Ovarian cancer and intraoperative surgery

This patient was told that she had a uterine fibroid, but from the first consultation we suspected that this was false… And as #KnowledgeIsSuccess we will tell you how to identify ovarian cancer, as well as the ideal way in which the surgery should be performed with intraoperatively to prevent the cancer from spreading.

When it comes to cancer, the essential thing is to protect life and its quality; early detection is essential. If you suffer from any of the symptoms explained in this video, go to Dr. Cortés or schedule a video call to review your studies.

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Introduction and basic studies

How about good afternoon! We had already had a very comfortable talk with our psychologist here at Creafam about the psycho-emotional and post-surgical aspects of hysterectomies, today is a little in relation to hysterectomies but the most important thing is that I want to introduce you to Dr. Carlos Cortés García, he He is our doctor who is here with us working at Creafam, he is an oncological surgeon, he has already graduated for 14 years and so you know, what is an oncological surgeon? Well, they are doctors who are surgical, that is, they are surgeons but they are specifically dedicated to malignant tumors although they can operate on benign ones.

It is a case that they sent to me of a 70-year-old patient and they told her that she had had or had a fibroid and that is why they sent her but during the interrogation and examination the patient had had that tumor for more than two years. and she had seen an impressive increase in volume in her abdomen for a year now and she could hardly walk or breathe anymore. She is a woman with 7 children and she went through menopause 25 years ago. After 25 years she begins with this accelerated abdominal growth and with this discomfort when walking and breathing and pain, but they tell her that it is a uterine fibroid and that is why she needs surgery and that is why she came to me but my first suspicion was that during the interrogation She was already 25 years old without a menstruation.

We must remember that uterine tumors, which are biomes specifically or mainly, I have always mentioned the videos that have a hormonal influence, that is, they are present in the reproductive age from the moment a woman begins to have menstrual cycles until they end because then that uterus or that fibroid begins to lose size and it is not normal for them to grow, so that caught my attention but secondly, to do the examination, when the patient lies down, you can see the increase in abdominal volume and I do the vaginal ultrasound and Oh surprise! The uterus is free, then we show them the ultrasound, in the vaginal ultrasound I see nothing but the small uterus because she is already a 70-year-old woman and then I decide to do a bimanual physical examination and that is where I notice the large tumor, very annoying and that was when we requested the interconsultation with Dr. Cortés but also the MRI and tumor markers.

How do I suspect it? How can we suspect that there is an ovarian tumor? And there are basically two pieces of information and they are precisely what the patient had: She had abdominal pain and felt that something grew, she felt a ball in her abdomen, so this is the most common way an ovarian tumor can present. These are suspicious data in a woman of this age already due to menopause who has a tumor that depends on one of the two ovaries and is solid, of course it is not normal and it is most likely a malignant tumor, so in addition to the review, exploration physics, the imaging studies that we routinely ask for when we suspect, laboratories that we call tumor markers.

The group of laboratories requested depends on the age of the patient. What do I mean? If it is a woman over 35 years of age or older, we generally ask for a single laboratory, we call it CA-125. This can guide us to identify a malignant ovarian tumor. At the end we are going to discuss what the main malignant ovarian tumors are. And if you are under 35 years of age, in addition to that laboratory, we ask for three other laboratories, also tumor markers called: Beta fraction human chorionic gonadotropin, Alpha fetoprotein and we call the last one DHL or lactic dehydrogenase. With this group of four laboratories we can support the suspicion or rule out that suspicion of a malignant tumor and depending on the result we definitively decide to do a diagnostic surgery which is the only way to confirm whether it is a benign tumor or a malignant tumor.

Ovarian cancer surgery with intraoperative studies

Once we decide that the patient has a suspicion of a malignant tumor or ovarian cancer, we have to go to surgery and in surgery the first point is: We explore all the sites of the abdomen to identify if the tumor we find is affecting others. organs and then very important: We identify the ovary that has a tumor and we have to remove it and give it to a pathologist so that after 30 minutes he can analyze it and confirm if it is a malignant tumor, if it is a cancer or if it is a tumor benign.

