixed pelvic massUrinary symptoms of urgency or frequencyFamily history of 1 or more first degree relatives with ovarian or breast cancerEvidence of abdominal or distant metastasisFamily history of one or more first-degree |
Surgery_Schwartz_12020 | Surgery_Schwartz | symptoms of urgency or frequencyFamily history of 1 or more first degree relatives with ovarian or breast cancerEvidence of abdominal or distant metastasisFamily history of one or more first-degree relatives with ovarian or breast cancer ACOG = American Congress of Obstetricians and Gynecologists.Data from Goff BA, Mandel LS, Drescher CW, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007;109:221-227; Dearking AC, Aletti GD, McGree ME, Weaver AL, Sommerfield MK, Cliby WA. How relevant are ACOG and SGO guidelines for referral of adnexal mass? Obstet Gynecol. 2007;110:841-848.Brunicardi_Ch41_p1783-p1826.indd 181618/02/19 4:35 PM 1817GYNECOLOGYCHAPTER 41Table 41-112014 International Federation of Gynecology and Obstetrics staging of epithelial ovarian cancerITumor confined to ovaries or fallopian tube(s)T1IATumor limited to one ovary (capsule intact) or fallopian tubeNo tumor on ovarian or fallopian tube surfaceNo malignant | Surgery_Schwartz. symptoms of urgency or frequencyFamily history of 1 or more first degree relatives with ovarian or breast cancerEvidence of abdominal or distant metastasisFamily history of one or more first-degree relatives with ovarian or breast cancer ACOG = American Congress of Obstetricians and Gynecologists.Data from Goff BA, Mandel LS, Drescher CW, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007;109:221-227; Dearking AC, Aletti GD, McGree ME, Weaver AL, Sommerfield MK, Cliby WA. How relevant are ACOG and SGO guidelines for referral of adnexal mass? Obstet Gynecol. 2007;110:841-848.Brunicardi_Ch41_p1783-p1826.indd 181618/02/19 4:35 PM 1817GYNECOLOGYCHAPTER 41Table 41-112014 International Federation of Gynecology and Obstetrics staging of epithelial ovarian cancerITumor confined to ovaries or fallopian tube(s)T1IATumor limited to one ovary (capsule intact) or fallopian tubeNo tumor on ovarian or fallopian tube surfaceNo malignant |
Surgery_Schwartz_12021 | Surgery_Schwartz | of epithelial ovarian cancerITumor confined to ovaries or fallopian tube(s)T1IATumor limited to one ovary (capsule intact) or fallopian tubeNo tumor on ovarian or fallopian tube surfaceNo malignant cells in the ascites or peritoneal washingsT1aIBTumor limited to both ovaries (capsules intact) or fallopian tubesNo tumor on ovarian or fallopian tube surfaceNo malignant cells in the ascites or peritoneal washingsT1bICTumor limited to one or both ovaries or fallopian tubes, with any of the following:IC1 Surgical spill intraoperativelyIC2 Capsule ruptured before surgery or tumor on ovarian or fallopian tube surfaceIC3 Malignant cells present in the ascites or peritoneal washingsT1cIITumor involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or peritoneal cancer (Tp)T2IIAExtension and/or implants on the uterus and/or fallopian tubes/and/or ovariesT2aIIBExtension to other pelvic intraperitoneal tissuesT2bIIITumor involves one or both ovaries, or | Surgery_Schwartz. of epithelial ovarian cancerITumor confined to ovaries or fallopian tube(s)T1IATumor limited to one ovary (capsule intact) or fallopian tubeNo tumor on ovarian or fallopian tube surfaceNo malignant cells in the ascites or peritoneal washingsT1aIBTumor limited to both ovaries (capsules intact) or fallopian tubesNo tumor on ovarian or fallopian tube surfaceNo malignant cells in the ascites or peritoneal washingsT1bICTumor limited to one or both ovaries or fallopian tubes, with any of the following:IC1 Surgical spill intraoperativelyIC2 Capsule ruptured before surgery or tumor on ovarian or fallopian tube surfaceIC3 Malignant cells present in the ascites or peritoneal washingsT1cIITumor involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or peritoneal cancer (Tp)T2IIAExtension and/or implants on the uterus and/or fallopian tubes/and/or ovariesT2aIIBExtension to other pelvic intraperitoneal tissuesT2bIIITumor involves one or both ovaries, or |
Surgery_Schwartz_12022 | Surgery_Schwartz | cancer (Tp)T2IIAExtension and/or implants on the uterus and/or fallopian tubes/and/or ovariesT2aIIBExtension to other pelvic intraperitoneal tissuesT2bIIITumor involves one or both ovaries, or fallopian tubes, or primary peritoneal cancer, with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodesT3IIIAMetastasis to the retroperitoneal lymph nodes with or without microscopic peritoneal involvement beyond the pelvisT1, T2, T3aN1IIIA1Positive retroperitoneal lymph nodes only (cytologically or histologically proven) IIIA1(i)Metastasis ≤10 mm in greatest dimension (note this is tumor dimension and not lymph node dimension)T3a/T3aN1IIIA1(ii)Metastasis >10 mm in greatest dimension IIIA 2Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodesT3a/T3aN1IIIBMacroscopic peritoneal metastases beyond the pelvic brim ≤2 cm in greatest dimension, | Surgery_Schwartz. cancer (Tp)T2IIAExtension and/or implants on the uterus and/or fallopian tubes/and/or ovariesT2aIIBExtension to other pelvic intraperitoneal tissuesT2bIIITumor involves one or both ovaries, or fallopian tubes, or primary peritoneal cancer, with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodesT3IIIAMetastasis to the retroperitoneal lymph nodes with or without microscopic peritoneal involvement beyond the pelvisT1, T2, T3aN1IIIA1Positive retroperitoneal lymph nodes only (cytologically or histologically proven) IIIA1(i)Metastasis ≤10 mm in greatest dimension (note this is tumor dimension and not lymph node dimension)T3a/T3aN1IIIA1(ii)Metastasis >10 mm in greatest dimension IIIA 2Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodesT3a/T3aN1IIIBMacroscopic peritoneal metastases beyond the pelvic brim ≤2 cm in greatest dimension, |
Surgery_Schwartz_12023 | Surgery_Schwartz | (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodesT3a/T3aN1IIIBMacroscopic peritoneal metastases beyond the pelvic brim ≤2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodesT3b/T3bN1III CMacroscopic peritoneal metastases beyond the pelvic brim >2 cm in greatest dimension, with or without metastases to the retroperitoneal nodes (Note 1)T3c/T3cN1IVDistant metastasis excluding peritoneal metastases Stage IV A: Pleural effusion with positive cytologyStage IV B: Metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of abdominal cavity) (Note 2)Any T, any N, M1Reproduced with permission from Mutch DG, Prat J: 2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer, Gynecol Oncol. 2014 Jun; 133(3):401-404.Table 41-12Components of comprehensive surgical staging and debulking of epithelial ovarian cancerVertical abdominal incision adequate to visualize the | Surgery_Schwartz. (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodesT3a/T3aN1IIIBMacroscopic peritoneal metastases beyond the pelvic brim ≤2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodesT3b/T3bN1III CMacroscopic peritoneal metastases beyond the pelvic brim >2 cm in greatest dimension, with or without metastases to the retroperitoneal nodes (Note 1)T3c/T3cN1IVDistant metastasis excluding peritoneal metastases Stage IV A: Pleural effusion with positive cytologyStage IV B: Metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of abdominal cavity) (Note 2)Any T, any N, M1Reproduced with permission from Mutch DG, Prat J: 2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer, Gynecol Oncol. 2014 Jun; 133(3):401-404.Table 41-12Components of comprehensive surgical staging and debulking of epithelial ovarian cancerVertical abdominal incision adequate to visualize the |
Surgery_Schwartz_12024 | Surgery_Schwartz | cancer, Gynecol Oncol. 2014 Jun; 133(3):401-404.Table 41-12Components of comprehensive surgical staging and debulking of epithelial ovarian cancerVertical abdominal incision adequate to visualize the diaphragmsEvacuation of ascitesPeritoneal washings of each pelvic gutter and diaphragmEn bloc hysterectomy and bilateral salpingo-oopherectomyInfragastric omentectomyRetroperitoneal and pelvic lymph node dissectionExamination of the entire bowelRandom biopsies of apparently uninvolved areas of peritoneum, pericolic gutters, diaphragmchemotherapy followed by interval debulking may be more appropriate and is supported by recent randomized controlled trials. Typically, treatment with NACT includes three cycles of platinum-based chemotherapy prior to open debulking, then three additional cycles after surgery. Diagnostic laparoscopic evaluation prior to cytoreductive surgery has been suggested as a means to avoid unnecessary laparotomy, resulting in subop-timal cytoreduction. Patients deemed | Surgery_Schwartz. cancer, Gynecol Oncol. 2014 Jun; 133(3):401-404.Table 41-12Components of comprehensive surgical staging and debulking of epithelial ovarian cancerVertical abdominal incision adequate to visualize the diaphragmsEvacuation of ascitesPeritoneal washings of each pelvic gutter and diaphragmEn bloc hysterectomy and bilateral salpingo-oopherectomyInfragastric omentectomyRetroperitoneal and pelvic lymph node dissectionExamination of the entire bowelRandom biopsies of apparently uninvolved areas of peritoneum, pericolic gutters, diaphragmchemotherapy followed by interval debulking may be more appropriate and is supported by recent randomized controlled trials. Typically, treatment with NACT includes three cycles of platinum-based chemotherapy prior to open debulking, then three additional cycles after surgery. Diagnostic laparoscopic evaluation prior to cytoreductive surgery has been suggested as a means to avoid unnecessary laparotomy, resulting in subop-timal cytoreduction. Patients deemed |
Surgery_Schwartz_12025 | Surgery_Schwartz | after surgery. Diagnostic laparoscopic evaluation prior to cytoreductive surgery has been suggested as a means to avoid unnecessary laparotomy, resulting in subop-timal cytoreduction. Patients deemed not to be candidates for cytoreduction could proceed immediately to NACT at the time of tissue collection for definitive diagnosis. A Fagotti predictive index ≥8 (Table 41-13) is a predictor of suboptimal cytoreduc-tion in advanced ovarian cancer with reasonable sensitivity and high specificity.149 These recommendations currently apply to HGSOC, clear cell cancer, and high-grade endometrioid ovarian Brunicardi_Ch41_p1783-p1826.indd 181718/02/19 4:35 PM 1818SPECIFIC CONSIDERATIONSPART IIcancers. Low-grade tumors are less chemotherapy sensitive, and primary surgical resection is recommended when feasible. Standard of care adjuvant therapy of advanced stage epithe-lial ovarian cancer remains intravenous platinumand tax-ane-based chemotherapy.150 In 2006, the National Cancer Institute | Surgery_Schwartz. after surgery. Diagnostic laparoscopic evaluation prior to cytoreductive surgery has been suggested as a means to avoid unnecessary laparotomy, resulting in subop-timal cytoreduction. Patients deemed not to be candidates for cytoreduction could proceed immediately to NACT at the time of tissue collection for definitive diagnosis. A Fagotti predictive index ≥8 (Table 41-13) is a predictor of suboptimal cytoreduc-tion in advanced ovarian cancer with reasonable sensitivity and high specificity.149 These recommendations currently apply to HGSOC, clear cell cancer, and high-grade endometrioid ovarian Brunicardi_Ch41_p1783-p1826.indd 181718/02/19 4:35 PM 1818SPECIFIC CONSIDERATIONSPART IIcancers. Low-grade tumors are less chemotherapy sensitive, and primary surgical resection is recommended when feasible. Standard of care adjuvant therapy of advanced stage epithe-lial ovarian cancer remains intravenous platinumand tax-ane-based chemotherapy.150 In 2006, the National Cancer Institute |
Surgery_Schwartz_12026 | Surgery_Schwartz | when feasible. Standard of care adjuvant therapy of advanced stage epithe-lial ovarian cancer remains intravenous platinumand tax-ane-based chemotherapy.150 In 2006, the National Cancer Institute issued a clinical alert indicating that combination intrave-nous/intraperitoneal platinum/taxane postoperative chemotherapy should be considered first line for women with optimally cytore-duced EOC. This was the result of completion and analysis of three independent randomized clinical trials showing a significant survival advantage for intraperitoneal therapy.151,152 Intraperitoneal (IP) therapy is administered via an implanted 9.6 French venous port catheter with the port placed over the right or left costal 9margin. The catheter is tunneled caudad with insertion through the fascia in the lower abdomen and the tip in the pelvis. The IP cath-eter may be placed at the time of surgical debulking via an open laparotomy approach or prior to initiating chemotherapy via a laparoscopic approach. In | Surgery_Schwartz. when feasible. Standard of care adjuvant therapy of advanced stage epithe-lial ovarian cancer remains intravenous platinumand tax-ane-based chemotherapy.150 In 2006, the National Cancer Institute issued a clinical alert indicating that combination intrave-nous/intraperitoneal platinum/taxane postoperative chemotherapy should be considered first line for women with optimally cytore-duced EOC. This was the result of completion and analysis of three independent randomized clinical trials showing a significant survival advantage for intraperitoneal therapy.151,152 Intraperitoneal (IP) therapy is administered via an implanted 9.6 French venous port catheter with the port placed over the right or left costal 9margin. The catheter is tunneled caudad with insertion through the fascia in the lower abdomen and the tip in the pelvis. The IP cath-eter may be placed at the time of surgical debulking via an open laparotomy approach or prior to initiating chemotherapy via a laparoscopic approach. In |
Surgery_Schwartz_12027 | Surgery_Schwartz | abdomen and the tip in the pelvis. The IP cath-eter may be placed at the time of surgical debulking via an open laparotomy approach or prior to initiating chemotherapy via a laparoscopic approach. In some centers, the IP catheter may be placed by interventional radiology with CT guidance.Patients who have suboptimally debulked advanced stage disease and/or who are not candidates for intraperitoneal ther-apy should receive intravenous adjuvant chemotherapy. Interest has increased in both dose dense IV chemotherapy dosing as well as incorporation of biologic agents.Secondary cytoreduction upon recurrence can be con-sidered (Table 41-14). Patients who have had a disease-free Table 41-13Laparoscopic assessment of advanced ovarian cancer to predict surgical resectabilityLAPAROSCOPIC FEATURESCORE 0SCORE 2Peritoneal carcinomatosisCarcinomatosis involving a limited area (along the paracolic gutter or the pelvic peritoneum) and surgically removable by peritonectomyUnresectable massive | Surgery_Schwartz. abdomen and the tip in the pelvis. The IP cath-eter may be placed at the time of surgical debulking via an open laparotomy approach or prior to initiating chemotherapy via a laparoscopic approach. In some centers, the IP catheter may be placed by interventional radiology with CT guidance.Patients who have suboptimally debulked advanced stage disease and/or who are not candidates for intraperitoneal ther-apy should receive intravenous adjuvant chemotherapy. Interest has increased in both dose dense IV chemotherapy dosing as well as incorporation of biologic agents.Secondary cytoreduction upon recurrence can be con-sidered (Table 41-14). Patients who have had a disease-free Table 41-13Laparoscopic assessment of advanced ovarian cancer to predict surgical resectabilityLAPAROSCOPIC FEATURESCORE 0SCORE 2Peritoneal carcinomatosisCarcinomatosis involving a limited area (along the paracolic gutter or the pelvic peritoneum) and surgically removable by peritonectomyUnresectable massive |
