Case Discussions in Obstetrics and Gynecology

Case Discussions in OBSTETRICS AND GYNECOLOGY Case Discussions in OBSTETRICS AND GYNECOLOGY Editors YM Mala MD DNB Professor Madhavi M Gupta MS Associate Professor Swaraj Batra MBBS MD FICOG Director-Professor and Head Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • St Louis (USA) • Panama City (Panama) • London (UK) • Ahmedabad Bengaluru • Chennai • Hyderabad • Kochi • Kolkata • Lucknow • Mumbai • Nagpur Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357, Fax: +91-11-43574314 Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021 +91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: jaypee@jaypeebrothers.com, Website: 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2031708910, e-mail: info@jpmedpub.com Case Discussions in Obstetrics and Gynecology © 2011, Jaypee Brothers Medical Publishers All rights reserved No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher This book has been published in good faith that the material provided by contributors is original Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error (s) In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only First Edition: 2011 ISBN: 978-93-5025-129-4 Typeset at JPBMP typesetting unit Printed at Dedicated to all our patients who have taught us the art of case discussion and will continue to so Contributors Anjali Tempe Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Avantika Gupta Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Anvika Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Binni Makkar Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Arima Nigam Assistant Professor Department of Cardiology Maulana Azad Medical College and G B Pant Hospital New Delhi, India Chanchal Gupta Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Ashok Kumar Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Chandan Dubey Assistant Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Asmita Muthal Rathore Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Deepti Goswami Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India viii Case Discussions in Obstetrics and Gynecology Devender Kumar Assistant Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Gauri Gandhi Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Jyoti J Banavaliker Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Krishna Agarwal Associate Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Latika Sahu Associate Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Leena Wadhwa Assistant Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Madhavi M Gupta Associate Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Meenakshi Garg Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Minu Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Mumtaz Khan Senior Specialist Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital, New Delhi Nancy Singh Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Neha Gupta Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Neha Singh Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Contributors Nilanchali Singh Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Pooja Pundhir Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Poonam Sachdeva Junior Specialist Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Puneet K Kochhar Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Rachna Sharma Junior Specialist Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Raksha Arora Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Renu Tanwar Assistant Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Reva Tripathi Director Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Ronita Devi Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Rupali Goyal Senior Resident Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Sangeeta Bhasin Chief Medial Officer (NFSG) Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Sangeeta Gupta Professor Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Saritha Shamsunder Junior Specialist Department of Obstetrics and Gynecology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India ix Carcinoma Vulva Q.7 How will you stage the lesion? Ans: In 1988, FIGO approved a surgico-pathological system for staging carcinoma vulva This staging has been revised by FIGO in 2008 and published in 2009 Although the previous stage IA remains unchanged because this is the only group of patients with a negligible risk of lymph node metastasis, the previous stages I and II have been combined because many studies have demonstrated that the size of the lesion (with negative lymph nodes) is no longer a prognostic factor in previous stages I and II Moreover, the number and morphology (size and extracapsular spread) of positive lymph nodes have been taken into account because they have been shown to be important prognostic factors, whereas the bilaterality of positive nodes have been discounted due to controversy from previous studies The revised FIGO staging for carcinoma vulva is: • Stage I Tumor confined to the vulva IA Lesions < cm in size, confined to the vulva or perineum and with stromal invasion 2 cm in size or with stromal invasion >1.0 mm*, confined to the vulva