CASE PRESENTATION

1. CASE PRESENTATION Dr. S. Bhattacharjee Radiation Oncologist HCG Bangalore.

2. CARCINOMA CERVIX STAGE II B POST RT + CT WITH LOCAL RECURRENCE CASE 1 • CLINICAL HISTORY: Patient was diagnosed with carcinoma cervix stage II B with pelvic lymphnode in Nov 2008. Patient was treated with radical radiotherapy with EBRT technique with a dose of 46 Gy / 23 # and single fraction of brachytherapy along with concurrent chemotherapy with weekly Cisplatin. Patient was on regular follow up and found to have loco regional recurrence in Aug 2009 in the cervix. Was referred here for further management.

8. PET CT scan on 03.09.09 revealed mild prominent cervix, metabolically active node measuring 9 mm in the posterior lip of cervix, consistent with recurrence. All treatment options were discussed with the patient and was planned for cyberknife treatment. • TREATMENT GIVEN: Patient was planned and treated with PET CT based Cyberknife treatment with a dose of 30 Gy / 5 # / 5 days to the recurrent lesion in the cervix from 29.09.09 to 03.10.09. Patient tolerated the therapy well.

9. Mrs. Sadhana Chaudhary/ 40 yrs CASE 2 Patient presented in Jun`07 with complaints of pain in lower abdomen and bleeding P/V, was evaluated by a Gyaenacologist at Thane, and diagnosed as Ca Cervix and was referred to Dr. Satish Kamath who evaluated further and diagnosed as locally advanced Ca Cervix. Was treated with 2 cycles of Neo adjuvant chemotherapy with 5 Fluro - Uracil + Cisplatin followed by Wertheims hysterectomy on 03.08.07,

10. HPR revealed Squamous cell carcinoma, Grade II / III , Perineural extension +, Bilateral iliac lymphnodes involved. • Patient received adjuvant CT + RT with EBRT – 50 Gy / 25 # followed by HDR Brachytherapy, 6 Gy / 3 # along with weekly Cisplatin in Nov`07. • Patient was asymptomatic for 1 year and in Nov `08 presented with pain in the left Inguinal region, Ultrasound revealed Lymphnode recurrence in pelvis..

11. Patient did not receive any treatment till Jun`09, re-evaluation revealed pelvic recurrence with left lower limb oedema, left hydronephrosis with left iliac mass. Patient was referred here for second opinion and further management • PET CT at HCG BIO revealed pelvic recurrence with no distant metastasis. It was decided to consider the patient for Cyberknife treatment. • Bowel and bladder habits are regular. Appetite normal. • Not a known case of DM / TB / CAD / HTN. • No loss of weight.

12. Ultrasound: Color Doppler Evaluation of Veins of Left Lower Extremity done on 18.06.09 at Gune Medical Centre, Ambernath revealed  • No evidence of deep vein thrombosis. (Superficial thrombosis noted involving long saphenous vein) • Ultrasound : Abdomen and Pelvis done on 18.06.09 at Gune Medical Centre, Ambernath revealed  • Tumor recurrence likely in L.I.F and moderate left Hydronephrosis.

13. CT Scan of Abdomen and Pelvis ( Oral+IV Contrast) done on 19.06.09 at Om Shree Siddhi Scanning & Diagnostic Centre, Thane revealed Post op status is seen. Soft tissue is seen along the left lateral pelvic side wall as described with extension to the left lateral wall of the bladder. This is seen to encase the left ureter with resultant left sided hydronephrosis as well as hydroureter. This is S/O recurrent local metastatic disease.

14. Whole Body PET CT Scan done on 26.06.09 at HCG, Bangalore revealed  Status post hysterectomy. • No obvious vaginal vault recurrence. • 5.5 x 5.0 x 3.7 cm predominantly necrotic metabolically active left iliac metastatic Lymphnode infiltrating left obturator internus muscle and adherent to the bladder wall. • 1.5 x 0.8 cm metabolically active right common iliac metastatic. • No pulmonary hepatic, adrenal or osseous metastases. • Atrophic left kidney with moderate hydroureteronephrosis. Recommend correlation with renogram. • Diffuse subcutaneous edema in the proximal thigh, likely due to left iliac vein obstruction and possibly lymphatic obstruction.

15. ONEXAMINATION: • Well built and nourished • Vitals Stable • No pallor/ icterus / clubbing / cyanosis / edema • CVS- S1 S2 heard, RS – NVBS, PA- soft, bowel sounds +. • INVESTIGATIONS: • Biochemistry and Haematology - WNL , reports attached to file. • TREATMENT : Patient was planned and treated with PET CT based CyberKnife to the involved area (pelvic Lymphnode region) with a dose of 25 Gy / 5 # from 14.07.09 to 19.07.09. Patient tolerated the therapy well.

16. CASE 3 Mariyamma 60 Yrs

17. CLINICAL HISTORY: Patient is a known case of carcinoma cervix diagnosed and treated in Kidwai by EBRT with a dose of 5000 Gy/ 25# from 30.09.09 to 10.11.09 followed by ICBT. Patient was treated with 4 cycles of chemotherapy with CDDP from 30.09.09 to 27.10.09. Now patient presented with complaints of bleeding P/V and foul smelling pus discharge from the vagina associated with fever. • Patient was treated with 3rd week of Chemotherapy with Inj. Docetaxel Inj. Cal. Leucovorin and Inj. 5 FU from 20.04.10 to 04.05.10. • MRI Abdomen and Pelvis on 10.04.10 revealed Lobulated lesion in the cervix with parametrial infiltration on either side (Left > right), no extension to bony side walls, no infiltration of urinary bladder or rectum, endocervical canal stenosis with pyometra, mildly enlarged bilateral iliac lymphnodes, no metastatic lesions in the abdominal viscera.