Surgery_Schwartz_12028 | Surgery_Schwartz | 0SCORE 2Peritoneal carcinomatosisCarcinomatosis involving a limited area (along the paracolic gutter or the pelvic peritoneum) and surgically removable by peritonectomyUnresectable massive peritoneal involvement as well as with a miliary pattern of distributionDiaphragmatic diseaseNo infiltrating carcinomatosis and no nodules confluent with the most part of the diaphragmatic surfaceWidespread infiltrating carcinomatosis or nodules confluent with the most part of the diaphragmatic surfaceMesenteric diseaseNo large infiltrating nodules and no involvement of the root of the mesentery as would be indicated by limited movement of the various intestinal segmentsLarge infiltrating nodules or involvement of the root of the mesentery indicated by limited movement of the various intestinal segmentsOmental diseaseNo tumor diffusion observed along the omentum up to the large stomach curvatureTumor diffusion observed along the omentum up to the large stomach curvatureBowel infiltrationNo bowel | Surgery_Schwartz. 0SCORE 2Peritoneal carcinomatosisCarcinomatosis involving a limited area (along the paracolic gutter or the pelvic peritoneum) and surgically removable by peritonectomyUnresectable massive peritoneal involvement as well as with a miliary pattern of distributionDiaphragmatic diseaseNo infiltrating carcinomatosis and no nodules confluent with the most part of the diaphragmatic surfaceWidespread infiltrating carcinomatosis or nodules confluent with the most part of the diaphragmatic surfaceMesenteric diseaseNo large infiltrating nodules and no involvement of the root of the mesentery as would be indicated by limited movement of the various intestinal segmentsLarge infiltrating nodules or involvement of the root of the mesentery indicated by limited movement of the various intestinal segmentsOmental diseaseNo tumor diffusion observed along the omentum up to the large stomach curvatureTumor diffusion observed along the omentum up to the large stomach curvatureBowel infiltrationNo bowel |
Surgery_Schwartz_12029 | Surgery_Schwartz | diseaseNo tumor diffusion observed along the omentum up to the large stomach curvatureTumor diffusion observed along the omentum up to the large stomach curvatureBowel infiltrationNo bowel resection was assumed and no miliary carcinomatosis on the ansae observedBowel resection assumed or miliary carcinomatosis on the ansae observedStomach infiltrationNo obvious neoplastic involvement of the gastric wallObvious neoplastic involvement of the gastric wallLiver metastasesNo surface lesionsAny surface lesionTable 41-14Guidelines for secondary therapy of epithelial ovarian cancerTIME FROM COMPLETION OF PRIMARY THERAPYDEFINITIONINTERVENTIONProgression on therapyPlatinum-refractoryNo value of secondary debulking unless remediating complication such as bowel obstructionNon–platinum-based chemotherapyConsider clinical trialProgression within 6 months of completion of primary therapyPlatinum-resistantNo value of secondary debulking unless remediating complication such as bowel | Surgery_Schwartz. diseaseNo tumor diffusion observed along the omentum up to the large stomach curvatureTumor diffusion observed along the omentum up to the large stomach curvatureBowel infiltrationNo bowel resection was assumed and no miliary carcinomatosis on the ansae observedBowel resection assumed or miliary carcinomatosis on the ansae observedStomach infiltrationNo obvious neoplastic involvement of the gastric wallObvious neoplastic involvement of the gastric wallLiver metastasesNo surface lesionsAny surface lesionTable 41-14Guidelines for secondary therapy of epithelial ovarian cancerTIME FROM COMPLETION OF PRIMARY THERAPYDEFINITIONINTERVENTIONProgression on therapyPlatinum-refractoryNo value of secondary debulking unless remediating complication such as bowel obstructionNon–platinum-based chemotherapyConsider clinical trialProgression within 6 months of completion of primary therapyPlatinum-resistantNo value of secondary debulking unless remediating complication such as bowel |
Surgery_Schwartz_12030 | Surgery_Schwartz | chemotherapyConsider clinical trialProgression within 6 months of completion of primary therapyPlatinum-resistantNo value of secondary debulking unless remediating complication such as bowel obstructionNon–platinum-based chemotherapy consider adding bevacizumabConsider clinical trialProgression after 6 months post completion of primary therapyPlatinum-sensitiveConsider secondary debulking if greater than 12 months intervalConsider platinum +/− taxane +/− bevacizumab, +/− pegylated liposomal doxorubicin, +/− gemcitabineConsider maintenance PARP inhibitorConsider clinical trialBrunicardi_Ch41_p1783-p1826.indd 181818/02/19 4:35 PM 1819GYNECOLOGYCHAPTER 41period of at least 12 months following an initial complete clini-cal response to surgery and initial chemotherapy, who have no evidence of carcinomatosis on imaging, and who have disease that can be completely resected are considered optimal candi-dates. A randomized controlled trial reported in abstract form demonstrated a benefit | Surgery_Schwartz. chemotherapyConsider clinical trialProgression within 6 months of completion of primary therapyPlatinum-resistantNo value of secondary debulking unless remediating complication such as bowel obstructionNon–platinum-based chemotherapy consider adding bevacizumabConsider clinical trialProgression after 6 months post completion of primary therapyPlatinum-sensitiveConsider secondary debulking if greater than 12 months intervalConsider platinum +/− taxane +/− bevacizumab, +/− pegylated liposomal doxorubicin, +/− gemcitabineConsider maintenance PARP inhibitorConsider clinical trialBrunicardi_Ch41_p1783-p1826.indd 181818/02/19 4:35 PM 1819GYNECOLOGYCHAPTER 41period of at least 12 months following an initial complete clini-cal response to surgery and initial chemotherapy, who have no evidence of carcinomatosis on imaging, and who have disease that can be completely resected are considered optimal candi-dates. A randomized controlled trial reported in abstract form demonstrated a benefit |
Surgery_Schwartz_12031 | Surgery_Schwartz | of carcinomatosis on imaging, and who have disease that can be completely resected are considered optimal candi-dates. A randomized controlled trial reported in abstract form demonstrated a benefit of secondary cytoreduction under strict entry criteria (DESKTOP3); the GOG-0213 study of secondary cytoreduction is maturing. Debulking surgery done after subse-quent relapses or in women with early recurrence has not been shown to result in an outcome benefit and should be used only to palliate disease complications.The most common cause of palliative surgery is bypass of bowel obstruction. The majority of women with advanced ovarian cancer will eventually develop and potentially die from malignant bowel obstruction. While management of these cases is controversial, in some cases surgical correction has been shown to prolong life and improve quality of life.153 Nonsurgical options include placement of a venting gastrostomy tube, per-formed endoscopically or surgically. Management of | Surgery_Schwartz. of carcinomatosis on imaging, and who have disease that can be completely resected are considered optimal candi-dates. A randomized controlled trial reported in abstract form demonstrated a benefit of secondary cytoreduction under strict entry criteria (DESKTOP3); the GOG-0213 study of secondary cytoreduction is maturing. Debulking surgery done after subse-quent relapses or in women with early recurrence has not been shown to result in an outcome benefit and should be used only to palliate disease complications.The most common cause of palliative surgery is bypass of bowel obstruction. The majority of women with advanced ovarian cancer will eventually develop and potentially die from malignant bowel obstruction. While management of these cases is controversial, in some cases surgical correction has been shown to prolong life and improve quality of life.153 Nonsurgical options include placement of a venting gastrostomy tube, per-formed endoscopically or surgically. Management of |
Surgery_Schwartz_12032 | Surgery_Schwartz | correction has been shown to prolong life and improve quality of life.153 Nonsurgical options include placement of a venting gastrostomy tube, per-formed endoscopically or surgically. Management of malignant bowel obstruction in women with recurrent advanced disease should be individualized.Chemotherapy is the mainstay of therapy for recurrent EOC. Treatment approaches are based upon platinum sensitivity.154 Referral to an oncologist with specific expertise in chemothera-peutic treatment of ovarian cancer and access to clinical trials is important. In determining secondary and subsequent ther-apy, consideration of prior therapies, sites of disease, organs at risk from cancer, organs sustaining injury from prior ther-apy, and quality of life desires of patient should be taken into consideration.Ovarian Germ Cell Tumors. Ovarian germ cell tumors occur most commonly in women under age 30. The most common benign germ cell neoplasm is the mature cystic teratoma; approximately 1% of | Surgery_Schwartz. correction has been shown to prolong life and improve quality of life.153 Nonsurgical options include placement of a venting gastrostomy tube, per-formed endoscopically or surgically. Management of malignant bowel obstruction in women with recurrent advanced disease should be individualized.Chemotherapy is the mainstay of therapy for recurrent EOC. Treatment approaches are based upon platinum sensitivity.154 Referral to an oncologist with specific expertise in chemothera-peutic treatment of ovarian cancer and access to clinical trials is important. In determining secondary and subsequent ther-apy, consideration of prior therapies, sites of disease, organs at risk from cancer, organs sustaining injury from prior ther-apy, and quality of life desires of patient should be taken into consideration.Ovarian Germ Cell Tumors. Ovarian germ cell tumors occur most commonly in women under age 30. The most common benign germ cell neoplasm is the mature cystic teratoma; approximately 1% of |
Surgery_Schwartz_12033 | Surgery_Schwartz | Germ Cell Tumors. Ovarian germ cell tumors occur most commonly in women under age 30. The most common benign germ cell neoplasm is the mature cystic teratoma; approximately 1% of teratomas contain a secondary malig-nancy arising from one of the components, most commonly squamous cell cancer and most commonly in postmenopausal women. Malignant germ cell tumors often grow and dissemi-nate rapidly and are symptomatic. The rapid growth may be accompanied by torsion or rupture, producing an acute abdo-men and the need for emergent intervention. Because they are derived from primordial germ cells, many produce charac-teristic tumor markers. Immature teratomas comprise a sig-nificant proportion of malignant germ cell tumors and may be associated with elevated lactate dehydrogenase (LDH) or α-fetoprotein (AFP). Excluding teratomas, the most common malignant germ cell tumor is dysgerminoma, made up of pure undifferentiated germ cells. Bilaterality occurs in up to 15% of patients; lactate | Surgery_Schwartz. Germ Cell Tumors. Ovarian germ cell tumors occur most commonly in women under age 30. The most common benign germ cell neoplasm is the mature cystic teratoma; approximately 1% of teratomas contain a secondary malig-nancy arising from one of the components, most commonly squamous cell cancer and most commonly in postmenopausal women. Malignant germ cell tumors often grow and dissemi-nate rapidly and are symptomatic. The rapid growth may be accompanied by torsion or rupture, producing an acute abdo-men and the need for emergent intervention. Because they are derived from primordial germ cells, many produce charac-teristic tumor markers. Immature teratomas comprise a sig-nificant proportion of malignant germ cell tumors and may be associated with elevated lactate dehydrogenase (LDH) or α-fetoprotein (AFP). Excluding teratomas, the most common malignant germ cell tumor is dysgerminoma, made up of pure undifferentiated germ cells. Bilaterality occurs in up to 15% of patients; lactate |
Surgery_Schwartz_12034 | Surgery_Schwartz | α-fetoprotein (AFP). Excluding teratomas, the most common malignant germ cell tumor is dysgerminoma, made up of pure undifferentiated germ cells. Bilaterality occurs in up to 15% of patients; lactate dehydrogenase is commonly elevated, and elevated b-hCG may occur.Less common malignant germ cell tumors include endo-dermal sinus or yolk sac tumors, embyronal carcinomas, mixed germ cell neoplasms, polyembryomas, and choriocarcinomas. Endodermal sinus tumors may have elevated AFP levels in the blood while embryonal and mixed germ cell tumors may have elevated b-hCG, LDH, or AFP. Tumor markers are useful to fol-low during surveillance and definitive therapy. Other than com-pletely resected stage I, grade I immature teratoma, adjuvant chemotherapy with a platinum-containing regimen has been his-torically recommended.155 Because of the high response rates to chemotherapy and the long-term toxicity of treatment, a “watch and wait” approach with treatment only upon recurrence has been | Surgery_Schwartz. α-fetoprotein (AFP). Excluding teratomas, the most common malignant germ cell tumor is dysgerminoma, made up of pure undifferentiated germ cells. Bilaterality occurs in up to 15% of patients; lactate dehydrogenase is commonly elevated, and elevated b-hCG may occur.Less common malignant germ cell tumors include endo-dermal sinus or yolk sac tumors, embyronal carcinomas, mixed germ cell neoplasms, polyembryomas, and choriocarcinomas. Endodermal sinus tumors may have elevated AFP levels in the blood while embryonal and mixed germ cell tumors may have elevated b-hCG, LDH, or AFP. Tumor markers are useful to fol-low during surveillance and definitive therapy. Other than com-pletely resected stage I, grade I immature teratoma, adjuvant chemotherapy with a platinum-containing regimen has been his-torically recommended.155 Because of the high response rates to chemotherapy and the long-term toxicity of treatment, a “watch and wait” approach with treatment only upon recurrence has been |