If they confirm that it is cancer, what we have to do next is in the case of the patient, approximately 70 years old, we have to do a hysterectomy; remove the uterus, the other ovary, take a sample of the lymph nodes in the pelvis and also other tissues that are near the intestine. Once this part of the surgery is finished, what we have to wait for is the definitive report from the pathologist to make decisions regarding what treatment to continue, that is, in ovarian malignancies, 8 out of every 10 patients will need chemotherapy treatments to be able to control that cancer. I remember that after the incision, what you did is before exploring the organs, you inserted something like a glass syringe, a “septum” we call it, and you washed with water, well with physiological solution, the peritoneum and the liquid that was crying or emanating from that tumor, you collected it in that septum and also sent it for analysis and this can also favor or deteriorate a post-surgical prognosis, especially in the survival of this patient.

That’s right, in fact, what we do immediately after making the wound is to do a peritoneal lavage with a saline solution in an amount of practically 100 milliliters and we recover that fluid so that it can be analyzed by the pathologist also when we find fluid, which we call ascites. , in the abdomen we extract it and it is also fixed in alcohol and sent to be analyzed by the pathologist. What good is this for us? Well, the surgery that we are discussing so far, which is initially diagnostic, can become a treatment or therapeutic surgery in the same event, that is, we must identify how widespread that tumor or ovarian cancer is, perform a staging and The peritoneal fluid that we obtain is part of the typing, with this we will know how advanced it is, what prognosis it will have and what treatments we need to add so that we ensure or try to ensure a cure for the patient.

The tumor we found, which was approximately 30 centimeters, fortunately had not broken the ovary envelope, had not broken the capsule and this was confirmed by the pathologist. The analysis of the tissues we send; the pelvic lymph nodes, the fluid that was sent for study, the peritoneal fluid also came out negative for malignant cells, the lymph nodes negative, the omentum also came out without tumors, without implants so that we confirmed that although the tumor was large we could say that in ovarian cancer the size does not matter, it matters more how much destruction the tumor has caused. There are very small tumors of 3 to 5 centimeters that have ruptured the capsule, have invaded the uterus, the intestine and well it also depends a lot on the aggressiveness of the ovarian cancer itself.

What would happen if I, as a gynecologist, said, Oh, if you have an ovarian tumor, I’m going to operate on you, remove your ovary and remove your uterus, and the matter is resolved? But the reality of things is that it is not like that, that is, I just remove the ovary and the uterus and with that the patient can go away peacefully. That’s what I want to make clear to people and for you to explain to them: Why is it important to do all these steps? The peritonial lavage, check if there is metastasis or not and in the same transoperative decide on the omentectomy that is to say remove part of the omentum, go to inguinal lymph nodes to also recover if there is metastasis because it is more important to take the 3 or 4 hours that a process lasts. like these, to close that patient with only the tumor and the uterus and then have to reoperate on her when you already have a definitive diagnosis.

I think the most important thing about the surgery we are talking about is that in the prior evaluation the doctor, the gynecologist who is reviewing, suspects that it could be cancer, because if he does not suspect it then yes, the only thing they are going to do is remove it. the ovary or the tumor and they are not going to ask for the surgical procedure, they are not going to suspect it or they are not going to decide to solve the problem in the same operation, then important, if there are studies that make me suspect cancer, it is best that the evaluation Before surgery, it should be done in conjunction with an oncologist, right? The oncologist who is a friend of the gynecologist.

Maybe it sounds a little difficult to people, but survival or 5-year survival? From a surgery that you already know is cancer and you only remove the tumor and you have to do a second surgery because you did not have a diagnosis or you did not previously address those questions or those studies in the transoperative period, to do it correctly with a peritonial lavage, with a hysterectomy, with an omentectomy and lymph node collection. .. What is the 5-year survival of one patient versus the other who did not go to a surgical oncologist and decided to have surgery and resolve it halfway?

