Multinodal cabcer uteri - effective treatment of lymphostasis/edema

This is a case where we may be dealing with a recurrent cervical cancer with uterine extension, or a second primary cancer (uterine cancer). Either case, a repeat radiation therapy may not be feasible since the pelvis can only tolerate a certain dose of radiation. If the patient's medical condition can be improved through diet up building, albumin and RBC transfusions, control of co-morbidities, the ideal treatment option would be surgical removal (THBSO, with para-aortic lymph node dissection, or maximal debulking)per the latest NCCN guidelines on uterine cancer. The scans show that the tumor is not infiltrating the rectum and the urinary organs so the surgeon may have a good chance of isolating the tumor and resecting it completely. However, it should be well explained to the patient that this approach carries significant risk since she has other comorbidities. Post operative chemotherapy (adjuvant) may be warranted depending on the surgical findings. If the risks are unacceptable to the patient, then palliative chemotherapy is the next best option. Chemotherapy for uterine cancer includes platinum agents, used singly or in combination. Most commonly used combination regimen is Paclitaxel+Carboplatin or Cisplatin+Doxorubicin. However, the patient's performance status may affect our judgment to use these combination treatment and we may limit ourselves in using single agent chemotherapy (either paclitaxel, carboplatin, cisplatin or doxorubicin used singly). The patient's hemoglobin and nutritional status should all be addressed before starting chemotherapy. The side-effects of each drug should also be well explained (Cisplatin=nephrotoxicity, paclitaxel+carboplatin=neutropenia, doxorubicin=neutropenia and cardiotoxicity). Another option for the patient's treatment is the use of hormonal therapy. This form of treatment offers the advantage of efficacy with a favorable side-effect profile. Present guidelines recommend the use of progestational agents,tamoxifen, or aromatase inhibitors (letrozole, anastrozole, exemestane). These agents are used for patients who may not be able to tolerate invasive procedures such as surgery or cytotoxic treatment (chemotherapy). The goal of treatment should be made clear, whether it is curative (surgery), or palliative (through chemotherapy or hormonal therapy), and the risk/benefit ratios assessed and explained. Informed consent for each option should be well documented. Addressing the primary tumor through chemotherapy or hormonal therapy may eventually relieve the edema. However, there are other pharmacologic and non-pharmacologic measures to address the problem. Correcting the patient's albumin through albumin transfusions or increasing the protein in the diet may help in decreasing the edema. Compressive stockings may also decrease the edema as well as exercises like leg elevation and passive leg movements. Correcting the hemoglobin levels through transfusions may also improve overall hemodynamics. The patient's primary tumor and the edema may be causing a lot of pain. For this reason pain medications are warranted. Opioid or opioid like pain relievers (like tramadol, or morphine) may be ideal since these drugs are less likely to interfere with the patient's kidney function (she already has a hydronephrotic right kidney). The patient may also be on prolonged bed rest and immobilization and she needs good nursing care to prevent decubitus ulcers. She may also need venous thrombosis prophylaxis in the form of low molecular weight heparins (like clexane) to lower risk of pulmonary embolism. Antibiotic treatment should be started if highly suspicious for infection, covering empirically to include urinary pathogens (gram negatives). If cultures (blood or urine) are able to isolate a pathogen, antibiotic treatment should be tailored to address such pathogens.

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