Surgery_Schwartz_12035 | Surgery_Schwartz | been his-torically recommended.155 Because of the high response rates to chemotherapy and the long-term toxicity of treatment, a “watch and wait” approach with treatment only upon recurrence has been suggested as safe for selected, well-staged patients with germ cell tumors.156 The cure rate remains high, near 90% even when metastatic disease is present; recurrent disease is more difficult to eradicate.155Fertility preservation is the standard surgical approach for ovarian germ cell tumors as disease tends to be diagnosed at stage I, and salvage chemotherapy is overall extremely suc-cessful. Staging should include removal of the involved ovary, biopsy of any suspicious areas, pelvic and para-aortic node dis-section, and omentectomy. Hysterectomy or removal of the sec-ond ovary is rarely indicated.Growing teratoma syndrome is a rare sequela of germ cell malignancies. Characteristically, during or after chemotherapy slow-growing tumors will increase in size and may even com-press | Surgery_Schwartz. been his-torically recommended.155 Because of the high response rates to chemotherapy and the long-term toxicity of treatment, a “watch and wait” approach with treatment only upon recurrence has been suggested as safe for selected, well-staged patients with germ cell tumors.156 The cure rate remains high, near 90% even when metastatic disease is present; recurrent disease is more difficult to eradicate.155Fertility preservation is the standard surgical approach for ovarian germ cell tumors as disease tends to be diagnosed at stage I, and salvage chemotherapy is overall extremely suc-cessful. Staging should include removal of the involved ovary, biopsy of any suspicious areas, pelvic and para-aortic node dis-section, and omentectomy. Hysterectomy or removal of the sec-ond ovary is rarely indicated.Growing teratoma syndrome is a rare sequela of germ cell malignancies. Characteristically, during or after chemotherapy slow-growing tumors will increase in size and may even com-press |
Surgery_Schwartz_12036 | Surgery_Schwartz | indicated.Growing teratoma syndrome is a rare sequela of germ cell malignancies. Characteristically, during or after chemotherapy slow-growing tumors will increase in size and may even com-press surrounding organs. Malignant transformation within these masses has been described. Treatment is with surgical resection.157Ovarian Sex Cord-Stromal Tumors. Sex cord-stromal cell tumors, rare tumors, are derived from cells that support and surround the oocyte and can present with symptoms referable to endocrine activity of the tumor. These include granulosa cell tumors (female differentiated), fibroma-thecomas, and Sertoli-Leydig cell tumors (male differentiated). Granulosa cell tumors are the most common in this group and are a low-grade malignancy with fewer than 3% bilaterality. They are treated with conservative surgery, similar to germ cell tumors in young women.155 Hysterectomy and bilateral salpingo-oophorectomy is recommended for women who have completed childbearing. Nodal staging | Surgery_Schwartz. indicated.Growing teratoma syndrome is a rare sequela of germ cell malignancies. Characteristically, during or after chemotherapy slow-growing tumors will increase in size and may even com-press surrounding organs. Malignant transformation within these masses has been described. Treatment is with surgical resection.157Ovarian Sex Cord-Stromal Tumors. Sex cord-stromal cell tumors, rare tumors, are derived from cells that support and surround the oocyte and can present with symptoms referable to endocrine activity of the tumor. These include granulosa cell tumors (female differentiated), fibroma-thecomas, and Sertoli-Leydig cell tumors (male differentiated). Granulosa cell tumors are the most common in this group and are a low-grade malignancy with fewer than 3% bilaterality. They are treated with conservative surgery, similar to germ cell tumors in young women.155 Hysterectomy and bilateral salpingo-oophorectomy is recommended for women who have completed childbearing. Nodal staging |
Surgery_Schwartz_12037 | Surgery_Schwartz | with conservative surgery, similar to germ cell tumors in young women.155 Hysterectomy and bilateral salpingo-oophorectomy is recommended for women who have completed childbearing. Nodal staging can be safely omitted in the absence of grossly involve nodes and fertility preservation is possible in disease limited to one ovary, the most common presentation. Debulking surgery is recommended for more extensive disease. These tumors and the thecomas in the same class often stimulate estrogen production and can be found in association with endometrial hyperplasia and cancer (5%). Granulosa cell tumors can recur over a prolonged period given their low rate of proliferation and tendency for local or intraperitoneal recurrence. Inhibin has been shown to be elaborated by these tumors and often is followed to identify recurrence of the disease. The Sertoli/Leydig cell tumors can present with virilization as a primary symptom. Evaluation of the ovary when this symptom is found is always of | Surgery_Schwartz. with conservative surgery, similar to germ cell tumors in young women.155 Hysterectomy and bilateral salpingo-oophorectomy is recommended for women who have completed childbearing. Nodal staging can be safely omitted in the absence of grossly involve nodes and fertility preservation is possible in disease limited to one ovary, the most common presentation. Debulking surgery is recommended for more extensive disease. These tumors and the thecomas in the same class often stimulate estrogen production and can be found in association with endometrial hyperplasia and cancer (5%). Granulosa cell tumors can recur over a prolonged period given their low rate of proliferation and tendency for local or intraperitoneal recurrence. Inhibin has been shown to be elaborated by these tumors and often is followed to identify recurrence of the disease. The Sertoli/Leydig cell tumors can present with virilization as a primary symptom. Evaluation of the ovary when this symptom is found is always of |
Surgery_Schwartz_12038 | Surgery_Schwartz | is followed to identify recurrence of the disease. The Sertoli/Leydig cell tumors can present with virilization as a primary symptom. Evaluation of the ovary when this symptom is found is always of value.Gestational Trophoblastic Disease. Gestational trophoblas-tic disease (GTD) is a spectrum of abnormal pregnancy–related trophoblastic proliferations. Premalignant histologic types include partial and complete hydatidiform moles. Primary sur-gery for diagnosis and initial therapy is a suction dilatation and curettage. Clinically, partial moles present as missed abortions and usually resolve with observation. Partial moles are triploid, usually XXY, which can result from dispermic fertilization of an egg. A previously described classical presentation of hyper-emesis gravidarum, hyperthyroidism, preeclampsia, pulmonary trophoblastic embolization, and uterine size larger than dates is rarely seen today because of routine ultrasound assessments during early pregnancy. Even in the first | Surgery_Schwartz. is followed to identify recurrence of the disease. The Sertoli/Leydig cell tumors can present with virilization as a primary symptom. Evaluation of the ovary when this symptom is found is always of value.Gestational Trophoblastic Disease. Gestational trophoblas-tic disease (GTD) is a spectrum of abnormal pregnancy–related trophoblastic proliferations. Premalignant histologic types include partial and complete hydatidiform moles. Primary sur-gery for diagnosis and initial therapy is a suction dilatation and curettage. Clinically, partial moles present as missed abortions and usually resolve with observation. Partial moles are triploid, usually XXY, which can result from dispermic fertilization of an egg. A previously described classical presentation of hyper-emesis gravidarum, hyperthyroidism, preeclampsia, pulmonary trophoblastic embolization, and uterine size larger than dates is rarely seen today because of routine ultrasound assessments during early pregnancy. Even in the first |
Surgery_Schwartz_12039 | Surgery_Schwartz | preeclampsia, pulmonary trophoblastic embolization, and uterine size larger than dates is rarely seen today because of routine ultrasound assessments during early pregnancy. Even in the first trimester, however, a characteristic “snow storm” appearance may be seen on ultra-sound. Pathologic examination will demonstrate no fetal tissue and have a diploid karyotype resulting from paternal duplication occurring after loss of maternal genetic material, or occasionally Brunicardi_Ch41_p1783-p1826.indd 181918/02/19 4:35 PM 1820SPECIFIC CONSIDERATIONSPART IIwith dispermic fertilization of an empty egg. Often associated theca lutein ovarian cysts, which can be greater than 6 cm in diameter, are seen on ultrasound. They should be followed without surgical intervention as they resolve with removal or treatment of the GTD. Following uterine evacuation, patients with molar pregnancies must be followed closely with weekly b-hCGs until normal for 3 weeks and then monthly for at least 6 months. | Surgery_Schwartz. preeclampsia, pulmonary trophoblastic embolization, and uterine size larger than dates is rarely seen today because of routine ultrasound assessments during early pregnancy. Even in the first trimester, however, a characteristic “snow storm” appearance may be seen on ultra-sound. Pathologic examination will demonstrate no fetal tissue and have a diploid karyotype resulting from paternal duplication occurring after loss of maternal genetic material, or occasionally Brunicardi_Ch41_p1783-p1826.indd 181918/02/19 4:35 PM 1820SPECIFIC CONSIDERATIONSPART IIwith dispermic fertilization of an empty egg. Often associated theca lutein ovarian cysts, which can be greater than 6 cm in diameter, are seen on ultrasound. They should be followed without surgical intervention as they resolve with removal or treatment of the GTD. Following uterine evacuation, patients with molar pregnancies must be followed closely with weekly b-hCGs until normal for 3 weeks and then monthly for at least 6 months. |
Surgery_Schwartz_12040 | Surgery_Schwartz | or treatment of the GTD. Following uterine evacuation, patients with molar pregnancies must be followed closely with weekly b-hCGs until normal for 3 weeks and then monthly for at least 6 months. Contraception should be provided to allow for sur-veillance. Any increase in b-hCG should trigger further evalua-tion and consideration of chemotherapy.158,159Invasive moles, choriocarcinoma, and placental site tro-phoblastic tumors are malignant disorders. Invasive moles are diagnosed following the diagnosis of a molar pregnancy if any of the following are demonstrated: (a) a plateau of b-hCG lasts for four measurements over a period of 3 weeks or longer; (b) a rise in b-hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; or (c) b-hCG level remains elevated for 6 months or more. Metastatic GTD can present on the cervix, vagina, liver, lung, or brain and should not be man-aged surgically. In a woman of reproductive age, a diagnosis of metastatic GTN can be | Surgery_Schwartz. or treatment of the GTD. Following uterine evacuation, patients with molar pregnancies must be followed closely with weekly b-hCGs until normal for 3 weeks and then monthly for at least 6 months. Contraception should be provided to allow for sur-veillance. Any increase in b-hCG should trigger further evalua-tion and consideration of chemotherapy.158,159Invasive moles, choriocarcinoma, and placental site tro-phoblastic tumors are malignant disorders. Invasive moles are diagnosed following the diagnosis of a molar pregnancy if any of the following are demonstrated: (a) a plateau of b-hCG lasts for four measurements over a period of 3 weeks or longer; (b) a rise in b-hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; or (c) b-hCG level remains elevated for 6 months or more. Metastatic GTD can present on the cervix, vagina, liver, lung, or brain and should not be man-aged surgically. In a woman of reproductive age, a diagnosis of metastatic GTN can be |
Surgery_Schwartz_12041 | Surgery_Schwartz | 6 months or more. Metastatic GTD can present on the cervix, vagina, liver, lung, or brain and should not be man-aged surgically. In a woman of reproductive age, a diagnosis of metastatic GTN can be made without biopsy if a b-hCG is found to be elevated in the setting of widespread metastatic disease. In fact, given the incidence of bleeding complications biopsy is not recommend.Chemotherapy is the primary recommended therapy. Per 2000 FIGO staging and classification, a risk score of 6 and below is classified as low risk and above 6 is considered high risk (Table 41-15). Low-risk patients are treated with single agent chemotherapy (methotrexate or actinomycin-D); high-risk patients receive multiagent chemotherapy. In either case, chemotherapy continues until b-hCG levels have normalized. Modern salvage and cure rates are high, with 5-year survival of high-risk patients reported as high as 90%.160 Twelve months of surveillance with contraception is recommended following treatment in | Surgery_Schwartz. 6 months or more. Metastatic GTD can present on the cervix, vagina, liver, lung, or brain and should not be man-aged surgically. In a woman of reproductive age, a diagnosis of metastatic GTN can be made without biopsy if a b-hCG is found to be elevated in the setting of widespread metastatic disease. In fact, given the incidence of bleeding complications biopsy is not recommend.Chemotherapy is the primary recommended therapy. Per 2000 FIGO staging and classification, a risk score of 6 and below is classified as low risk and above 6 is considered high risk (Table 41-15). Low-risk patients are treated with single agent chemotherapy (methotrexate or actinomycin-D); high-risk patients receive multiagent chemotherapy. In either case, chemotherapy continues until b-hCG levels have normalized. Modern salvage and cure rates are high, with 5-year survival of high-risk patients reported as high as 90%.160 Twelve months of surveillance with contraception is recommended following treatment in |
Surgery_Schwartz_12042 | Surgery_Schwartz | Modern salvage and cure rates are high, with 5-year survival of high-risk patients reported as high as 90%.160 Twelve months of surveillance with contraception is recommended following treatment in order to allow complete surveillance for relapse.Beyond dilation and curettage, surgery may have a role in the management of GTD. Hysterectomy is recommended for placental site trophoblastic tumors for which metastasis is rare. Laparotomy may be indicated in the cases of uncontrolled intra-abdominal or uterine bleeding. Neurosurgery may be required if there is intracranial bleeding or increased intracranial pressure due to metastatic disease.159MINIMALLY INVASIVE GYNECOLOGIC SURGERYHysteroscopySee earlier section, “Hysteroscopy” under “Procedures Per-formed for Structural Causes of Abnormal Uterine Bleeding.”LaparoscopyThe standard method for gynecologic laparoscopy follows the same methods as all minimally invasive surgery. In general, a camera port is placed near the umbilicus. Sometimes | Surgery_Schwartz. Modern salvage and cure rates are high, with 5-year survival of high-risk patients reported as high as 90%.160 Twelve months of surveillance with contraception is recommended following treatment in order to allow complete surveillance for relapse.Beyond dilation and curettage, surgery may have a role in the management of GTD. Hysterectomy is recommended for placental site trophoblastic tumors for which metastasis is rare. Laparotomy may be indicated in the cases of uncontrolled intra-abdominal or uterine bleeding. Neurosurgery may be required if there is intracranial bleeding or increased intracranial pressure due to metastatic disease.159MINIMALLY INVASIVE GYNECOLOGIC SURGERYHysteroscopySee earlier section, “Hysteroscopy” under “Procedures Per-formed for Structural Causes of Abnormal Uterine Bleeding.”LaparoscopyThe standard method for gynecologic laparoscopy follows the same methods as all minimally invasive surgery. In general, a camera port is placed near the umbilicus. Sometimes |