It is important that it be done in the first surgery. Surgery that is diagnostic becomes staging and therapeutic surgery simultaneously because of the following: In Mexico, and Latin America, unfortunately, 60% or 70% of these tumors, of this ovarian cancer, are identified in an advanced stage, if we also occupy a Second surgery to resolve what was not done at the beginning can even reduce the 5-year survival of these patients by up to half.

That is very important and it is good that you mention it because it is not the same as 100 surgeries, 60 being disease-free in 5 years, because if you did not do all the staging, then the patient, out of 100 patients only 30 will have the opportunity of “disease-free” in 5 years.

It is an epithelial ovarian cancer, we suspected that it could be advanced but with the pathology report we can conclude that it is a stage 1 ovarian cancer, that means that with pure surgery only the patient’s situation has been resolved for now and only You will have to recover from the surgery and begin a series of surveillance consultations. Ok, I mean I understand so that people know, if you have as if it were the lemon that is the ovary and the shell is the capsule – and it is already broken – Even if it is a 4 cm tumor. It could be that that capsule, that little shell, has ruptured, releasing cells, that is called metastasis, that is, like they plant that little tumor in the intestine or in the uterus or even in the liver or wherever, right?

Exactly we call these seedings ovarian cancer implants on the organs of the abdomen or pelvis and in that we would talk about a more advanced cancer. During the operation, and at the beginning I told you that we approach the wound very large so that we can carefully mobilize the ovarian tumor, trying not to break the capsule and extract it as it is, that is, as intact as possible because in ovarian cancer, once the capsule ruptures, we are talking about a stage that will automatically require other treatments and we would already be changing the patient’s prognosis, so it is not a question of what will happen to the ovary by opening something, if It won’t happen if we handle it aggressively and don’t take care not to break it.

In order not to scare the public because that’s not what it’s about… Of 10 tumors, 9 are going to be benign, depending on the age of the woman, because if she is 70 years old and 25 years old and did not have a menstruation, then this patient is 10, 9 They are going to be cancer, that is to say, it is reversed a little, that is why the importance is always there when I mention to people “Knowledge is power.” Because first we have to document ourselves, if they already told me that, who are the specialists? Who can guide me best? and above all, who can board? Because? Because I always insist on benign tumors that it is not necessary, for example, to remove the entire ovary. Why? Because if it is a teratoma or if it is an endometriotic cyst, you remove the entire capsule, even if it ruptures, as Dr. Cortés mentioned just now, it will not spread. You simply wash it, clean it, and you can leave up to half of it. ovary or more than the ovary but it is completely different in a cancer because the cancer, even if it is a stage 0 or 1, as Dr. Cortés mentions in this patient whose capsule was not broken, we have to remove it there if all of us, that is, we have to remove the entire ovary and the entire internal genital organ which are the fallopian tubes and which is the other ovary against the side and also the uterus but there we already had a diagnosis, it was not a definitive diagnosis because definitive is when they give you the result of pathology, but we already had the diagnosis at least clinical, medical and presumptive and that is why the approach was different and the incision had to open a lot because aesthetics is no longer so important because here what we need is to do a surgery that is as neat as possible, that this tumor does not rupture, make all the trans-operative diagnoses right there as Dr. Cortés said, solve it surgically and not have to do a second intervention, see the difference in this 70-year-old patient than if she had had surgery in another On the other hand, they would have removed the ovarian tumor and the uterus without performing an omentectomy, washing the fluid and lymph nodes and they would have been positive… Her survival would be different and she would have needed chemotherapy. In this case, chemotherapy will not even be necessary for this patient.

Types of cancer or age classifications

We divide into women under 20 years of age, which includes even adolescent girls and young adults and those over 20 years of age, and in that group of over 20 years of age, if we divide those who have not yet reached menopause and those who are postmenopausal, then in the first group of those under 20 years of age the main tumors are benign fortunately like cysts, mainly ovarian cysts, but they are benign, the most important thing is that around 20% are malignant and these are called ovarian terminal tumors, which have a great possibility of treatment both with surgery and chemotherapy. After the age of 20, terminal tumors are also common, but epithelial tumors, epithelial ovarian cancer, begin to increase in frequency, and in postmenopausal women they are definitely epithelial ovarian tumors, which are the most common. These are basically two types of ovarian cancer, those of young women, germ cell tumors, those of women over 20 years of age, so as not to get into the details of this, they are older than others, they are epithelial ovarian cancer. Its treatment in principle is the same, diagnosis is made with surgery, treatment with surgery but the chemotherapy for the two types will be completely different.