18. Whole body PET CT scan on 17.04.10 revealed large necrotic metabolically active mass in the uterine cervix extending to lower posterior wall of the body of uterus and the vaginal vault, bilateral pelvic fat stranding, likely representing post radiation changes versus neoplastic extension, multiple enlarged metabolically active pelvic, bilateral iliac – inguinal and lower retroperitoneal lymphnodes – metastatic, multiple enlarged / enhancing neck, mediastinal and bilateral axillary lymphnodes. While these may represent inflammatory / infectious etiology, possibility of metastatic lymphadenopathy cannot be entirely excluded, slightly prominent tonsil and nasopharynx - ? inflammatory / infectious etiology, ?? neoplastic, small ill defined area of subtle lysis involving the posterior end of left 11th rib - ? Metastatic.

19. No Comorbidities. • ONEXAMINATION: Moderately build and nourished. • Vitals – stable • No pallor /icterus/edema/clubbing/cyanosis. • CVS- S1 S2 heard, RS – NVBS, PA- soft, bowel sounds +. • P/S examination: Grade III uterine prolapse , Ulcerated cervical mass 4x5 cm extending into bilateral parametrium involving upper 1/3rd of vagina. • PR – Rectal mucosa normal • TREATMENT GIVEN: Patient was planned and treated with MRI & PET CT Based CyberKnife Robotic Radiosurgery with a dose of 3000 cGy / 5 # / 5 days to the cervix from 06.05.10 to 10.05.10. Patient tolerated the treatment well.

20. Following received chemotherapy

21. CASE 4 Mrs. Sumitra Devi. R / 86 yrs

22. Patient initially presented with complaints of bleeding per vagina in Dec 2009. Patient was investigated and diagnosed as carcinoma cervix stage II B and started on radiation. History of weight loss present. History of Allergy to penicillin. • Ultrasound of chest on 23.01.10 revealed Left lower lobe pneumonitis. • Ultrasound of abdomen and pelvis on 25.01.10 revealed dilated endometrial cavity and left adnexal cystic as lesion. • Cervix mass biopsy on 29.01.10 at Manipal Hospitalrevealed poorly differentiated non-keratinizing squamous carcinoma.

23. Wholebody PET CT Scan on 10.02.10 revealed 5.9 x 4.6 x 3.6 cm metabolically active cervical mass infiltrating the lower uterine corpus. Cervical mass is abutting the bladder base and anterior wall of rectum without obvious infiltration. No parametrial infiltration of abdomino –pelvic lymphadenopathy, 7.8 x 8.2 x 4.9 cm left paracardiac heterogenous density mass with peripheral nodular enhancement and central fluid density. Consider possibility of pleuro-pericardial cyst with possible chronic inflammatory changes-metabolically active, 3 mm subpleural nodule in the posterior segment of upper lobe, 5.4 x 4.8 x 3.9 cm simple left ovarian cyst-Metabolically inactive. • Comorbidities:Not a Known diabetic. Known case of hypertensive since 2 years.

24. ONEXAMINATION: Moderately built and nourished. • Vitals – stable • No pallor /icterus/edema/clubbing/cyanosis. • CVS- S1 S2 heard, RS – NVBS, PA- soft, bowel sounds +. • TREATMENT GIVEN: Patient was planned and treating with External Beam Radiotherapy using IMRT technique with a dose of 5040 cGy / 28 # from 16.02.10 to 25.03.10. Patient tolerated the treatment well.

25. CASE 5 Mrs. Pramila Devi S [ 57 Yrs ]

26. CARCINOMA ENDOMETRIUM POST CHEMOTHERAPY, POST OP, WITH VAULT RECURRENCE CLINICAL HISTORY: Patient was diagnosed with Adenocarcinoma Endometrium Grade I with pulmonary nodular metastasis in Dec 2005. Patient was treated with 6 cycles of chemotherapy with Paclitaxel + Carboplatin, last cycle was in Apr 2006. Patient underwent surgery – TAH and lymphnode sampling in June 2007. In Jan 2008, patient presented with growth in the vulva adjacent to lamina minor, underwent Biopsy which revealed Adenocarcinoma. Patient was treated with radiotherapy with EBRT technique with a dose of 50 Gy / 25 # to the pelvic region from 01.02.08 to 07.03.08 followed by brachytherapy with a dose of 12 Gy / 2 # on 19.03.08 and 26.03.08.

27. Patient was on follow up and found to have recurrence in the vaginal vault region in Feb 2009, was treated with chemotherapy for the same with Gemcitabine + Cisplatin. PET CT scan on 21.10.09 revealed mass in the retrovesical pouch measuring 8.3 x 6.5 cm and bilateral lung metastasis, mediastinal lymphnodes, pelvic lymphnodes and aortocaval lymphnode. Now admitted here for further management. GENERAL PHYSICAL EXAMINATION: • Moderately built and nourished • Vitals – stable. • No pallor/icterus/cyanosis/clubbing/pedal oedema. • CVS – S1, S2 heard, RS- NVBS,

28. Patient was planned and treated with PET CT based Cyberknife treatment with a dose of 35 Gy / 5 # over 5 days to the lesions (vagina & pelvic lymph nodes) in the pelvic region from 06.11.09 to 10.11.09. Patient tolerated the therapy well.

29. Thank you