Surgery_Schwartz_12043 | Surgery_Schwartz | Bleeding.”LaparoscopyThe standard method for gynecologic laparoscopy follows the same methods as all minimally invasive surgery. In general, a camera port is placed near the umbilicus. Sometimes it must be placed more cephalad if the patient has a larger fibroid uterus. Two additional ports are placed laterally, usually just superior and medial to the anterior superior iliac spines. Single site lapa-roscopic procedures may improve cosmesis and reduce post-operative pain, but challenges including lack of triangulation and instrument crowding at the umbilicus make this technique challenging to apply to more complex procedures.161Robotic SurgeryOver the last decade, there has been increased use of robot-ics for gynecologic surgery. With the DaVinci robotic system, the surgeon sits at a console and visualizes the operative field with three-dimensional optics. The use of robotic surgery has been described for virtually every gynecologic procedure that has been performed abdominally or | Surgery_Schwartz. Bleeding.”LaparoscopyThe standard method for gynecologic laparoscopy follows the same methods as all minimally invasive surgery. In general, a camera port is placed near the umbilicus. Sometimes it must be placed more cephalad if the patient has a larger fibroid uterus. Two additional ports are placed laterally, usually just superior and medial to the anterior superior iliac spines. Single site lapa-roscopic procedures may improve cosmesis and reduce post-operative pain, but challenges including lack of triangulation and instrument crowding at the umbilicus make this technique challenging to apply to more complex procedures.161Robotic SurgeryOver the last decade, there has been increased use of robot-ics for gynecologic surgery. With the DaVinci robotic system, the surgeon sits at a console and visualizes the operative field with three-dimensional optics. The use of robotic surgery has been described for virtually every gynecologic procedure that has been performed abdominally or |
Surgery_Schwartz_12044 | Surgery_Schwartz | and visualizes the operative field with three-dimensional optics. The use of robotic surgery has been described for virtually every gynecologic procedure that has been performed abdominally or laparoscopically. The lapa-roscopic instruments are “wristed” and move as the surgeon’s hands/fingers move the actuators at the console. Robotic surgery Table 41-15International Federation of Gynecology and Obstetrics/World Health Organization scoring system for gestational trophoblastic disease based on prognostic factors SCORE 0124Age<40>40––Antecedent pregnancyMoleAbortionTermInterval from index pregnancy, months<44–67–12>12Pretreatment hCG mIU/mL<103>103–104>104–105>105Largest tumor size including uterus, cm–3–4≥5–Site of metastases including uterusLungSpleen, kidneyGastrointestinal tractBrain, liverNumber of metastases identified–1–45–8>8Previous failed chemotherapy––Single drugTwo or more drugsBrunicardi_Ch41_p1783-p1826.indd 182018/02/19 4:35 PM 1821GYNECOLOGYCHAPTER 41uses a camera | Surgery_Schwartz. and visualizes the operative field with three-dimensional optics. The use of robotic surgery has been described for virtually every gynecologic procedure that has been performed abdominally or laparoscopically. The lapa-roscopic instruments are “wristed” and move as the surgeon’s hands/fingers move the actuators at the console. Robotic surgery Table 41-15International Federation of Gynecology and Obstetrics/World Health Organization scoring system for gestational trophoblastic disease based on prognostic factors SCORE 0124Age<40>40––Antecedent pregnancyMoleAbortionTermInterval from index pregnancy, months<44–67–12>12Pretreatment hCG mIU/mL<103>103–104>104–105>105Largest tumor size including uterus, cm–3–4≥5–Site of metastases including uterusLungSpleen, kidneyGastrointestinal tractBrain, liverNumber of metastases identified–1–45–8>8Previous failed chemotherapy––Single drugTwo or more drugsBrunicardi_Ch41_p1783-p1826.indd 182018/02/19 4:35 PM 1821GYNECOLOGYCHAPTER 41uses a camera |
Surgery_Schwartz_12045 | Surgery_Schwartz | liverNumber of metastases identified–1–45–8>8Previous failed chemotherapy––Single drugTwo or more drugsBrunicardi_Ch41_p1783-p1826.indd 182018/02/19 4:35 PM 1821GYNECOLOGYCHAPTER 41uses a camera port, two to three robotic ports, and an accessory port. More meticulous dissection, improved visualization, and ability to operate with lower intra-abdominal pressures make the robotic platform advantageous, especially in obese patients. Longer set-up time and increased cost, however, are distinct disadvantages. The robotic unit costs up to $2.3 million and is associated with annual maintenance costs of $180,000 a year.162There is significant data to support robotic surgery in gynecologic malignancy; however, most procedures can be per-formed successfully with either robotic or laparoscopic platform depending on operator comfort and skill set. One large study sug-gested a lower conversion to laparotomy rate for robotic versus laparoscopic hysterectomy, but this was not statistically | Surgery_Schwartz. liverNumber of metastases identified–1–45–8>8Previous failed chemotherapy––Single drugTwo or more drugsBrunicardi_Ch41_p1783-p1826.indd 182018/02/19 4:35 PM 1821GYNECOLOGYCHAPTER 41uses a camera port, two to three robotic ports, and an accessory port. More meticulous dissection, improved visualization, and ability to operate with lower intra-abdominal pressures make the robotic platform advantageous, especially in obese patients. Longer set-up time and increased cost, however, are distinct disadvantages. The robotic unit costs up to $2.3 million and is associated with annual maintenance costs of $180,000 a year.162There is significant data to support robotic surgery in gynecologic malignancy; however, most procedures can be per-formed successfully with either robotic or laparoscopic platform depending on operator comfort and skill set. One large study sug-gested a lower conversion to laparotomy rate for robotic versus laparoscopic hysterectomy, but this was not statistically |
Surgery_Schwartz_12046 | Surgery_Schwartz | platform depending on operator comfort and skill set. One large study sug-gested a lower conversion to laparotomy rate for robotic versus laparoscopic hysterectomy, but this was not statistically signifi-cant: conversion to laparotomy for laparoscopic hysterectomy was 9.9% compared with 4.9% for robotic cases (P =.06).163Complications Pertinent to Gynecologic SurgeryAbdominal Wall Vessels. The vessel at greatest risk of injury during the lateral trocar placement is the inferior epigastric artery. The superficial epigastric vessels and the superficial circumflex iliac vessels can be injured as well (Fig. 41-23). The primary methods to avoid vessel injury are knowledge of the vessels at risk and their visualization prior to trocar placement, when possible. The superficial vessels often can be seen and avoided by transillumination of the abdominal wall with the laparoscope. In contrast, the larger inferior epigastric vessels cannot be seen by transillumination because of their deeper | Surgery_Schwartz. platform depending on operator comfort and skill set. One large study sug-gested a lower conversion to laparotomy rate for robotic versus laparoscopic hysterectomy, but this was not statistically signifi-cant: conversion to laparotomy for laparoscopic hysterectomy was 9.9% compared with 4.9% for robotic cases (P =.06).163Complications Pertinent to Gynecologic SurgeryAbdominal Wall Vessels. The vessel at greatest risk of injury during the lateral trocar placement is the inferior epigastric artery. The superficial epigastric vessels and the superficial circumflex iliac vessels can be injured as well (Fig. 41-23). The primary methods to avoid vessel injury are knowledge of the vessels at risk and their visualization prior to trocar placement, when possible. The superficial vessels often can be seen and avoided by transillumination of the abdominal wall with the laparoscope. In contrast, the larger inferior epigastric vessels cannot be seen by transillumination because of their deeper |
Surgery_Schwartz_12047 | Surgery_Schwartz | be seen and avoided by transillumination of the abdominal wall with the laparoscope. In contrast, the larger inferior epigastric vessels cannot be seen by transillumination because of their deeper location; these vessels often can be seen laparoscopically and avoided as they course along the peritoneum between the lateral umbilical fold of the bladder and the insertion of the round ligament into the inguinal canal. Anatomic variation and anastomoses between vessels make it impossible to know the exact location of all the abdominal wall vessels. For this reason, other strategies also should be used to avoid vessel injury, including the use of trocars with conical tips rather than pyramid tips and the use of the smallest trocars possible lateral to the midline.Intestinal Injury. Another potentially serious complication of laparoscopic surgery is injury to either small or large intestines. 10An estimated incidence of bowel injury during laparoscopic gynecologic surgery is estimated to be | Surgery_Schwartz. be seen and avoided by transillumination of the abdominal wall with the laparoscope. In contrast, the larger inferior epigastric vessels cannot be seen by transillumination because of their deeper location; these vessels often can be seen laparoscopically and avoided as they course along the peritoneum between the lateral umbilical fold of the bladder and the insertion of the round ligament into the inguinal canal. Anatomic variation and anastomoses between vessels make it impossible to know the exact location of all the abdominal wall vessels. For this reason, other strategies also should be used to avoid vessel injury, including the use of trocars with conical tips rather than pyramid tips and the use of the smallest trocars possible lateral to the midline.Intestinal Injury. Another potentially serious complication of laparoscopic surgery is injury to either small or large intestines. 10An estimated incidence of bowel injury during laparoscopic gynecologic surgery is estimated to be |
Surgery_Schwartz_12048 | Surgery_Schwartz | serious complication of laparoscopic surgery is injury to either small or large intestines. 10An estimated incidence of bowel injury during laparoscopic gynecologic surgery is estimated to be 0.13%, 41% of which had a delayed diagnosis.164 Bowel injury can occur at the time of trocar insertion, especially if the patient has had previous abdominal procedures that often result in bowel adhesions to the anterior abdominal wall peritoneum, but rates appear simi-lar regardless of entry technique. Due to the proximity of sur-gery to the bowel, thermal injury due to electrosurgery is also frequently implicated in intestinal injury. Time to diagnosis in these cases is typically several days postoperatively as a thermal injury takes time to mature and necrose.Urologic Injuries. A risk of injury to the urogenital tract is inherent to gynecologic surgery due to proximity. Prevention of injury and intraoperative recognition and repair are crucial to avoiding long-term sequelae. Most urogenital | Surgery_Schwartz. serious complication of laparoscopic surgery is injury to either small or large intestines. 10An estimated incidence of bowel injury during laparoscopic gynecologic surgery is estimated to be 0.13%, 41% of which had a delayed diagnosis.164 Bowel injury can occur at the time of trocar insertion, especially if the patient has had previous abdominal procedures that often result in bowel adhesions to the anterior abdominal wall peritoneum, but rates appear simi-lar regardless of entry technique. Due to the proximity of sur-gery to the bowel, thermal injury due to electrosurgery is also frequently implicated in intestinal injury. Time to diagnosis in these cases is typically several days postoperatively as a thermal injury takes time to mature and necrose.Urologic Injuries. A risk of injury to the urogenital tract is inherent to gynecologic surgery due to proximity. Prevention of injury and intraoperative recognition and repair are crucial to avoiding long-term sequelae. Most urogenital |
Surgery_Schwartz_12049 | Surgery_Schwartz | to the urogenital tract is inherent to gynecologic surgery due to proximity. Prevention of injury and intraoperative recognition and repair are crucial to avoiding long-term sequelae. Most urogenital fistulae are the result of unrecognized injuries to the urogenital tract at the time of surgery.Bladder Injury. Placement of a Foley catheter prior to gyne-cologic surgery is critical to reducing risk of bladder injuries. Bladder injury during open or laparoscopic surgery results from retroperitoneal perforation during lower trocar placement or during sharp dissection of the bladder from the lower uterine segment during hysterectomy. The latter of these two situa-tions is usually recognized intraoperatively; the first sign of the former may be postoperative hematuria, lower-port incisional drainage, or pneumoturia during laparoscopy. Once diagnosed, large defects require layered closure, whereas smaller defects usually close spontaneously within days or weeks with the aid of transurethral | Surgery_Schwartz. to the urogenital tract is inherent to gynecologic surgery due to proximity. Prevention of injury and intraoperative recognition and repair are crucial to avoiding long-term sequelae. Most urogenital fistulae are the result of unrecognized injuries to the urogenital tract at the time of surgery.Bladder Injury. Placement of a Foley catheter prior to gyne-cologic surgery is critical to reducing risk of bladder injuries. Bladder injury during open or laparoscopic surgery results from retroperitoneal perforation during lower trocar placement or during sharp dissection of the bladder from the lower uterine segment during hysterectomy. The latter of these two situa-tions is usually recognized intraoperatively; the first sign of the former may be postoperative hematuria, lower-port incisional drainage, or pneumoturia during laparoscopy. Once diagnosed, large defects require layered closure, whereas smaller defects usually close spontaneously within days or weeks with the aid of transurethral |
