Gynaecologic Oncology

Name: Yashoda P
Age: 27years
OP. No: 3954919
IP. No: 1295756
Ward: Gynae Onco
DOA:19.08.17
Date of transfer from OBG :24.08.17
DOD: 05.09.17
History
• Patient came with h/o amenorrhea for 3 month, Urine pregnancy
test(UPT): +ve done 2 months before , took MTP pills after UPT test
followed by continuous heavy bleeding, with clots and passage of
fleshy mass P/V since 2 months
• Bleeding stopped for 20 days and again had another episode of heavy
bleeding P/V. she was prescribed medications and bleeding stopped.
Followed again by h/o of ? Grape like vesicles P/V 15 days before
admission at St johns hospital
History
• Menstrual history: Menarche-15 yrs, Previous Menstrual cycles :
Regular, avg flow, No dysmenorrhea, LMP-09.04.17
• Obstetric history: Age of marriage-18 yrs, Obstetric score:P2 L2 A3,
First Child birth – 6yrs(FTND), Last Child Birth-4 yrs (LSCS), last
abortion June 2017(medical method)
• Past Medical History: k/c/o Bronchial Asthma not on treatment.
Examination
• Height-150cms, Weight-54kgs,
• P: 82/min, BP: 130/80mmHg, no pallor/edema, no lymph nodes
palpable,
• Thyroid-/Breast:Normal,CVS/RS :NAD,
• P/A: Soft, nontender, pfannenstiel scar +
• P/S:Cervix & Vagina healthy
• P/V/R: Uterus anteverted, bulky, firm, mobile, nontender, cervix firm
in consistency, fornices free, nontender.RM free.
Investigations
• Blood Group: B Positive, HIV/HBsAg: Negative(Rapid)
• 19.08.17-Cervical Swab C/S: MRSA, Sensitive Teicoplanin,Chloramphenicol,Netilmicin,Tetracycline,Vancomycin
• 19.08.17- Hb-12.80,TC-7.11,DC-61.00/25.70/7.70/4.60/1.00/0.0,PC-313, Urea-26,
• S.Creat-0.68 , LFT-7.35/3.9/0.95/0.17/0.78/14/26/71.00,GGT-24.0,
• S.Beta HCG in dilution-5.38
• 20.08.17-SE-140.00/4.32/105.00,FBS-100,S.TSH-1.005
• 21.08.17-Serum Beta HCG-5.58
• 21.08.17-UrineR/M-NAD,
• 25.08.17-Serum Beta HCG-3.62
• 25.08.17-PTP-11.6/12,INR-1.04,APTT-28.5/32
• 29.08.17-Strip (Pregnancy Test)-Negative
• 04.09.17-Serum Beta HCG- <0.6
• 19.08.17-Cervix Pap smear: (C-2630/17):NILM
• 21.08.17- Chest X-ray Normal
IMAGING
• MRI-Abdomen and Pelvis-(Plain and Contrast)
• Bulky uterus (8.5x4.7x4.5 cm) with evidence of a heterogenous lesion
with avid contrast enhancement measuring 4.6x3.1x2.4 cm, within
the endometrial cavity with predominantly anterior myometrial
invasion.
• Zonal anatomy of uterus is disrupted anteriorly. The lesion is noted to
extend upto almost level of serosa anteriorly. Fat planes with bladder
appears normal.Tortuous vessels with flow voids noted in bilateral
parametrial/adnexal region and in the myometrium and endometrial
cavity.The lesion is abutting the urinary bladder with no obvious
invasion.
MRI-Abdomen and Pelvis-(Plain and Contrast)
(contd)
• Ovaries : Prominent follicles noted in bilateral ovaries, largest
measuring 1.6x1.9 cm on right. Few T2 hyperintense foci in upper and
midpole of right kidney, largest measuring 13x9mm – likely renal
cysts.
• Impression: Bulky uterus with a enhancing, heterogenous
hypervascular lesion within the endometrial cavity with
predominantly anterior myometrial invasion.
• In a background of positive UPT and borderline BHCG elevation – to
consider gestational trophoblastic disease / placental site
trophoblastic tumour (PSTT)
 Abdominal Pelvic Scan-
• Uterus: The uterus measures 7.0x5.3x4.0 cm, with normal in size, contour and echotexture.
A Hyperechoic lesion with partially ill defined margins, measuring 2.8x4.0x3.3 cm is noted
in anterior myometrium, abutting the endometrium cavity with prominent cystic spaces
within, which show increased vascularity on colour Doppler. Then endometrial thickness is
5.5 mm. No abnormal vascularity noted within the endometrium. The cavity is empty.
• Ovaries:Right ovary measures 2.3x1.6 cm and Left ovary measures 2.8x2.1 cm and shows
dominant follicles measures 18x6 mm. Both ovaries are normal.
• A Simple cystic lesion measuring 2.2x1.8 cm is noted in right adnexa seen separately from
the ovary in its superolateral aspect.
• Impression: Anterior myometrium lesion with increased vascularity – To consider
possibility of
• 1. AV malformation.
• 2. Molar etiology (less likely in view of normal Beta HCG level).
• Right adnexal small simple cystic lesion-Suggested follow up scan.
• Hepatomegaly.
• Non obstructive right renal calculus with mild pelviectasia
Procedure
• B/L Uterine Artery Embolisation on 02.09.17
Post procedure imaging
• Pelvic Scan with uterine artery Doppler (Post Procedure)
• The uterus measures 6.9 x4.0 x 5.1 cm with normal contour and
echotexture. A hyperechoic lesion anterior myometrium of the uterus with
partial abutting endometrial cavity. Few cystic areas noted within, there is
significant decrease in morphology and vascularity compared to the
previous study. The endometrial thickness is 5.5 mm. The cavity is empty.
• The right uterine artery is not visualised. Left Vmax -36.5 cm/s, PI-2.4, RI-
0.86. Both ovaries are normal. No free fluid in the POD.
• Impression: S/p post UA embolization. There is significant decrease in
morphology of cystic areas and vascularity compared to the previous study.
Right uterine artery not visualised.
Discussion
• She was admitted with above complaints. She was serially monitored
with serum beta hcg. Patient underwent uterine artery embolisation
on 02.09.17. Procedure uneventful. Post procedure USG pelvis done
on 04.09.17 revealed significant decrease in morphology of cystic
areas and vascularity compared to the previous study. Right uterine
artery not visualised. She was discharged in stable condition on
04.09.17.