Multinodal cabcer uteri - effective treatment of lymphostasis/edema

	Asked by user (Male ) on Thu 10, Apr 2008 09:05am for $9.00:
	Woman, 65 yo, with history of myoma uteri, diabetes and hypertension has been diagnosed with cervical cancer stage IIb-III(verified by biopsy) in April 2007. Oncologist made a decision to perform combined radiotherapy. After combined treatment: external gamma radiation + intracavital alfa-radiation(May-June 2007) cervical biopsy (September 2007) was negative. However, general condition during October-December progressively worsened: weight loss about 10 kg, abdominal pain (hypogastrium symmetrically and separately right side), body temperature elevations (37-39 C). December 2007 X-ray detected obstruction of right ureter and hydronephrotic transformation of right kidney. This had been treated by placing stent in right ureter(December 2007). However, fever continued with development of anemia (8,4-8,6), leucocytosis (up to 29 G/l), edema of legs, abdomen, low back. Cervical biopsy in early February was still negative. CT(March 2007) detected enlargement of uterus (11, 7cm in fundo-cervical dimension) followed by MRT that showed non-homogenous multinodal structure of enlarged uterus compressing urinary bladder and closely contacting with rectum, edema of rectum wall at all levels, increase of pelvic lymphatic nodes up to aortal bifurcation with signs of fibrosis, significant subcutaneous edema, free liquid in pelvis was not detected. The conclusion was multinodal neoplasma of uterus(seems to mean cancer uteri). The last blood tests (March 28) were RBC 2.9, Hemoglobin 8.4, WBC 23.5(segments - 84), C-reactive protein 169, albumin 23.5,. The questions: 1.What are treatment options in this situation: is it useful to repeat radiotherapy or proceed to chemotherapy or both. If chemotherapy then what particular agent/combination is supposed to be effective, what about anti-estrogenes like tamoxifen? 2.What is effective treatment of lymphostasis/edema? 3.What else may be done to relief the patient condition?
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	Answer by Dr Paul S, MD (oncologist) on Sun 13, Apr 2008 08:51am: 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. Thank you for using our service.  If you are satisfied with the answer or if you want a detailed answer for your question, please make a donation and request for further clarifications.  Our oncologists will provide an elaborate answer for your clarification.   Please make a donation by clicking the button below. You may donate using funds from your PayPal account or Credit Card. Please rate my answer (select the stars below, no need to log in.)
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