Surgery_Schwartz_12050 | Surgery_Schwartz | or pneumoturia during laparoscopy. Once diagnosed, large defects require layered closure, whereas smaller defects usually close spontaneously within days or weeks with the aid of transurethral catheter drainage.Ureteral Injury. Although ureteral injury is rare, occurring in less than 1% of gynecologic procedures, it is the most serious of the complications related to gynecologic surgery, particularly if unrecognized.165,166 There are three anatomic locations where the ureter is at risk during gynecologic procedures (see Fig. 41-5): (a) the ureter descends over the pelvic brim as it courses over the bifurcation of the common iliac artery into the external and internal iliac arteries just below the ovarian vessels; (b) in the pelvis, the ureter courses along the lateral aspect of the broad ligament to enter the base of the broad ligament; and (c) the ure-ter is found less than 2 cm lateral to the cervix, passing under the uterine artery and then medially over the anterior vaginal | Surgery_Schwartz. or pneumoturia during laparoscopy. Once diagnosed, large defects require layered closure, whereas smaller defects usually close spontaneously within days or weeks with the aid of transurethral catheter drainage.Ureteral Injury. Although ureteral injury is rare, occurring in less than 1% of gynecologic procedures, it is the most serious of the complications related to gynecologic surgery, particularly if unrecognized.165,166 There are three anatomic locations where the ureter is at risk during gynecologic procedures (see Fig. 41-5): (a) the ureter descends over the pelvic brim as it courses over the bifurcation of the common iliac artery into the external and internal iliac arteries just below the ovarian vessels; (b) in the pelvis, the ureter courses along the lateral aspect of the broad ligament to enter the base of the broad ligament; and (c) the ure-ter is found less than 2 cm lateral to the cervix, passing under the uterine artery and then medially over the anterior vaginal |
Surgery_Schwartz_12051 | Surgery_Schwartz | broad ligament to enter the base of the broad ligament; and (c) the ure-ter is found less than 2 cm lateral to the cervix, passing under the uterine artery and then medially over the anterior vaginal for-nix before entering the trigone of the bladder—this is the most common location of ureteral injury. Ureteral injuries, including complete ligation, partial resection, or thermal injuries, usually will manifest within hours to days of surgery. Complete obstruc-tion most often manifests as flank pain, whereas the first sign of partial or complete transection may be symptoms of intra-abdominal irritation caused by urine leakage. Transperitoneal thermal injuries resulting from fulguration of endometriosis may be similar to those after transection, but the appearance of symp-toms may be delayed several days until tissue necrosis occurs.Routine cystoscopy following hysterectomy is advocated by some gynecologists. For procedures performed for prolapse or incontinence where injury to the | Surgery_Schwartz. broad ligament to enter the base of the broad ligament; and (c) the ure-ter is found less than 2 cm lateral to the cervix, passing under the uterine artery and then medially over the anterior vaginal for-nix before entering the trigone of the bladder—this is the most common location of ureteral injury. Ureteral injuries, including complete ligation, partial resection, or thermal injuries, usually will manifest within hours to days of surgery. Complete obstruc-tion most often manifests as flank pain, whereas the first sign of partial or complete transection may be symptoms of intra-abdominal irritation caused by urine leakage. Transperitoneal thermal injuries resulting from fulguration of endometriosis may be similar to those after transection, but the appearance of symp-toms may be delayed several days until tissue necrosis occurs.Routine cystoscopy following hysterectomy is advocated by some gynecologists. For procedures performed for prolapse or incontinence where injury to the |
Surgery_Schwartz_12052 | Surgery_Schwartz | several days until tissue necrosis occurs.Routine cystoscopy following hysterectomy is advocated by some gynecologists. For procedures performed for prolapse or incontinence where injury to the urinary tract is highest, rou-tine cystoscopy is recommended. Consideration of a surgeon’s individual complication rate and the difficulty of an individ-ual procedure are considerations for the provision of routine cystoscopy.166Vaginal Vault Dehiscence. This complication of hysterec-tomy seems to be more common in laparoscopic and robotic DeepvesselsSuperficial vessels Inferiorepigastric DeepcircumflexiliacSuperficial epigastricSuperficialcircumflex iliacFigure 41-23. Location of anterior abdominal wall blood vessels.Brunicardi_Ch41_p1783-p1826.indd 182118/02/19 4:35 PM 1822SPECIFIC CONSIDERATIONSPART IIsurgeries. This may be due to the use of cautery in dividing the vaginal cuff or in the method of vaginal closure when done mini-mally invasively. Vaginal closure of the cuff | Surgery_Schwartz. several days until tissue necrosis occurs.Routine cystoscopy following hysterectomy is advocated by some gynecologists. For procedures performed for prolapse or incontinence where injury to the urinary tract is highest, rou-tine cystoscopy is recommended. Consideration of a surgeon’s individual complication rate and the difficulty of an individ-ual procedure are considerations for the provision of routine cystoscopy.166Vaginal Vault Dehiscence. This complication of hysterec-tomy seems to be more common in laparoscopic and robotic DeepvesselsSuperficial vessels Inferiorepigastric DeepcircumflexiliacSuperficial epigastricSuperficialcircumflex iliacFigure 41-23. Location of anterior abdominal wall blood vessels.Brunicardi_Ch41_p1783-p1826.indd 182118/02/19 4:35 PM 1822SPECIFIC CONSIDERATIONSPART IIsurgeries. This may be due to the use of cautery in dividing the vaginal cuff or in the method of vaginal closure when done mini-mally invasively. Vaginal closure of the cuff |
Surgery_Schwartz_12053 | Surgery_Schwartz | CONSIDERATIONSPART IIsurgeries. This may be due to the use of cautery in dividing the vaginal cuff or in the method of vaginal closure when done mini-mally invasively. Vaginal closure of the cuff appears to decrease the rate of vaginal cuff dehiscence in MIS hysterectomy.Hemodynamically stable women without bowel eviscera-tion may be candidates for transvaginal repair without abdomi-nal exploration. Vaginal approach may also be appropriate in select cases of evisceration in which the bowel can be com-pletely evaluated vaginally. Since bowel evisceration can lead to peritonitis and sepsis, all women with bowel eviscerations are considered to have a surgical emergency, and surgery should not be delayed for imaging. In most cases of bowel eviscera-tion, evaluation of the bowel by laparoscopy or laparotomy is indicated to ensure bowel integrity.REFERENCES 1. Anson B. Atlas of Human Anatomy. Philadelphia: WB Saunders, 1950. 2. Force USPST. Screening for gynecologic conditions with pel-vic | Surgery_Schwartz. CONSIDERATIONSPART IIsurgeries. This may be due to the use of cautery in dividing the vaginal cuff or in the method of vaginal closure when done mini-mally invasively. Vaginal closure of the cuff appears to decrease the rate of vaginal cuff dehiscence in MIS hysterectomy.Hemodynamically stable women without bowel eviscera-tion may be candidates for transvaginal repair without abdomi-nal exploration. Vaginal approach may also be appropriate in select cases of evisceration in which the bowel can be com-pletely evaluated vaginally. Since bowel evisceration can lead to peritonitis and sepsis, all women with bowel eviscerations are considered to have a surgical emergency, and surgery should not be delayed for imaging. In most cases of bowel eviscera-tion, evaluation of the bowel by laparoscopy or laparotomy is indicated to ensure bowel integrity.REFERENCES 1. Anson B. Atlas of Human Anatomy. Philadelphia: WB Saunders, 1950. 2. Force USPST. Screening for gynecologic conditions with pel-vic |
Surgery_Schwartz_12054 | Surgery_Schwartz | or laparotomy is indicated to ensure bowel integrity.REFERENCES 1. Anson B. Atlas of Human Anatomy. Philadelphia: WB Saunders, 1950. 2. Force USPST. Screening for gynecologic conditions with pel-vic examination: US Preventive Services Task Force recom-mendation statement. JAMA. 2017;317:947-953. 3. McNicholas C, Peipert JF. Is it time to abandon the routine pel-vic examination in asymptomatic nonpregnant women? JAMA. 2017;317:910-911. 4. Schiffman M, Wentzensen N, Wacholder S, Kinney W, Gage JC, Castle PE. Human papillomavirus testing in the prevention of cervical cancer. J Natl Cancer Inst. 2011;103:368-383. 5. US Preventive Services Task Force. Cervical cancer: screen-ing. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervi-cal-cancer-screening2. Accessed August 11, 2018. 6. US Preventive Services Task Force. Screening for Cervical CancerUS Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-686. | Surgery_Schwartz. or laparotomy is indicated to ensure bowel integrity.REFERENCES 1. Anson B. Atlas of Human Anatomy. Philadelphia: WB Saunders, 1950. 2. Force USPST. Screening for gynecologic conditions with pel-vic examination: US Preventive Services Task Force recom-mendation statement. JAMA. 2017;317:947-953. 3. McNicholas C, Peipert JF. Is it time to abandon the routine pel-vic examination in asymptomatic nonpregnant women? JAMA. 2017;317:910-911. 4. Schiffman M, Wentzensen N, Wacholder S, Kinney W, Gage JC, Castle PE. Human papillomavirus testing in the prevention of cervical cancer. J Natl Cancer Inst. 2011;103:368-383. 5. US Preventive Services Task Force. Cervical cancer: screen-ing. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervi-cal-cancer-screening2. Accessed August 11, 2018. 6. US Preventive Services Task Force. Screening for Cervical CancerUS Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-686. |
Surgery_Schwartz_12055 | Surgery_Schwartz | Accessed August 11, 2018. 6. US Preventive Services Task Force. Screening for Cervical CancerUS Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-686. 7. Petrosky E, Bocchini Jr JA, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vac-cination recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep. 2015;64:300-304. 8. Paavonen J, Naud P, Salmeron J, et al. Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by onco-genic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women. Lancet. 2009;374: 301-314. 9. Meites E. Use of a 2-dose schedule for human papillomavi-rus vaccination—updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408. 10. Gynecologists ACoOa. ACOG committee opinion: number 280, December 2002. The role of | Surgery_Schwartz. Accessed August 11, 2018. 6. US Preventive Services Task Force. Screening for Cervical CancerUS Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-686. 7. Petrosky E, Bocchini Jr JA, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vac-cination recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep. 2015;64:300-304. 8. Paavonen J, Naud P, Salmeron J, et al. Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by onco-genic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women. Lancet. 2009;374: 301-314. 9. Meites E. Use of a 2-dose schedule for human papillomavi-rus vaccination—updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408. 10. Gynecologists ACoOa. ACOG committee opinion: number 280, December 2002. The role of |
Surgery_Schwartz_12056 | Surgery_Schwartz | of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408. 10. Gynecologists ACoOa. ACOG committee opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol. 2002;100(6):1413-1416. 11. Mutch DG, Powell MA, Allsworth JE, Taylor NP, Brooks RA. How accurate is Pipelle sampling: a study by Huang et al. Am J Obstet Gynecol. 2007;196:280-281. 12. Margesson LJ. Vulvar disease pearls. Dermatol Clin. 2006;24:145-155. 13. McPherson T, Cooper S. Vulval lichen sclerosus and lichen planus. Dermatol Ther. 2010;23:523-532. 14. Downs MC, Randall HW, Jr. The ambulatory surgical manage-ment of Bartholin duct cysts. J Emerg Med. 1989;7:623-626. 15. Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Morb Mortal Wkly Rep. 2006;55:1-94. 16. Stanley M. Chapter 17: genital human papillomavirus infec-tions—current and prospective therapies. J | Surgery_Schwartz. of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408. 10. Gynecologists ACoOa. ACOG committee opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol. 2002;100(6):1413-1416. 11. Mutch DG, Powell MA, Allsworth JE, Taylor NP, Brooks RA. How accurate is Pipelle sampling: a study by Huang et al. Am J Obstet Gynecol. 2007;196:280-281. 12. Margesson LJ. Vulvar disease pearls. Dermatol Clin. 2006;24:145-155. 13. McPherson T, Cooper S. Vulval lichen sclerosus and lichen planus. Dermatol Ther. 2010;23:523-532. 14. Downs MC, Randall HW, Jr. The ambulatory surgical manage-ment of Bartholin duct cysts. J Emerg Med. 1989;7:623-626. 15. Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Morb Mortal Wkly Rep. 2006;55:1-94. 16. Stanley M. Chapter 17: genital human papillomavirus infec-tions—current and prospective therapies. J |
Surgery_Schwartz_12057 | Surgery_Schwartz | transmitted diseases treatment guidelines, 2006. MMWR Morb Mortal Wkly Rep. 2006;55:1-94. 16. Stanley M. Chapter 17: genital human papillomavirus infec-tions—current and prospective therapies. J Natl Cancer Inst Monogr. 2003;(31):117-124. 17. Habel LA, Van Den Eeden SK, Sherman KJ, McKnight B, Stergachis A, Daling JR. Risk factors for incident and recur-rent condylomata acuminata among women. A population-based study. Sex Transm Dis. 1998;25:285-292. 18. Massad LS, Xie X, Darragh T, et al. Genital warts and vulvar intraepithelial neoplasia: natural history and effects of treat-ment and human immunodeficiency virus infection. Obstet Gynecol. 2011;118:831-839. 19. Tan H-H, Goh C-L. Viral infections affecting the skin in organ transplant recipients. American J Clin Dermatol. 2006;7:13-29. 20. Brodell LA, Mercurio MG, Brodell RT. The diagnosis and treatment of human papillomavirus-mediated genital lesions. Cutis. 2007;79:5-10. 21. Fanning J, Lambert HC, Hale TM, Morris PC, Schuerch C. | Surgery_Schwartz. transmitted diseases treatment guidelines, 2006. MMWR Morb Mortal Wkly Rep. 2006;55:1-94. 16. Stanley M. Chapter 17: genital human papillomavirus infec-tions—current and prospective therapies. J Natl Cancer Inst Monogr. 2003;(31):117-124. 17. Habel LA, Van Den Eeden SK, Sherman KJ, McKnight B, Stergachis A, Daling JR. Risk factors for incident and recur-rent condylomata acuminata among women. A population-based study. Sex Transm Dis. 1998;25:285-292. 18. Massad LS, Xie X, Darragh T, et al. Genital warts and vulvar intraepithelial neoplasia: natural history and effects of treat-ment and human immunodeficiency virus infection. Obstet Gynecol. 2011;118:831-839. 19. Tan H-H, Goh C-L. Viral infections affecting the skin in organ transplant recipients. American J Clin Dermatol. 2006;7:13-29. 20. Brodell LA, Mercurio MG, Brodell RT. The diagnosis and treatment of human papillomavirus-mediated genital lesions. Cutis. 2007;79:5-10. 21. Fanning J, Lambert HC, Hale TM, Morris PC, Schuerch C. |
