Stage IIB carcinoma of the cervix that is associated with pelvic kidney Atherapeutic dilemma

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Slide 1 : CASE PRESENTATION A 50-year-old patient, para 5 was referred to gynecologic oncology service after an evaluation for abnormal vagina bleeding led to cervical biopsies which demonstrated invasive adenocarcinoma of the cervix. Her general and systemic physical examination was normal.
Slide 2 : CASE PRESENTATION Pelvic examination showed 7cm barrel shape cervical lesion, invading the upper 1/3 of the anterior vaginal wall, other vaginal walls are free of disease. The left parametrium was invaded up to 1cm from the pelvic sidewall The medial third of the right parametrium was also involved by the lesion. Rectal mucosa free of disease.
Slide 3 : CASE PRESENTATION Cystoscopy showed Bulging in the trigone area but no evidence of disease, both ureteric orifices seen with difficulty but free of disease. The patient was staged as FIGO IIB. Metastatic workup revealed an incidental finding of an ectopic left pelvic kidney without hydronephrosis.
Slide 4 : CASE PRESENTATION The renal isotope scan showed that the right kidney is normally located with normal function, but the left kidney is an ectopic, located in the pelvis with good function. Split function was 79% in the right kidney, and 21% in the left one.
Slide 5 : CASE PRESENTATION Because the left kidney was not functioning properly, and the right kidney is functioning normally. we offered the patient radiotherapy with cisplatin-based chemotherapy with curative intent and to sacrifice the left kidney.
Slide 6 : CASE PRESENTATION The patient received a radical course of external beam therapy (EBRT) as follows: 4500 cGy/25frs/5weeks to the whole pelvis; box technique; concomitantly with weekly cisplatinum (i.v) 40mg/m2, for 5 cycles. 540 cGy/3frs/0.6 weeks – boost to the parametrium with midline shielding, she completed the EBRT part of her treatment with fair tolerance.
Slide 7 : CASE PRESENTATION Thereafter, she received 2500 cGy/5frs using high dose rate (HDR) – microselectrone technology over 3 weeks, with good tolerance. She completed her treatment in 9weeks period. It has been 24 months since her treatment and the patient remains free of disease, and her serum creatinine and urea nitrogen are still within normal values.
Slide 8 : CASE PRESENTATION DISCUSSION: Evaluation of the kidney function before therapy is essential. In this case, the pelvic kidney was marginally functional and the oftehr kidney was fully functional. Standard treatment of locally advanced cervix cancer “ chemo radiation” was given.
Slide 9 : CASE PRESENTATION Two years later, the patient was free of disease. Blood pressure and kidney function tests were normal.
Slide 10 : CASE PRESENTATION Literature review: Bakri et al reported a case of stage IIB cervix cancer with ectopic kidney. They performed radical Hyster. with PLND and resection of the distal ureter and ureteric reimplantaion into urinary bladder using Boari-flap technique. Adjuvant chemotherapy was needed.
Slide 11 : CASE PRESENTATION Rosenshein et al, reported a case of cervical cancer with ectopic kidney. The kidney was mobilized into the Lt iliac fossa and was fixed to the psoas muscle. Radiotherapy was the definitive treatment.
Slide 12 : CASE PRESENTATION Roth et al, reported a case of bilateral pelvic kidneys and stage IIB cervix cancer. Anterior exenteration without vaginal reconstruction and a distal ileal urinary conduit were performed. This was complicated by Lt ureteroileal anastomotic leak that required reoperation on 2 occasions and Lt nephrectomy. The LN were negative with no adjuvant treatment required.
Slide 13 : CASE PRESENTATION Another option, not yet reported, to use neoadjuvant chemotherapy followed by radical hyster. And PLND. Pretreatment PET scan help to define any metastatic disease.
Slide 14 : CASE PRESENTATION CONCLUSION: Reported treatment experience is limited to sporadic case reports. Because of the rarity of the condition, each case must be managed on its merits, with the use of a multidisciplinary team that consist of a gyne-onc, radiation oncologist and a medical oncologist.

 


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