or perineum, with negative nodes • Stage II Tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with negative nodes • Stage III Tumor of any size with or without extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguinofemoral lymph nodes IIIA (i) With lymph node metastasis >5 mm, or (ii) 1-2 lymph node metastasis 5 mm (ii) or more lymph node metastases 2 cm but does not involve adjacent perineal structures and no palpable nodes are present, it appears to be Stage IB according to the new staging (and earlier would have been Stage II) Q.8 What other investigations should be done? Ans: The following investigations should be done to rule out surrounding vulvar dystrophies and other genital malignancies • Pap smear • Colposcopy of cervix and vagina • Vulvoscopy for lesions at other sites on vulva Pre-operative investigations, which include– • Complete blood count • LFT, KFT • Blood sugar • Serum electrolytes • Chest X-ray, ECG • Urine-albumin, sugar, microscopy and culture • Special investigations for co-morbid conditions in elderly * The depth of invasion is defined as the measurement of the tumor from the epithelialstromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion 358 Case Discussions in Obstetrics and Gynecology Imaging: • Ultrasound pelvis to rule out other pelvic pathology • CT/MRI scan of groin, pelvis and abdomen may be done to see the extent and resectability of the tumor and involvement of lymph nodes If the lesion is large and locally advanced, the following investigations may be required: • Cystourethroscopy – if bladder or urethra seems involved • Intravenous pyelography – if bladder base is involved • Proctosigmoidoscopy – if anus or rectum seems involved Q.9 What are the routes of spread of vulvar cancer? Ans: Vulvar cancer spreads by the following routes: Direct extension, to involve adjacent structures such as vagina, urethra and anus Lymphatic spread: Lymphatic metastases may occur early in the disease Initially, spread is usually to the inguinal lymph nodes, which are located between Camper’s fascia and fascia lata From these superficial groin nodes, the disease will spread to the deep femoral nodes, which are located medially along the femoral vessels Cloquet’s or Rosenmuller’s node, situated beneath the inguinal ligament, is the most caphalad of the femoral node group Metastases to the femoral nodes without involvement of the inguinal nodes have been reported and the lymphatics of the vulva from either side form a rich network of anastomoses along the midline Lymphatic drainage from the clitoris, anterior labia minora and perineum is bilateral For lateral tumors, metastases to contralateral lymph nodes in the absence of ipsilateral nodal involvement is rare From the inguinofemoral nodes, the cancer spreads to the pelvic nodes, particularly the external iliac group The overall incidence of inguino-femoral lymph node metastases is about 30% Metastases to pelvic nodes occur in about 12% cases Pelvic nodal metastases is rare (0.6%) in the absence of groin node involvement Hematogenous spread to ditant sites, including the lungs, liver and bone Hematogenous spread usually occurs late and is rare in the absence of lymph node metastasis Q.10 What is the treatment for this patient? Ans: Surgery is the mainstay of treatment Earlier radical vulvectomy with bilateral inguinofemoral lymphadenectomy by en bloc dissection was the standard therapy for Stage IB However, the disadvantages of en bloc dissection are: • Large loss of vulvar tissue with psychosexual sequelae • A 50% wound breakdown rate • A high incidence of lower extremity lymphedema The en bloc dissection has now been replaced by the triple incision technique Separate incisions are given for vulvectomy and lymphadenectomy This results in significant reduction in wound morbidity Radical Vulvectomy This is done by two elliptical incisions on the vulva The outer one is placed on the labiocrural folds and anteriorly brought across the mons pubis and posteriorly across the perineal body The inner incision circumscribes the vaginal introitus and vulvar vestibule The dissection is carried down to the deep perineal fascia The aim should be to have 2cm tumor free margin Once dissection is complete, the levator ani muscles should be approximated to prevent rectocele formation After achieving hemostasis, the skin is sutured to vaginal mucosa by interrupted sutures Carcinoma Vulva Lymphadenectomy Bilateral inguinofemoral lymphadenectomy is done by separate longitudinal incisions centered midway between the femoral artery and pubic tubercle, extending from one inch above to two inch below the inguinal ligament The skin and subcutaneous tissue is incised The superficial inguinal lymph nodes lie above the cribriform fascia and associated with saphenous vein and its tributaries (superficial circumflex, superficial external pudendal and superficial epigastric) These tributaries of saphenous vein are first identified and ligated and superficial inguinal lymph nodes are removed The saphenous vein is identified and ligated at its entry to the femoral vein A segment of the saphenous vein along with the longitudinal group of lymph nodes is removed All lymph nodes around