Surgery_Schwartz_12058 | Surgery_Schwartz | LA, Mercurio MG, Brodell RT. The diagnosis and treatment of human papillomavirus-mediated genital lesions. Cutis. 2007;79:5-10. 21. Fanning J, Lambert HC, Hale TM, Morris PC, Schuerch C. Paget’s disease of the vulva: prevalence of associated vulvar adenocarcinoma, invasive Paget’s disease, and recurrence after surgical excision. Am J Obstet Gynecol. 1999;180:24-27. 22. Darragh TM, Colgan TJ, Cox JT, et al. The lower anogenital squamous terminology standardization project for hpv-asso-ciated lesions: background and consensus recommendations from the college of American pathologists and the American society for colposcopy and cervical pathology. Arch Pathol Lab Med. 2012;136:1266-1297. 23. Modesitt SC, Waters AB, Walton L, Fowler WC Jr, Van Le L. Vulvar intraepithelial neoplasia III: occult cancer and the impact of margin status on recurrence. Obstet Gynecol. 1998;92:962-966. 24. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. | Surgery_Schwartz. LA, Mercurio MG, Brodell RT. The diagnosis and treatment of human papillomavirus-mediated genital lesions. Cutis. 2007;79:5-10. 21. Fanning J, Lambert HC, Hale TM, Morris PC, Schuerch C. Paget’s disease of the vulva: prevalence of associated vulvar adenocarcinoma, invasive Paget’s disease, and recurrence after surgical excision. Am J Obstet Gynecol. 1999;180:24-27. 22. Darragh TM, Colgan TJ, Cox JT, et al. The lower anogenital squamous terminology standardization project for hpv-asso-ciated lesions: background and consensus recommendations from the college of American pathologists and the American society for colposcopy and cervical pathology. Arch Pathol Lab Med. 2012;136:1266-1297. 23. Modesitt SC, Waters AB, Walton L, Fowler WC Jr, Van Le L. Vulvar intraepithelial neoplasia III: occult cancer and the impact of margin status on recurrence. Obstet Gynecol. 1998;92:962-966. 24. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. |
Surgery_Schwartz_12059 | Surgery_Schwartz | neoplasia III: occult cancer and the impact of margin status on recurrence. Obstet Gynecol. 1998;92:962-966. 24. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. 2004;291:1368-1379. 25. Eschenbach DA, Davick PR, Williams BL, et al. Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis. J Clin Microbiol. 1989;27:251-256. 26. Cardosi RJ, Bomalaski JJ, Hoffman MS. Diagnosis and man-agement of vulvar and vaginal intraepithelial neoplasia. Obstet Gynecol Clin North Am. 2001;28:685-702. 27. Stenchever M, Droegemueller W, Herbst A, Mishell D. Com-prehensive Gynecology. St Louis: Mosby; 2001. 28. The American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in non-pregnant reproductive-aged women. ACOG Committe Opin-ion. Reaffirmed 2017. Available at: | Surgery_Schwartz. neoplasia III: occult cancer and the impact of margin status on recurrence. Obstet Gynecol. 1998;92:962-966. 24. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. 2004;291:1368-1379. 25. Eschenbach DA, Davick PR, Williams BL, et al. Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis. J Clin Microbiol. 1989;27:251-256. 26. Cardosi RJ, Bomalaski JJ, Hoffman MS. Diagnosis and man-agement of vulvar and vaginal intraepithelial neoplasia. Obstet Gynecol Clin North Am. 2001;28:685-702. 27. Stenchever M, Droegemueller W, Herbst A, Mishell D. Com-prehensive Gynecology. St Louis: Mosby; 2001. 28. The American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in non-pregnant reproductive-aged women. ACOG Committe Opin-ion. Reaffirmed 2017. Available at: |
Surgery_Schwartz_12060 | Surgery_Schwartz | American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in non-pregnant reproductive-aged women. ACOG Committe Opin-ion. Reaffirmed 2017. Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Acute-Abnormal-Uterine-Bleeding-in-Nonpregnant-Reproductive-Aged-Women. Accessed August 11, 2018. 29. Van Bogaert LJ. Clinicopathologic findings in endometrial polyps. Obstet Gynecol. 1988;71:771-773. 30. Costa-Paiva L, Godoy CE, Jr, Antunes A, Jr, Caseiro JD, Arthuso M, Pinto-Neto AM. Risk of malignancy in endome-trial polyps in premenopausal and postmenopausal women according to clinicopathologic characteristics. Menopause. 2011;18:1278-1282. 31. Byun JY, Kim SE, Choi BG, Ko GY, Jung SE, Choi KH. Dif-fuse and focal adenomyosis: MR imaging findings. Radio-graphics. 1999;19:S161-S170. 32. Filicori M, Hall DA, Loughlin JS, Rivier J, Vale W, Crowley WF, Jr. A conservative | Surgery_Schwartz. American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in non-pregnant reproductive-aged women. ACOG Committe Opin-ion. Reaffirmed 2017. Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Acute-Abnormal-Uterine-Bleeding-in-Nonpregnant-Reproductive-Aged-Women. Accessed August 11, 2018. 29. Van Bogaert LJ. Clinicopathologic findings in endometrial polyps. Obstet Gynecol. 1988;71:771-773. 30. Costa-Paiva L, Godoy CE, Jr, Antunes A, Jr, Caseiro JD, Arthuso M, Pinto-Neto AM. Risk of malignancy in endome-trial polyps in premenopausal and postmenopausal women according to clinicopathologic characteristics. Menopause. 2011;18:1278-1282. 31. Byun JY, Kim SE, Choi BG, Ko GY, Jung SE, Choi KH. Dif-fuse and focal adenomyosis: MR imaging findings. Radio-graphics. 1999;19:S161-S170. 32. Filicori M, Hall DA, Loughlin JS, Rivier J, Vale W, Crowley WF, Jr. A conservative |
Surgery_Schwartz_12061 | Surgery_Schwartz | GY, Jung SE, Choi KH. Dif-fuse and focal adenomyosis: MR imaging findings. Radio-graphics. 1999;19:S161-S170. 32. Filicori M, Hall DA, Loughlin JS, Rivier J, Vale W, Crowley WF, Jr. A conservative approach to the management of uter-ine leiomyoma: pituitary desensitization by a luteinizing hormone-releasing hormone analogue. Am J Obstet Gynecol. 1983;147:726-727. 33. Matsuo H, Maruo T. GnRH analogues in the manage-ment of uterine leiomyoma (in Japanese). Nippon Rinsho. 2006;64(suppl 4):75-79.Brunicardi_Ch41_p1783-p1826.indd 182218/02/19 4:35 PM 1823GYNECOLOGYCHAPTER 41 34. Szabo E, Nagy E, Morvay Z, Palko A, Csernay L. Uterine artery embolization for the conservative management of leio-myoma (in Hungarian). Orv Hetil. 2001;142:675-680. 35. Mutter GL. Diagnosis of premalignant endometrial disease. J Clin Pathol. 2002;55:326-331. 36. Kurman RJ, Kaminski PF, Norris HJ. The behavior of endome-trial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients. Cancer. | Surgery_Schwartz. GY, Jung SE, Choi KH. Dif-fuse and focal adenomyosis: MR imaging findings. Radio-graphics. 1999;19:S161-S170. 32. Filicori M, Hall DA, Loughlin JS, Rivier J, Vale W, Crowley WF, Jr. A conservative approach to the management of uter-ine leiomyoma: pituitary desensitization by a luteinizing hormone-releasing hormone analogue. Am J Obstet Gynecol. 1983;147:726-727. 33. Matsuo H, Maruo T. GnRH analogues in the manage-ment of uterine leiomyoma (in Japanese). Nippon Rinsho. 2006;64(suppl 4):75-79.Brunicardi_Ch41_p1783-p1826.indd 182218/02/19 4:35 PM 1823GYNECOLOGYCHAPTER 41 34. Szabo E, Nagy E, Morvay Z, Palko A, Csernay L. Uterine artery embolization for the conservative management of leio-myoma (in Hungarian). Orv Hetil. 2001;142:675-680. 35. Mutter GL. Diagnosis of premalignant endometrial disease. J Clin Pathol. 2002;55:326-331. 36. Kurman RJ, Kaminski PF, Norris HJ. The behavior of endome-trial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients. Cancer. |
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Surgery_Schwartz_12063 | Surgery_Schwartz | more accurately than the 1994 World Health Organization classification system. Cancer. 2005;103:2304-2312. 40. Cooper JM, Brady RM. Intraoperative and early postoperative complications of operative hysteroscopy. Obstet Gynecol Clin North Am. 2000;27:347-366. 41. Worldwide AAMIG. AAGL practice report: practice guide-lines for the management of hysteroscopic distending media: (replaces hysteroscopic fluid monitoring guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-168.). J Minim Invasive Gynecol. 2013;20:137-148. 42. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 81, May 2007. Obstet Gynecol. 2007;109:1233-1248. 43. Longinotti MK, Jacobson GF, Hung Y-Y, Learman LA. Prob-ability of hysterectomy after endometrial ablation. Obstet Gynecol. 2008;112:1214-1220. 44. van Dongen H, Emanuel MH, Wolterbeek R, Trimbos JB, Jansen FW. Hysteroscopic morcellator for removal of intra-uterine polyps and myomas: a randomized controlled pilot study among | Surgery_Schwartz. more accurately than the 1994 World Health Organization classification system. Cancer. 2005;103:2304-2312. 40. Cooper JM, Brady RM. Intraoperative and early postoperative complications of operative hysteroscopy. Obstet Gynecol Clin North Am. 2000;27:347-366. 41. Worldwide AAMIG. AAGL practice report: practice guide-lines for the management of hysteroscopic distending media: (replaces hysteroscopic fluid monitoring guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-168.). J Minim Invasive Gynecol. 2013;20:137-148. 42. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 81, May 2007. Obstet Gynecol. 2007;109:1233-1248. 43. Longinotti MK, Jacobson GF, Hung Y-Y, Learman LA. Prob-ability of hysterectomy after endometrial ablation. Obstet Gynecol. 2008;112:1214-1220. 44. van Dongen H, Emanuel MH, Wolterbeek R, Trimbos JB, Jansen FW. Hysteroscopic morcellator for removal of intra-uterine polyps and myomas: a randomized controlled pilot study among |
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Surgery_Schwartz_12084 | Surgery_Schwartz | C, Kjær SK. Tubal ligation and salpingectomy and the risk of epithelial ovarian cancer and borderline ovarian tumors: a nationwide case– control study. Acta Obstetricia et Gynecologica Scandinavica. 2015;94:86-94. 141. Bijron JG, Seldenrijk CA, Zweemer RP, Lange JG, Verheijen RH, van Diest PJ. Fallopian tube intraluminal tumor spread from noninvasive precursor lesions: a novel meta-static route in early pelvic carcinogenesis. Am J Surg Pathol. 2013;37:1123-1130. 142. McAlpine JN, Hanley GE, Woo MM, et al. Opportunistic sal-pingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention. Am J Obstet Gynecol. 2014;210:e471. 143. Young RC, Walton LA, Ellenberg SS, et al. Adjuvant therapy in stage I and stage II epithelial ovarian cancer. N Engl J Med. 1990;322:1021-1027. 144. Bell J, Brady MF, Young RC, et al. Randomized phase III trial of three versus six cycles of adjuvant carboplatin and paclitaxel in early stage epithelial ovarian carcinoma: a | Surgery_Schwartz. C, Kjær SK. Tubal ligation and salpingectomy and the risk of epithelial ovarian cancer and borderline ovarian tumors: a nationwide case– control study. Acta Obstetricia et Gynecologica Scandinavica. 2015;94:86-94. 141. Bijron JG, Seldenrijk CA, Zweemer RP, Lange JG, Verheijen RH, van Diest PJ. Fallopian tube intraluminal tumor spread from noninvasive precursor lesions: a novel meta-static route in early pelvic carcinogenesis. Am J Surg Pathol. 2013;37:1123-1130. 142. McAlpine JN, Hanley GE, Woo MM, et al. Opportunistic sal-pingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention. Am J Obstet Gynecol. 2014;210:e471. 143. Young RC, Walton LA, Ellenberg SS, et al. Adjuvant therapy in stage I and stage II epithelial ovarian cancer. N Engl J Med. 1990;322:1021-1027. 144. Bell J, Brady MF, Young RC, et al. Randomized phase III trial of three versus six cycles of adjuvant carboplatin and paclitaxel in early stage epithelial ovarian carcinoma: a |
Surgery_Schwartz_12085 | Surgery_Schwartz | 1990;322:1021-1027. 144. Bell J, Brady MF, Young RC, et al. Randomized phase III trial of three versus six cycles of adjuvant carboplatin and paclitaxel in early stage epithelial ovarian carcinoma: a Gynecologic Oncology Group study. Gynecol Oncol. 2006;102:432-439. 145. Young RC, Decker DG, Wharton JT, et al. Staging laparotomy in early ovarian cancer. JAMA. 1983;250:3072-3076. 146. Chang SJ, Hodeib M, Chang J, Bristow RE. Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis. Gynecol Oncol. 2013;130:493-498. 147. Vergote I, Trope CG, Amant F, et al. Neoadjuvant chemo-therapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med. 2010;363:943-953. 148. Kehoe S, Hook J, Nankivell M, et al. Primary chemotherapy versus primary surgery for newly diagnosed advanced ovar-ian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet. 2015;386:249-257. 149. Gómez-Hidalgo NR, | Surgery_Schwartz. 1990;322:1021-1027. 144. Bell J, Brady MF, Young RC, et al. Randomized phase III trial of three versus six cycles of adjuvant carboplatin and paclitaxel in early stage epithelial ovarian carcinoma: a Gynecologic Oncology Group study. Gynecol Oncol. 2006;102:432-439. 145. Young RC, Decker DG, Wharton JT, et al. Staging laparotomy in early ovarian cancer. JAMA. 1983;250:3072-3076. 146. Chang SJ, Hodeib M, Chang J, Bristow RE. Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis. Gynecol Oncol. 2013;130:493-498. 147. Vergote I, Trope CG, Amant F, et al. Neoadjuvant chemo-therapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med. 2010;363:943-953. 148. Kehoe S, Hook J, Nankivell M, et al. Primary chemotherapy versus primary surgery for newly diagnosed advanced ovar-ian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet. 2015;386:249-257. 149. Gómez-Hidalgo NR, |
Surgery_Schwartz_12086 | Surgery_Schwartz | versus primary surgery for newly diagnosed advanced ovar-ian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet. 2015;386:249-257. 149. Gómez-Hidalgo NR, Martinez-Cannon BA, Nick AM, et al. Predictors of optimal cytoreduction in patients with newly diagnosed advanced-stage epithelial ovarian cancer: time to incorporate laparoscopic assessment into the standard of care. Gynecol Oncol. 2015;137:553-558. 150. McGuire WP, Hoskins WJ, Brady MF, et al. Cyclophospha-mide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer [see com-ments]. N Engl J Med. 1996;334:1-6. 151. Armstrong DK, Bundy BN, Wenzel L, et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. 2006;354:34-43. 152. Walker JL, Armstrong DK, Huang HQ, et al. Intraperitoneal catheter outcomes in a phase III trial of intravenous versus intraperitoneal chemotherapy in optimal stage III ovarian and primary peritoneal | Surgery_Schwartz. versus primary surgery for newly diagnosed advanced ovar-ian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet. 2015;386:249-257. 149. Gómez-Hidalgo NR, Martinez-Cannon BA, Nick AM, et al. Predictors of optimal cytoreduction in patients with newly diagnosed advanced-stage epithelial ovarian cancer: time to incorporate laparoscopic assessment into the standard of care. Gynecol Oncol. 2015;137:553-558. 150. McGuire WP, Hoskins WJ, Brady MF, et al. Cyclophospha-mide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer [see com-ments]. N Engl J Med. 1996;334:1-6. 151. Armstrong DK, Bundy BN, Wenzel L, et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. 2006;354:34-43. 152. Walker JL, Armstrong DK, Huang HQ, et al. Intraperitoneal catheter outcomes in a phase III trial of intravenous versus intraperitoneal chemotherapy in optimal stage III ovarian and primary peritoneal |
