Case Conference Juni 7th 2017

07-Jun-2017, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

Mrs. Y

Cervical Carcinoma stg III B with Uterine Myoma

Case Description

Patient was referred because of bleeding since three months ago. Patient complained the bleeding was fresh blood, without pain. Patient has been menopause for 3 years. Then, patient went to RS Hermina Kemayoran. Patient was having curettage and biopsied of the cervix. Based on pathology anatomic examination from curettage shown suspect squamous cell carcinoma DD/Adenocarcinoma. Then, the patient still waiting for the biopsy result.

Physical examination on May 17^th, 2017

General Status

CM. BP: 122/81 mmHg, HR: 97 bpm, RR 20x/m, T: 36,5^oC, Height 152 cm, weight 61 kgs.

Head: Pale conjunctiva (-/-), icteric sclera (-/-)

Thorax: mammae lump (-/-) mass (-/-),  symmetry shape and movement of hemithorax

Lung: vesicular breath sound on both lungs, no wheezing or rhales

Cardia: S1-S2 normal, no murmur, no gallop

Abd:  palpable mass size 15x10x12 cm, normal intestinal sound (click and gurgles)

Extremity: no oedema, CRT <2 seconds, warm extremity

 

Gyn state: 

Inspection: v/u within normal limit, no bleeding

Inspeculo: there are mass endophytic size 5x4,5x3cm, fragile

RVT: portio endophytic, easily to bleed, stiff of both parametrium, smooth mucosa ani, TSA within normal limit.

 

Anoscopy examination Results, May 30^th, 2017

Mucosa within normal limit, there is no mass or infiltration.

 

Chest X-ray result, May 23^rd, 2017

Cardiomegaly with aortic elongation

Fibrotic in the right paracardial

Suspect Bilateral Pleural Effusion

USG Result, May 19^th, 2017

Description :

Anteflexion uterine, enlarged, swelled. In posterior corpus, there is hypoechoic mass with fixed border, diameter 86 mm, origins from intramural myoma uterine. In cavum uterine, there is blood clot and solid mass, irregular border and shape size 51x32 mm, origins from cavum uteri malignancy mass. Invasion mass spread until distal vagina with size 27x22x14 mm.

Stratum basalis endometrium hard to examined. Endocervix and portio within normal limit. There are lymph node enlargement in parailiaca bilateral, size 11 and 11 mm (right) and 8 mm (left).

Conclusion:

Malignancy mass in cavum uterine

Invasion mass in distal vagina

Metatases mass in bilateral parailiaca lymph node

Intramural uterine myom

 

Histopathology Results, May 09^th, 2017

Macroscopic:

White brownish tattered specimen. All mounted

Microscopic:

Tissue originated from vagina consist of scrapping tissue layered by squamous epithelial.

In subepithelial, there are solid and infltrative tumor mass islands, glandular structure. Tumor cell consists of oval nucleus, pleiomorphic, vesicular with clear nucleoli, hyperchromatic, eosinophilic cytoplasm, mitotic were found. On Fibrotic stroma, there are infiltration of chronic inflammatory cells.

Conclusion:

Poor differentiatied Adenocarcinoma

 

Problem to be discussed

Is external beam boost combined with EBRT better than EBRT alone for patients with locally advanced cervical cancer with difficulties/contraindications to brachytherapy?

Introduction

That concurrent chemoradiation therapy (CCRT) followed by intracavity radiation is effective in the treatment of advanced cervical cancer. Although external beam radiotherapy combined with brachytherapy is associated with high survival rates and low complication rates, patients with contraindications to brachytherapy, namely patients with unusual anatomic configurations of the pelvis or tumors, may benefit from higher doses of external beam irradiation.

Uterine myomas are the most common neoplasms of the female pelvis, occurring in 20 - 25% of women of reproductive age and the common symptoms were menorrhagia or metrorrhagia, or both. It is the existence and level of bother of uterine fibroid symptoms that lead women to seek treatment, with the current standard of care being abdominal hysterectomy.

