Cervical case

[Damn_Daniel]

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Well, based on the very productive discussion I was just involved in, I thought I'd post a case.

A very healthy 39 year old woman went to her PCP complaining of a new pelvic pain and some foul smelling vaginal discharge. She was referred to a gynecologist who examined her and found a 4cm mass on the cervix. She biopsied it, and it came back as squamous cell carcinoma. Went to a gyn onc, and evaluation revealed 4cm cervical mass, thickening of the left parametrium, no vaginal extension. EUA didn't give us any new information. PET-CT confirmed the mass in the cervix was FDG avid, and there was a 2.6cm lymph node that was FDG avid in the left obturator. No other disease seen. When I saw her, I didn't feel parametrial extension but I trust the gyn onc. So, IIB with a positive lymph node. I got an MRI for treatment planning purposes, it didn't add any new info. The plan was for CRT with cis and brachy.

On the treatment planning CT, the right kidney wasn't where I thought it would be. It was smack dab in the pelvis, at about L4-L5 and extending down. It was on its back, not upright. She had never had imaging, so she had no idea this was the case. She has no PMH. No FH.

So, treating with a normal 3D plan (4 field), the right kidney gets full RX dose. IMRT was approved and we could spare the kidney, a bit, but I didn't chase the PA nodes that I typically treat when there is a positive pelvic node, because I didn't want the left kidney getting any dose. There was a surgeon willing to transpose it, but the patient was uninterested. After discussion with the med onc, we are set to proceed with cisplatin based chemo, with the patient understanding she was at risk for renal insufficiency in the future. She had a normal renal perfusion scan. Weekly taxotere was discussed, but the patient declined it.

The volume stops below the left kidney. The positive lymph node is getting. 2.2 to 55. The parametrium on the left side will get a bit of a boost.

Any other thoughts? Any dose constraints other than what RTOG protocols suggest?

Thanks!

 

[seper]

I personally don't treat PA with positive low pelvic nodes, so agree with pelvis only.
When one kidney gets more than tolerance, I get nuclear renal scan for differential fucntion prior to XRT.

 

[evilbooyaa]

Are you saying that the kidney moved after the previous imaging (considering she'd had a PET-CT which would show any gross abnormalities, as well as the MRI) or was the kidney in a similar position when looking back at the previous imaging? I don't know the answer to your final question and will defer to others on the board, but just curious if there's a chance the kidney's position is somehow fluid within the abdomen/pelvis.

 

[Damn_Daniel]

Thanks for the help! I don't particularly have the best DR guys. But even dum-dums like me and my dosimetrist can pick that up! It WAS on the PET-CT. Just not talked about.

 

[thecarbonionangle]

Daaaaaaaaaaaamn brother, very interesting case!

 

[xrthopeful]

Daaaaaaaaamn Daniel, back at it with the troll posts!

 

[Damn_Daniel]

Man, this board has quite a trigger fingerwith calling people trolls. Thanks for your "help".

 

[thecarbonionangle]

That's some quality from the Harvard of the caribbean. Daaaaaaaaaaaaaaaaaamn!

 

[Damn_Daniel]

Thanks! I may not have been clear - I'm from the Harvard of the Caribbean, but my dosimetrist is American educated and gives good plan. But, he's kind of a dope about other stuff.

**** my dosimetrist says:

So, the Haiti disaster happens, and our clinic is very good about helping in these situations (though, I don't give nada for Girl Scouts, haha!). Anyway, I tell them to make a plan of what we should do. A few days pass, and then at chart rounds, the dosimetrist gives a talk. Basically talks about establishing a "Dosimetry Without Borders" program. In Port-Au-Prince.*** At first, I was thinking they were pranking me. But, no, my dude had a 20 minute talk on this. I seriously peed myself (only second time at work, don't judge, me and the staff are not the sharpest forks in the dishwasher), laughing so hard. I ended up just cutting a check to the Red Cross, memo'd it "dosimetrists without borders". Framed a pic of it.

*** look up how many linacs Haiti has. That's what makes this even more hilarious.