Surgery_Schwartz_12087 | Surgery_Schwartz | JL, Armstrong DK, Huang HQ, et al. Intraperitoneal catheter outcomes in a phase III trial of intravenous versus intraperitoneal chemotherapy in optimal stage III ovarian and primary peritoneal cancer: a Gynecologic Oncology Group Study. Gynecol Oncol. 2006;100:27-32. 153. Chi DS, Phaeton R, Miner TJ, et al. A prospective outcomes analysis of palliative procedures performed for malignant intestinal obstruction due to recurrent ovarian cancer. Oncolo-gist. 2009;14:835-839. 154. Markman M, Reichman B, Hakes T, Jones W. Responses to second-line cisplatin-based intraperitoneal therapy in ovarian cancer: influence of a prior response to intravenous cisplatin. J Clin Oncol. 1991;9:1801-1805. 155. Gershenson DM. Treatment of ovarian cancer in young women. Clin Obstet Gynecol. 2012;55:65-74. 156. Mangili G, Sigismondi C, Lorusso D, et al. The role of stag-ing and adjuvant chemotherapy in stage I malignant ovarian Brunicardi_Ch41_p1783-p1826.indd 182518/02/19 4:35 PM 1826SPECIFIC | Surgery_Schwartz. JL, Armstrong DK, Huang HQ, et al. Intraperitoneal catheter outcomes in a phase III trial of intravenous versus intraperitoneal chemotherapy in optimal stage III ovarian and primary peritoneal cancer: a Gynecologic Oncology Group Study. Gynecol Oncol. 2006;100:27-32. 153. Chi DS, Phaeton R, Miner TJ, et al. A prospective outcomes analysis of palliative procedures performed for malignant intestinal obstruction due to recurrent ovarian cancer. Oncolo-gist. 2009;14:835-839. 154. Markman M, Reichman B, Hakes T, Jones W. Responses to second-line cisplatin-based intraperitoneal therapy in ovarian cancer: influence of a prior response to intravenous cisplatin. J Clin Oncol. 1991;9:1801-1805. 155. Gershenson DM. Treatment of ovarian cancer in young women. Clin Obstet Gynecol. 2012;55:65-74. 156. Mangili G, Sigismondi C, Lorusso D, et al. The role of stag-ing and adjuvant chemotherapy in stage I malignant ovarian Brunicardi_Ch41_p1783-p1826.indd 182518/02/19 4:35 PM 1826SPECIFIC |
Surgery_Schwartz_12088 | Surgery_Schwartz | G, Sigismondi C, Lorusso D, et al. The role of stag-ing and adjuvant chemotherapy in stage I malignant ovarian Brunicardi_Ch41_p1783-p1826.indd 182518/02/19 4:35 PM 1826SPECIFIC CONSIDERATIONSPART IIgerm cell tumors (MOGTs): the MITO-9 study. Ann Oncol. 2017;28:333-338. 157. Merard R, Ganesan R, Hirschowitz L. Growing teratoma syn-drome: a report of 2 cases and review of the literature. Int J Gynecol Pathol. 2015;34:465-472. 158. Lurain JR. Gestational trophoblastic disease II: classification and management of gestational trophoblastic neoplasia. Am J Obstet Gynecol. 2011;204:11-18. 159. Ngan HYS, Seckl MJ, Berkowitz RS, et al. Update on the diagnosis and management of gestational trophoblastic dis-ease. Int J Gynecol Obstet. 2015;131:S123-S126. 160. Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet. 2010;376:717-729. 161. Sinha R, Sundaram M, Mahajan C, et al. Single-incision total laparoscopic hysterectomy. J Minim Access Surg. 2011;7:78-82. 162. Sinha | Surgery_Schwartz. G, Sigismondi C, Lorusso D, et al. The role of stag-ing and adjuvant chemotherapy in stage I malignant ovarian Brunicardi_Ch41_p1783-p1826.indd 182518/02/19 4:35 PM 1826SPECIFIC CONSIDERATIONSPART IIgerm cell tumors (MOGTs): the MITO-9 study. Ann Oncol. 2017;28:333-338. 157. Merard R, Ganesan R, Hirschowitz L. Growing teratoma syn-drome: a report of 2 cases and review of the literature. Int J Gynecol Pathol. 2015;34:465-472. 158. Lurain JR. Gestational trophoblastic disease II: classification and management of gestational trophoblastic neoplasia. Am J Obstet Gynecol. 2011;204:11-18. 159. Ngan HYS, Seckl MJ, Berkowitz RS, et al. Update on the diagnosis and management of gestational trophoblastic dis-ease. Int J Gynecol Obstet. 2015;131:S123-S126. 160. Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet. 2010;376:717-729. 161. Sinha R, Sundaram M, Mahajan C, et al. Single-incision total laparoscopic hysterectomy. J Minim Access Surg. 2011;7:78-82. 162. Sinha |
Surgery_Schwartz_12089 | Surgery_Schwartz | Gestational trophoblastic disease. Lancet. 2010;376:717-729. 161. Sinha R, Sundaram M, Mahajan C, et al. Single-incision total laparoscopic hysterectomy. J Minim Access Surg. 2011;7:78-82. 162. Sinha RY, Raje SR, Rao GA. Three-dimensional lapa-roscopy: principles and practice. J Minim Access Surg. 2017;13:165-169. 163. Gaia G, Holloway RW, Santoro L, Ahmad S, Di Silverio E, Spinillo A. Robotic-assisted hysterectomy for endome-trial cancer compared with traditional laparoscopic and laparotomy approaches: a systematic review. Obstet Gynecol. 2010;116:1422-1431. 164. Llarena NC, Shah AB, Milad MP. Bowel injury in gyneco-logic laparoscopy: a systematic review. Obstet Gynecol. 2015;125:1407-1417. 165. Sharp HT, Adelman MR. Prevention, recognition, and man-agement of urologic injuries during gynecologic surgery. Obstet Gynecol. 2016;127:1085-1096. 166. Teeluckdharry B, Gilmour D, Flowerdew G. Urinary tract injury at benign gynecologic surgery and the role of cystos-copy: a systematic review | Surgery_Schwartz. Gestational trophoblastic disease. Lancet. 2010;376:717-729. 161. Sinha R, Sundaram M, Mahajan C, et al. Single-incision total laparoscopic hysterectomy. J Minim Access Surg. 2011;7:78-82. 162. Sinha RY, Raje SR, Rao GA. Three-dimensional lapa-roscopy: principles and practice. J Minim Access Surg. 2017;13:165-169. 163. Gaia G, Holloway RW, Santoro L, Ahmad S, Di Silverio E, Spinillo A. Robotic-assisted hysterectomy for endome-trial cancer compared with traditional laparoscopic and laparotomy approaches: a systematic review. Obstet Gynecol. 2010;116:1422-1431. 164. Llarena NC, Shah AB, Milad MP. Bowel injury in gyneco-logic laparoscopy: a systematic review. Obstet Gynecol. 2015;125:1407-1417. 165. Sharp HT, Adelman MR. Prevention, recognition, and man-agement of urologic injuries during gynecologic surgery. Obstet Gynecol. 2016;127:1085-1096. 166. Teeluckdharry B, Gilmour D, Flowerdew G. Urinary tract injury at benign gynecologic surgery and the role of cystos-copy: a systematic review |
Surgery_Schwartz_12090 | Surgery_Schwartz | surgery. Obstet Gynecol. 2016;127:1085-1096. 166. Teeluckdharry B, Gilmour D, Flowerdew G. Urinary tract injury at benign gynecologic surgery and the role of cystos-copy: a systematic review and meta-analysis. Obstet Gynecol. 2015;126:1161-1169. 167. Centers for Disease Control and Prevention. Sexually Trans-mitted Diseases Treatment Guidelines: Pelvic Inflammatory Disease. Available: https://www.cdc.gov/std/tg2015/pid.htm. Accessed August 11, 2018. 168. Dearking AC, Aletti GD, McGree ME, Weaver AL, Som-merfield MK, Cliby WA. How relevant are ACOG and SGO guidelines for referral of adnexal mass? Obstet Gynecol. 2007;110:841-848. 169. Mutch DG, Prat J. 2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer. Gynecol Oncol. 2014;133:401-404.Brunicardi_Ch41_p1783-p1826.indd 182618/02/19 4:35 PM | Surgery_Schwartz. surgery. Obstet Gynecol. 2016;127:1085-1096. 166. Teeluckdharry B, Gilmour D, Flowerdew G. Urinary tract injury at benign gynecologic surgery and the role of cystos-copy: a systematic review and meta-analysis. Obstet Gynecol. 2015;126:1161-1169. 167. Centers for Disease Control and Prevention. Sexually Trans-mitted Diseases Treatment Guidelines: Pelvic Inflammatory Disease. Available: https://www.cdc.gov/std/tg2015/pid.htm. Accessed August 11, 2018. 168. Dearking AC, Aletti GD, McGree ME, Weaver AL, Som-merfield MK, Cliby WA. How relevant are ACOG and SGO guidelines for referral of adnexal mass? Obstet Gynecol. 2007;110:841-848. 169. Mutch DG, Prat J. 2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer. Gynecol Oncol. 2014;133:401-404.Brunicardi_Ch41_p1783-p1826.indd 182618/02/19 4:35 PM |
Surgery_Schwartz_12091 | Surgery_Schwartz | NeurosurgeryAshwin G. Ramayya, Saurabh Sinha, and M. Sean Grady 42chapterOverview 1827Neuroanatomy 1827Neurologic Examination 1829Diagnostic Studies / 1829Neurologic and Neurosurgical Emergencies 1831Raised Intracranial Pressure / 1831Brain Stem Compression / 1833Stroke / 1833Seizure / 1833Trauma 1833Head Trauma / 1833Spine Trauma / 1842Peripheral Nerve Trauma / 1847Cerebrovascular Disease 1849Ischemic Diseases / 1849Thrombotic Disease / 1849Embolic Disease / 1849Hemorrhagic Diseases / 1850Tumors of the Central Nervous System 1854Intracranial Tumors / 1854Metastatic Tumors / 1854Glial Tumors / 1855Neural Tumors and Mixed Tumors / 1857Neural Crest Tumors / 1857Miscellaneous Tumors / 1857Embryologic Tumors / 1858Spinal Tumors / 1859Future Directions / 1861Spine: Basic Concepts 1861Stability / 1861Neural Compression / 1862Patterns of Disease / 1862Spine Fusion Surgery / 1865Spinal Instrumentation / 1865Arthrodesis / 1866Peripheral Nerve 1866Peripheral Nerve Tumors / 1866Entrapment | Surgery_Schwartz. NeurosurgeryAshwin G. Ramayya, Saurabh Sinha, and M. Sean Grady 42chapterOverview 1827Neuroanatomy 1827Neurologic Examination 1829Diagnostic Studies / 1829Neurologic and Neurosurgical Emergencies 1831Raised Intracranial Pressure / 1831Brain Stem Compression / 1833Stroke / 1833Seizure / 1833Trauma 1833Head Trauma / 1833Spine Trauma / 1842Peripheral Nerve Trauma / 1847Cerebrovascular Disease 1849Ischemic Diseases / 1849Thrombotic Disease / 1849Embolic Disease / 1849Hemorrhagic Diseases / 1850Tumors of the Central Nervous System 1854Intracranial Tumors / 1854Metastatic Tumors / 1854Glial Tumors / 1855Neural Tumors and Mixed Tumors / 1857Neural Crest Tumors / 1857Miscellaneous Tumors / 1857Embryologic Tumors / 1858Spinal Tumors / 1859Future Directions / 1861Spine: Basic Concepts 1861Stability / 1861Neural Compression / 1862Patterns of Disease / 1862Spine Fusion Surgery / 1865Spinal Instrumentation / 1865Arthrodesis / 1866Peripheral Nerve 1866Peripheral Nerve Tumors / 1866Entrapment |
Surgery_Schwartz_12092 | Surgery_Schwartz | / 1861Neural Compression / 1862Patterns of Disease / 1862Spine Fusion Surgery / 1865Spinal Instrumentation / 1865Arthrodesis / 1866Peripheral Nerve 1866Peripheral Nerve Tumors / 1866Entrapment Neuropathies / 1867Autoimmune and Inflammatory Disorders / 1867Infection 1867Cranial / 1867Spine / 1868Functional Neurosurgery 1869Epilepsy Surgery / 1869Deep Brain Stimulation / 1869Trigeminal Neuralgia / 1871Stereotactic Radiosurgery 1871Arteriovenous Malformations / 1872Vestibular Schwannomas / 1872Intracranial Metastases / 1872Congenital and Developmental Anomalies 1872Dysraphism / 1872Spina Bifida Occulta / 1872Spina Bifida With Myelomeningocele / 1872Encephalocele / 1872Craniosynostosis / 1872Hydrocephalus / 1873Chiari I Malformation / 1873OVERVIEWNeurologic surgery provides the operative and nonoperative man-agement (i.e., prevention, diagnosis, evaluation, treatment, criti-cal care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems (ANSs). | Surgery_Schwartz. / 1861Neural Compression / 1862Patterns of Disease / 1862Spine Fusion Surgery / 1865Spinal Instrumentation / 1865Arthrodesis / 1866Peripheral Nerve 1866Peripheral Nerve Tumors / 1866Entrapment Neuropathies / 1867Autoimmune and Inflammatory Disorders / 1867Infection 1867Cranial / 1867Spine / 1868Functional Neurosurgery 1869Epilepsy Surgery / 1869Deep Brain Stimulation / 1869Trigeminal Neuralgia / 1871Stereotactic Radiosurgery 1871Arteriovenous Malformations / 1872Vestibular Schwannomas / 1872Intracranial Metastases / 1872Congenital and Developmental Anomalies 1872Dysraphism / 1872Spina Bifida Occulta / 1872Spina Bifida With Myelomeningocele / 1872Encephalocele / 1872Craniosynostosis / 1872Hydrocephalus / 1873Chiari I Malformation / 1873OVERVIEWNeurologic surgery provides the operative and nonoperative man-agement (i.e., prevention, diagnosis, evaluation, treatment, criti-cal care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems (ANSs). |
Surgery_Schwartz_12093 | Surgery_Schwartz | and nonoperative man-agement (i.e., prevention, diagnosis, evaluation, treatment, criti-cal care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems (ANSs). Such disorders include those of the brain, meninges, skull and skull base, and their blood supply, including surgical and endovascular treat-ment of disorders of the intracranial and extracranial vasculature supplying the brain and spinal cord; disorders of the pituitary gland; disorders of the spinal cord, meninges, and vertebral col-umn, including those that may require treatment by fusion, instru-mentation, or endovascular techniques; and disorders of the cranial and spinal nerves throughout their distribution.An accurate history is the first step toward neurologic diagnosis. A history of trauma or of neurologic symptoms is of obvious interest, but general constitutional symptoms are also important. Neurologic disease may have systemic effects, while diseases of other systems may affect | Surgery_Schwartz. and nonoperative man-agement (i.e., prevention, diagnosis, evaluation, treatment, criti-cal care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems (ANSs). Such disorders include those of the brain, meninges, skull and skull base, and their blood supply, including surgical and endovascular treat-ment of disorders of the intracranial and extracranial vasculature supplying the brain and spinal cord; disorders of the pituitary gland; disorders of the spinal cord, meninges, and vertebral col-umn, including those that may require treatment by fusion, instru-mentation, or endovascular techniques; and disorders of the cranial and spinal nerves throughout their distribution.An accurate history is the first step toward neurologic diagnosis. A history of trauma or of neurologic symptoms is of obvious interest, but general constitutional symptoms are also important. Neurologic disease may have systemic effects, while diseases of other systems may affect |
Surgery_Schwartz_12094 | Surgery_Schwartz | or of neurologic symptoms is of obvious interest, but general constitutional symptoms are also important. Neurologic disease may have systemic effects, while diseases of other systems may affect neurologic function. The patient’s general medical ability to withstand the physi-ologic stress of anesthesia and surgery should be understood. A detailed history from the patient and/or family, along with a reliable physical examination, will clarify these issues.NEUROANATOMYAn understanding of neuroanatomy is the foundation of com-prehensive neurologic examination and diagnosis. Salient fea-tures will be considered, from cephalad to caudad. The cerebral hemispheres (or telencephalon) consist of the cerebral cortex, underlying white matter, the basal ganglia, hippocampus, and amygdala. The cerebral cortex is the most recently evolved part of the nervous system. Its functions are mapped to discrete ana-tomic areas. The frontal areas are involved in executive function, decision making, and | Surgery_Schwartz. or of neurologic symptoms is of obvious interest, but general constitutional symptoms are also important. Neurologic disease may have systemic effects, while diseases of other systems may affect neurologic function. The patient’s general medical ability to withstand the physi-ologic stress of anesthesia and surgery should be understood. A detailed history from the patient and/or family, along with a reliable physical examination, will clarify these issues.NEUROANATOMYAn understanding of neuroanatomy is the foundation of com-prehensive neurologic examination and diagnosis. Salient fea-tures will be considered, from cephalad to caudad. The cerebral hemispheres (or telencephalon) consist of the cerebral cortex, underlying white matter, the basal ganglia, hippocampus, and amygdala. The cerebral cortex is the most recently evolved part of the nervous system. Its functions are mapped to discrete ana-tomic areas. The frontal areas are involved in executive function, decision making, and |