 

Discussion

The treatment for locally advanced cervical cancer (Stage IB2–IVA) is external beam radiotherapy to the pelvis, followed by intracavitary radiation. The intracavitary radiotherapy dose was give as a booster to the cervix, uterus, and parametrium. However, there are a variety of situations in which intracavitary radiation cannot be carried out. For example, technical limitations lead to difficulty cannulating the cervical ostium due to a significant degree of residual disease in the endocervical canal. Other technical difficulties arise from instability of the applicators due to cervical destruction, leaving a large hole, after a good response to external beam radiotherapy. In our case, it is a large myoma (size 15x10x12 cm) in the uterus.

A study of Barraclough et. al. in 2008, has included forty-four patients with cervical cancer with technical difficulties for intracavitary radiotherapy. The study was conducted to assess the outcome of patients treated with radical radiotherapy for cervical cancer who received an external beam boost, in place of intracavitary brachytherapy (ICT), after irradiation to the whole pelvis. Clinical International Federation of Gynecology and Obstetrics or radiologic stage for Stages I, II, III, and IV, respectively, was 16%, 48%, 27%, and 7%. A total radiation dose of 54–70 Gy was given (75% received ≥60 Gy). Reasons for ICT not being performed were technical limitations in 73%, comorbidity or isolation limitations in 23%, and patient choice in 4%. The median follow-up was 2.3 years. Recurrent disease was seen in 48%, with a median time to recurrence of 2.3 years. Central recurrence was seen in 16 of the 21 patients with recurrent disease. The 5-year overall survival rate was 49.3%. The 3-year cancer-specific survival rate by stage was 100%, 70%, and 42% for Stages I, II, and III, respectively. Late Grades 1 and 2 bowel, bladder, and vaginal toxicity were seen in 41%. Late Grade 3 toxicity was seen in 2%. An external beam boost is a reasonable option after external beam radiotherapy to the pelvis when it is not possible to perform ICT.

Another strategy has been reported for patients with locally advanced cervical cancer with difficulties for brachytherapy was the using of CyberKnife stereotactic body radiotherapy (SBRT). Six consecutive patients with anatomic or medical conditions precluding a tandem and ovoid boost were treated with combined external beam radiation and CyberKnife boost to the cervix. Five patients received 45 Gy to the pelvis with serial intensity-modulated radiation therapy boost to the uterus and cervix to a dose of 61.2 Gy. These five patients received an SBRT boost to the cervix to a dose of 20 Gy in five fractions of 4 Gy each. One patient was treated to the pelvis to a dose of 45 Gy with an external beam boost to the uterus and cervix to a dose of 50.4 Gy. This patient received an SBRT boost to the cervix to a dose of 19.5 Gy in three fractions of 6.5 Gy. Five percent volumes of the bladder and rectum were kept to ≤75 Gy in all patients. All of the patients remain locally controlled with no evidence of disease following treatment. Grade 1 diarrhea occurred in 4/6 patients during the conventional external beam radiation. There has been no grade 3 or 4 rectal or bladder toxicity. There were no toxicities observed following SBRT boost. At a median follow-up of 14 months, CyberKnife radiosurgical boost is well tolerated and efficacious in providing a boost to patients with cervix cancer who are unable to undergo brachytherapy boost. Further follow-up is required to see if these results remain durable.

A case report of A 46-year-old woman presented with an 8-month history of abnormal vaginal bleeding. Biopsy revealed squamous cell carcinoma of the cervix. Magnetic resonance imaging (MRI) showed a cervical tumor with direct invasion of the right parametrium, bilateral hydronephrosis, and multiple uterine myomas. International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical cancer was diagnosed. Concurrent chemoradiation therapy (CCRT) followed by SBRT delivered via HT was administered instead of brachytherapy because of the presence of multiple uterine myomas with bleeding tendency. Total abdominal hysterectomy was performed after 6 weeks of treatment because of the presence of multiple uterine myomas. Neither pelvic MRI nor results of histopathologic examination at X-month follow-up showed evidence of tumor recurrence. Only grade 1 nausea and vomiting during treatment were noted. Lower gastrointestinal bleeding was noted at 14-month follow-up. No fistula formation and no evidence of haematological, gastrointestinal or genitourinary toxicities were noted on the most recent follow-up.

 

Conclusion

In this patient, the best choice of treatment is perform myomectomy before radiation.

 

 

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