I would like to assume that ovarian cancer obviously has a higher mortality rate than breast cancer, although breast cancer is more common, that is, if we see it in volume, it is true that there are more patients who die year after year from breast cancer. but because there is more breast cancer, but if you have 100 women with breast cancer and 100 with ovarian cancer, there are more 100 ovarian cancer patients dying because it is a more aggressive tumor. What background? What can make a woman’s risk higher? Call it age, or call it overweight, or call it direct family history or something else where that hereditary type has a greater predisposition to ovarian cancer.

Specifically for ovarian cancer that shares risk factors with other cancers such as breast cancer, endometrial cancer: Being diabetic, being hypertensive and being overweight… And we hear it in these more than 2 years of pandemic in which patients, people who have this combination of three factors have a greater risk of suffering from serious illnesses and suffering from ovarian cancer, as this is no exception, and if the patient has a family member with some type of gynecological cancer such as ovarian cancer , breast cancer or even if you have male relatives who have or had prostate cancer for example, they are candidates for a separate evaluation, before they have discomfort.

What do I mean before you have discomfort? For oncologists, ovarian cancer has been the bogeyman of cancers because it sometimes grows so slowly that it does not cause any discomfort and when it does cause discomfort, it turns out that the patient has had abdominal pain for months or years that identifies data such as colitis or gastritis and They keep giving her treatments for months and it turns out that it is ovarian cancer, so… I would recommend not only to the patient but to our general medical colleagues and other specialties and even gynecologist friends that when a patient has many weeks of abdominal pain and has already stopped menstruating, that she is postmenopausal, so let’s immediately review that patient and perform an endovaginal ultrasound, which is the ideal study to try to detect the conditions of the ovaries, before doing any other blood test, tumor markers, is to suspect an endovaginal ultrasound in a patient with abdominal pain otherwise classified as gastritis or colitis.

Historically we have been taught or women have been taught that if you have pain in the lower abdomen it is all due to the ovary, the uterus and the tubes and it can also be due to the intestine but specifically in this case and it is very important… Can a menopausal woman have ovarian pain? Well, in theory there should no longer be any discomfort because the ovary is no longer working, so both the ovary and the uterus, let’s say, are losing size and becoming deflated, so to speak, to such a degree that if a woman, that is the key that also Carlos was saying just now, if a menopausal woman, after three years of not having menstruation, starts with annoying abdominal pain, distension, inflammation, sometimes even when eating she feels a little reflux or wants to return her stomach and begins to notice an abnormal growth. and more constant pain, the first thing is a vaginal ultrasound, I have always said that. Now I have another question that came to mind right now:

Has ovarian cancer in relation to, for example, breast or cervical cancer increased in the last 10 years to date? Does the pace of life of the current population have much to do with it? Or has it remained stable at the figures of per 1

,000 patients so much percentage of ovarian cancer?

If it has increased and they also share this situation of risk factors with respect to lifestyle, that is, for example, the moment in which they decide to get pregnant, they increasingly become pregnant at an older age… At an older age, I would not want say an advanced age because criticism is going to rain down on us, right? At an advanced age, we are not going to go into those details but having few children or few pregnancies is a risk factor – Smoking – There I am going to tell you right now a detail with smoking, it is associated with many types of cancer but Smoking in gynecological cancer, in ovarian cancer it is not so clear that it is a risk factor, even in endometrial cancer it seems that those who smoke have a lower chance of getting cancer, but it is not the only factor. So all the other factors that we had mentioned and we added having few or no pregnancies or waiting to have one after the age of 30 are risk factors for ovarian cancer.