Surgery_Schwartz_12095 | Surgery_Schwartz | cortex is the most recently evolved part of the nervous system. Its functions are mapped to discrete ana-tomic areas. The frontal areas are involved in executive function, decision making, and restraint of emotions. The motor strip, or precentral gyrus, is the most posterior component of the frontal lobes, and is arranged along a homunculus with the head inferior and lateral to the lower extremities superiorly and medially. The motor speech area (Broca’s area) lies in the left posterior inferior frontal lobe in almost all right-handed people and in up to 90% of left-handed people. The parietal lobe lies between the central sulcus anteriorly and the occipital lobe posteriorly. The postcen-tral gyrus is the sensory strip, also arranged along a homunculus. The rest of the parietal lobe is involved with awareness of one’s body in space and relative to the immediate environment, body orientation, and spatial relationships. The occipital lobes are most posterior. The visual cortex is | Surgery_Schwartz. cortex is the most recently evolved part of the nervous system. Its functions are mapped to discrete ana-tomic areas. The frontal areas are involved in executive function, decision making, and restraint of emotions. The motor strip, or precentral gyrus, is the most posterior component of the frontal lobes, and is arranged along a homunculus with the head inferior and lateral to the lower extremities superiorly and medially. The motor speech area (Broca’s area) lies in the left posterior inferior frontal lobe in almost all right-handed people and in up to 90% of left-handed people. The parietal lobe lies between the central sulcus anteriorly and the occipital lobe posteriorly. The postcen-tral gyrus is the sensory strip, also arranged along a homunculus. The rest of the parietal lobe is involved with awareness of one’s body in space and relative to the immediate environment, body orientation, and spatial relationships. The occipital lobes are most posterior. The visual cortex is |
Surgery_Schwartz_12096 | Surgery_Schwartz | is involved with awareness of one’s body in space and relative to the immediate environment, body orientation, and spatial relationships. The occipital lobes are most posterior. The visual cortex is arrayed along the apposing 1Brunicardi_Ch42_p1827-p1878.indd 182701/03/19 7:16 PM 1828medial surfaces of the occipital lobes. The left occipital lobe receives and integrates data from the left half of each retina. A left occipital lesion would therefore result in an inability to see objects right of center. The temporal lobes lie below the Sylvian fissures. The hippocampus, amygdala, and lower optic radia-tions (Meyer’s loops) are important components of the temporal lobe and are involved in memory, emotion, and vision, respec-tively. The receptive speech area (Wernicke’s area) typically is found in the area of the left posterior superior temporal lobe and inferior parietal lobe. The basal ganglia include the caudate, putamen, globus pallidus, subthalamic nucleus, substantia nigra, and | Surgery_Schwartz. is involved with awareness of one’s body in space and relative to the immediate environment, body orientation, and spatial relationships. The occipital lobes are most posterior. The visual cortex is arrayed along the apposing 1Brunicardi_Ch42_p1827-p1878.indd 182701/03/19 7:16 PM 1828medial surfaces of the occipital lobes. The left occipital lobe receives and integrates data from the left half of each retina. A left occipital lesion would therefore result in an inability to see objects right of center. The temporal lobes lie below the Sylvian fissures. The hippocampus, amygdala, and lower optic radia-tions (Meyer’s loops) are important components of the temporal lobe and are involved in memory, emotion, and vision, respec-tively. The receptive speech area (Wernicke’s area) typically is found in the area of the left posterior superior temporal lobe and inferior parietal lobe. The basal ganglia include the caudate, putamen, globus pallidus, subthalamic nucleus, substantia nigra, and |
Surgery_Schwartz_12097 | Surgery_Schwartz | found in the area of the left posterior superior temporal lobe and inferior parietal lobe. The basal ganglia include the caudate, putamen, globus pallidus, subthalamic nucleus, substantia nigra, and nucleus accumbens. These structures are involved in the selection, activation and termination of movement, and facilitate learning of appropriate context-dependent motor behaviors.Lying deep to the cerebral hemispheres is the diencepha-lon, which includes the thalamus and hypothalamus. The thala-mus is a key processor and relay circuit for most motor and sensory information traveling to or from cortex. The hypothala-mus regulates homeostasis via the autonomic and neuroendo-crine systems.The brain stem consists of the midbrain (mesencephalon), pons (metencephalon), and medulla (myelencephalon). Longi-tudinal fibers run through the brain stem, carrying motor and sensory information between the cerebral hemispheres and spi-nal cord. The corticospinal tract is the major motor tract, while the | Surgery_Schwartz. found in the area of the left posterior superior temporal lobe and inferior parietal lobe. The basal ganglia include the caudate, putamen, globus pallidus, subthalamic nucleus, substantia nigra, and nucleus accumbens. These structures are involved in the selection, activation and termination of movement, and facilitate learning of appropriate context-dependent motor behaviors.Lying deep to the cerebral hemispheres is the diencepha-lon, which includes the thalamus and hypothalamus. The thala-mus is a key processor and relay circuit for most motor and sensory information traveling to or from cortex. The hypothala-mus regulates homeostasis via the autonomic and neuroendo-crine systems.The brain stem consists of the midbrain (mesencephalon), pons (metencephalon), and medulla (myelencephalon). Longi-tudinal fibers run through the brain stem, carrying motor and sensory information between the cerebral hemispheres and spi-nal cord. The corticospinal tract is the major motor tract, while the |
Surgery_Schwartz_12098 | Surgery_Schwartz | Longi-tudinal fibers run through the brain stem, carrying motor and sensory information between the cerebral hemispheres and spi-nal cord. The corticospinal tract is the major motor tract, while the medial lemniscus and spinothalamic tracts are the major sensory tracts. The nuclei of cranial nerves III through XII are also located within the brain stem. These nerves relay the motor, sensory, and special sense functions of the eye, face, mouth, and throat.The cerebellum arises from the dorsal aspect of the brain stem. It integrates somatosensory, vestibular, and motor infor-mation for coordination and timing of movement. Midline, or vermian, lesions lead to truncal ataxia. Lateral, or hemispheric, lesions lead to tremor and dyscoordination in the extremities.The ventricular system is the cerebrospinal fluid (CSF)–containing contiguous space inside the brain, continuous with the subarachnoid space outside the brain. The paired lateral ventricles consist of temporal, occipital, and | Surgery_Schwartz. Longi-tudinal fibers run through the brain stem, carrying motor and sensory information between the cerebral hemispheres and spi-nal cord. The corticospinal tract is the major motor tract, while the medial lemniscus and spinothalamic tracts are the major sensory tracts. The nuclei of cranial nerves III through XII are also located within the brain stem. These nerves relay the motor, sensory, and special sense functions of the eye, face, mouth, and throat.The cerebellum arises from the dorsal aspect of the brain stem. It integrates somatosensory, vestibular, and motor infor-mation for coordination and timing of movement. Midline, or vermian, lesions lead to truncal ataxia. Lateral, or hemispheric, lesions lead to tremor and dyscoordination in the extremities.The ventricular system is the cerebrospinal fluid (CSF)–containing contiguous space inside the brain, continuous with the subarachnoid space outside the brain. The paired lateral ventricles consist of temporal, occipital, and |
Surgery_Schwartz_12099 | Surgery_Schwartz | the cerebrospinal fluid (CSF)–containing contiguous space inside the brain, continuous with the subarachnoid space outside the brain. The paired lateral ventricles consist of temporal, occipital, and frontal horns, as well as the main body. CSF travels from each lateral ventricle through the foramina of Monroe to the third ventricle, located between the left and right thalami. CSF then drains through the cerebral aqueduct to the fourth ventricle within the brain stem. The foramen of Magendie (midline) and paired foram-ina of Luschka (lateral) drain to the subarachnoid space. The approximate CSF volume in an average adult is 150 mL, and the choroid plexus produces approximately 500 mL of CSF per day.The spinal cord starts at the bottom of the medulla and extends caudally through the spinal canal to the first lumbar ver-tebra, approximately. Motor tracts (efferent pathways) continue from the brain stem down via the lateral and anterior corticospi-nal tracts to anterior horn cells, and | Surgery_Schwartz. the cerebrospinal fluid (CSF)–containing contiguous space inside the brain, continuous with the subarachnoid space outside the brain. The paired lateral ventricles consist of temporal, occipital, and frontal horns, as well as the main body. CSF travels from each lateral ventricle through the foramina of Monroe to the third ventricle, located between the left and right thalami. CSF then drains through the cerebral aqueduct to the fourth ventricle within the brain stem. The foramen of Magendie (midline) and paired foram-ina of Luschka (lateral) drain to the subarachnoid space. The approximate CSF volume in an average adult is 150 mL, and the choroid plexus produces approximately 500 mL of CSF per day.The spinal cord starts at the bottom of the medulla and extends caudally through the spinal canal to the first lumbar ver-tebra, approximately. Motor tracts (efferent pathways) continue from the brain stem down via the lateral and anterior corticospi-nal tracts to anterior horn cells, and |
Surgery_Schwartz_12100 | Surgery_Schwartz | canal to the first lumbar ver-tebra, approximately. Motor tracts (efferent pathways) continue from the brain stem down via the lateral and anterior corticospi-nal tracts to anterior horn cells, and then exit via ventral nerve roots. Sensory information (afferent pathways) enters via dorsal nerve roots, travels cranially via the dorsal columns (proprio-ception and fine touch) or spinothalamic tract (pain and tem-perature), and into the brain stem. Paired nerves exit the spinal cord at each level. There are 31 pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.The dorsal and ventral nerve roots at each level fuse to form mixed motor-sensory spinal nerves and spread through the body to provide innervation to muscles and sensory organs. The C5–T1 spinal nerves intersect in the brachial plexus and divide to form the main nerve branches to the arm, including the median, ulnar, and radial nerves. The L2–S4 spinal nerves intersect in the lumbosacral plexus, and divide to | Surgery_Schwartz. canal to the first lumbar ver-tebra, approximately. Motor tracts (efferent pathways) continue from the brain stem down via the lateral and anterior corticospi-nal tracts to anterior horn cells, and then exit via ventral nerve roots. Sensory information (afferent pathways) enters via dorsal nerve roots, travels cranially via the dorsal columns (proprio-ception and fine touch) or spinothalamic tract (pain and tem-perature), and into the brain stem. Paired nerves exit the spinal cord at each level. There are 31 pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.The dorsal and ventral nerve roots at each level fuse to form mixed motor-sensory spinal nerves and spread through the body to provide innervation to muscles and sensory organs. The C5–T1 spinal nerves intersect in the brachial plexus and divide to form the main nerve branches to the arm, including the median, ulnar, and radial nerves. The L2–S4 spinal nerves intersect in the lumbosacral plexus, and divide to |
Surgery_Schwartz_12101 | Surgery_Schwartz | the brachial plexus and divide to form the main nerve branches to the arm, including the median, ulnar, and radial nerves. The L2–S4 spinal nerves intersect in the lumbosacral plexus, and divide to form the main nerve branches to the leg, including the femoral and sciatic nerves.The principal motor tract of the spinal cord is the cortico-spinal tract. It is a two-neuron path, including an upper motor neuron and a lower motor neuron. The upper motor neuron cell body is located within the motor strip of the cerebral cortex. The axon travels through the internal capsule to the brain stem, decussates at the brain stem–spinal cord junction, and travels down the contralateral corticospinal tract to the lower motor Key Points1 Neurologic surgery specializes in primarily surgical manage-ment of central, peripheral, and autonomic nervous system disorders.2 Although clinical examination is paramount, neurosurgical diagnosis and treatment are aided largely by a variety of modalities, such as | Surgery_Schwartz. the brachial plexus and divide to form the main nerve branches to the arm, including the median, ulnar, and radial nerves. The L2–S4 spinal nerves intersect in the lumbosacral plexus, and divide to form the main nerve branches to the leg, including the femoral and sciatic nerves.The principal motor tract of the spinal cord is the cortico-spinal tract. It is a two-neuron path, including an upper motor neuron and a lower motor neuron. The upper motor neuron cell body is located within the motor strip of the cerebral cortex. The axon travels through the internal capsule to the brain stem, decussates at the brain stem–spinal cord junction, and travels down the contralateral corticospinal tract to the lower motor Key Points1 Neurologic surgery specializes in primarily surgical manage-ment of central, peripheral, and autonomic nervous system disorders.2 Although clinical examination is paramount, neurosurgical diagnosis and treatment are aided largely by a variety of modalities, such as |
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