the saphenofemoral junction should be removed and any prominent deeper lymph node (Cloquet node) medial to the femoral vein should also be removed This can be used as the sentinel node and sent for frozen section If positive, extraperitoneal pelvic lymphadenectomy may be done The alternative treatment for positive inguinofemoral nodes is postoperative radiotherapy to the pelvis and groin 359 negligible The negative predictive value of this method is 97% – If positive, pelvic lymphadenectomy or pelvic LN radiation can be done – The advantage of this method is that extensive lymphadenectomy is avoided in cases where sentinel node is negative – Sentinel node mapping is still under trial Q.12 What is the role of unilateral groin dissection? Ans This has been done in well lateralized early tumors that are well differentiated, with no capillary or lymphatic space involvement and negative ipsilateral inguinal lymph nodes Stehman et al (1992), in a GOG study reported out of 121 patients undergoing unilateral lymphadenectomy had a recurrence in contralateral lymph nodes but all these tumors were poorly differentiated Q.13 When can groin dissection be omitted? Ans: This can only be done in non midline tumors cm or stromal invasion > mm with no nodal metastasis): Various factors have to be considered to decide the surgical approach These include the patient’s age, size of tumor and site of lesion a Radical local excision with inguinofemoral lymphadenectomy: • It is suitable for younger patients with a well-localized small unifocal lesions • Recommendation is to resect the primary tumor with a cm margin of normal tissue and to carry the dissection up to the deep perineal fascia of the urogenital diaphragm • In tumors < cm size, radical local excision results in 90% survival rate • In well-lateralized early tumor that is well differentiated, with no capillary or lymphatic space involvement ipsilateral inguinofemoral lymphadenectomy is done These are sent for frozen section If positive, then contralateral and pelvic lymph node dissection is done If negative, no further dissection or postoperative radiotherapy is needed • Bilateral lymph node dissection should be done in tumors involving midline structures (clitoris or labia minora or perineal body) or within cm of midline b Radical vulvectomy with bilateral inguinofemoral lymphadenectomy: • Radical vulvectomy with bilateral inguinofemoral lymphadenectomy by triple incision technique which has been described earlier Treatment of Advanced Vulvar Cancer Stage II Tumor involving adjacent perineal structures, i.e lower 1/3 urethra, lower 1/3 vagina, anus) Stage III (stage I or II with positive inguinofemoral lymph nodes) Advanced vulvar cancer can be managed by a Ultra-radical surgery b Radiotherapy c Combined modality using chemotherapy and radiotherapy a Ultra-radical vulvectomy with bilateral inguinofemoral lymphadenectomy by triple incision technique When tumor involves the distal urethra, vagina or anus, but is still resectable by partial resection of these structures may be done If >1 cm of urethra is excised then risk of urinary incontinence is there Partial resection of the external anal sphinter in combination with radical local resection of perianal tissue is associated with a significant rate of subsequent fecal incontinence Careful sphincter reapproximation and levator muscle placation are done in an effort to minimize incontinence This surgery should be done in highly selected cases which are clearly respectable with none or or lymph nodes positive b Radiotherapy This may be the only option in medically unfit patients or unresectable disease The current high energy radiotherapy techniques have relative skin sparing effect Teletherapy at a dose of 45-55 Gy to the whole pelvis, including vulva and groins, is given This can be combined with 65-70 Gy to the tumor bed by a single direct electron beam or interstitial needles, but this local treatment is highly morbid A more effective method is to combine preoperative chemoradiation followed by a more limited resection Megavoltage radiotherapy causes regression of advanced cancer to a point where limited resection can be done, with sparing of organ function and better quality of life Surgery is performed 2-6 weeks after completion of external beam radiotherapy, delivering 50 Gy to whole pelvis Carcinoma Vulva Stage IV Tumor invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures The options available are: a Ultra-radical surgery - pelvic exenteration b Radiotherapy (Teletherapy of pelvis including the vulva and groin has been done at a dose of 45 to 55 Gy), followed by limited resection if possible c Combination modality using chemoradiation and surgery 5-flurouracil, cisplatinum, mitomycin and bleomycin have been used for chemotherapy Q.15 What is the role of radiation in the treatment of cancer vulva? Ans: Radiotherapy for cancer vulva is indicated in: a Preoperatively in patients with advanced disease who would otherwise require pelvic exenteration, as described earlier b Postoperatively to treat the pelvic and groin lymph node of patients with positive groin nodes c To prevent local recurrence in patients with close surgical margins (