So remember to finish at Creafam there is Dr. Carlos Cortés, whatever you have regarding women: Colposcopy to identify cervical lesions Dr. Cortés, thyroid tumors, breast tumors, ovarian tumors mainly, we always help each other a lot and that’s why I wanted to do this talk because fortunately we had the advantage of operating on this 70-year-old patient together, but I do benign ovarian tumors because there are many and there are many benign ovarian tumors that we have already given some talks about, but malignant tumors Almost no one wants to talk about ovarian cancer, but it is very important that patients between the ages of 20 and 60, 70 know that there are people specialized in this and the main thing is that they do not have surgery if they do not have a doctor who is not sure about it. What is going to be done beforehand, intraoperatively and postoperatively because the most important thing is survival or years free of a tumor depends a lot on the surgeon.

So Dr. Any last things or comments you want on this? Especially ovarian cancer.

If you have any abdominal discomfort, abdominal pain, do not waste time waiting for it to be resolved with a simple analgesic, it is better to go to a check-up with your gynecologist and, if possible, perform an endovaginal ultrasound and in some cases a pelvic ultrasound, but not Let more than four weeks pass, more than a month with pain that does not resolve with common treatment, it is better to go to a consultation.

What she has, this patient has a pending review to ensure that she has recovered from the surgery, remove the stitches, evaluate the final report that we already mentioned but evaluate it together with her and her family and the following surveillance consultations will be every 3 to 3 years. 4 months during the next 2 years but at least for 5 years he should be under surveillance.

Here the most important thing is specifically in ovarian cancer tumors, the specialist is Dr. Carlos Cortés, he is fortunately with us at Creafam and you can call him for a consultation, it is not about seeing if it is bad or bad or what they told him. It is about giving you a different vision or an opinion from a specialist about what Dr. Cortés would do because it is the same thing that I do with my fibroid patients, I do not tell them what they should have done or what they should do to them. I tell them: “I would do this” and then from there the patient makes the decision whether to stay with us or not, but I assure them and I can recommend Dr. Cortés as one of the best options in oncological surgery, especially in the area gynecological and obviously, what better than being in Creafam?

Thyroid cancer

We want to talk to you about thyroid cancer, it is less common, certainly less common than cervical cancer and breast cancer. Even though it is less common, some types of thyroid cancer can be associated with other problems, other tumors. These are the 4 main types, the first two are the most common, 8 out of 10 cases of thyroid cancer are called papillary or follicular. The important thing about these two types is that with surgery more than 80% of cases can be cured, fortunately. These last two types of thyroid cancer, called anaplastic and medullary thyroid cancer, are very aggressive and can be associated with other types of tumors that manifest some time after the initial treatment.

Due to the location of the thyroid, we can give some signs, such as noticing some growth, some bulge in the neck can be associated with changes in the voice, some recent change such as a hoarse voice, a voice that begins to be a little more dull, in itself alterations in our our voice, independent of what happens when we get sick with our throat, for example. There may also be some difficulty passing food, difficulty swallowing is what it is called and there is another piece of information that we did not write down here but it is the sensation that something is in the way of my neck, that is, the sensation that I have something strange that It makes me uncomfortable, because it can make it difficult for me to pass saliva and food, and sometimes if this increases a lot, the pain can be seen.

It is important then, given these signs, to do two exams, one is the physical exam, a physical examination of the neck that can be performed on all our patients during a general examination and an ultrasound of the neck, this ultrasound of the neck will give us very good details. about how our thyroid is, if there is any alteration, if there is a nodule or tumor that is causing us these discomforts. We have been talking about two things that are different: Prevention and detection. How can we prevent some types of cancer? We have commented: A healthy life, healthy eating, exercising and something different is detection.

“If you suffer from pain that, even with analgesics, is still present after 4 weeks, the recommendation would be to go to your gynecologist and perform a vaginal or abdominal ultrasound, before any other study”

Dr. Carlos A. Cortés
Dr. Carlos A. Cortés
Oncologist Surgeon

Subspecialty in Oncological Surgery.
Oncology Hospital National Medical Center “Siglo XXI”

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